Heart Failure Diagnostic Pathway Pardeep S Jhund Mark C Petrie - PowerPoint PPT Presentation

Heart Failure Diagnostic Pathway Pardeep S Jhund Mark C Petrie Alan Foster Yvonne McBride Jackie Taylor Iain Findlay Caroline Morrison David Murdoch

New Diagnostic Pathway for Heart Failure • Why do we need a new diagnostic pathway for HF? • What are the benefits of the pathway? • What is the new diagnostic pathway? • How did it perform? • How was the service designed and the costs met?

New Diagnostic Pathway for Heart Failure • Why do we need a new diagnostic pathway for HF? • What are the benefits of the pathway? • What is the new diagnostic pathway? • How did it perform? • How was the service designed and the costs met?

Why do we need a new diagnostic pathway for HF? • HF can be difficult to diagnose – Relies on identification of signs and symptoms – Echocardiography is the cornerstone of diagnosis – New blood tests are helping to refine the diagnosis • BNP and NT-proBNP • HF costs the NHS a lot of money – 2% of annual expenditure • Effective therapies are available – Medication (ACE inhibitors, beta blockers) through to cardiac resynchronisation and transplantation

Benefits to the patient • Find the cause of HF – valve disease, HOCM, and many others • Access to life saving therapy – ACE inhibitors, beta-blockers, mineralocorticoid receptor blockers, cardiac resynchronisation therapy • Contact with services – HF specialists, HF Nurse Liaison Service, Transplant services, Palliative care

The Old Model Direct/ Open access echo Suspected heart failure in primary care Direct access echocardiography No LVSD Result to GP LVSD ACE inhibitor No ACE inhibitor

The Old Model Direct/ Open access echo Suspected heart failure in primary care NO HF SPECIALIST DIRECTLY INVOLVED Direct access echocardiography No LVSD Result to GP LVSD No diagnosis, limited therapy ACE inhibitor No ACE inhibitor

Benefits for primary care Pros • Allows those without HF to have HF excluded without waiIng to see cardiologist • Allows those with symptoms and evidence of cardiac disease to see cardiologist for diagnosis and management plan (including treatment) Cons ? • Only valuable if applied to the correct paIents

Benefits for secondary care Pros • Allows those without HF to have HF excluded without waiIng to see cardiologist • Allows those with symptoms and evidence of cardiac disease to see cardiologist for diagnosis and management plan (including treatment) • Frees up resources for other paIents and services Cons ? • Only valuable if applied to the correct paIents

New Diagnostic Pathway for Heart Failure • Why do we need a new diagnostic pathway for HF? • What are the benefits of the pathway? • What is the new diagnostic pathway? • How did it perform? • How was the service designed and the costs met?

How should heart failure be investigated? Suspected HF in primary care Refer to HF diagnosIc service Recommended by ECG / BNP SIGN/ ESC If normal HF unlikely Return to GP If abnormal, echo and cardiology without cardiological review (aeIology, invesIgaIon review and management plan)

What is BNP? • PepIde produced in LV wall • Plasma levels high in HF • Very high negaIve predicIve value • CauIon – raised in renal dysfuncIon, pulmonary embolism, acute ischaemia, hypertension/ LVH – plasma levels can be normal if treated HF • recommended by SIGN

O=GP or cardiac physiologist O=cardiologist *=standard letter **=info from referral form Appendix 1: West of Scotland Suspected NEW Heart Failure Patient Diagnostic Pathway Patient has reasonable clinical suspicion of heart failure + one of No ECG abnormalities the following at time of Pre-referral Perform BNP or other indications for referral History including (B-Type echo (see below) • New onset previous cardiac Natriuretic breathlessness history and Peptide) test Relevant signs • Ankle oedema examination to ECG and/or ECG shows BBB, Q wave, • Dyspnoea on exertion/ exclude red flag signs symptoms LVH, AF rest and symptoms. OR male+ankle oedema ** • Orthopnoea Tests required: OR previous MI ** • Fatigue/tiredness Full blood count (for No relevant (with 1 of the above) anaemia), Check symptoms/ symptoms Abnormal BNP TFTs signs or signs Normal F (no ankle oedema ** ) >110pg/ NB symptoms may not be U&Es (for creatinine) on referral form ** BNP ml present at diagnostic CXR F (+ankle oedema ** ) >55pg/ml appointment if on trial of Return to M (no ankle oedema ** ) >70pg/ diuretic. ml GP for RED FLAG review of CHF RETURN to GP SYMPTOMS : issues * Confirm heart failure diagnostic If none of these Obtain • Paroxysmal extremely unlikely – other service but clinical echocardiogram cause of symptoms should nocturnal dyspnoea suspicion of heart be sought* • Lung crepitations failure, please Cardiologist to identify refer to cardiology If HF still considered likely underlying cause and any clinic try response to appropriate intervention furosemide. Symptoms severe If improvement refer to enough for admission cardiology clinic Confirmed left ventricular systolic dysfunction (LVSD) If no improvement, HF very unlikely. YES NO GP for management as per Personalised No LVSD local guidelines * management plan Consider hospital admission Personalised management plan

