A ‘paradigm shift’ in the treatment of heart failure created an atmosphere full of excitement at the 19th British Society for Heart Failure (BSH) Annual Autumn Meeting. Held in London from 24th–25th November 2016, Dr Matthew Kahn reports some of the highlights from the comprehensive and hugely educational programme.
Systems of heart failure delivery
Best practice tariff
There is now a ‘best practice tariff’ (BPT) programme for heart failure (and for many other conditions). Professor Iain Squire (University of Leicester) reviewed the implications of this and discussed National Institute for Health and Care Excellence (NICE) quality standards for chronic heart failure (CHF).
The first year of the BPT (April 2015–March 2016) was voluntary but it has been compulsory since the beginning of the 2016–2017 financial year. For the financial year 2016–2017, the tariff is worth a 5% uplift in the amount a trust is paid for each and every admission. It is an ‘all or none’ phenomenon with the trust being paid for every heart failure admission or for ‘none’ of them. It is not calculated for each individual patient.
The National Heart Failure Audit return is pivotal because to meet the requirements for the BPT, the trust has to meet two criteria:
- 70% of patients must have had input into their in-patient care from the heart failure specialist team as recorded in the national audit return; and
- 60% of patients coded (in the first diagnostic position) in the trust’s ‘Hospital Episode Statistics (HES)’ as having had an admission for heart failure must be entered into the National Heart Failure Audit.
Another item of note is that hospital-level mortality statistics will be published for the next report (i.e. based on the data being collected between April 2015 and March 2016). Outliers (those who lie more than three standard deviations from the mean for in-patient mortality) will be identified by name. Outliers include those who return 0% in-hospital mortality; such a thing is not plausible and suggests that patients who die are not being entered into the audit.
In order that this process works efficiently, reports will be delivered quarterly moving forward (so the trust will know how well it is performing against various benchmarks). Given the increased frequency of data entry into the audit, systems may need to be adjusted to account for this. These changes may require different working patterns and an increase in the resources required for the national audit at local level. The uplift paid by meeting the requirements for the BPT, however, should provide an incentive.
NICE quality standard for CHF
Professor Squire went on to discuss the NICE quality standard for CHF in adults, which covers the assessment, diagnosis and management of CHF. It defines CHF as ‘a complex clinical syndrome of symptoms and signs that suggest the efficiency of the heart as a pump is impaired’. The quality standard document emphasises the individual, familial and societal impact of heart failure and is expected to contribute to improvements in the following outcomes:
- mortality due to heart failure
- hospital admissions
- ability to manage a long-term condition
- quality of life
- medication safety.
The quality standard outlines a concise set of prioritised statements designed to drive measurable improvements in the three dimensions of quality – patient safety, patient experience and clinical effectiveness. They are derived from high‑quality guidance, such as that from NICE or other sources accredited by NICE.
Heart failure services should be commissioned from and co-ordinated across all relevant agencies encompassing the whole CHF care pathway. A person‑centred, integrated approach to providing services is fundamental to delivering high‑quality care to adults with CHF. The quality standard acknowledges the pivotal role of multidisciplinary teams in the ongoing management of heart failure.1
Ms Jayne Masters (University Hospitals Southampton NHS Foundation Trust) discussed the importance of self-management in heart failure. Certain key factors hinder a patient’s ability to self-manage their condition. Such factors are either modifiable (e.g. lack of understanding, psychological factors, fatigue, lack of specialist input) or non-modifiable (e.g. age, cognition, lack of social support, finance, presence of other co-morbidities).
In order to identify patients that need additional help, various tools can be used such as the Hospital Anxiety and Depression (HAD) Score or other cognitive assessment tools such as a Mini Mental State Examination (MMSE). Jaarsma et al. developed the European Heart Failure Self-care Behaviour Scale in order to measure self-care behaviour in patients with CHF. The scale has been tested and validated in 442 patients in six European centres from the Netherlands, Sweden, and Italy.2
The team at Southampton have developed a ‘conditioning and wellbeing’ programme with specific goals, which include improving quality of life, improving understanding of the condition and reducing heart failure readmissions. The programme is aimed at the following patients who would not be likely to be candidates for heart failure rehabilitation:
- symptomatic (New York Heart Association III/IV)
- multiple co-morbidities
- multiple admissions
- psychological distress
- socially isolated.
The 12-week programme uses peer support, psychological assessment, visiting speakers and addresses care needs in order to target modifiable factors to improve self-management. There have been clear improvements in measurable outcomes as a result of the programme.
