Medicine for Members - Heart failure: a serious but treatable and reversible condition

Aug 26, 2023

Medicine for Members - Heart failure: a serious but treatable and reversible condition

This event showcased the amazing work of the Royal Free London’s specialist heart failure clinicians.

Content

0 -> so um my name's Tim Lockey I'm sorry we

2.46 -> had a couple of the inevitable I.T

4.44 -> issues

5.58 -> um with this no matter how much

6.779 -> preparation the team had put into this

9.96 -> which was very impressive I'd like to

11.34 -> thank George and everyone in the back

12.719 -> office uh lots of careful support and

15.42 -> everything

16.26 -> um we are meant to have a chair but

17.64 -> unfortunately she's not able to actually

18.779 -> join for some reason so I'm going to

20.52 -> kick off my name is Tim Lockey I'm a

22.32 -> consultant cardiologist at the Royal

23.76 -> free

25.38 -> um and this is a cross-site service not

27.48 -> just

28.92 -> um raw free of course we have other very

31.14 -> important institutions within our group

33.42 -> including a Barnet Chase Farm Finchley

35.82 -> edgeware and various other community

38.46 -> clinics that we'll discuss later

41.7 -> um it's my great pleasure to present the

43.98 -> heart failure team at the Royal free who

45.96 -> have been carrying out some incredibly

48 -> Innovative and really in many ways

50.16 -> life-changing work in the last few years

52.2 -> I think for a minute for a long time

53.82 -> heart failure had sort of been the

55.98 -> result of many cardiac problems and

58.26 -> there was once he got to that it was a

59.94 -> kind of a spiral downhill there wasn't

61.559 -> really much you could do other than just

63.3 -> very very basic treatment that hadn't

65.339 -> changed for about 20 years so there's

67.2 -> been some real Innovations in the last

69.24 -> few years and many of these have

71.64 -> genuinely been kind of total game

73.86 -> changers for our patients we're seeing

75.479 -> it both in terms of improvement in

77.88 -> symptoms reduction in hospital stay in

80.82 -> terms of their reducing the risk of

83.22 -> their bouncing back into hospital and

84.84 -> leaving a good independent quality of

86.52 -> life which is what we're all here for so

89.7 -> um but obviously in order to deliver

90.96 -> these treatments we need a fantastic

92.88 -> team and we need Diagnostics we need

95.04 -> support and we need the appropriate

98.04 -> setup to do that and that's what we're

100.079 -> going to be talking a little bit about

101.1 -> they both all through and across the

103.2 -> group and I'm delighted to have Carol

105.479 -> Whelan and meet Mackay who are to our

107.46 -> senior cardiologists who head up the

108.96 -> service to talk through some of their

111.299 -> work they've been doing so coming up

114 -> next slide please George

116.46 -> so to put all of this into context

119.88 -> um heart failure isn't a diagnosis and

121.86 -> it's such in itself in the fact that it

124.02 -> can be due to a whole variety of

125.759 -> different causes but it really describes

127.74 -> a syndrome or a constellation of

130.44 -> symptoms and clinical findings that can

133.26 -> result from any structural or functional

135.3 -> cardiac disorder that impairs the

137.459 -> pumping ability of the heart remember

138.78 -> that at the end of the day the heart is

140.28 -> an engine it pumps blood to all the

142.2 -> vital organs in our body and if the pump

144.84 -> doesn't work then our bodies are in

146.58 -> serious trouble and there are many many

148.44 -> causes for heart failure but the end

150.72 -> syndrome unfortunately is a very very

153.48 -> difficult one to manage and can be

155.459 -> incredibly debilitating in causing huge

157.5 -> morbidity and mortality in the country

159.84 -> it affects almost a million people in

162.3 -> the UK can you keep going please

164.519 -> next slide and as I said it can be due

167.519 -> to a whole variety of causes the one of

169.62 -> the commonest causes at least in this

171.239 -> country is ischemic heart disease or

172.86 -> blockages in the heart arteries causing

175.019 -> heart attacks and damage to the heart as

176.94 -> a result of that now there have been

178.739 -> lots of kind of innovations that we've

180.959 -> managed

182.16 -> um to improve that and we're certainly

185.04 -> we perform very very well in the UK now

186.9 -> with our kind of joined up healthcare

188.76 -> service it lends itself very well to

190.5 -> getting rapid and quick treatment but

192.84 -> there's still a huge amount of morbidity

195.239 -> related to blockages in the heart

196.98 -> arteries not to mention the whole host

198.9 -> of other causes with everything from

200.64 -> high blood pressure or hypertension

202.14 -> valve disease atrial fibrillation or

204.959 -> other Rhythm abnormalities in a group of

207.54 -> patients we just don't know what's going

208.92 -> on the so-called primary

210.319 -> cardiomyopathies and that's due to a

212.22 -> whole sort of inherited or acquired

214.76 -> primary muscle problems and it can be

217.379 -> related to alcohol it can be related to

219.42 -> lots of other illnesses myocarditis and

221.94 -> more recently we saw a huge speech of

224.099 -> this relating to it covered

226.2 -> so next slide please

229.099 -> now the diagnosis of heart failure is a

232.26 -> bad one and although we don't want to

234.959 -> alarm people and these are sort of

