Background, recognition and differentials.

By Dr L Axten

Clinical Context900,000 people affected by heart failure in the

UK.About the same amount of patients again with

damaged hearts and no symptoms as yet.Risk of heart failure greater in men but more

women with HF.Incidence and prevalence rise with age- 1 in 35 aged 64-74 1 in 15 aged 75-84 1 in 7 aged 85 & over

Clinical Context ContinuedPrevalence of HF expected to rise due to the

aging population, improved outcomes for those with IHD and better treatments for HF.

Causes-previous MI, also associated with HTN & AF. Damage to heart structures-dilated cardiomyopathy.

PrognosisPoor30-40% mortality in one yearThereafter mortality is 10% a yearPrognosis has improved in the last ten yearsYounger patients do better, as do those

without co- morbiditiesHF failure has a massive impact on quality of

life and is associated with mood disorder

GP perspectiveOn average a GP will have 30 patients on

their list with HFA GP will have on average 10 new diagnosis

per yearDeprived areas have a higher incidence of HFGP consultations cost approx £45m a yearWith referral to OPD costing approx £35m a

yearCost of community pharmacy being £129m a

year

NHS perspective1 million in-patient beds per day5% of all admissions to MAUHospital admissions for HF are expected to

rise by 50% over the next 25 yearsProtracted hospital admission 7-9 days1 in 4 readmissions in 3 months

Patients perspectiveAffect on quality of lifeLoss of earningsMood disordersPhysical limitationMany patients receive sub optimal treatment

Diagnosing heart failureWhat are the signs and symptoms of heart

failure?

Diagnosing Heart FailureSigns and symptoms of HF are often non specificCommon-breathlessness, during activity or at

rest (PND or orthopnoea) FatigueExercise intolerance Fluid retentionNon-specific symptoms of heart failure include

nocturia, anorexia, abdominal bloating and discomfort, constipation, and cerebral symptoms such as confusion, dizziness and memory impairment

Signs and symptoms do not correlate to the severity of heart damage

Diagnosing heart failure 2Raised JVP has high predictive value for HF

but is not often presentTachycardia, third heart sound, displaced

apex beat are not significant to HF in isolation

Lung crepitationsHepatomegaly

New York Heart Association Classification of heart failure

Grade 1- No limitations.Grade 2- Slight limitations on physical activity.

Ordinary activity results in breathlessness, palpitations, fatigue or angina. (Mild HF)

Grade 3- Marked limitation of physical activity. Comfortable at rest although less than ordinary physical activity will lead to symptoms in grade 2. (Moderate HF)

Grade 4- Inability to carry out physical tasks without discomfort. Symptoms present at rest. (Severe HF)

DifferentialsMany conditions present with symptoms similar to

HFObesity, chest disease, venous insufficiency, drug

induced ankle swelling (calcium channels blockers), drug induced fluid retention (NSAID’s),

Hypoalbuminaemia Intrinsic renal or hepatic diseasePulmonary embolic diseaseDepression and anxietySevere anaemia or thyroid diseaseBilateral renal artery stenosis