Care for the individual patient

Br J Cardiol 2012;19:16 Leave a comment
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The 14th British Society for Heart Failure (BSH) annual meeting, entitled ‘Care for the individual patient’, was held in late November at the Queen Elizabeth Conference Centre in London. Attracting 400 delegates with its multidisciplinary programme, Dr Dominic Kelly reports on the highlights.

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Bureaucracy

The mortality rate for heart failure remains unchanged with 11.6% of heart failure (HF) admissions dying as inpatients, and 33% mortality at around one year, according to the most recent data from the National Heart Failure Audit.  This was presented to the meeting by Professor Theresa McDonagh (King’s College Hospital, London). Data collection continues to improve with 85% of NHS trusts submitting data over the preceding 12 month period, she said.  Access to cardiology services was associated with improved outcomes and a higher usage of evidence-based therapy and subsequent access to outpatient HF services.

The likely challenges for HF commissioning following the development of clinical commissioning groups, were discussed by Dr Nigel Rowell (Endeavour Practice, Middlesbrough), who was optimistic that this would be a good opportunity to improve services across the UK.  Annie MacCallum and Jim Moore (Gloucestershire PCT/Stoke Road Surgery, Bishops Cleeve, Cheltenham) were more circumspect, emphasising the need to ensure the expertise of specialist nurses was maintained and supported, and to ensure these and other opportunities to optimise HF care were maintained.

Commissioners should demand higher standards of the acute trusts, and improving inpatient HF care, including drug up-titration, results in fewer readmissions and a reduction in both inpatient and 12 month mortality, Dr Suzanna Hardman (Whittington Hospital, London) argued. This was supported by trial data and local data from the National HF Audit, which resonated with the messages of Professor McDonagh’s earlier presentation.

Individual problems

Comorbidities which complicate the management of patients with HF, including lung disease, renal impairment, diabetes and the complexities of elderly patients, were the focus of this session. Although the data for use of beta blockers in patients with chronic obstructive pulmonary disease (COPD) is limited, for the majority of patients the mortality and morbidity benefit of these agents far outweighs any minor observed reductions in FEV1, said Dr Nat Hawkins (Institute of Cardiovascular Medicine and Science, Liverpool Heart and Chest Hospital). Data extrapolated from other studies suggest that the concomitant use of beta agonists may worsen prognosis and alternative bronchodilators such as tiotropium may be more beneficial.

Dr Paul Kalra (Queen Alexandra Hospital, Portsmouth) highlighted the high prevalence of chronic kidney disease in HF patients and the association with adverse outcome. Dr John Baxter (Sunderland Royal Hospital) gave an incisive and entertaining presentation on HF in elderly patients, emphasising the need for a genuine focus on the individual patient. This should include a formal assessment involving the entire multi-disciplinary team and to include screening for cognitive impairment, as recently advocated by the National Institute for Health and Clinical Excellence (NICE).

An increasing number of HF patients are likely to seek advice about the safety of air travel, due to increasing ease of access, according to Dr William Toff (Glenfield Hospital, Leicester).  It is likely that the majority of patients in New York Heart Association (NYHA) stage I/II would be safe to fly, he said. For patients in stage III, airport assistance and in-flight oxygen should be considered and for those patients in NYHA IV, the decision should be individualised to the patient.

Professor Andrew Clark (Castle Hill Hospital, Kingston upon Hull) followed with a background of the historical data surrounding exercise in HF patients. He highlighted the emerging evidence that there is little relationship between LV ejection fraction and exercise tolerance, with exercise capacity in HF being largely related to skeletal muscle.  He presented evidence to support the use of exercise training in HF, which showed improvements in surrogate markers of LV function as well as improvements in morbidity and quality of life, with no adverse effect on mortality.

The close relationship between HF and erectile dysfunction (ED) was described by Professor Michael Kirby (University of Hertfordshire, Faculty of Health and Human Sciences, Hatfield). The two conditions have several similar risk factors and therefore it is not surprising that ED is common in the HF patient with a prevalence of 60–90%.  The presentation also emphasised the benefits of maintaining sexual activity and that sexual relationships within stable normal partnerships should not be discouraged, whereas some risk was associated with illicit relationships.

Dr Lorna Swan (Royal Brompton Hospital, London) described the physiological changes occurring in pregnancy and their risks to both mother and foetus in sufferers of HF, and illustrated her talk with some informative case presentations. The need for pre-conception counselling was stressed for any female HF patients of childbearing age.

Genetics

The first day ended with Dr Edward Blair’s (Churchill Hospital, Oxford) description of the genetic background for several HF aetiologies including hypertrophic, dilated and arrhythmogenic right (and left) ventricular cardiomyopathies. The presentation also described the complexities of the relationship between genotype and clinical phenotype in many inherited cardiomyopathies due to effects of penetrance, expression and multiple gene involvements.

