Leeds Heart Failure Pathway - Adult Leeds

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1. Background Information / Scope of Pathway

This pathway is for adults with symptoms suggestive of heart failure. It is also for those with confirmed heart failure with deteriorating symptoms requiring clinician input. The pathway was developed in accordance with the 2010 NICE guidelines for Chronic Heart Failure (CG108) and NICE Quality Standards.

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2. Information Resources for Patients and Carers

Useful websites for patients with heart failure:
Pumpingmarvellous.org
Heartfailurematters.org
Bhf.org.uk
Cardiomyopathy.org

Heart failure self-management traffic light tool

The traffic light tool, to help patients with self-management, is available (on next page) to be printed off for patients.

Many of the websites will provide free information booklets for patients on request. The Community Cardiac Service has a number of useful information booklets and would be happy to send these to patients. Please contact them on 0113 8434200 to arrange this.

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3. Development & Updates to this Pathway

This pathway contains information on the Leeds Teaching Hospitals Trust pathway. Other providers may be available through Choose & Book should patients wish to choose an alternative provider following result of BNP test.

The service commenced on the 1st May 2012. Recommendations of the guideline include:

  • Access to a blood test to measure serum natriuretic peptides (NTproBNP)
  • Referral to dedicated specialist cardiology Heart Failure services
  • Discharge to community and primary care for ongoing management
  • Inclusion of palliative care services for patients with Heart Failure at end of life.

The pathway has been reviewed and updated in December 2013 and June 2017

Key Clinicians involved:

  • Dr Klaus Witte, Senior Lecturer & Honorary Consultant Cardiologist
  • Dr Greg Reynolds, Clinical Director, LTHT
  • Professor Mark Kearney, Consultant Cardiologist, LTHT
  • Gillian Whitehead, Cardiac Service Manager, LCH
  • Dr Anne Houghton, Clinical Lead for LTC, NHS Leeds
  • Dr Manjit Purewal, Leeds North CCG
  • Dr Mark Davis, Leeds South and East CCG
  • Dr Mitul Patel, Leeds West CCG

Clinicians involved in June 2017 review:

  • Dr Alex Simms, Consultant Cardiologist, LTHT
  • Dr Kate Gatenby, Locum Consultant Cardiologist, LTHT
  • Sarah Winsor, Heart Failure Nurse Specialist, LTHT
  • Gill Whittle, Cardiac Services Manager, LTHT
  • Caroline Senior, Clinical Lead Cardiac Services, LCH
  • Rani Khatib, Consultant Cardiology Pharmacist, LTHT

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4. Referral Forms

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5. Signs and symptoms Suggestive of Heart Failure

Symptoms & Signs of Heart Failure

  • Breathlessness - the patient has a reduced exercise tolerance, they become breathless on exertion or even at rest
  • Orthopnoea, the patient is unable to lay flat or in the usual sleeping position due to breathlessness, they may require additional pillows to sleep
  • Paroxysmal Nocturnal Dyspnoea - the patient is waking in the night feeling short of breath or has a sensation or difficulty breathing
  • Oedema - the patient has peripheral or abdominal oedema that is not normal for them. This is likely associated with weight gain
  • Fatigue

Other symptoms patient may experience:

  • Chest pain (ischaemia should be ruled out)
  • Palpitations - check for atrial fibrillation (high prevalence in Heart Failure).
  • Nausea or poor appetite
  • Dizziness
  • A persistent cough or wheeze
  • Bloating
  • Confusion
  • Low mood or anxiety
  • Cachexia
  • Sexual dysfunction
  • Reduced urine output

References:

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8. NT-pro-BNP

Quick info:

  • Measuring serum peptide NT-proBNP can help stratify symptomatic (breathless) patients into groups at high, intermediate and low risk of heart failure.
  • Please also check U+Es, FBC, TFTs and perform ECG at this stage to help identify any other causes of dyspnoea.
  • Consider starting low dose diuretics for symptom relief if appropriate while awaiting Cardiology review and test results.

How to take test

  • Take and collect blood sample in tube lithium heparin preferably without gel.
  • Green/ top with black ring
  • Minimum volume - 0.5mL
  • Bloods should be sent to the lab within 24 hours

Click here for the pathology BNP page for guidance

Results

  • Results will be categorised as high, intermediate or low NTproBNP.
  • Results will be available on the results server

High or intermediate NT-proBNP

Refer patient to the Heart Failure Service LTHT - click link

Referrals are now indirectly bookable.

High NTproBNP (>2000ng/L): These patients will be given an urgent (within 2 weeks) outpatient appointment with ECG and Echo performed on the day (one stop)and review by the heart failure multidisciplinary team.

