‘The heart failure multidisciplinary team’ was the theme for the 21st Annual Autumn Meeting of the British Society of Heart Failure (BSH), which took place from 29th-30th November 2018 at the Queen Elizabeth II Conference Centre, London. BSH Chair, Dr Paul Kalra (Portsmouth), welcomed delegates to another stimulating programme, put together by Dr Lisa Anderson (London), Mrs Louise Clayton (Leicester), Mr Paul Forsyth (Glasgow) and Professor Iain Squire (Leicester). Dr Richard Baker reports some of the meeting highlights.
NICE heart failure guidelines
The latest National Institute for Health and Care Excellence (NICE) guidelines for management of chronic heart failure (NG 106)1 were presented by Dr Abdallah Al-Mohammed (Sheffield Teaching Hospitals). It was fascinating to hear Dr Al-Mohammed describe his work on producing the guidelines with respect to what recommendations the authors are permitted to include and how recommendations may be presented.
Key changes include the removal of a history of a previous myocardial infarction from the initial assessment of a patient with suspected chronic heart failure. Other changes include the guidelines now using the term heart failure with reduced ejection fraction (HFrEF) rather than left ventricular systolic dysfunction, and the inclusion of heart failure with preserved ejection fraction (HRpEF).
NICE defines a cut-off for referral to heart failure diagnostic services as an N-terminal pro B-type natriuretic peptide (NT-proBNP) measurement of more than 400ng/L, different to the 125ng/L specified in European Society of Cardiology (ESC) guidance.2 Dr Al-Mohammed highlighted that this was seen as the most cost effective cut-off point according to NICE. (NT-proBNP should also be used prioritise referrals – those with an NT-proBNP greater than 2,000ng/L should receive assessment within two weeks. NT-proBNP should also be used to monitor treatment.)
The new guidance also includes new treatment recommendations. These include the use of sacubitril/valsartan, following the results of PARADIGM-HF (Prospective Comparison of ARNI With ACEI to Determine Impact on Global Mortality and Morbidity in Heart Failure ) study;3 the use of a specialist prescriber in the heart failure multi-disciplinary team (MDT) and recommendations that patients with chronic kidney disease and an estimated glomerular filtration rate (eGFR) of more than 30ml/min/1.73m2 should receive the same therapy as other patients.
More specific guidance was provided on information that should be given to patients. This included, for example, discussing “…prognosis in a sensitive, open and honest manner” and to “be frank about the uncertainty in predicting the course of their heart failure”.
A lively debate was generated by the new guidance during question time. Statements from the floor highlighted frustrations that a treatment flow chart included in full guidelines was not included in the summary. Furthermore, no place for intravenous iron was found in the final guidelines. Dr Al-Mohammed explained the set formats used in NICE documents and the necessity to keep within these. The panel stressed that whilst guidelines exist from NICE, decisions can still be taken based on other sources of evidence.
How to address gaps in palliative care services
Palliative heart failure service delivery and MDT communication
A one-year pilot study integrating palliative care and heart failure services for patients in their last year of life, was presented by Dr Joy Ross (Consultant in Palliative Medicine, St. Christopher’s Hospice, London). Funding was obtained from Bromley Clinical Commissioning Group for an advanced nurse practitioner (ANP) and a total of 102 patients were referred to the service, of whom 89 were accepted due to an intentionally broad referral criteria.
Positive impacts were seen on hospital bed days with a 51% reduction from the figures prior to the pilot. Other positive impacts noted were improvements in professionals working well together. Awareness of the ANP role also encouraged GPs to discuss cases informally before crisis points were reached.
Goals for the future include ensuring greater integrative working and, importantly, that patients are enabled to die in their chosen place.
Following the pilot, funding has been obtained to support a heart failure nurse and sessions for cardiology consultants in St. Christopher’s Hospice.
Managing the psychological elements of dyspnoea
Dr John Sharp (Consultant Clinical Psychologist, Golden Jubilee National Hospital Glasgow) reviewed dyspnoea and many ongoing symptoms experienced by heart failure patients. Dr Sharp reflected the formulation and thought processes patients may go through when they have been told by their clinician that these symptoms have been treated, but symptoms persist. The low yield of further investigations when pre-test probabilities are low was highlighted and that further tests do not serve to reassure the patient.4 A series of do’s and dont’s in interacting with patients with persistent symptoms were provided, to help healthcare professionals to consider better strategies for communicating with this patient group.
Young Investigators’ Award: rapid fire abstracts
Four young investigator finalists presented their research as rapid fire five-minute abstracts.
First to present was the eventual winner, Dr Dan Bromage (King’s College Hospital, London), who outlined data comparing the left ventricular ejection fraction (LVEF) recorded on echocardiography with cardiac magnetic resonance imaging (MRI). Echocardiography consistently underestimated LVEF across all subgroups of left ventricular dysfunction. This may have relevance in reclassifying patients with heart failure with a mid-range ejection fraction (HFmrEF) into a HFpEF group.