Primary care pre- referral Pre-referral Patient has reasonable History including clinical suspicion of previous cardiac heart failure + one of history and the following at time examination to of referral exclude red flag • New onset symptoms/signs. breathlessness Tests required: • Ankle oedema Full blood count (for • Dyspnoea on exertion/ anaemia), rest TFTs • Orthopnoea U&Es (for creatinine) • Fatigue/tiredness CXR (with 1 of the above) RED FLAG NB symptoms may not SYMPTOMS/SIGNs : be present at diagnostic • Paroxysmal appointment if on trial of nocturnal dyspnoea diuretic. • Lung crepitations Symptoms severe CHF diagnostic enough for admission service Admit NO YES

Normal ECG No ECG Check symptoms/ Perform BNP abnormalities or signs (B-Type ECG other indications for on referral form ** Natriuretic echo (see below) Peptide) test Normal BNP RETURN to GP Confirm heart failure extremely unlikely – other cause of symptoms should be sought* If HF still considered likely try response to furosemide. If improvement refer to cardiology clinic

Abnormal ECG Check symptoms/ signs ECG on referral form ** ECG shows BBB, Q wave, LVH, AF OR male+ankle oedema ** OR previous MI ** Obtain echocardiogram GP for Confirmed left Cardiologist to identify No Personalised management ventricular underlying cause and any management plan LVSD as per local systolic appropriate intervention guidelines * dysfunction (LVSD) GP for ongoing management

Normal ECG, Raised BNP Check symptoms/ No ECG Perform BNP signs abnormalities or ECG (B-Type on referral form ** other indications for Natriuretic echo (see below) Peptide) test ECG shows BBB, Q Abnormal BNP wave, LVH, AF F (no ankle oedema ** ) OR male+ankle >110pg/ml oedema ** F (+ankle oedema ** ) >55pg/ OR previous MI ** ml M (no ankle oedema ** ) >70pg/ml Obtain echocardiogram Confirmed left GP for ventricular management Cardiologist to identify No systolic Personalised as per local underlying cause and any dysfunction LVSD management guidelines * appropriate intervention (LVSD) plan GP for ongoing management

New Diagnostic Pathway for Heart Failure • Why do we need a new diagnostic pathway for HF? • What are the benefits of the pathway? • What is the new diagnostic pathway? • How did it perform? • How was the service designed and the costs met?

Results • Western Infirmary, Victoria Infirmary, Glasgow Royal Infirmary, Southern General Hospital, Stobhill Hospital, Royal Alexandria Hospital • April 2011 to March 2012 (Victoria April 2010 to March 2012) • 848 referrals • 53 “Did not attend” • 1 admitted to hospital before entering the pathway

Abnormal ECG • 323 ECG and Echo • 49 Confirmed LVSD, – 3 Echo review and management plan, – 35 echo review and cardiology appointment, – 11 referred back to GP, – 13 referred to HFNLS

Normal ECG, Normal BNP • 278 normal ECG and BNP • 8 cardiology appointment • 270 referred back to GP

Normal ECG, Abnormal BNP • 197 ECG normal, abnormal BNP and Echo performed • 16 confirmed LVSD • 1 admitted to hospital • 3 echo reviewed and management plan made • 11 echo reviewed and cardiology appointment made • 2 referred back To GP • 1 referred to HFNLS

“Savings” • 794 potential echocardiograms • 794 cardiology appoitments? • 520 performed • “saving” of 274 echocardiograms

Pick up rate • 794 attenders • 65 had LVSD • 8% of attenders

Is it safe? • During a median follow up of 286 days there were no re-attendances at outpatients or admissions for HF in those identified as not having LVSD by the pathway during the pilot