blood transfusion

1. Management of Heart
Failure in 2014
Dr CJ Whelan MD FRCP
Consultant Cardiologist and
Honorary Senior Lecturer
Royal Free London NHS Foundation Trust

2. DIAGNOSIS
Chronic heart failure
A complex syndrome
that can result from
any structural or
functional cardiac
disorder that impairs
the pumping ability
of the heart

3. HF Clinic Patient
 RS is a 69 yr old gentleman recently referred
to the HF team.
 He has a history of LV dysfunction with an EF
of 20% due to IHD.
 He has had recent multiple admissions to
hospital with worsening symptoms NYHA IV.
 He is now in NYHA III
 With PND, orthopnoea and pitting oedema to
his knees
 He has LBBB on his ECG with a QRS of 160
ms

4. Medication
 During last admission beta blocker has
been stopped due to symptomatic
bradycardia.
 ACE I has been reduced due to
worsening renal function and
symptomatic hypotension.
 Spironolactone has been reduced due
to hyperkalaemia

5. Further Management
 What next?

6. Treatment
 After discussion at the HF MDT,
referred for Biventricular PPM (CRT)
with ICD.
 He was brought into a pre assessment
clinic and assessed and counselled by
the HF nurse.
 He was admitted for CRT-D the next
week

7. 6 months later
 RS was followed up in the nurse Led HF clinic 2-4 weekly
for assessment and titration of medication.
 Beta Blocker was reinstated and he is now tolerating 10
mg Bisoprolol.
 His ACE I was reintroduced and slowly titrated - now on
5mg Ramipril
 He is tolerating 50 mg Spironolactone
 His renal function is normal
 He is biventricular paced
 He is in NYHA II
 An echo was repeated showing an improvement with EF
35-40%
 He attends a cardiac rehab exercise class regularly
 He has not been admitted to hospital since his CRT-D was
implanted

8. Case 2
 ED is a 67 yr old gentleman
admitted to the medical ward with
a history of breathlessness and
bilateral ankle oedema. He has had
a reduction in exercise tolerance
over the last three months and has
experienced PND and orthopnoea
for a few days prior to admission.

9. Past Medical History
 STEMI 2008
 PPCI to LAD 2008
 HTN
 Hyperlipidaemia
 Arthritis

10. Drugs on admission
 Atenolol 25 mg od
 Perindopril 2 mg od
 Simvastatin 40 mg od
 Aspirin 75 mg od
 Piroxicam 20mg od

11. Social
 His wife has recently died and he
now lives alone.
 He is retired
 He has two grown up daughters
living in Manchester and Scotland.
 He drinks up to 5 pints of beer every
Friday and Saturday night.
 He eats mainly microwave meals
 He is a current smoker of 5
cigarettes per day for 50 yrs.

12. Observations
 BP 160/90 mmHg
 HR 100bpm reg Sinus Rhythm
 Respirations 22/min
 Bilateral basal creps
 Third heart sound
 His ECG shows SR with anterior q
waves
 His Chest x Ray shows Pulmonary
oedema

13. Further Findings
 NT proBNP is raised on admission at
560pmol/L
 Echo carried out the day after
admission shows impaired LV systolic
function with an EF of 20% and severe
AS
 He is referred to the HF team.

14. HF Review
 He is assessed the next day.
 Diagnosis LV dysfunction due to IHD and severe
AS
 Stop Piroxicam
 PLAN: Change Atenolol to Bisoprolol 2.5 mg
titrating up as tolerated, aim for a resting HR of
<70 bpm
 Commence Furosemide
 Commence Spironolactone 12.5 mg titrating up
to maximum tolerated dosage
 Aim to increase perindopril if BP and renal
function will allow to the maximum tolerated
dosage.
 Regular bloods for renal function

15. Life Style advice / Education
 Reduction in salt and advice on changing
his diet from convenience foods
 Reduction in alcohol intake
 Highlight the importance of compliance of
medication
 Explain possible symptoms and the
importance of reporting any changes in
symptoms to the HF team.
 Encourage stopping smoking, referral to
cessation, give patches.

