‘Pathways of care’ was the theme for the 18th British Society for Heart Failure (BSH) Annual Autumn Meeting, held in London from 26–27th November 2015. In recognition of a lifetime of landmark heart failure studies, Professor Marc Pfeffer (Boston, USA) was the deserved recipient of the Philip Poole-Wilson Memorial award presented during the meeting. Drs Parminder Chaggar and Matthew Kahn report some of the highlights from the comprehensive programme.
Bridging the gap: from trials to inner cities
Within the field of heart failure, there is a breadth of prognostic therapies derived from large, randomised controlled trials. Professor Iain Squire (Glenfield Hospital, Leicester) described how new treatments require approval in the European Union before they can be implemented into clinical practice within the member states. The European Medicines Agency (EMA) ensures the best use of scientific resources across Europe. While certain classes of technologies must undergo licencing via a centralised procedure, most therapies will be eligible for licensing by one member state on behalf of other nations. In the UK, the National Institute for Health and Care Excellence (NICE) provides clinical guidelines and technology appraisals. Although adherence to NICE guidelines is not mandatory, the technology appraisal outcomes are enforced in the UK since these are based on cost effective analyses. Assessment of cost effectiveness is governed by the cost per quality adjusted life year (QALY), with an acceptable cost being defined as less than £30,000 per QALY.
New therapies are referred for NICE technology appraisal by the Department of Health; NICE can only consider the novel treatment under its marketing licence indication. Any appraisal follows a standardised pathway beginning with the company submission and critique of the evidence. The first appraisal meeting is attended by clinical experts, lay people, NICE and the company, with members of the public allowed to observe. The first meeting generates an appraisal document containing a recommendation, which is open for comments by stakeholders, including the company and national societies, prior to a final recommendation. The process of approval can be time consuming. As an example, Professor Squire illustrated that despite publication of the landmark PARADIGM-HF trial in August 2014,1 sacubitril/valsartan was only granted EMA authorisation in September 2015 and the NICE technology appraisal recommendation is still awaited.
Getting new treatments to the right patient
Significant challenges remain in ensuring healthcare systems are able to direct prognostic therapies to the target patients when new treatments become available. Dr Suzanna Hardman (Whittington Hospital, London) discussed the development over many years of integrated heart failure services across Islington, including community and acute care. Cardiovascular mortality in Islington was amongst the highest in the UK with heart failure contributing substantially to these outcomes. Islington contains high levels of social deprivation, unemployment, alcohol and smoking use, language diversity and transient populations.
Tackling the high heart failure mortality required concerted engagement with both primary care and public health to provide rapid access to heart failure care pathways, including B-type natriuretic peptide (BNP)2 and hospital-based diagnostic clinics, alongside the development of responsive community specialist heart failure nursing services. In addition, a consultant-led inpatient heart failure programme was instituted including active identification and investigation of patients with suspected heart failure. This included echocardiograms within 48 hours, outreach consultations to non-cardiology wards, hospital-wide protocols for drug titration, ensuring 48-hours stability prior to discharge with personalised care plans and early outpatient follow-up. This progressive and pioneering approach pre-dates by over a decade the very similar current NICE heart failure guidance.3 Its impact is evident in the current mortality statistics. Cardiovascular mortality has steadily fallen in Islington over the past 15 years whilst inpatient mortality for those admitted with heart failure is now only 2.6% (National Heart Failure Audit data) compared to the reported national average of 9.4%.4
Meanwhile, Dr Simon Woldman (University College Hospital, London) described the challenges in utilising national data to improve local standards. National data are often subject to a lag of several months and thus University College Hospital has adopted data points from the National Heart Failure Audit into a monthly internal monitoring scheme. As a result, local hospitals are able to evaluate their ‘real-time’ performance including accessibility to investigations, drug prescription rates and outcomes. Audit-driven service changes have been associated with improvements on subsequent audits.
Dr Woldman has also evaluated heart failure prevalence rates in his local GP practices and noticed an inverse relationship with heart failure admission rates from each practice. This suggests that missed heart failure diagnoses may not be receiving appropriate management and are at higher risk of hospitalisation. Active identification and management of 300 patients with previously undiagnosed heart failure has been associated with a reduction in heart failure admissions (unpublished data). In summary, Dr Woldman highlights there is a wealth of data available to drive service improvement, which can be utilised with minimum resources but result in significant outcome benefits and cost savings.
