Heart Failure Simon Woldman

Speaker key

IVInterviewer

SWSimon Woldman

SWMy name is Simon Woldman. I'm the Clinical Lead for Heart Failure for University College Hospital. My talk today was about the organisation Heart Failure Services in Camden, and about how to diagnose heart failure.

IVHow are the Heart Failure Services in Camden organised, and are there any changes?

SWHeart Failure Services in Camden, historically, have been very good, but multiple different agencies were feeding into the heart failure patient, but without any coordination. Now we have taken several steps to improve that by using technical solutions like EMIS Web, which is a GP notes system, which secondary care doctors can use, by putting in resources into the community nurses, where they now have clinical leadership from secondary care, and by setting up a heart failure steering group consisting of two GPs and two consultant cardiologists, who will look a the management of heart failure in Camden in totality.

IVWhat is the aim of the service?

SWThe aim of the service is to try to treat as many patients with heart failure as well as we possibly can. We have a problem in Camden that only 0.6% of the population are diagnosed as having heart failure, but the expected prevalence is probably closer to 1.2%. In order to deal with our problem of high admission and readmission rates we need to make sure that we identify many more patients before they come to hospital with heart failure, and that involves early diagnosis and accurate diagnosis, and then appropriate treatment, which has been difficult for us to achieve in the past.

IVHow do GPs diagnose heart failure?

SWIf heart failure diagnosis is considered then, if the patient has had a previous myocardial infarction, they should be sent direct to secondary care for a diagnosis to be confirmed. If a patient has not had a previous myocardial infarction then a BNP measurement should be made. If the level is very high, above 235 picomoles per litre, then the patient should be again referred for assessment within two weeks to secondary care. If the BNP is moderate, between 47 and 235 picomoles per litre then the patient should be sent routinely, within six weeks, to be seen by secondary care, for confirmation of the diagnosis.

IVHow does it usually present?

SWHeart failure usually presents with breathlessness and ankle swelling, as we were all taught in university, but it can present as malaise, tiredness, weakness, nausea, even, in some patients. It's particularly important to think of these symptoms as being heart failure if the patient is known to have left ventricular systolic dysfunction, for example, if they’ve had a previous heart attack.

IVHow can GPs improve the diagnosis rate?

SWWe have a lot of work to do to improve the diagnosis rate. It's important to consider other symptoms as potential causes of heart failure, to look back at some GP records, to see if patients are getting drugs that might be used to treat the symptoms of heart failure, for example, diuretics, but yet have not got a formal diagnosis of heart failure, and indeed, in some of the screening programme we have discovered patients that have been taking medication for a very long time, but actually don’t have a formal diagnosis of heart failure, nor are properly treated for it.

IVWhat tests are there in primary care to enable diagnosis?

SWThe principle test that's available in primary care is measurement of the BNP. BNP is a very sensitive marker of left ventricular systolic dysfunction. As the left ventricle expands BNP is increasingly released. It's sometimes falsely low in patients on ACE inhibitors, and one has to be aware of that, but other than that a negative BNP almost excludes the diagnosis of heart failure.

BNP though, should not be measured in patients with a previous myocardial infarction because the diagnosis of heart failure is so likely, and also because the diagnosis of heart failure is so significant in these patients that they should be referred rapidly to secondary care for assessment and diagnosis, so that treatment can be initiated before the patient either dies or gets admitted to hospital.

IVAre there any important differential diagnoses?

SWYes, there are a lot of very important differential diagnoses for patients who present with breathlessness. Principal amongst them is COPD, butone of the commonest causes that I see of breathlessness in my clinic is either anaemia or obesity, so many other conditions need to be considered when a patient presents with breathlessness, not just heart failure.

IVAre there any common pitfalls in diagnosis to try to avoid.

SWYes, there are important pitfalls. The most common of these are anaemia, so a misdiagnosis of anaemia, which can mimic heart failure, a misdiagnosis of valvular heart disease, which of course mimics heart failure, and other things like obesity and chronic obstructive pulmonary disease that also need to be thought about.

IVOnce diagnosed what should a GP do next?

SWIf the GP suspects heart failure they should refer the patient to secondary care, but the urgency will be dictated by the clinical circumstances. Patients who have had a previous myocardial infarction, or who have a very high NT-proBNP should be referred urgently to be seen within two weeks. Patients who have a lowish NT-proBNP but above the threshold of 47 picomoles per litre should be referred routinely, and will be seen within six weeks.

IVWhat advances to improve diagnosis will there be in the next five years?

SWOver the next few years we're going to see a change in the emphasis of heart failure diagnosis, I'm certain. Previously we have not worried too much about what the cause of the heart failure was, but treated them all equivalently. That's going to change. Patients with dilated cardiomyopathy often have a first degree relative with heart failure, and they need to be screened. Patients who have ischaemic cardiomyopathy may well get revascularisation. Patients who have myocarditis may be suitable for biopsy and identification of the virus causing it, and so on and so forth.

It will be about the diagnosis of the cause of the heart failure, and the treatment of the specific cause, in addition to the treatment of the heart failure.

IVWhere can GPs find out more?

SWGPs can find out more from the NICE guidance, and also from the Camden website, which has full details of the new heart failure pathway for Camden

SWI can be contacted at UCLH. We have a new email address. Our email address is .