27 Heart Rate Control in High Risk Heart Failure Patients

Abstract

Introduction NICE estimates that 900,000 people in the UK have heart failure (HF). It is well established that beta adrenoceptor blockade improves prognosis in HF patients via a variety of proposed mechanisms, including reduction in heart rate. In recent years, there has been an increased focus on heart rate control. The SHIFT trial (Systolic Heart failure treatment with If inhibitor Ivabradine Trial), found a reduction in mortality and hospital admissions in selected patients due to a rate-related effect. These findings have been incorporated in the NICE guidelines; Chronic Heart Failure- Ivabradine. Aims This study looks into a high risk HF population who have had two or more hospital admissions within a year to Lancashire Teaching Hospitals (LTHTr). The study looked at whether heart rate is being adequately controlled prior to discharge and whether beta-blockers are being maximally uptitrated. Patients who did not have a heart rate within target range, were assessed for their suitability to Ivabradine, thus assessing this new medication’s role within a high risk HF group. Methods A retrospective review of 100 patient’s case notes was carried out. Their heart rate upon discharge 1 and discharge 2 were analysed, alongside their beta-blocker dose and whether this was maximally up-titrated. For those whose heart rate was not adequately controlled, their suitability for Ivabradine was assessed. Results 32 patients died on their second admission to hospital, or were discharged to a hospice. After the second admission, only 30% of patients were on maximally tolerated beta-blocker therapy. Between hospital admissions, 14% had their beta-blocker down-titrated, 36% had no up-titration of beta-blocker. From the hospital notes, it was difficult to ascertain the reasons for this. On the second discharge; the average heart rate was 77, with 71% of patients having a heart rate which was above the target range (75bpm). Out of these patients, 24 patients were suitable candidates for Ivabradine. Conclusion/implications The population audited had a demonstrated high mortality rate. The common themes of lack of beta-blocker titrated and communication between primary and secondary care were evident. Patient’s heart rates are not being properly controlled prior to discharge, despite two admissions, and two opportunities to do so. Whilst many patients do not fulfil the criteria for Ivabradine, a high proportion of audited patients would be candidates. This is an important new medication on the HF market, which should be considered in appropriate HF patients. LTHTr is trialling a ‘heart failure passport’, in order to facilitate communication between the GP and hospital setting, and provide a summary of the patient’s care. They are also using a heart failure ‘sticker’ in the medical notes, aimed at encouraging all health professionals to employ a holistic approach to these patients, and of course, consider heart rate.