One of the most difficult challenges presented to healthcare professionals during the COVID-19 pandemic has been maintaining standards of care in non-COVID related chronic illness. Many members of our heart failure multidisciplinary (MDT) teams were redeployed and, while many have returned to their original positions, the impact of COVID-19 will be felt for years. It was, therefore, particularly poignant that in its 25th year, the British Society of Heart Failure (BSH) hosted a two-day immersive programme focusing on the heart failure MDT. Held at the Golden Jubilee Conference Hotel in Glasgow, on 12th May 2022, the meeting gave heart failure enthusiasts the opportunity to ‘reconnect in the real world’. Dr Tiffany Kemp reports on the highlights of the meeting.
President of the BSH, Professor Roy Gardner opened the meeting asking where his ‘mute button’ had gone to silence the excited chatter after two years of predominantly virtual meetings. He recognised the room was full of professionals with a passion for caring for patients with heart failure, and encouraged everyone to share their knowledge and continue to promote heart failure awareness.
Why do people develop heart failure?
The first session explored some of the many reasons patients can develop heart failure. Dr Caroline Coates (University of Glasgow) highlighted the importance of taking a thorough family history to identify an inherited cardiac condition (ICC) as a cause. While genetic testing is very important, the results are not black and white and, therefore, it is vital to take a holistic approach when making a diagnosis of an ICC. She explored the impact of a genetic diagnosis, including the likelihood of improvement in cardiac function with treatment1, decision making regarding early implantation of cardiac devices, and the consequences of the result on family members. It is vital that ICC services are joined up with heart failure services in order to provide best care for patients. With the huge rise in the consumer market for genetic testing, the importance of this relationship will only increase.
Arrhythmias
Dr Derek Connelly (Golden Jubilee National Hospital, Glasgow) explored the relationship between arrhythmia and heart failure. With new onset acute fibrillation doubling the risk of hospitalisation and mortality in those with heart failure with reduced ejection fraction (HFrEF)2, heart failure specialists must consider which patients may benefit from ablation, and Dr Connelly noted the European Society of Cardiology (ESC) guidelines on management of arrhythmia in heart failure will soon be updated.
Valve disease
Valvular disease can cause a highly abnormal haemodynamic state, and Dr Alison Duncan (Royal Brompton Hospital, London) took the meeting on a whistle-stop tour on how different valvular pathologies can contribute to heart failure. She discussed how specialists should strongly consider structural intervention for aortic stenosis even if already in heart failure with HFrEF, and that the impending new guidelines will support this providing the patient has a prognosis of over 12 months. Newer options such as MitraClip™ (transcatheter mitral valve repair) and transcatheter edge-to-edge mitral valve repair (TMVR) have been shown to improve symptoms and survival for selected patients with HFrEF and severe secondary mitral regurgitation despite optimal medical therapy.3
Ischaemia
Coronary artery disease is often forgotten when treating heart failure, particularly in younger patients, according to Professor Mark Petrie (University of Glasgow). The STICH (Surgical Treatment for Ischemic Heart Failure) study is the only trial focusing on patients with both severe left ventricular systolic impairment (left ventricular ejection fraction <35%) and severe coronary artery disease. While the results can be complex to interpret, the study shows benefit in revascularisation surgery at 10 years; therefore young patients are likely to benefit more. We do not yet have firm evidence regarding percutaneous coronary intervention (PCI) in HFrEF patients, as many trials exclude ejection fraction; but trials are ongoing.
Managing emergencies
There are several scenarios that will scare most heart failure specialists and session two aimed to educate the meeting in order to reduce this fear.
Cardiogenic shock
Dr Robyn Smith (Golden Jubilee National Hospital, Glasgow) presented a pragmatic approach in managing patients with cardiogenic shock, starting with ‘ABC and beyond.’ There are four main causes of shock (distributive, hypovolaemic, cardiogenic and obstructive), but the cause is not always clear. With a logical approach and remembering the key five variables (cardiac output, heart rate and rhythm, preload, afterload and contractility), it is possible to implement supportive measures, including medications targeted towards the problem area.
Left ventricular assist device
Dr Jane Cannon (Golden Jubilee National Hospital, Glasgow) explained how the left ventricular assist device (LVAD) is surgically implanted into the left ventricular apex and then pulls blood from the left ventricle into the motorised Impella® and then out into the ascending aorta. Patients with an LVAD may not have a palpable pulse or recordable blood pressure using standard methods, so it is important to assess the patient clinically and also perform a Doppler blood pressure reading where possible. The most frequent issues in LVAD patients include infection of the drive line, thrombus in the motor and bleeding due to ‘warfarinisation’. Clinicians are advised to contact the ventricular advice device (VAD) centre early should patients present elsewhere with any VAD issues.