Self-care is an important aspect for patients with heart failure. Instructing and improving the behaviour of patients with heart failure is one of the main purposes of patient education. The importance of allowing patients to understand the diagnosis of heart failure and the prognosis is vital to build confidence and improve patient outcomes.
Virtual telephone clinic
Ms Jenny Welstand (Betsi Cadwaladr University Health Board, Wrexham) described the development and use of a virtual telephone clinic in North East Wales as a key part of service provision for heart failure. Initially the virtual clinic was used to augment follow up between face-to-face outpatient clinic appointments. Over time, the team have developed the model to be a formal part of clinical service delivery alongside outpatient clinics, in-patient ward rounds and an advice hotline for patients and families. The pre-booked clinic usually has 30–40 patient calls daily. These can range from simple follow-up calls including medical optimisation, through to more complex calls requiring management of fluid retention or symptom deterioration. Suitability for the virtual clinic is initially assessed in a formal outpatient setting initially.
The virtual clinic has become extremely popular with patients and families and is an extremely useful way of monitoring patient progress. At a time when resources are limited in healthcare, use of a virtual clinic maybe helpful for some specialist teams to maximise their time. There are limitations and some patients may not be suitable for such monitoring. It should also be noted that telephone assessment might be a new skill that will take time to learn and to develop.
BSH Young Investigator’s Award
The standard of rapid-fire abstracts for the ‘Young Investigators Award’ was once again of the highest quality. Dr Brian Halliday (Royal Brompton Hospital, London) was the eventual winner of the prestigious award with his presentation on risk stratifying patients with dilated cardiomyopathy (DCM) and mild or moderate left ventricular dysfunction. His research focussed on whether mid-wall fibrosis (MWF), detected by late gadolinium enhancement cardiovascular magnetic resonance (LGE-CMR), predicts an increased risk of sudden cardiac death (SCD) in patients with DCM and LVEF >40%. In total, 432 patients were followed up for 4.5 years. On multivariate analysis, after adjustment for conventional prognostic factors, MWF remained an independent predictor of the primary end point (composite of SCD or aborted SCD). MWF may therefore identify a sub-group of patients with DCM and a LVEF>40% who may benefit from implantable cardioverter defibrillator (ICD) therapy.
Frailty and heart failure
Dr Callum Chapman (West Middlesex University Hospital) discussed the complexities of frailty and heart failure. Heart failure management and self-care behaviour are complicated by ageing, co-morbid conditions, cognitive impairment, frailty and limited social support.
Frailty is common in older adults with heart failure with a prevalence of over 70% (in patients with heart failure aged >80 years).3 Frailty is a fluid state and the phenotype is not fixed; as such it is difficult to define. It is generally characterised by weakness, fatigue and increased vulnerability to physiological stressors with associated adverse health outcomes. It typically increases in frequency and worsens with advanced age, and results in dependency. Frailty in heart failure is associated with increased mortality, increasing readmissions and a longer in-patient hospital stay.4 Importantly the frailty phenotype may respond to appropriate interventions. The 2016 European Society of Cardiology guidelines suggest the use of a scoring system, such as the Frail Score, to identify and monitor patients.3
Older patients with heart failure should be managed using the same evidence-based approach, which has proven so effective in the general population. A multi-disciplinary approach is vital and there should be a careful approach to additional co-morbidities. Flexibility is important with such patients as treatment goals may change over time with emphasis changing from prolongation of life to improving quality of life.
Counting the cost of co-morbidities in heart failure
Professor Michael Bohn (University of the Saarland, Germany) delivered the keynote lecture and addressed the impact of co-morbid conditions on heart failure. Co-morbidity is of great importance in the treatment of heart failure since it can interfere with the diagnostic process, aggravate symptoms and prognosis, and can affect the use of standard evidence-based cardioprotective treatments. The evidence base for heart failure treatment in the presence of co-morbidities is more limited as co-morbidities were often used as an exclusion criterion for trials. Efficacy of intervention is therefore lacking in the presence of co-morbidities. Drugs used to treat co-morbidities may cause worsening heart failure symptoms and various co-morbidities may preclude effective pharmacotherapy for heart failure (e.g. beta blockers in patients with chronic obstructive pulmonary disease).3
Co-morbidity load increases with progressing severity of heart failure and therefore the majority of recurrent hospitalisations are not necessarily due to heart failure. Treatment of co-morbidities has been shown to improve outcome measures; e.g. intravenous iron has been shown to improve quality of life and NYHA class in the FAIR-HF (Ferinject Assessment in Patients with Iron Deficiency and Chronic Heart Failure) trial.5 Other co-morbidity treatments might favourably influence outcomes, and more randomised clinical trials are needed.