A local audit of heart failure admissions in South London by Dr Lisa Anderson (St George’s University Hospitals NHS Foundation Trust, London) demonstrated worrying statistics; a 60% increase in heart failure admissions over a five-year period with a significant number of patients having a length of stay of one day or less. Further analysis of these short admissions revealed over half had pulmonary oedema and very high BNP but with very little inpatient heart failure specialist input. Only 8% received an echocardiogram and only 42% were referred to the heart failure clinic. Presentation of the data at the local Care Quality Review meeting provided support for £1.2 million investment into a dedicated inpatient heart failure unit. Although delayed by recent global financial pressures, the 15-bed unit comprising dedicated nurses, fellows, technicians, pharmacists and administrative staff is due to open imminently. Its effectiveness will be subject to external assessment.
These success stories in heart failure management demonstrate how the use of local data can be used to effect change and are inspiring models for care in the 21st century. They are testament to the significant vision and commitment of their orchestrators.
BSH Young Investigators Award
The standard of rapid-fire abstracts for the ‘Young Investigators Award’ was once again of the highest quality. Dr Soren Lund Kristensen (University of Copenhagen, Denmark) was the eventual winner of the prestigious award with his presentation on employment following first hospitalisation for heart failure in patients of working age. By linking nationwide Danish administrative registries, over 13,000 patients were identified in order to assess the impact of first hospitalisation for heart failure on subsequent labour market attachment in patients previously available to the labour market. The group showed that one year after first hospitalisation for heart failure, employment among patients of working age dropped more than 25% regardless of age group. Younger age, chronic kidney disease and cancer were the most significant predictors of employment status.
Treating atrial fibrillation and heart failure
Dr Derek Connelly (Glasgow) presented an up-to-date summary of the importance of diagnosing and treating atrial fibrillation (AF) in the setting of heart failure. Antithrombotic therapy remains of paramount importance in patients with AF and heart failure. Virtually all patients should be anticoagulated, either with warfarin (aiming for an international normalised ratio of 2−3) or with a non-vitamin K antagonist oral anticoagulant (NOAC).
The pharmacological options for rate and/or rhythm control strategies for the management of AF in patients with heart failure remain extremely limited. To look at this, the AF-CHF trial − a multicentre, prospective, open label trial − randomised 1,376 patients with heart failure and an ejection fraction <35% with a history of AF to rhythm control versus rate control. Over a follow-up period of 37 months, rhythm control did not improve patient outcomes compared to a rate control strategy.5
Of the available drugs for rate control, calcium channel antagonists are contra-indicated due to their negative inotropic effects. Digoxin may be of use in selected patients but several studies have drawn attention to adverse effects on mortality with digoxin use in AF. Beta blockers remain the mainstay of rate control therapy. Three beta blockers are approved for use in heart failure (carvedilol, bisoprolol and slow-release metoprolol).
The CIBIS II trial studied the relationships between baseline heart rate, nature of cardiac rhythm (sinus rhythm or AF), and outcomes (mortality and hospitalisation for heart failure). Bisoprolol reduced mortality in patients with sinus rhythm but not in patients with AF.6 In the COMET trial, 3,029 patients with heart failure were randomised to carvedilol or metoprolol. Treatment with carvedilol, compared with metoprolol, was found to offer additional benefits among patients with AF and heart failure.7
Pharmacological options for rhythm control are even more limited in this group of patients. Realistically the only drug routinely available is amiodarone. Class I anti-arrhythmic drugs and dronedarone are contraindicated, while sotalol is not indicated in heart failure.
Catheter ablation strategies targeting primarily the substrate and/or the initiating triggers for AF have been established in recent years. Selected patients with heart failure and AF may be eligible for such treatments. It is essential to identify those with high potential benefit and low expected risks of complications for rhythm control strategy. Several small studies have assessed the efficacy of AF ablation in heart failure, and most studies have documented improvement in symptoms and ejection fraction during short term follow up. Longer term data are not yet available.
The PABA-CHF trial − a prospective, multicentre trial − randomly assigned patients with symptomatic, drug-resistant AF, an ejection fraction of 40% or less, and New York Heart Association class II or III heart failure, to undergo either pulmonary vein isolation or atrioventricular-node ablation with biventricular pacing. The group concluded that pulmonary vein isolation was superior to atrioventricular node ablation with biventricular pacing in patients with heart failure who had drug-refractory atrial fibrillation.8 It is important to note that ablation for atrial flutter is highly efficacious and extremely safe, and thus patients with heart failure and atrial flutter should be prioritised for ablation.
