BSH: Improving quality and reducing inequality in heart failure

The popular annual autumn meeting of the British Society for Heart Failure (BSH) boasted a line-up of internationally recognised authorities in heart failure. Held in London on 28^th–29^th November 2019, the meeting’s focus was on improving quality and reducing inequality. Drs Sanjay S Bhandari and Daniel CS Chan report its highlights.

Advanced heart failure

From a trainee’s perspective, recognising when a heart failure (HF) patient is entering into the advanced stages is critical and sets off “transplant alarm bells”. Dr Sai Bhagra (Royal Papworth Hospital, Cambridge) delivered a great talk on this spectrum of the disease, essentially defining this as a failure of optimal therapy, requiring escalating diuretics with the development of end-organ dysfunction. The 2018 European Society of Cardiology definition of advanced HF encompasses:

• severe symptom limitation
• severe cardiac impairment
• pulmonary/systemic congestion requiring intravenous diuretics or malignant arrhythmias requiring hospitalisation in the last year
• impairment of exercise capacity with a low six-minute walk test of <300m.¹

A helpful mnemonic, ‘I NEED HELP’, was suggested for when making a referral to a quaternary centre for consideration of advanced HF therapies. It captures the salient points the receiving physician will want to know:

• Inotropes – ongoing need for inotropes
• New York Heart Association (NYHA) class 3 / 4 or high brain natriuretic peptide (BNP)
• End organ dysfunction
• Ejection fraction (EF) <35%
• Defibrillator shocks (recurrent)
• Hospitalisation – more than one episode in the last year
• Escalating diuretic requirement
• Low blood pressure (BP) with systolic BP <90mmHg
• Prognostic medication (down titration).

Dr Steve Shaw (Wythenshawe Hospital, Manchester) informed us of the INTERMACS (Interagency Registry of Mechanically Assisted Circulatory Support) score. This score is a way of conveying the clinical status of an advanced HF patient and the urgency with which heart transplantation or mechanical circulatory support need to be considered. This is a far more descriptive tool than the crude NYHA classification we use in everyday practice. There are seven profiles to the INTERMACS score, with INTERMACS 1 reflecting our “crash and burn” type of advanced HF patient, who requires escalating inotropes with deteriorating renal function. This patient would require an emergency intervention, via mechanical circulatory support, to avoid imminent death. On the other end of the spectrum, INTERMACS 7, reflects our clinically and biochemically stable HF patient, in whom consideration of heart transplantation would be untimely and inappropriate.

Percutaneous adjuncts that might improve a patient’s cardiovascular haemodynamics, were described by Dr Shaw. These range from the intra-aortic balloon pump to more recent advances, such as the impella device. The latter is positioned in the left ventricular outflow tract (LVOT) across the aortic valve and helps propel blood from the left ventricle to the aorta, reducing afterload. The impella device is left in situ for up to five days, while the Centrimag device – an extracorporeal circuit – provides circulatory support in ITU settings for up to 30 days.

Advanced HF therapies are now used more often as a destination therapy rather than as the conventional bridge to transplant. Cardiac transplantation remains the gold standard treatment but the lack of donor hearts remains a major stumbling block for the treatment of many advanced HF patients. For patients with an INTERMACS score of 1, mortality is extremely high, thus mechanical circulatory support is more appropriate to enable a period of clinical stability to ensue before cardiac transplant surgery, which carries its own inherent risks.

This year the Phillip Poole-Wilson Memorial lecture was awarded to Dr Jayan Parameshwar (Royal Papworth Hospital, Cambridge), who gave a wonderful insight into the training and path he has taken to becoming one of the most established leaders in cardiac transplantation.

Cardio-oncology

Cardio-oncology is a niche subspecialty with increasing importance as advances in cancer detection and primary treatments have led to improving cancer morbidity and mortality. Dr Alex Lyon (Royal Brompton Hospital, London) spoke on cancer drugs and the heart, explaining that cancer therapies interfere with various cellular signalling pathways, which halt and regress tumour growth. These also often have some overlap with cardiac signalling pathways that ultimately result in cardiac dysfunction.

Anthracyclines, such as doxorubicin, used in the treatment of Hodgkin’s lymphoma have a dose-dependent irreversible cardiotoxic effect. Cumulative doxorubicin doses of between 500–550 mg/m² cause a 4% incidence in the development of HF, steeply increasing to 20% with 550-600mg/m² doses of the drug.² Furthermore, the interplay of risk factors such as diabetes and ischaemic heart disease, can amplify the effect of sensitivity to the doxorubicin dose. This drug sensitivity may have a key role in treatment strategies, according to Dr Lyon, and may assist the move towards more personalised therapy for patients. Genotyping may offer a potential solution, with patients carrying high-risk genes for the development of cardiotoxicity being treated with different, less toxic, drug therapies.

Immunotherapy, in the form of trastuzumab, has improved the prognosis of HER2 positive breast cancer but the development of cardiac dysfunction in some patients may prevent them receiving further doses of this potentially cancer-curing therapy. Dr Lyon described the SAFE-HEART study, which optimised the treatment of patients with a mild left ventricular systolic dysfunction (EF of 40–49%) with beta blockers and angiotensin-converting enzyme (ACE) inhibitors, and resulted in the vast majority of patients being able to successfully complete their course of immunotherapy.³

Young Investigator’s Award

The BSH young investigator award was closely contested between three very good candidates.