Intermediate NTproBNP (400-2000ng/L): On receipt of the referral, the Heart Failure team at LTHT will initially request and send the patient for echocardiogram. The referral and echo will then be triaged by a Consultant Cardiologist with an interest in heart Failure to either advice and guidance letter with no clinic appointment or clinic appointment within 6 weeks.

An LTHT audit of >4400 patients has shown that very few people with an NT-pro-BNP 400-2000pmol/L have heart failure due to left ventricular systolic dysfunction (LVSD). Hence we have altered this pathway in response to demand: patients with an intermediate BNP and no history of myocardial infarction and symptoms/signs of Heart Failure will undergo an Echocardiogram.

Patient Information Sheet for O/P Echocardiogram - GP can print this off for the patient (TBC)

Low NTproBNP (<400ng/L): A low result carries a small probability of Heart Failure so an alternative diagnosis should be sought for the patient’s symptoms. The patient should not be referred to the Heart Failure Clinic and an Echocardiogram is not advised in this case.

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12. Pre-review Outpatient Echocardiogram

In those patients with symptoms and signs suggestive of heart failure who have an intermediately elevated NTproBNP referred to the Leeds Heart Failure service will be sent for an Echocardiogram prior a decision to review in clinic. There is a < 25% chance of systolic dysfunction with an intermediate BNP result. It is appropriate to consider alternative diagnoses (e.g. COPD, AF, Hypertension).
The LTHT Heart Failure service will review the Echocardiogram result. Either an out-patient appointment will be arranged with the appropriate service or an advice and guidance letter will be sent back to the GP regarding the Echo result and management plan if appropriate.

Patient Information Sheet for O/P Echocardiogram - GP can print this off for the patient (TBC)

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13. Echo shows LVSD

The Echocardiogram will be reviewed by a Heart Failure clinician. If the Echocardiogram finds a new diagnosis of LVSD then an out-patient appointment will usually be arranged in the Heart Failure Clinic. There may exceptions to this e.g. in a case of mild LVSD but significant valve disease it may be more suitable for the patient to be seen in the valve clinic.

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14. No LVSD on Echo - Advice and Guidance Service

The Echocardiogram will be reviewed by a Heart Failure clinician. If there is no evidence of LVSD then an advice and guidance letter will be sent to the GP explaining the results of the Echocardiogram and detailing and management advice if appropriate (Advice and Guidance). If there are other abnormalities on the Echocardiogram then the patient may be redirected to the appropriate service (e.g. Valve Clinic, AF clinic or General Cardiology).

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15. Urgent outpatient appointment

Patients with either a High NTproBNP or history of Myocardial Infarction will be given an appointment at the clinic. The aim of the service is to see the patient within 2 weeks of receiving the referral.
Clinic Information sheet - GP can print this off for the patient (TBC)

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16. LTHT Clinician Led Heart Failure Clinic

Consultants:

  • Dr Alex Simms
  • Professor Mark Kearney
  • Dr Klaus Witte
  • Dr Richard Cubbon
  • Dr Kate Gatenby

The clinic is also supported by Cardiology Registrars and Heart Failure Clinical Nurse Specialists.

What patients should expect

Patients should be informed that the first visit might be the only one they need, but that they may spend several hours in the department being assessed.

Investigations involve an ECG and Echocardiogram with further bloods tests or Chest X-Ray if deemed necessary. The patient will receive a diagnosis regarding their suspected Heart Failure at the clinic.

Patients diagnosed with LVSD will be referred to the Community Cardiac team if felt appropriate.

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20. Management Plan and Medicines optimisation

Patients with diagnosed LVSD will either be discharged back to their GP with a management plan or may require further follow up. The management plan will advise on medicine optimisation in line with NICE 2010 Guidance (CG108) and ESC Clinical Practice Guidelines (2016).

ESC Clinical Practice Guidelines (2016).

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21. Alternative Diagnosis Likely. Continue Primary Care Management

Consider the following conditions associated with shortness of breath:

  • HF with preserved ejection fraction (often multifactorial with hypertension and DM)
  • Respiratory conditions, such as: COPD, asthma, pneumonia, pulmonary embolism, sleep apnoea, cancer
  • Obesity
  • Volume overload from renal failure or nephrotic syndrome
  • Angina
  • Severe anaemia
  • Psychogenic causes, eg anxiety
  • Deconditioned

Consider the following conditions associated with peripheral oedema [1]:

  • Dependent oedema that is not pathological, eg from prolonged inactivity
  • Nephrotic syndrome
  • Medications, e.g. dihydropyridine calcium-channel blockers, non-steroidal anti-inflammatory drugs (NSAIDs)
  • hypoalbuminaemia, e.g. from renal or hepatic disease
  • venous insufficiency

References:

  • National Institute for Health and Clinical Excellence (NICE). Chronic heart failure - management of chronic heart failure in adults in primary and secondary care. Clinical guideline 108. London: NICE; 2010.
  • Map of Medicine (MoM) Clinical Editorial team and Fellows. London: MoM; 2011.

