The Waikato Integrated Heart Failure Service (WIHFS)

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The Waikato Integrated Heart Failure Service
(WIHFS)

• Debbie Chappell
• CNS Heart Failure
• Taumarunui/Te Kuiti/Otorohanga/Te Awamutu

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The Waikato Integrated Heart Failure Service Team

• HF CNSs
• Julie Jay, Eileen Gibbons, Karyn Haeata,Debbie
  Chappell, Simona Inkrot, Catherine Callagher
• Cardiologists
• Mark Davis, Gerry Devlin, Raewyn Fisher
• Sonographers

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HF in Aotearoa/NZ

• 2 Heart Failure prevalence in Western societies
  
• HF Incidence is rising with an ageing population
  and the improved treatment and survival of
  heart disease
• Median survival of 3.5 years after initial HF
  admission in NZ
• One-year HF mortality rates after initial
  hospital admission are between 25 and 35
• Maori patients admitted with HF are significantly
  younger than NZ European mean age 62 vs. 78
  years

McMurray et al., 2012 Wasywich et al, 2010
Schaufelberger et al., 2004 Wall et al., 2012
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Refresher AP
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Definition

• Heart Failure is a clinical syndrome where the
  heart is unable to pump blood at a rate required
  by the body, patients present with some or all of
  the following features
• Symptoms typical of heart failure
• (breathlessness at rest or on exercise, fatigue,
  tiredness, ankle swelling) AND
• Signs typical of heart failure
• (tachycardia, tachypnoea, pulmonary rales,
  pleural effusion, raised jugular venous pressure,
  peripheral oedema, hepatomegaly)
• AND
• Objective evidence of structural or functional
  abnormality of the heart at rest
• (cardiomegaly, third heart sound, cardiac
  murmurs, abnormality on the echocardiogram,
  raised natriuetic peptide concentration)

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Normal HF-REF HF-PEF
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Some causes of heart failure

• Coronary artery disease
• Hypertension
• Valvular heart disease
• Cardiomyopathies
• Endocrine disorders-thyrotoxicosis
• Genetic conditions
• Congenital heart disease
• Inflammatory
• Chronic arrhythmias
• Also think of co morbidities diabetes, obesity,
  COPD

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Pathophysiology

• Compensatory mechanisms of acute heart failure
• Sympathetic nervous system activation
• Renin-angiotensin system activation
• LV remodelling
• OUTCOME
• Vasoconstriction Increased HR, SV leads to
  increased CO
• Attempt to maintain cardiac output and vital
  organ perfusion heart, brain, kidneys

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Maladaptation

• Compensatory mechanisms become maladaptive in
  chronic heart failure
• OUTCOME
• Excessive vasoconstriction
• Increased afterload
• Excessive salt and water retention
• Electrolyte abnormalities
• Arrhythmias

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Investigations

• Observations TPR BP (lying/standing), weight,
  height BMI
• ECG old and new changes
• Bloods CBC, UE, Cardiac enzymes, NT-pro BNP,
  LFT,
• Cholesterol, TFT
• CXRay old and new
• ECHO- normal EF gt55, moderate severe HFlt40

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Treatment Options medical vs intervention

• Non pharmacological
• -fluid management
• -nutrition
• -physical activity
• -smoking
• -psychosocial support
• -other factors

• Pharmacological
• - Diuretics
• -ACEi
• -Beta-blockers
• -Other drugs

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Case studies

• 75 year old female
• History incr SOBOE (getting worse)
• Bilateral pitting oedema
• JVP 2, chest clear
• History hypertension
• Dip stick, LFT, UE
• NT pro BNP 400 pg/mL
• Refer - ECHO normal LV, elevated filling
  pressures, HFpEF
• Treatment options

• 49 year old male
• Bilateral oedema, pants tight
• Appetite depressed
• JVP normal, ascites, ? pulsatile liver
• Jaundiced
• Dip stick (bilirubin)
• LFT - abnormal
• NT pro BNP normal
• Renal normal
• Check ? Hepatitis, alcohol, blood transfusion

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Aims of treatment / nursing role

• Improve symptoms fluid restrict, daily weigh,
  medication
• Improve LV function medication, medical
  intervention
• Improve exercise tolerance moving, pacing
  themselves
• Improve patient education self-management HF
  booklet
• Decrease hospital admissions - improve survival
• End of life care

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CNS led interventions for HF patients

• Decreased hospitalisation, decreased number of
  events, readmissions and days in hospital
• Improved survival
• Cost effective
• Improved self-care behaviour

Stromberg et al., 2003 Phillips et al., 2005
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Referral Criteria

• Inclusion
• Patients with possible heart failure and/or at
  high risk for heart failure in the community,
  e.g. previous MI, family history of
  cardiomyopathy
• Patients readmitted for heart failure within 3
  months
• Heart failure patients with significant
  co-morbidities affecting optimisation of
  treatment
• Shared care for end stage/palliative care
• Exclusion
• Lack of consent from patient
• Acute coronary syndrome
• Patients already under the care of a
  cardiologist, unless referred by this
  cardiologist (inclusion criteria must be
  satisfied)
• COMPONENTS OF WIHFS
• Specialist clinics (CNS and cardiologists), Home
  visits, Telephone care
• Patient and family/whanau education heart
  failure knowledge and self-care
• Clinical monitoring
• Titration of heart failure medications in
  consultation with GP and/or cardiologist
• Professional education/CME for other health
  professionals and community teams

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Thank you
Debbie Chappell Taumarunui
Te Kuiti/Otorohanga/Te Awamutu 0212419452 07
8785192

• Questions?