16. Discharge
 Mr Smith is discharged after 4 days on
the medical ward, with a plan for FU in
the HF clinic in 2 weeks.
 His U&E s were normal
 His HR was 70 bpm on 5 mg of
Bisoprolol
 BP 120/80 on perindopril 4 mg
 His chest was clear

17. Follow up
 He was seen two weeks later in the HF
clinic.
 His U&Es were checked showing his
creatinine had increased to 161 umol/l
and urea up to 15.4 umol/l
 He was reporting symptoms of
increasing lethargy and dizziness
 His HR was 50bpm SR BP 100/50

18. Treatment plan
 Reduce Bisoprolol to 2.5 mg
 Reduced Perindopril back to 2 mg
 Plan to recheck U&E s in one week
 Readmitted with worsening HF
symptoms
 Blood renal chemistry deteriorates
further despite stopping ACEI –
creatinine 288 umol/l
 Renal review

19. Ongoing management
 Joint care between HF team and
renal team
 Started on haemodialysis
 Becomes euvolaemic with
improvement in HF symptoms
 Discussed at HF MDT

20. Further progress
 Referred for consideration of TAVI
in view of severe AS
 TAVI performed December 2013
Heart Hospital
 Repeat echo March 2014 shows
improvement of LV function to 35%
 Now on 8mg perindopril, 7.5mg
bisoprolol and 25mg
spironolactone
 In NYHA class II

21. Size of the problem
Summary
Common
 Affects 1-2% of the population
 Annual incidence is 0.5-1%
Serious (but improving)
 40% mortality at 1 year, 10% per year thereafter
Increasing
 Ageing population and better treatment of acute MI
Disabling
 Symptoms have enormous impact on quality of life, worse than
many other chronic conditions
Expensive
 Around 2% of NHS budget, 5% of acute admissions,
and 10% of bed occupancy
EPIDEMIOLOGY AND HEALTH
SERVICE IMPACT
BMJ, 2002; Eur J Heart Failure, 1999; NICE, 2003; BHF, 2002; DOH 2009

22. HF GUIDELINES

23. The NICE algorithm for new diagnosis 2010
Adapted from NICE 2010.

24. TREATMENT

25. Aims of treatment of chronic heart failure
 The aims of therapy in heart failure are to:
• Improve life expectancy
• Improve quality of life
 The relative importance of these aims varies:
• Between patients
• Over time
TREATMENT
NICE, 2003

26. Modern management
 The therapeutic approach in chronic heart
failure due to systolic dysfunction consists of:
• Non-pharmacological measures
 Patient education
 Avoid obesity
 Dietary measures e.g. salt restriction if
prescribed
 Avoid excessive fluid intake
 Smoking cessation
 Exercise/rehabilitation
 Influenza/pneumococcal vaccination
• Pharmacological therapy
• Devices and surgery ESC, 2008
TREATMENT

27. Co-morbidities that may impact
on treatment (1)
Co-morbidity Comments
COPD/asthma/reversible
airways disease
Beta-blockers are contraindicated in
patients with reversible airways disease
Renal dysfunction
(serum creatinine > 200
µmol/l)
ACE inhibitors and angiotensin II receptor
blockers may be contraindicated
NICE, 2003
TREATMENT
Adapted from NICE 2003.

28. Treatment options for chronic heart failure
Drug therapy
 Diuretics
 Neurohormonal antagonists
• ACE inhibitors
• Beta blockers
• Mineralocorticoid antagonists
• Angiotensin II receptor blockers
 Ivabradine (If channel blocker)
 Digoxin
 Other drugs
• Amiodarone
• Nitrates/Hydralazine
• Aspirin
• Warfarin
TREATMENT

29. Diuretic therapy
 Rapid relief of congestive symptoms and
fluid retention, improving:
• Breathlessness
• Exercise performance
 May be titrated according to need following
initiation of subsequent therapies
 No evidence for mortality benefit
 No effect on disease progression
“Diuretics should be routinely used for the relief of congestive
symptoms and fluid retention in patients with heart failure, and titrated
(up and down) according to need following initiation of subsequent
heart failure therapies”
NICE, 2003
TREATMENT

30. Use of oral diuretics
NICE, 2003
Drug Initial dose
(mg)
Maximum recommended
daily dose (mg)
Loop diuretics
Bumetanide
Furosemide
Torasemide
0.5–1.0
20–40
5–10
5–10
250–500
100–200
Thiazides*
Bendroflumethiazide (bendrofluazide)
Indapamide
Metolazone
2.5
2.5
2.5
5
2.5
10
Potassium-sparing diuretic
Amiloride
Triamterene
+ACEI –ACEI
2.5 5
25 50
+ACEI –ACEI
20 40
100 200
*May be effective when added to loop diuretics when fluid retention is resistant, but can
promote dramatic diuresis and disturbance in fluid balance and electrolytes. Patients must be
closely monitored and specialist advice is required. ACEI=ACE inhibitor
TREATMENT
Adapted from NICE et al. 2003.