Dr Ify Mordi (Ninewells Hospital, Dundee) presented his research on genomic insights into the pathophysiology of heart failure with reduced and preserved ejection fraction. The Dundee group was able to determine differences in causality of both these two classes of heart failure based on two risk factors – coronary artery disease and hypertension. It was found that those with a higher genetic risk of coronary artery disease were more likely to develop heart failure with reduced ejection fraction, while those with a genetic risk of hypertension were more at risk of heart failure with reduced ejection fraction.
The value of wireless left ventricular endocardial cardiac resynchronisation therapy, was discussed by Dr Benjamin Sieniewicz (Guy’s and St. Thomas’ Hospital, London). The technique of implantation and suitable patients for the device were presented with feasibility and performance in the real world data at the time of presentation.
Frailty is a common comorbidity in chronic heart failure and this was the focus of the fourth finalist’s research. Tools exist for both in-depth assessment of frailty and for screening. Dr Shirley Sze (Hull University Teaching Hospitals) presented her investigations on the level of agreement between frailty screening tools and in-depth assessments. It was found that the clinical frailty scale5 had the best agreement. This tool can be used to rapidly assess patients.
The burden of atrial fibrillation (AF) in heart failure and the links between the two conditions, was highlighted by Dr Anthony Chow (Barts Health London). He noted that previous studies of rhythm versus rate control for AF in chronic heart failure did not include ablation.6,7 If rate control is selected for AF, generally, more lenient rate control of <110 beats per minute is acceptable.8
Evidence from randomised, controlled trials is limited. The AATAC (Ablation versus Amiodarone for Treatment of AF in Patients With CHF and an Implanted Device) included patients with heart failure and a device. The study found catheter ablation was more successful than amiodarone in maintaining sinus rhythm in heart failure with persistent AF (the primary outcome) and it also beneficially influenced hospitalisations, death, LVEF and the six-minute walk distance in 203 participants.9 A rate control group did not feature.
Discussion of CASTLE-AF (Catheter Ablation for Atrial Fibrillation with Heart Failure) generated debate,14 which presented an opportunity to compare catheter ablation for paroxysmal or persistent AF with medical therapy, be it rate or rhythm control. The study found catheter ablation reduced death and hospitalisation for heart failure. Criticisms from the floor suggested that the population was highly selective, there was a relatively high loss to follow up, and the trial included patients who had failed or were unwilling to take antiarrhythmic therapy.
It was agreed that catheter ablation has a place in heart failure patients with AF, as one potential solution suitable for an individual patient.
Next year’s meeting
To find out more about next year’s meeting, which will take place on the 28th–29th November 2019 at the QEII Centre, London, visit http://www.bsh.org.uk/meetings/bsh-future-meetings/#22nd-bsh-annual-autumn-meeting-2019
Further information about the BSH can be found at www.bsh.org.uk
Conflicts of interest
RB receives research funding from the BSH.
Cardiology Research Fellow
University of Bristol and Bristol Heart Institute
1. National Institute for Health and Care Excellence. Chronic heart failure in adults: diagnosis and management (NG106). London: NICE, updated 12th September 2018. Available from: https://www.nice.org.uk/guidance/ng106
2. 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). Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur J Heart Fail 2016;18:891–975. https://doi.org/10.1002/ejhf.592
3. McMurray JJ, Packer M, Desai AS et al. Angiotensin-neprilysin inhibition versus enalapril in heart failure. N Engl J Med 2014;371:993–1004. https://doi.org/10.1056/NEJMoa1409077
4. Rolfe A, Burton C. Reassurance after diagnostic testing with a low pretest probability of serious disease: systematic review and meta-analysis. JAMA Int Med 2013;173:407–16. https://doi.org/10.1001/jamainternmed.2013.2762
5. Rockwood K, Song X, MacKnight C et al. A global clinical measure of fitness and frailty in elderly people. CMAJ 2005;173:489–95. https://doi.org/10.1503/cmaj.050051
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7. Wyse DG, Waldo AL, DiMarco JP et al. A comparison of rate control and rhythm control in patients with atrial fibrillation. N Engl J Med 2002;347:1825–33. https://doi.org/10.1056/NEJMoa021328
8. Van Gelder IC, Groenveld HF, Crijns HJ et al. Lenient versus strict rate control in patients with atrial fibrillation. N Engl J Med 2010;362:1363–73. https://doi.org/10.1056/NEJMoa1001337
9. Di Biase L, Mohanty P, Mohanty S et al. Ablation versus Amiodarone for Treatment of Persistent Atrial Fibrillation in Patients with Congestive Heart Failure and an Implanted Device: Results From the AATAC Multicenter Randomized Trial. Circulation 2016;133:1637–44. https://doi.org/10.1161/CIRCULATIONAHA.115.019406
10. Marrouche NF, Brachmann J, Andresen D et al. Catheter ablation for atrial fibrillation with heart failure. N Engl J Med 2018;378:417–27. https://doi.org/10.1056/NEJMoa1707855