Adult congenital heart disease
Dr Niki Walker (University of Glasgow) is an adult congenital heart disease (ACHD) expert and she highlighted the importance in asking patients about their own baseline parameters, including oxygen saturations. ACHD is an increasing specialty, particularly in the number of patients surviving to adulthood with complex congenital conditions. Those hospitalised with heart failure and ACHD currently have a one-year mortality after hospital admission, and thus an admission should be seen as an opportunity to improve care. The main precipitants for decompensated heart failure in this group are arrhythmia, infection, endocrine abnormalities, and structural change. Young adults with ACHD may present more insidiously with heart failure and so specialists need to look for it carefully, and escalate to ACHD and advanced heart failure services where necessary.
Pregnancy
Approximately 80–90% of those who die in pregnancy of cardiac disease had no known cardiac diagnosis prior to this devastating event. Dr Lorna Swann (Golden Jubilee National Hospital, Glasgow) showed the two peaks in morbidity and mortality are at 23–24 weeks of gestation and at delivery. This earlier peak is particularly challenging as it is the grey zone for foetal viability and, therefore, can make decision making about management even more difficult. Symptoms of heart failure and normal pregnancy can overlap, but symptoms such as chronic cough, orthopnoea, atrial fibrillation, cyanosis, diastolic murmur and loud systolic murmur should trigger high suspicion for heart failure. It is important to involve all the right specialists early when managing a pregnant patient with cardiac disease, including intensive care, obstetricians and the labour ward, neonatologists, the cardio-obstetric team, the transplant and mechanical circulatory support team, and pharmacy.
Breakout sessions
Devices
Dr Parin Shah (Golden Jubilee National Hospital, Glasgow), Dr Phil Matthews (Golden Jubilee National Hospital, Glasgow) and Dr Zaheer Yousef (University Hospital of Wales) worked alongside device industry experts to run a workshop on cardiac devices, including a practical approach to device decision making, as well as implantation, monitoring and deactivation. It is important to consider each patient individually when deciding if device implantation is appropriate, and which device they should receive. Additionally, for those heart failure patients who receive a defibrillator implant, it is imperative to start talking about device deactivation early, prior to the stage where a patient may deteriorate. As heart failure becomes more advanced the probability of sudden cardiac death (SCD) from cardiac arrhythmia decreases, and thus it may be appropriate to deactivate the defibrillator. MERIT-HF (Metoprolol CR/XL randomised intervention trial in congestive heart failure)showed that 64% of those who died with New York Heart Association (NYHA) class II died of sudden cardiac death versus 27% of those with NYHA IV.
Imaging
This breakout session focused on the use of imaging in heart failure and was run by Dr Alison Duncan (The Royal Brompton, London) and Dr Lisa Anderson (St George’s Hospital, London). Constrictive and restrictive cardiomyopathy can be challenging to differentiate, but echocardiography can be used alongside clinical signs to make a diagnosis non-invasively. While echocardiography is the first-line investigation in suspected heart failure, cardiac magnetic resonance imaging can supply additional information about the aetiology and prognosis of heart failure, due to the ability to characterise myocardial tissue and to provide simultaneous imaging of the thorax.
Psychological support and safety
Support for patients and their families
Dr Annabel Farnood (University of Glasgow) spoke about heart failure online health information and specifically about what patients with heart failure want to know and how this can be provided. She highlighted online forums that can be used as a source of support for patients with heart failure, but that sometimes can contain misleading information. It is, therefore, important that patients are given the opportunity to discuss information they have found online. The audience benefited from hearing from two service users, Mr Laurence Humphreys-Davies and Mrs Wendy Panton who reported the benefits of a multidisciplinary team and the need for signposting to support groups.
Psychotropic drugs
A presentation from principal pharmacist Dr Siobhan Gee (South London and Maudsley NHS Foundation Trust) about psychotropic drugs in patients with comorbid physical illness was particularly well received. About one in five patients with heart failure meet the diagnostic criteria for depression, so it is vital that heart failure specialists screen carefully for depression. For patients with heart failure and depression alone, sertraline is recommended as the first-line treatment, however in certain patients, sertraline and other serotonin receptor inhibitors can increase the risk of bleeding, particularly in those on dual antiplatelets due to inhibiting platelet aggregation. Other psychotropic medications such as mirtazapine and agomelatine may need to be considered.
HFpEF in the real world
Professor John McMurray (University of Glasgow) gave an impassioned overview of heart failure with preserved ejection fraction (HFpEF) evidence and the challenges in its management. Recent studies, such as EMPEROR-Preserved (Empagliflozin outcome trial in patients with cohort failure with preserved ejection fraction) give some hope for evidence, although the updated ESC guidelines for HFpEF management were published prior to EMPEROR-Preserved reporting and thus sodium-glucose co-transporter-2 (SGLT-2) inhibitors were only given a class IIa recommendation by the ESC, which means they may be considered. Diuretic therapy in HFpEF remains an IC recommendation, which means the benefits appear to outweigh the risks. Professor McMurray also advised that based on the TRED-HF (Therapy withdrawal in recovered dilated cardiomyopathy – heart failure) trial, prognostic heart failure medication should be continued in those who recover their ejection fraction, and the DELIVER (Dapagliflozin evaluation to improve the lives of patients with preserved ejection fraction heart failure) trial will also report on this. The FINEARTS-HF (Finerenone in heart failure patients) study is currently recruiting and will look at the impact of adding finereone in those with LVEF >40%.