31. ACE inhibitor therapy for heart failure
and LVSD
 Systematic overview of data
from five long-term RCTs
 Compared with placebo,
ACE inhibitors reduce:
• Mortality (p<0.0001)
• Readmission (p<0.0001)
• Reinfarction (p<0.0001)
 Benefit begins early after
the start of therapy and
persists in the long-term
Flather et al, Lancet; 2000
TREATMENT
5
Cumulative
mortality (%)
40
30
20
10
0
0 1 2 3 4
Time since randomisation (years)
All trials
ACE-1
Placeb0
6391
6372
5378
5279
4204
4025
2457
2364
892
742
Adapted from Elather et al. 2000.

32. ACE inhibitor therapy for heart failure
due to LVSD
“All patients with heart failure due to left
ventricular systolic dysfunction should be
considered for treatment with an ACE inhibitor.
ACE inhibitor therapy should be instituted in
patients with heart failure due to left ventricular
systolic dysfunction before beta-blockade is
introduced.”
“ACE inhibitor therapy should be initiated at the
appropriate dose, and titrated upwards at short
intervals (eg every two weeks) until the optimal
tolerated or target dose is achieved.”
NICE, 2003
TREATMENT

33. Practical recommendations on use of
ACE inhibitors (1)
How to use
 Start with a low dose
 Seek specialist advice where the patient is on a high dose (eg
furosemide 80mg) of a loop diuretic
 Double dose at not less than two weekly intervals
 Aim for target dose or the highest tolerated dose
 Remember some ACE inhibitor is better than no ACE inhibitor
 Monitor blood electrolytes (in particular potassium), urea,
creatinine and blood pressure
NICE, 2003
If the patient develops a troublesome dry cough which
interferes with sleep and is likely to be caused by an ACE inhibitor,
consider substituting an angiotensin-II receptor blocker
TREATMENT

34. Practical recommendations on use of
ACE inhibitors (2)
Advice to patients
 Explain expected benefits
 Treatment is given to improve symptoms, to prevent
worsening of heart failure and to increase survival
 Symptoms improve within a few weeks to a few months
 Advise patients to report principal adverse effects, i.e.
dizziness/symptomatic hypotension, cough.
NICE, 2003
TREATMENT
If the patient develops a troublesome dry cough which
interferes with sleep and is likely to be caused by an ACE inhibitor,
consider substituting an angiotensin-II receptor blocker

35. Beta-blocker therapy for heart failure
due to LVSD
 Pooled data from 25
RCTs (6511 patients and
810 deaths)
 Compared with placebo,
beta-blockers reduced
odds of death by 36%
• (95% CI 25% to 45%)
 No evidence of
heterogeneity between
trial results
 Benefit is additional to
that of ACE inhibitors
Cleland et al, BMJ, 1999
TREATMENT
Bisoprolol pooled (2 trials)
Bucindolol pooled (4 trials)
Carvedilol pooled (5 trials)
Metoprolol pooled (9 trials)
5 small trials
Overall (25 trials)
Fig 1 Pooled odds ratios (and 95% confidence intervals)
describing the effect of beta blockers on mortality in
patients with heart failure
Fig 2 Effect on annual rate of mortality (%) of angiotensin
inhibitors alone, with beta blockers added, and with both
drugs. Risk differences and 95% confidence intervals.
ACE inhibitors alone
Beta Blockers added
Combined effect
Absolute reduction in mortality in
1 year attributable to treatment (%)
0.1 0.2 0.5 1 2 5 10
-8 -6 -4 -2 0
Adapted from Cleland et al. 1999.