Microbes and the myocardium
Dr Susanna Price (Royal Brompton Hospital, London) discussed the management of severe infections in heart failure. Myocardial dysfunction in sepsis is a well-recognised clinical entity and may occur in previously normal hearts, or in patients with heart failure admitted with sepsis. A cardiogenic component to septic shock should always be explored, and it is important to assess cardiac performance in sepsis in the context of the expected response of the heart in sepsis (i.e. increased cardiac output and contractility). Alongside left ventricular function, careful evaluation of right ventricular function is vital in the intensive care setting. In the absence of specific treatment for ventricular dysfunction in sepsis, management remains supportive with the use of volume, vasopressor and/or positive inotropic agents with aggressive reduction of pulmonary vascular resistance where required.
Dr Stephen Pettit (Papworth Hospital, Cambridge) delivered a fascinating presentation on myocarditis. This inflammatory disorder presents with clinical features such as arrhythmias and acute heart failure. In addition to clinical and imaging features, the diagnosis is confirmed with histopathological examination of the myocardium. Whilst endomyocardial biopsy is recommended in patients with suspected myocarditis, the diagnostic yield can be poor in many cases.6 Myocarditis can be classified according to the inflammatory infiltrate (lymphocytic, eosinophilic, polymorphic, giant cell or granulomatous). The presence of viral genetic material or cardiac auto-antibodies may imply an underlying viral or autoimmune cause.
Treatment remains challenging and all patients with heart failure should receive standard evidence-based cardioprotective treatment. Patients with haemodynamic instability may require inotropes and mechanical support. Patients with a particularly fulminant presentation may have a favourable prognosis and so transplantation should not be performed unless it is certain recovery will not happen.7 Early advice from the transplant centre should be sought.
It is important to note that myocarditis is a relapsing condition; biomarkers such as troponin may help to monitor disease response to treatment. Long-term follow-up is vital.
Heart failure remains a multisystem problem and a multi-disciplinary approach remains essential when treating this complex syndrome.
Dr Matthew Kahn
Post CCT Cardiology Fellow in Advanced Heart Failure and Devices
North West Heart Centre, University Hospital of South Manchester, Southmoor Road, Manchester, M23 9LT
The BSH gratefully acknowledges the support provided by the friends of BSH: Bayer, Biotronik, Boston Scientific, Medtronic, Novartis Pharmaceuticals, Roche Diagnostics, Servier Laboratories, St. Jude Medical and Vifor Pharma.
Conflict of interest
Future BSH meetings include:
- 2nd March 2017: 9th BSH Heart Failure Day for Revalidation and Training, Regent’s Conferences & Events, London
- 3rd March 2017: 7th BSH Heart Failure Nurse & Healthcare Professional Study Day, Regent’s Conferences & Events, London
- 23th–24th November 2017: 20th BSH Annual Autumn Meeting, QE II Centre, London
1. National Institute for Health and Care Excellence. Chronic heart failure in adults. Quality Standard QS9. http://www.nice.org.uk/guidance/qs9
2. Jaarsma T, Strömberg A, Martensson J, et al. Development and testing of the European Heart Failure Self-Care Behaviour Scale. Eur J Heart Fail. 2003;5:363–70. https://doi.org/10.1016/S1388-9842(02)00253-2
3. Ponikowski P, Voors AA, Anker SD, et al. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). Eur Heart J 2016;37:2129–200. https://doi.org/10.1093/eurheartj/ehw128
4. Vidan MT, Blaya-Novakova V, Sanchez E, et al. Prevalence and prognostic impact of frailty and its components in non-dependent elderly patients with heart failure. Eur J Heart Fail 2016;18:869–75. https://doi.org/10.1002/ejhf.518
5. Anker SD, Comin J, Filippatos G, et al. Ferric Carboxymaltose in patients with heart failure and iron deficiency. N Engl J Med 2009;361:2436–48. https://doi.org/10.1056/NEJMoa0908355
6. Bennett MK, Gilotra NA, Harrington C, et al. Evaluation of the role of endomyocrdial biopsy in 851 patients with unexplained heart failure from 2000–2009. Circ Heart Fail 2013;6:676–84. https://doi.org/10.1161/CIRCHEARTFAILURE.112.000087
7. Cafono AL, Pankuweit S, Arbustini E, et al. Current state of knowledge of aetiology, diagnosis, management and therapy of myocarditis: a position statement of the European Society of Cardiology Working Group on Myocardial and Pericardial Diseases. Eur Heart J 2013;34:2636–48. https://doi.org/10.1093/eurheartj/eht210