heart failure.doc - Heart Failure protocol These guidelines...

Heart Failure protocol
These guidelines apply to those with reduced LV ejection fraction or LV
systolic dysfunction. In patients with preserved ejection fraction >50%,or
diastolic heart failure, the evidence base for treatment remains unclear.
Risk factors
Age > 65, IHD, HT, AF, valvular heart disease, renal failure, anaemia,
thyrotoxicosis, myocarditis and cardiomyopathy.
Diagnosis of suspected Heart failure.
If previous MI – refer within 2 weeks (NICE CG 108 2010 Chronic heart
failure )
If no previous MI – check BNP:
1. 100-400 : refer* within 6w.
2. > 400: refer* within 2w.
3. Normal <100 : consider other diagnosis.
Other causes of a raised BNP = LVH, ischaemia, tachycardia, RV overload,
hypoxaemia (inc. PE), GFR <60, sepsis, diabetes, COPD, age >70 and liver
cirrhosis.
Beware, BNP levels are reduced by heart failure treatment such as ACE,
diuretics and betablockers )
*Refer = refer cardiology and Echo.
Then, evaluate further:
ECG.
Consider, CXR
Bloods (creatinine, electrolytes, eGFR, TFT, lipids, glycoHb , FBC.
Note ESR raised in HF so CRP used to detect inflammation
Urinalysis.
Peak flow or spirometry.
. .
Ensure they have the ‘CCF’ G58..% Read code once the diagnosis has
been confirmed with Echo and promote to major active problem .
NB: If confirmed LV systolic dysfunction , add ADDITIONAL code (see
below)
1

New York Heart Association Classification
Grade Read Symptoms Mortality at 12 months
I 662F No limitation of normal activity
II 662G Some limitation of normal activity 15%
III 662H Severe limitation of normal activity 30%
IV 662I SOB at rest 60%
Indications for referral
1. Initial diagnosis.
2. Managing severe HF (NYHA class IV), HF not responding to
treatment , HF due to valve disease or HF which can no longer be
managed at home.
3. Pregnant or preconception.
Treatment
1. PROGNOSIS improvement in LVSD .
NB: code LVSD if diagnosed, as well as CCF/HF : XaJ98 and XaIIq.
(see QOF : HF 003 and 004 – those patients with HF due to LVSD the %
currently treated with and ACEI – or ARB . And the % of those patients who
are additionally treated with a BB)
 First line treatment ; both ACE inhibitors and, Betablockers; titrated to
maximal tolerated doses.