36. All patients with heart failure due to LVSD should be
considered for treatment with a beta-blocker (2)
How to use?
NICE, 2003
TREATMENT
 Start with a low dose
 Double dose at not less than two weekly intervals
 Aim for target dose (see above) or, failing that, the highest
tolerated dose
 Remember some beta-blocker is better than no beta-blocker
 Monitor heart rate, blood pressure, clinical status
(symptoms, signs, especially signs of congestion and body
weight)
 Check blood electrolytes, urea and creatinine one to two weeks
after initiation and one to two weeks after final dose titration

37. When starting a patient on a beta-blocker (1)
Ensure that the patient
TREATMENT
 Understands the expected benefits of beta-blockers:
 prevent worsening of heart failure
 improve symptoms (but may take 3-6 months or more)
 increase survival
 Knows that symptoms may deteriorate during initiation / up-
titration phase
 Knows that beta-blockers should not be stopped without first
seeking advice
 Understands that any deterioration (tiredness, fatigue,
breathlessness) should be reported as this can be easily
managed by adjusting other drugs
 Is encouraged to weigh themselves each day (after waking,
before dressing, after voiding, before eating)
NICE, 2003

38. When starting a patient on a beta-blocker (2)
If patients experience worsening symptoms/signs
TREATMENT
NICE, 2003
 Congestion – double dose of diuretic or halve dose of
beta-blocker
 Fatigue – halve dose of beta-blocker (rarely necessary)
 Review patient in 1-2 weeks; if not improved seek
specialist advice
 Serious deterioration – halve beta-blocker dose or stop
treatment and seek specialist advice

39.  The Randomised Aldactone
Evaluation Study (RALES)
 1663 patients with NYHA III or IV
heart failure and ejection fraction
≤35% who were already treated with
ACE inhibitor, diuretic ± digoxin
 Spironolactone 25mg od vs placebo,
with patients followed for an average
of 2 years
 30% reduction in the risk of death
(p<0.001) and 35% reduction in risk
of hospitalisation (p<0.001) among
patients randomised to
spironolactone
Mineralocorticoid receptor antagonist
(MRA) therapy for heart failure due to
LVSD
Pitt et al, N Engl J Med, 1999
TREATMENT
Probability
of Survival
P < 0.001
RRR=0.30 (0.18-0.40)
Spironolactone
Placebo
Months
0 3 6 9 12 15 18 21 24 27 30 33 36
0.00
0.45
0.50
0.55
0.60
0.65
0.70
0.75
0.80
0.85
0.90
0.95
1.00
Adapted from Pitt et al. 1999.

40. NICE recommendation on spironolactone
Patients with heart failure due to LV systolic dysfunction
who remain moderately to severely symptomatic despite
optimal therapy should be prescribed spironolactone at a
dose of 12.5 to 50 mg once per day – specialist advice
should be sought
Patients with heart failure taking spironolactone should
have blood potassium and creatinine levels monitored
for signs of hyperkalaemia and/or deteriorating renal
function. If hyperkalaemia is a problem then the dose of
spironolactone should be halved and biochemistry
rechecked
• Symptom improvement occurs within a few weeks to a few months of starting
treatment
• Patients should avoid NSAIDs (including OTC products e.g. ibuprofen)
• Temporarily stop spironolactone if diarrhoea and/or vomiting and contact
physician
• Male patients may develop breast discomfort and/or gynaecomastia
NICE, 2003
TREATMENT

41.  3313 patients were randomised to eplerenone
25 mg/day and 3319 to placebo (in addition to
‘standard’ medical therapy).
 Mean follow-up of 16-months. Among those
taking eplerenone there was:
• 15% relative risk reduction in all-cause death
(p=0.008)
• 13% relative risk reduction in cardiovascular
death or hospitalisation (p=0.002)
• 21% relative risk reduction in sudden cardiac
death ( p=0.03)
 Compared with spironolactone, eplerenone is
less likely to cause gynaecomastia or breast
tenderness, but K+ monitoring is still essential.
Mineralocorticoid receptor antagonist
therapy for
heart failure after MI
EPHESUS trial
Pitt et al, N Engl J Med, 2003
TREATMENT
36
No. at Risk
Placebo
Eplerenone
Cumulative
Incidence (%)
Months since Randomization
p=0.008
RR=0.85
0 3 6 9 12 15 18 21 24 27 30 33
0
5
10
15
20
25
30
35
40
Placebo
Eplerenone
3313
3319
3064
3125
2983
3044
2830
2896
2418
2463
1801
1857
1213
1260
709
728
323
336
99
110
2
0
0
0
0
0
Adapted from Pit et al. 2003.

42. 0 6 12 18 24 30
40
30
20
10
0
Primary composite end point
(CV death or hospital admission for worsening HF)
Cumulative frequency (%)
Placebo
Ivabradine
HR = 0.82 (0.75–0.90)
P < 0.0001
Swedberg K, et al. Lancet. 2010;376:875-885.
Months
18% RRR

43. New EU license for ivabradine
February 2012
“Ivabradine is indicated in chronic heart failure NYHA II to
IV class with systolic dysfunction, in patients in sinus
rhythm and whose heart rate is ≥ 75 bpm, in combination
with standard therapy including beta-blocker therapy or
when beta-blocker therapy is contraindicated or not
tolerated.”