Infiltrative cardiomyopathy
Storage and infiltrative cardiomyopathies can cause HFpEF. Dr Joanna Simpson (University of Glasgow) described the diverse group of diseases that can have overlapping phenotypes, although most initially cause increased left ventricular wall thickness with preserved ejection fraction, but can then relate in dilatation and impaired function. A diagnosis of amyloid is often difficult, and patients can be known to several specialties without a unifying cause being identified until the late stages of the condition. Fabry’s disease is an uncommon, but treatable cause of cardiomyopathy, and must be considered in unexplained left ventricular hypertrophy.
Multidisciplinary team and service models
Dr Sue Piper (King’s College, London) noted heart failure is a multi-morbid complex condition, with a mean patient age of 77 years. This means heart failure specialists must consider each patient holistically, and work closely with the MDT, including other specialties. The patient should be placed at the heart of the multidisciplinary team, particularly now patient care is becoming more complex and in a wider range of settings. The National Institute of Clinical Excellence (NICE) and the ESC both give IA levels of support that a heart failure MDT improves care for the patient, as it is backed up with data from multiple randomised clinical trials. Furthermore, the National Confidential Enquiry into Patient Outcome and Death report, Failure to function, Getting it right first time4 report both state the need for an effective heart failure multidisciplinary team.
Nurse-led medication initiation
Miss Norma Caples (Waterford, Ireland) presented her groundbreaking nurse-led medication initialisation service, where she starts patients on the four pillars of heart failure therapy (angiotensin-converting enzyme [ACE] inhibitors, angiotensin receptor neprilysin inhibitor [ARNI], beta blocker, mineralocorticoid receptor antagonists [MRA], SGLT-2 inhibitors) within a four-week period.This is based on Packer and McMurray’s paper recommended rapid sequencing5. She managed to establish 90% of her patients on all four pillars within four weeks, and found the average BNP fell from 2230 before to 1398 afterwards. Additionally, many patients reported an improvement in functional class, and her re-admission rate fell from 13% locally (25% nationally) to 3.7%.
Advanced heart failure assessment
Dr Jonathan Dalzell (Scottish National Advanced Heart Failure Service) talked about features that he would encourage clinicians to see as a prompt for referral, including inotrope dependency, NYHA III-IV, end organ dysfunction, reducing ejection fraction, defibrillator therapy, escalating diuretic need, and hypotension. Mechanical circulatory support (MCS) such as LVAD can be used as a bridge to transplant or bridge to candidacy for transplant in those who have other issues that need to be addressed prior to being eligible for transplant listing. Advanced heart failure services can provide a full workup for MCS and/or transplant and patients should be referred early for consideration.
Cardiotoxicity
Dr Ninian Lang (University of Glasgow) told the meeting that cancer survival has doubled since the 1970s, and therefore cardiac consequences of successful cancer treatment must be identified. The two main types of cardiotoxicity are divided into myocardial damage, which is usually reversible (type 1) and irreversible myocardial injury (type 2). Immune checkpoint inhibitor usage is rapidly increasing for malignancy and associated myocarditis should be treated by stopping the agent and giving five days of IV methylprednisolone.
Much-needed opportunity
This meeting was a much-needed opportunity to assemble face to face and to re-establish links between heart failure specialists. The multidisciplinary focus enabled dynamic and diverse discussion between attendees, and new connections and plans have been made that will further benefit the wider heart failure specialist community, and thus improve the care for heart failure patients.
References
1. Escobar-Lopez et al. (2021); ‘Association of genetic variants with outcomes in patients with non-ischaemic dilated cardiomyopathy’ Journal of the American College of Cardiology 2021 Oct 26;78(17):1682-1699
2. Mogensen UM, Jhund PS, Abraham WT, Desai AS, Dickstein K, Packer M, Rouleau JL, Solomon SD, Swedberg K, Zile MR, et al. (2017) ‘Type of atrial fibrillation and outcomes in patients with heart failure and reduced ejection fraction.’ Journal of the American College Cardiology. 2017;70(20):2490–2500
3. Stone G, Lindfield K, Abraham W et al. Transcatheter mitral-valve repair in patients with heart failure. N Engl J Med 2018;379:2307–18. https://doi.org/10.1056/NEJMoa1806640
4. Failure to function, Getting it right first time www.gettingitrightfirsttime.co.uk
5. Packer and Murray (2021) ‘Rapid evidence based sequencing of foundational drugs for heart failure and a reduced ejection fraction.’ Euorpean Journal of Heart Failure 2021;23(6):882-894
