Heart Failure

 

Heart failure is a complex clinical syndrome of symptoms and signs that suggest the efficiency of the heart as a pump is impaired.  It is caused by structural or functional abnormalities of the heart

Left-sided heart failure

Some patients have heart failure due to left ventricular systolic dysfunction (LVSD) which is associated with a reduced left ventricular ejection fraction.  Others have heart failure with a preserved ejection fraction (HFPEF).  Most of the evidence on treatment is for heart failure due to LVSD.  The most common cause of heart failure in the UK is coronary artery disease, and many patients have had a myocardial infarction in the past

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Right-sided heart failure

Other patients will have right-sided heart failure.  Right-sided or right ventricular (RV) heart failure usually occurs as a result of left-sided failure.  When the left ventricle fails, increased fluid pressure is, in effect, transferred back through the lungs, ultimately damaging the heart's right side. When the right side loses pumping power, blood backs up in the body's veins.  This usually causes swelling or congestion in the legs, ankles and swelling within the abdomen such as the GI tract and liver (causing ascites).  Patients will often present with swelling in the legs and / or abdomen

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Referral form

Please find below the Heart Failure MDM referral form.  This is a referral for an advisory discussion regarding your patient at the East Kent Heart Failure MDM and is not a referral letter for the patient to be seen in a clinic.  The GP will receive a report following the outcome of the MDM

Heart Failure MDM Referral Form

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Diagnosis

  1. Refer patients with suspected heart failure and previous myocardial infarction (MI) urgently, to have transthoracic Doppler 2D echocardiography and specialist assessment within 2 weeks
  2. Measure serum natriuretic peptides (B-type natriuretic peptide [BNP] or N-terminal pro-Btype natriuretic peptide [NTproBNP]) in patients with suspected heart failure without previous MI
  3. Because very high levels of serum natriuretic peptides carry a poor prognosis, refer patients with suspected heart failure and a BNP level above 400 pg/ml (116 pmol/litre) or an NTproBNP level above 2000 pg/ml (236 pmol/litre) urgently, to have transthoracic Doppler 2D echocardiography and specialist assessment within 2 weeks

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Treatment

  1. Offer both ACE inhibitors and beta-blockers licensed for heart failure to all patients with heart failure due to left ventricular systolic dysfunction.  Use clinical judgement when deciding which drug to start first
  2. Offer beta-blockers licensed for heart failure to all patients with heart failure due to left ventricular systolic dysfunction, including:
    1. older adults and
    2. patients with:
      1. peripheral vascular disease
      2. erectile dysfunction
      3. diabetes mellitus
      4. interstitial pulmonary disease and
      5. chronic obstructive pulmonary disease (COPD) without reversibility
  3. Seek specialist advice and consider adding one of the following if a patient remains symptomatic despite optimal therapy with an ACE inhibitor and a beta-blocker:
    1. an aldosterone antagonist licensed for heart failure (especially if the patient has moderate to severe heart failure) [NYHA class III-IV] or has an MI within the past month) or
    2. an angiotensin II receptor antagonist (ARB) licensed for heart failure (especially if the patient has mild to moderate heart failure [NYHA class II-III]) or
    3. hydralazine in combination with nitrate (especially if the patient is of African or Caribbean origin and has moderate to severe heart failure [NYHA class III-IV])

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Rehabilitation

Offer a supervised group exercise-based rehabilitation programme designed for patients with heart failure

  • Ensure the patient is stable and does not have a condition or device that would preclude an exercise-based rehabilitation programme
  • Include a psychological and educational component in the programme
  • The programme may be incorporated within an existing cardiac rehabilitation programme

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Monitoring

All patients with chronic heart failure require monitoring. This monitoring should include:

  • a clinical assessment of functional capacity, fluid status, cardiac rhythm (minimum of examining the pulse), cognitive status and nutritional status
  • a review of medication, including need for changes and possible side effects
  • serum urea, electrolytes, creatinine and eGFR

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When a patient is admitted to hospital because of heart failure, seek advice on their management plan from a specialist in heart failure

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Electrocardiogram

An electrocardiogram (ECG) can usually be undertaken in primary care.  If your practice does not offer ECGs, please request an ECG from East Kent Hospitals

Blood tests / Phlebotomy

If your practice does not have a practice nurse who is trained to take bloods, you can refer a patient to the Pathology Department at East Kent Hospitals for a blood test (find details here)

Alternatively, Buckland Hospital (Dover) and the Royal Victoria Hospital (Folkestone) both operate a walk-in service where no appointment is necessary, except for if the patient requires a Glucose Tolerance Test (GTT).  In the event that a GTT is required, please call 01304 222552 (for Buckland) and 01303 854484 (for Royal Victoria) to arrange a suitable appointment

Please ensure that the patient remembers to take with them their blood test form to the walk-in centres

Advice and Guidance is being made available for all specialties, and is being provided by consultant specialists at East Kent Hospitals.  To make a request or to check to if a query has been answered, you will need to log in via the electronic Referral System (eRS)

Click here for the "how to access" e-Referral Advice and Guidance Manual for instructions on how to make a request and check responses

Have a question or query?

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