44. Digoxin
 The oldest established treatment
for heart failure
 Digoxin has a narrow therapeutic
window
 Arrhythmias and gastrointestinal
side effects are common
TREATMENT

45. How useful is digoxin?
The DIG trial
 6800 patients with heart failure (EF45%) already on diuretic + ACE inhibitor
 Randomised to digoxin or placebo, 250 g/day (mean dose) and followed for
average of 37 months
 No difference in total mortality (p=0.80)
 28% relative risk reduction in death or hospitalisation due to worsening HF
(p<0.001)
DIG, N Engl J Med, 1997
TREATMENT
40
30
20
10
0
0 4 8 12 16 20 24 28 32 36 40 44 48 52
Placebo
Digoxin
p=0.80
Months
Mortality
from
Any
Cause (%)
40
30
20
10
0
0 4 8 12 16 20 24 28 32 36 40 44 48 52
Placebo
Digoxin
P<0.001
Months
Death or
Hospitalisation
Due to
Worsening
Heart
Failure (%)
Adapted from DIG 1997. Adapted from DIG 1997.

46. NICE recommendation on digoxin
• Digoxin is recommended for:
• worsening or severe heart failure due to LV
systolic dysfunction despite ACE inhibitor,
beta-blocker and diuretic therapy
• patients with atrial fibrillation and any degree
of heart failure
 Several drugs can alter the pharmacokinetics of digoxin, especially:
 anti-arrhythmic drugs affecting renal clearance and/or volume
of distribution (verapamil, amiodarone, propafenone and
quinidine)
 drugs increasing its absorption (erythromycin, omeprazole and
tetracycline)
 drugs decreasing its absorption (colestipol, cholestyramine)
NICE, 2003
TREATMENT

47. 2012

48. 2012

50. Other medical treatments (1)
Anticoagulants
“Anticoagulation is indicated for patients with the
combination of heart failure and atrial fibrillation.”
“In patients with heart failure in sinus rhythm,
anticoagulation should be considered for those with a
history of thromboembolism, left ventricular aneurysm, or
intracardiac thrombus.”
Amiodarone
“The decision to prescribe amiodarone should be made in
consultation with a specialist. The need to continue the
prescription should be reviewed regularly.”
“Patients taking amiodarone should have a routine six-
monthly clinical review, including liver and thyroid function
tests, including a review of side effects.”
NICE, 2003
TREATMENT

51. Aspirin
“Aspirin (75–150 mg once daily) should be prescribed for
patients with the combination of heart failure and
atherosclerotic arterial disease (including coronary heart
disease).”
Calcium channel blockers
‘Amlodipine should be considered for the treatment of co-
morbid hypertension and/or angina in patients with heart
failure, but verapamil, diltiazem or short-acting
dihydropyridine agents should be avoided”
NICE, 2003
TREATMENT
Other medical treatments (2)

52. Other medical treatments (3)
Isosorbide/hydralazine combination
“An isosorbide/hydralazine combination may be used in
patients with heart failure who are intolerant of ACE
inhibitors or angiotensin-II receptor antagonists.”
Inotropic agents
“Intravenous inotropic agents (such as dobutamine,
milrinone or enoximone) should only be considered for the
short-term treatment of acute decompensation of chronic
heart failure. This will require specialist advice.”
NICE, 2003
TREATMENT

53. Statins in chronic heart failure
 Two randomised controlled trials — CORONA and
GISSI-HF — have shown no mortality benefit of statin
therapy in patients with chronic heart failure, irrespective
of its aetiology
Kjekshus et al, N Engl J Med 2007;
GISSI-HF investigators, Lancet 2008

54. ANYTHING NEW?

55. RELAXIN

56. Patient self-monitoring
 Patients can monitor their volume status by daily
weighing and appropriate adjustment of their diuretic
regimen
 Requires education and support
 Patients should be taught how to recognise early signs
of decompensation and how to seek professional help
 Heart failure nurse usually most appropriate
professional to ‘train’ patient
NICE, 2003
CHRONIC DISEASE
MANAGEMENT

