BHF Community Heart Failure Specialist Nurses Team Mary

BHF Community Heart Failure Specialist Nurses Team Mary Gadsby Stephanie Smith Miriam Quinn Maggie Clark Haley Read Gemma Tarr Wendy Phillips Occupational Therapist Stephanie Kidder Administrator Lisa Gibbs Assisstant Practitioner Teresa Denham Physiotherapist Helen Barritt Jan Walsh Sajith Narayanan Lekshmy

The Heart

The Heart

Heart Failure https: //www. youtube. com/watch? v=r 7 Idp. Jjyc. WY &list=FLw. VDZKS 5 FYAFGs. OTG 8 njl. IQ&index=2

Heart Failure – a Definition “a complex clinical syndrome of symptoms and signs that suggest impairment of the heart as a pump supporting physiological circulation. It is caused by structural or functional abnormalities of the heart. The demonstration of objective evidence of these cardiac abnormalities is necessary for the diagnosis of heart failure to be made. The symptoms most commonly encountered are breathlessness (exertional dyspnoea, orthopnoea and paroxysmal nocturnal dyspnoea) fatigue and ankle swelling. ” NICE (2010)

Prevalence and cost • 1% of people under 65 years are thought to have heart failure • Prevalence rises to 7% in those aged 75 -84 years • 15% of those aged 85 years and above have the condition (Scarborough et al, 2010) • Annual cost to the NHS: £ 628. 6 m (www. heartstats. org)

Heart failure prevalence in Nottingham City § 2, 118 patients registered with Heart Failure § 1, 109 patients with Left Ventricular Dysfunction § Patients from more deprived areas were twice as likely to be admitted to Hospital as patients from the least deprived areas § Stats taken from Public Health Nottingham 2014

Causes of Heart Failure • • Coronary Heart Disease / Ischemia Hypertension Valvular Heart Disease Heart Rhythm Abnormality Thyroid Dysfunction Chronic anaemia Cardiomyopathy - alcoholic; drug induced; viral; congenital; familial; ischaemic

Signs and Symptoms: • • • Breathlessness Fluid retention / oedema Haemodynamic changes Tiredness / fatigue Weight loss / cachexia Nocturnal cough Difficulty in concentrating/confusion Depression Impaired appetite

New York Heart Association Classification Class I No limitations on activity. No fatigue, breathlessness or palpitation on ordinary physical activity Annual mortality 3 -5% Class II Patients are comfortable at rest but ordinary physical activity such as climbing stairs or doing housework results in symptoms ‘Mild’ heart failure Annual mortality 10% Class III Patients have a marked limitation of physical activity. Although patients are comfortable at rest, less than ordinary physical activity will lead to symptoms ‘Moderate’ heart failure Annual mortality 12 -16% Class IV Patients have symptoms even at rest and are unable to undertake any physical activity without discomfort ‘Severe’ heart failure Annual mortality 15 -20% Adapted from ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure; Eur Heart J, 2008

Breathlessness is a key feature of heart failure and the NYHA classification is based on it. Contributing factors are: • Pulmonary oedema – back pressure on the lungs from an overloaded left atrium • Overdrive of the breathing muscles by chemoreceptor response to CO 2 • Weakness of breathing muscles • Usually worse on exertion • Paroxysmal nocturnal dyspnoea (PND) and Orthopnoea

Fluid Retention Two main mechanisms cause fluid retention / oedema in heart failure: • Heart failure causes back pressure on the circulation causing lower limb oedema and a raised JVP • Neurohormonal activation due to reduced renal perfusion stimulates the production of angiotensin, aldosterone and anti-diuretic hormone. This causes sodium and water retention.

Fluid Retention • Pulmonary oedema Increased breathlessness – Change in breathing pattern – Cough – Chest examination: lung crackles, reduced air entry, dullness on percussion – • Central oedema Abdominal ascites – Raised JVP – • Peripheral oedema Legs – Sacral –

Fatigue • Skeletal muscle changes – reduced ability to respond to exertion • Effortful breathing • Poor sleep quality (PND, apnoea, nocturia, nocturnal cough) • Reduced oxygen saturation due to impaired gaseous exchange • Accompanying anaemia • Medication eg betablockers • Anxiety / depression

Haemodynamic changes • • Hypotension Postural changes Heart rate and rhythm changes Peripheral cyanosis

Treatment - Medication • ACE(Angiotensin Converting Enzyme) inhibitor eg, Ramipril; Lisinopril, Enalapril; Perindopril Lowers blood pressure • Assists heart function • Can reduce mortality • • ARBs (Angiotensin Receptor Blockers) • Diuretics eg, Furosemide; Bumetanide; Metolazone For symptom control (breathlessness and oedema) Offloads fluid • Aldosterone Antagonists eg, Spironolactone; Eplerenone

Treatment - Medication • Beta blockers eg, Bisoprolol; Carvedilol Reduce blood pressure and heart rate, therefore reducing heart’s workload • Prevent remodelling of the heart • Can reduce mortality, sudden death and hospitalisation • Patients may feel worse before they feel better • • Hydralazine / Nitrate combination • Ivabradine

Management • Pharmacological – titration and optimisation. • Non pharmacological / interventional Implantable defibrillator – Cardiac resynchronisation therapy – Cardiac surgery / transplantation / LVAD – • Monitoring and management of symptoms • Lifestyle advice Physical activity – Dietary advice – Smoking – Alcohol –

Management: • Self management strategies Daily weights/Fluid restriction – Low salt diet – Monitoring of symptoms – Diuretic dose adjustment – • • • Anxiety management Counselling Carer support Spiritual support Cardiac Rehabilitation

Aims of the BHF Heart Failure Nurse “To offer interventions appropriate to the patients’ needs, incorporating psychosocial and educational input and a review of their medical condition / treatment” (BHF, 2003) Evidence from various studies shows that nurse-led heart failure programmes can reduce readmission rates, prolong event-free survival, improve prescribing practices and general quality of life. (Stewart and Blue, 2004)

Role of the Heart Failure Nurse • Work in liaison with acute, social and voluntary sectors • Manage a caseload of patients with Heart Failure at home or in a community clinic • Monitor the patient’s clinical and psychosocial status and manage appropriately • Reduce avoidable hospital admissions • Medicines management Optimising evidence based therapy Titrate medication to alleviate symptoms and improve quality of life – Prescribe Heart Failure Therapy – Medication review (including concordance) – – • Deliver IV Diuretics at home

Role of the Heart Failure Nurse • Provide patients and carers with advice on lifestyle changes • Provide emotional support for patients and carers from diagnosis to end of life. • Educate and advise local healthcare professionals • Ongoing service development and Innovation • Develop and work to agreed nursing and medical therapy guidelines drawn up with nursing colleagues, general practitioners and cardiologists • Empower patients to be actively involved in managing and monitoring their own care.

Referral Criteria • Patients with Left Ventricular Systolic Dysfunction (LVSD) confirmed by echocardiography and / or angiography: § Experiencing decompensating heart failure at home or in hospital. § Requiring review of treatment regime concordance. § Not on optimal treatment regimes § Requiring further education and support

Any Questions?

Nurse Contact information: Room 29 New Brook House 385 Alfreton Road Radford, NG 7 5 LR Office: 0115 8834733 Fax: 0115 883 4798 firstname. surname@nottinghamcity. nhs. uk Mon-Fri 8 am-6. 30 pm