• Dr Gaurav Gulsin (Leicester) investigated the impact of a 12-week intervention of aerobic exercise, or a low-calorie diet, or routine care on diastolic function in obese patients with type 2 diabetes, assessed using cardiovascular magnetic resonance imaging (CMR). Patients who underwent the exercise programme had an improved peak early diastolic strain rate despite not losing weight. Interestingly, patients in the low calorie diet group, experienced significant weight loss but their peak early diastolic strain rate worsened. Dr Gulsin’s research was the first prizewinner.
• The effect of SLGT2 inhibition on cardiac remodelling in HF, was investigated by runner-up Dr Jagdeep Singh (Dundee). Patients with echocardiographically-confirmed HF with reduced EF (HFrEF) were treated with either dapagliflozin 10 mg or placebo for one year. The primary end point was the difference in the left ventricular end systolic volume determined by CMR. Dapagliflozin did not show a statistically significant reduction in left ventricular end systolic volume, but there was a trend towards reverse remodelling in those patients with diabetes and mild left ventricular systolic dysfunction.
• Dr Shirley Sze (Leicester), the second runner up, looked at the impact of frailty on all-cause mortality and hospitalisation in ambulatory patients with HF. Using a number of frailty scoring tools, 467 patients were recruited into this study. Frailty tools were associated with mortality and the composite end point of mortality/HF admission in addition to the classic variables, including NTproBNP, NYHA status etc.

Exercise and rehabilitation

An important insight into a patient’s experience after an important cardiac diagnosis in hospital, was discussed by Dr Scott Murray (Royal Liverpool and Broadgreen University Hospitals NHS Trust). He showed how patients are ‘processed’ like ‘a product’ in hospital and then ‘pushed out’ at the other end back into ‘fast-flowing rivers’ without support. He described the current role of cardiac rehabilitation as ‘rescuing’ these patients from fast-flowing rapids, when the vision is for a seamless transition back into the real world.

Although rehabilitation and prevention are now at the forefront of the NHS Long Term Plan, there is a gap, with only 52% of patients eligible for rehabilitation taking it up, despite evidence showing that it is really effective. It can reduce HF hospitalisations by 39%, with a number-needed-to-treat of only 18, and a cost of £7,000 per quality-adjusted life-year. Notably, however, meta-analyses for exercise-based cardiac rehabilitation suggest that the benefits are only for hospitalisation and quality of life improvement, and not mortality. Furthermore, he said, the benefit of rehabilitation is uniform across all modalities whether the programme is home-based, institution-based or remotely.

Heart failure trials

An update of 2019 HF trials, was given by Professor John Cleland (University of Glasgow). The message from his session was that future randomised, controlled trials need to be a hybrid between registry/randomised controlled trials, with an effort to enrol patients for multiple trials (if compatible) at the same time, to increase both the rate of uptake and translation from conception to results. Interestingly, China is increasing its contribution to trial data and recruitment, but the UK still remains in the top three countries for recruiting into clinical trials. Most clinical trial activity is currently from oncology trials. Clinical trials that will be conducted in the near future will involve inotropes, diuretics, cell and gene therapies, SGLT2 inhibitors, iron therapy and systems of care.

IT innovations

Professor Ken McDonald (St Vincent’s University Hospital, Dublin, Ireland) explained how remote HF consultations may work to deliver specialist HF input to the wider community. The delivery of timely, specialist HF input has been plagued by the waiting times to see a heart failure specialist. As HF is a ubiquitous condition, more initial community-based interventions may help improve heart failure care delivery and the rate of diagnosis. Moving the knowledge, instead of the patient, to provide virtual consultations could provide a solution.

An interesting model was trialled in the Republic of Ireland, where primary care providers assembled patients to be discussed with the heart failure specialists, and referred them before a virtual clinic. This involved a teleconference between the specialist and the referring primary care provider, which covered multiple aspects of the assessment, enabling six to seven cases to be covered in an hour-long session. This model of service delivery was found to lead to reduced waiting times, less patient travel and more patients being seen per hour. The HF virtual clinics not only had the same patient mix as those seen in the real clinic (average age 75 years; 80% with >4 co-morbidities; 65% with HF with preserved EF [HFpEF]), but they also led to increasing and better engagement of GPs in both diagnosis and delivery of personalised heart failure treatment plans. The only downside of the model was the increased mental load, which is very intense as several decisions are made per hour.

One of the most important talks of the day was the session on advanced care planning by Professor Jackie Taylor (Glasgow Royal Infirmary), which discussed its purpose and when it should be considered. The take-away message from the session was that it’s never too early to discuss advanced care planning. The purpose of the advanced care plan is to help create a sense of control for the patients in an out of control journey. It can alleviate fears of what happens next and help dispel myths about the end of life, also relieving the pressure on family/caregivers/healthcare providers, who may feel that it is their decision on how to provide care to individuals when they are no longer able to make a choice.

Diary dates

• March 27^th 2020 BSH Nurses and Allied Health Care Professionals training day, Birmingham
• 26^th–27^th November 2020 BSH annual autumn meeting, QEII Centre, London

Further information on these events is available at https://www.bsh.org.uk/meetings/future-meetings/

Sanjay S Bhandari
Cardiology Specialist Registrar

Daniel CS Chan
Cardiology Specialist Registrar

Glenfield Hospital, Leicester

References

1. Crespo-Leiro MG, Metra M, Lund LH, et al. Advanced heart failure: a position statement of the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail 2018;20:1505-35. https://doi.org/10.1002/ejhf.1236

2. Singal PK, Iliskovic N. Doxorubicin-induced cardiomyopathy. N Engl J Med 1998;339:900-5. https://doi.org/10.1056/NEJM199809243391307

3. Lynce F, Barac A, Tan MT, et al. SAFE-HEaRt: Rationale and design of a pilot study investigating cardiac safety of HER2 targeted therapy in patients with HER2-positive breast cancer and reduced left ventricular function. Oncologist 2017;22:518-25. https://doi.org/10.1634/theoncologist.2016-0412