57. Remote monitoring
 Remote monitoring of
patients’ clinical status
(telemonitoring) can improve
access to health care
 Facilitates earlier detection of
deterioration
 Acceptable and easy to use
by patients
 Likely to become part of a
modern heart failure
management programme
CHRONIC DISEASE
MANAGEMENT
Typical equipment for telemonitoring
Riley, Heart, 2009

58. Other treatment options
Surgery and devices
 Cardiac resynchronisation therapy (CRT)
 Implantable cardioverter defibrillator (ICD)
 Coronary revascularisation (PCI/CABG)
 Transplantation
 Left ventricular assist device (LVAD)
 Other invasive therapies
• Valve repair/replacement
• Left ventricular aneurysmectomy
NICE, 2003
TREATMENT

59. Treatment monitoring checklist
Follow-up interval should be a maximum of six months
CHRONIC DISEASE
MANAGEMENT
NICE, 2010

60. Side-effects of drugs commonly used
in the treatment of heart failure (2)
NICE, 2003
CHRONIC DISEASE
MANAGEMENT
Digoxin
 Common: nausea
 Serious: life threatening arrhythmias
Angiotensin II receptor blockers
 Common: hypotension including postural
 Serious: worsening renal function, renal infarction in renal artery
stenosis
Amiodarone
 Common: photosensitivity, nausea, thyroid dysfunction, sleep
disturbance, corneal microdeposits
 Serious: thyrotoxic storm, pro-arrhythmia, pulmonary/hepatic
fibrosis

61. Side-effects of drugs commonly used
in the treatment of heart failure (1)
NICE, 2003
CHRONIC DISEASE
MANAGEMENT
Diuretics
 Common: postural hypotension, gout, urinary urgency
 Serious: electrolyte imbalance (hypokalaemia, hypomagnesia,
hyponatraemia), arrhythmia
ACE inhibitors
 Common: cough, hypotension including postural
 Serious: worsening renal function, renal infarction in renal artery
stenosis, angio-oedema
Beta-blockers
 Common: tiredness, bradycardia, coldness
 Serious: asthmatic attack, exacerbation of heart failure, heart
block
Spironolactone
 Common: gynaecomastia, tiredness, rashes;
 Serious: hyperkalaemia, hyponatraemia

62. Improving adherence to drug therapy
 Non-adherence with treatment is associated
with a high risk of readmission to hospital
 Non-adherence may be reduced by:
• Simplifying drug dosing regimens
• Educating patients/carers about medicines,
and the reasons for taking them
NICE recommendation: Dosing regimens should be kept
as simple as possible, and the healthcare professional
should ensure that the patient and carer are fully informed
about their medication
NICE, 2003 & 2009
CHRONIC DISEASE
MANAGEMENT

63. Depression: common and important
 Consider depression in all patients with heart failure
 Studies suggest a prevalence of depression of around
30% in non-hospitalised patients with heart failure
 Diagnosis is more common in those with physical
symptoms and poorer physical functioning
 Depressive symptoms are strongly linked with a
worse outcome
Rumsfeld et al, 2003; Friedman et al 2001, Jiang et al, 2004
CHRONIC DISEASE
MANAGEMENT

64. End of life issues
 Palliative care aims to improve the quality of life
for terminally ill patients and to help family and
carers by:
• Providing symptom control
• Providing psychological and social support
• Planning for the future and providing end of life
care
 Specialist palliative care in cancer:
• Improves symptom control
• Reduces time spent in hospital
• Improves patient and carer choice and
satisfaction
• Reduces overall costs
 Anecdotal evidence suggests benefit in heart
failure
 Providing palliative care is complex
NICE, 2003
CHRONIC DISEASE
MANAGEMENT

65. Initiatives in end of life care
 First National End of Life Care
strategy
 ‘Better Together’ palliative care
service for heart failure patients
set up by British Heart
Foundation and Marie Curie
Cancer Care
CHRONIC DISEASE
MANAGEMENT

66. Communication is essential for good
discharge planning
 Patients with heart failure should generally be discharged
from hospital only when their clinical condition is stable
and their management plan is optimised
 The timing of discharge should take into account both
patient and carer wishes and the level of care and support
that can be provided in the community
 The primary care team, patient and carer must be aware
of the management plan
 Clear instructions should be given as to how the
patient/carer can access advice particularly in the high
risk period immediately following discharge
NICE, 2003
CHRONIC DISEASE
MANAGEMENT

67. THANK YOU
rf.heartfailure@nhs.net