The genetic basis for cardiac failure is being increasingly recognised, he said, with molecular genetics improving diagnosis and ultimately allowing the development of new therapies. Case histories were used by Dr Gerry Carr-White (St Thomas Hospital, London) to demonstrate how to identify and investigate patients with suspected inherited cardiomyopathies.

The highlight of the first day and indeed the whole conference was the Philip Poole-Wilson lecture given by Professor Sir John Burn (Newcastle University), entitled ‘10 things Mendel missed’. Sir John gave an intriguing synopsis of the developments in genetic biology since the original discoveries of Gregor Mendel. Included in the discoveries were disorders linked to sex chromosomes and the effects of anticipation, penetrance and polygenic models on clinical phenotypes in several disease states. The day ended with the presentation of a medal to Sir John in honour of the late Professor Philip Poole-Wilson, a doyen of heart failure.

Professor Sir John Burn receives the Philip Poole-Wilson Medal from Mrs Mary Poole-Wilson (photo courtesy of Rob Masters)

Case histories

The second day focussed on the individual patient, the first session chaired by Professor Martin Cowie (Royal Brompton Hospital, London) and Dr Jim Moore (GPwSI, Gloucestershire) examining four very individual and well-received case presentations of HF. Cases included the use of ultrafiltration in decompensated HF, left ventricular assist devices (LVADs) in giant cell myocarditis and elsewhere, and end of life care.

The individual experience

The individual experience session was enlightening with presentations from two patients with HF, who gave distinct and articulate descriptions of their personal experiences of developing HF and learning to live with it. They described the physical, psychological and social impact of the diagnosis, including the difficulties in accepting and living with the condition. Both stressed the importance of HF services and the multi-disciplinary team in their ongoing wellbeing, but had more diverse views on other areas.

Advanced therapy

Professor Henry Dargie (University of Glasgow) set the scene by defining advanced HF, describing its prevalence and what interventions are available. He described the falling rate of heart transplantation in the UK with a comparison with other European countries.

Discussing the updated UK guidelines for referral and assessment of adults for heart transplantation, Dr Simon Williams (Wythenshawe Hospital, Manchester) described how patients with advanced HF have a dismal prognosis. Heart transplantation may provide effective treatment in a subset of patients, he said. He stressed the importance of timing of referrals, and stated that the majority of patients referred for transplantation consideration were beyond the stage at which this could be considered due to the development of comorbidities, such as renal impairment or pulmonary hypertension.

The conventional criteria for heart transplantation and indication for urgent inpatient referral such as the requirement for continuous inotropic support were presented, alongside some uncommon indications for transplantation. Dr Nick Banner (Royal Brompton & Harefield Hospital NHS Trust, London) described the developments in left ventricular assist devices (LVADs) over the last decade, highlighting problems experienced and the refinements made to address these issues. He emphasised the role of the right ventricle (RV) and RV failure in patients with LVAD therapy, and then summarised future challenges and potential innovations for LVAD therapy.

Success and the future

Professor John Cleland (University of Hull) gave a summary of recent clinical trials including STITCH (Surgical Treatment for Ischemic Heart Failure Trial), SHIFT (Systolic Heart failure treatment with the If inhibitor ivabradine Trial) and TARGET (Targeted Left Ventricular Lead Placement to Guide Cardiac Resynchronisation Therapy). He also encouraged the involvement of UK physicians and other members of the multi-disciplinary team in active research projects.

Dr Guy MacGowan (Freeman Hospital, Newcastle upon Tyne) discussed the future of heart transplantation in the UK, arguing for long-term ventricular devices as destination therapy rather than as a bridge to transplant, whilst recognising the need for further research in the area. Professor Tom Treasure (University College London) then provided a stimulating and provocative commentary on the role of transplantation and all that had gone before, emphasising the tensions between care for all and the high expenditure received by a few.

Conclusions

The meeting was of very high quality with experienced speakers and delegates from a broad mix of specialty areas and backgrounds. There was an energy and enthusiasm throughout the meeting, and lively but always good-humoured discussions with the audience, relevant to all those involved in the care of HF patients. The meeting was supported through the friends of the BSH (see www.bsh.org.uk).

Diary date

Next year the 15th Annual Autumn meeting will be held on November 29th–30th 2012 at the Queen Elizabeth Conference Centre, London. The BSH will also hold its Medical Training meeting on February 9th and Heart Failure Nurse Study day on February 10th 2012 at the Wellcome Collection Conference Centre, London. Information available at www.bsh.org.uk.

Dominic Kelly
SpR Cardiology/Fellow in Cardiac Rhythm Management
On behalf of the BHF

University Hospital Southampton, Tremona Road, Southampton, SO16 6YD
(kelly.dominic@talk21.com)

 

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