New approaches to heart failure treatment
Professor Michael Frenneaux (University of East Anglia, Norwich) delivered a fascinating presentation on the metabolic treatment of heart failure. The heart requires huge quantities of energy (approximately 6 kg of ATP daily) in its role as a relentless pump. Abnormalities of cardiac energy metabolism make an important contribution to chronic heart failure. Energetic impairment has been reported in patients with a variety of heart muscle disease (including dilated cardiomyopathy, hypertrophic cardiomyopathy, heart failure with preserved ejection fraction, aortic stenosis). Multiple mechanisms contribute to this.9
Agents that cause a metabolic shift from predominant fatty acid to carbohydrate oxidation increase left ventricular mechanical efficiency in experimental models. Two particular agents with actions, at least in part, via this mechanism (perhexiline and trimetazidine) have been shown to improve cardiac function and exercise capacity in patients with systolic heart failure.10,11 Such therapies offer significant promise for the treatment of symptomatic heart failure and thus more studies, especially larger multicentre randomised controlled trials, are warranted to clarify the effect of these drugs in heart failure.
Dr John Baxter (Sunderland Royal Hospital) concluded the BSH conference with a hugely entertaining and practical talk outlining strategies to change pathways of care in the workplace. The importance of the multidisciplinary heart failure service aspiring to deliver an early accurate diagnosis and optimal well-integrated care for all patients with heart failure was discussed. Reference was made to Dr Hardman’s presentation (see above), reflecting on the emergence of an integrated heart failure service from 1999 to the present coinciding with a low all-cause mortality and heart failure–related mortality at the Whittington Hospital.
The BSH gratefully acknowledges support from Bayer HealthCare, Biotronik, Boston Scientific, Medtronic, Novartis, Pfizer, ResMed, Servier Laboratories, St Jude Medical and Vifor Pharma.
Future BSH meetings include the Heart Failure Day for Revalidation and Training on 3rd March 2016, the Heart Failure Nurse and Healthcare Professional Study Day on 4th March 2015 and the 19th Annual Meeting on 24–25th November 2015. For further information, contact the BSH at: www.bsh.org.uk; twitter:
@BSHeartFailure; and email: firstname.lastname@example.org
Conflict of interest
Parminder S Chaggar
Dr Matthew Kahn
North West Heart Centre, University Hospital of South Manchester, Southmoor Road, Manchester, M23 9LT
Correspondence to: email@example.com
1. McMurray JJ, Packer M, Desai AS, et al. Angiotensin-neprilysin inhibition versus enalapril in heart failure. N Engl J Med 2014;371:993−1004. http://dx.doi.org/10.1056/NEJMoa1409077
2. Zaphiriou A, Robb S, Murray-Thomas T, et al. The diagnostic accuracy of plasma BNP and NTproBNP in patients referred from primary care with suspected heart failure: results of the UK natriuretic peptide study. Eur J Heart Fail 2005;7:537−41. http://dx.doi.org/10.1016/j.ejheart.2005.01.022
3. National Institute for Health and Care Excellence. Chronic heart failure in adults: management. Clinical guideline 108. https://www.nice.org.uk/guidance/cg108/resources/chronic-heart-failure-in-adults-management-35109335688901
4. National Institute for Cardiovascular Outcomes Research. National Heart Failure Audit April 2013 – March 2014. http://www.ucl.ac.uk/nicor/audits/heartfailure/documents/annualreports/hfannual13-14.pdf
5. Roy D, Talajic M, Nattel S, et al. Rhythm control versus rate control for atrial fibrillation and heart failure. N Engl J Med 2008;358:2667−77. http://dx.doi.org/10.1056/NEJMoa0708789
6. Lechat P, Hulot JS, Escolano S, et al. Heart rate and cardiac rhythm relationships with bisoprolol benefit in chronic heart failure in CIBIS II Trial. Circulation 2001;103:1428−33. http://dx.doi.org/10.1161/01.CIR.103.10.1428
7. Swedberg K, Olsson LG, Charlesworth A, et al. Prognostic relevance of atrial fibrillation in patients with chronic heart failure on long-term treatment with beta-blockers: results from COMET. Eur Heart J 2005;26:1303−8. http://dx.doi.org/10.1093/eurheartj/ehi166
8. Khan MN, Jaïs P, Cummings J, et al. Pulmonary-vein isolation for atrial fibrillation in patients with heart failure. N Engl J Med 2008;359:1778−85. http://dx.doi.org/10.1056/NEJMoa0708234
9. Neubauer S. The failing heart–an engine out of fuel. N Engl J Med 2007;356:1140−51. http://dx.doi.org/10.1056/NEJMra063052
10. Lee L, Campbell R, Scheuermann-Freestone M, et al. Metabolic modulation with perhexiline in chronic heart failure: a randomized, controlled trial of short-term use of a novel treatment. Circulation 2005;112:3280−8. http://dx.doi.org/10.1161/CIRCULATIONAHA.105.551457
11. Gao D, Ning N, Niu X, Hao G, Meng Z. Trimetazidine: a meta-analysis of randomised controlled trials in heart failure. Heart 2011;97:278−86. http://dx.doi.org/10.1136/hrt.2010.208751