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22. The Leeds Integrated Heart Failure Service

Patients with diagnosed LVSD who are felt to need continued input will be seen by either the LTHT Clinician led HF clinic, the LTHT Heart Failure CNS clinic or the Leeds Community Cardiac Nurses.

Patients under the care of the LTHT HF CNS clinic or the Leeds Community Cardiac Nurses can be referred back to the clinician led HF clinic if required

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23. Optimised Heart Failure

If the patient’s symptoms are stable and medications are optimised, then the ongoing management of their heart failure will be transferred back to the GP.

The patient should be added to the Heart Failure register at the surgery and require a 6-monthly review in practice (e.g. by practice nurse) as per NICE quality standards on CHF. Appropriate monitoring of U+E’s, LFT’s, FBC, TFT’s, BP and Pulse should be carried out.

If the patient’s heart failure symptoms deteriorate then refer to point 28.

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26. Community Heart Failure Service

The Leeds Community Cardiac Service will see all patients with confirmed LVSD on Echo who are still symptomatic or require further medicines optimisation.

The link below provides access to the referral form for the community cardiac team:
Community Cardiac Service Referral Criteria and Form

Further information about the Leeds service and useful leaflets and documents are available from the link below. You may find it helpful to print off a leaflet for your patients if you are referring them to the service:
Leeds Community Cardiac Team Website & Leaflets

Please contact the Community Cardiac team on 0113 8434200 if you have an queries or wish to discuss a patient

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27. Discharged to GP

If the patient’s symptoms are stable and medications are optimised, then the ongoing management of their heart failure will be transferred back to the GP.

The patient should be added to the Heart Failure register at the surgery and require a 6-monthly review in practice (e.g. by practice nurse) as per NICE quality standards on CHF. Appropriate monitoring of U+E’s, LFT’s, FBC, TFT’s, BP and Pulse should be carried out.

If the patient’s heart failure symptoms deteriorate then refer to point 28.

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28. Deteriorating Known Heart Failure Patients

In patients re-presenting with deterioration or decompensation of known heart failure with known LVSD, please check patients are on optimised treatment (NICE and ESC guidelines) and consider referral to the Community HF service in the first instance if this is felt appropriate. The community service is supported by a weekly virtual clinic and monthly MDT with Dr A Simms and Dr K Gatenby.

Patients are encouraged to self-refer, if previously under active review in the HF community service, if they notice deterioration in their condition.

It may also be appropriate to consider referral to Community palliative care services if the patient is end stage HF.

Admission to hospital if acutely unwell.

Key Dates

  • Published: 17-Oct-2014, by Leeds
  • Valid until: 01-Oct-2016
  • Reviewed: June 2017
  • Valid until June 2019 but will be amended according to service changes where applicable.

References

This is a list of all the references that have passed critical appraisal for use in the care map Heart failure

ID Reference

  • National Institute for Health and Clinical Excellence (NICE). Chronic heart failure - National clinical guideline for diagnosis and management in primary and secondary care. Clinical Guideline No 108. London: NICE; 2010. http://www.nice.org.uk/nicemedia/live/13099/50514/50514.pdf
  • Clinical Knowledge Summaries. Heart failure - chronic. Version 1.0. Newcastle upon Tyne: CKS; 2009. http://www.cks.nhs.uk/heart_failure_chronic#375288001
  • Scottish Intercollegiate Guidelines Network (SIGN). Management of chronic heart failure. Publication no 95. Edinburgh: SIGN; 2007. http://www.sign.ac.uk/pdf/sign95.pdf
  • Map of Medicine (MoM) Clinical Editorial team and Fellows. London: MoM; 2011.
  • European Society of Cardiology (ESC). ESC guidelines for the diagnosis and treatment of acute and
  • chronic heart failure 2008. Eur Heart J 2008; 29: 2388-2442. http://eurheartj.oxfordjournals.org/content/29/19/2388.full.pdf+html
  • Driver and Vehicle Licensing Agency (DVLA). At a glance guide to the current medical standards of fitness to drive. Swansea: DVLA; 2010. http://www.dft.gov.uk/dvla/~/media/pdf/medical/at_a_glance.ashx
  • National Institute for Health and Clinical Excellence (NICE). Cardiac resynchronisation therapy for the treatment of heart failure. Technology appraisal 120. London: NICE; 2011. http://www.nice.org.uk/nicemedia/pdf/TA120Guidance.pdf
  • National Institute for Health and Clinical Excellence (NICE). Implantable cardioverter defibrillators (ICDs) for the treatment of arrhythmias (review of TA11). Technology appraisal 95. London: NICE; 2006. http://www.nice.org.uk/nicemedia/live/11566/33167/33167.pdf
  • National Institute for Health and Clinical Excellence (NICE). Short-term circulatory support with left ventricular assist devices as a bridge to cardiac transplantation or recovery. Interventional procedure
  • guidance 177. London: NICE; 2006. http://guidance.nice.org.uk/nicemedia/live/11049/30742/30742.pdf
  • National Institute for Health and Clinical Excellence (NICE). Venous thromboembolism: reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in patients admitted to hospital. Clinical guideline 92. London: NICE; 2010. http://www.nice.org.uk/nicemedia/live/12695/47195/47195.pdf
  • The task force on myocardial revascularization of the European Society of Cardiology (ESC) and the European Association for Cario-Thoracic Surgery (EACTS). Guidelines on myocardial revascularization. Eur Heart J 2010; 31: 2501-2555. http://www.escardio.org/guidelines-surveys/esc-guidelines/GuidelinesDocuments/guidelines-revasc-FT.pdf
  • McKelvie RS. Heart Failure. London: Clin Evid; 2011. ttp://www.ncbi.nlm.nih.gov/pubmed/21878135
  • van der Meer S, Zwerink M, van Brussel M et al. Effect of outpatient exercise training programmes in patients with chronic heart failure: a systematic review. Eur J Cardiovasc Prev Rehabil 2011; [Epub ahead of print]: http://www.marcovanbrussel.com/publicaties/48.pdf
  • Kuenzli A, Bucher HC, Anand I et al. Meta-analysis of combined therapy with angiotensin receptor
  • antagonists versus ACE inhibitors alone in patients with heart failure. PLoS One 2010; 5: e9946. http://www.ncbi.nlm.nih.gov/pubmed/20376345
  • Adabag S, Roukoz H, Anand IS et al. Cardiac resynchronization therapy in patients with minimal heart failure: a systematic review and meta-analysis. J Am Coll Cardiol 2011; 58: 935-41. http://www.ncbi.nlm.nih.gov/pubmed/21851882
  • Swedberg K, Komajda M, Bohm M et al. Ivabradine and outcomes in chronic heart failure (SHIFT): a randomised placebo-controlled study. Lancet 2010; 376: 875-85. http://www.ncbi.nlm.nih.gov/pubmed/20801500
  • Lambrinou E, Kalogirou F, Lamnisos D et al. Effectiveness of heart failure management programmes with nurse-led discharge planning in reducing re-admissions: A systematic review and meta-analysis. Int J Nurs Stud 2011; 49: 610-24. http://www.ncbi.nlm.nih.gov/pubmed?term=22277180%20
  • Lowery J, Hopp F, Subramanian U et al. Evaluation of a nurse practitioner disease management model for chronic heart failure: a multi-site implementation study. Congest Heart Fail 2012; 18: 64-71. http://www.ncbi.nlm.nih.gov/pubmed?term=22277180%20
  • Bleeker GB, Holman ER, Steendijk P et al. Cardiac resynchronization therapy in patients with a narrow QRS complex. J Am Coll Cardiol 2006; 48: 2243-50. http://www.ncbi.nlm.nih.gov/pubmed/17161254
  • Van Bommel RJ, Gorcsan J III, Chung ES et al. Effects of cardiac resynchronisation therapy in patients with heart failure having a narrow QRS Complex enrolled in PROSPECT. Heart 2010; 96: 1107-13. http://www.ncbi.nlm.nih.gov/pubmed/20610457
  • 21 Foley PW, Patel K, Irwin N et al. Cardiac resynchronisation therapy in patients with heart failure and a normal QRS duration: the RESPOND study. Heart 2011; 97: 1041-7. http://www.ncbi.nlm.nih.gov/pubmed/21339317
  • Contributors representing the Royal College of Physicians;. London: 2012.
  • Higgins J, Lamarche Y, Kaan A et al. Microaxial devices for ventricular failure: a multi-centre, population based experience. Can J Cardiol 2011; 27: 725-30. http://www.ncbi.nlm.nih.gov/pubmed/21983112