237.06 -> slightly historic data you'll see that

239.58 -> the year there is 2002 and I think

243.12 -> although the

244.26 -> prognosis and heart failure remains bad

246.299 -> there have been some changes in the last

248.22 -> few years that I've talked about and Dr

249.599 -> Whelan will mentioned some of these

251.64 -> later but you can see that to you know

254.4 -> without going into absolute specifics

256.32 -> the the the

257.78 -> survival or the prognosis of people with

260.4 -> heart failure can be as bad as many of

263.1 -> the common cancers so it's a really

265.86 -> serious and important diagnosis both for

268.68 -> people but also their families and

270.54 -> support networks to manage next slide

273.12 -> please

275.28 -> and you can see here that the this again

278.699 -> is slightly old data and I'm sure it's

280.979 -> probably higher than that now but you

283.02 -> know as much as two percent of the

284.4 -> entire NHS and your budget is spent on

287.34 -> heart failure and its complications you

289.08 -> can see that the vast majority of that

290.94 -> is due to people being in hospital you

293.16 -> know the average length of stay is still

294.72 -> around two weeks and so everything that

297.06 -> we can do to try to stop people coming

298.8 -> into Hospital in the first place and

300.72 -> then

301.919 -> firstly getting them home sooner and

304.32 -> thirdly stopping them they're bounced

306.24 -> back in a few weeks later is really what

308.04 -> a lot of this is all about and I think

309.9 -> not only is it going to drive huge

311.94 -> improvements to the quality of life to

313.86 -> patients and their families but also

315.479 -> deliver some well-needed cut sorry

318.24 -> cuts to the enormous cost in the NHS

321.96 -> budget next slide please

325.94 -> so the size of the problem

329.52 -> um Carol just interrupt me when um your

332.22 -> you take over I can't quite remember

333.9 -> where we were going to take over don't

335.94 -> worry um you you can talk through this

338.16 -> slide and then my name will come up okay

340.44 -> perfect ly so I'll just keep going sorry

342.479 -> we're we're doing a bit of a joint uh

344.82 -> presentation today and I didn't want to

346.44 -> overstep but I think this is really just

349.08 -> kind of summarizing the scale of the

351.36 -> problem you can see you know the

353.52 -> morbidity the mortality you can see the

356.52 -> increasing incidence as patients get

358.919 -> older and they're surviving they're more

360.479 -> acute illness you can see the disabling

362.28 -> impact it has on quality of life and the

365.22 -> enormous expense that's being used by

368.22 -> the NHS and all the

370.74 -> ongoing costs in terms of social care as

373.44 -> a result of heart failure so it's a

374.88 -> massive problem and we as a sector and

378.06 -> as a hospital have put a huge amount of

380.58 -> time effort and resource into trying to

382.62 -> shift the dial of this thing and try to

384.66 -> make a better experience for all of us

386.4 -> so I'm going to hand over now to Carol

387.72 -> to show some of the really Innovative

389.699 -> work that she's been doing in the heart

391.68 -> failure team Carol thank you

394.56 -> thank you Tim

397.56 -> so I'm going to be talking about the

399.479 -> diagnosis of heart failure and also the

402.6 -> treatments that are available to us and

404.759 -> and Tim's absolutely right the the

406.94 -> slides that he presented

409.8 -> um are um quite old however

413.52 -> um when I was looking at more recent

415.56 -> data with respect to the prognosis of

418.38 -> heart failure compared to

420.6 -> um other cancers

422.699 -> um unfortunately it remains you know as

425.4 -> bad as and worse than many of the common

427.68 -> cancers

429.479 -> um and although the slide looking at

433.16 -> inpatient stay and the budget inpatient

436.44 -> budget again was quite an old slide

439.68 -> um unfortunately still 80 percent of

441.9 -> patients have their first diagnosis of

444 -> heart prayer made as an inpatient and

447.12 -> these patients will have had symptoms

448.56 -> before they're admitted to a hospital

452.099 -> um and yet they either have been waiting

454.979 -> for outpatient appointments or they

457.199 -> haven't in their GP

459.72 -> um or they have presented with symptoms

462.3 -> so quickly that they felt they needed to

465.479 -> go straight to hospital but I think we

467.28 -> can really work on that and make the

469.08 -> diagnosis earlier so that's what we've

470.699 -> been striving to do

472.44 -> um with um our work in the heart failure

474.96 -> service next next slide

478.38 -> so I'm going to talk a little bit about

480.479 -> what heart failure is

483.06 -> um Tim has alluded to that in terms of

485.699 -> you know it's a problem with the pumping

487.919 -> action of the heart and so what symptoms

490.259 -> might one expect breathlessness

493.62 -> um is a common symptom for many

495.36 -> different conditions but there is

497.699 -> breathlessness that can happen and when

500.039 -> someone lies flat and that's called

501.599 -> orthoplia or indeed when they are asleep

505.199 -> at night and are woken up Suddenly by

507.96 -> being breathless and gasping for breath

510 -> and that's called paroxysmal nocturnal

512.94 -> dyspnea and orthopnia and pnd are

516.3 -> specific to heart failure

518.82 -> um whereas breathlessness per se is not

521.82 -> um so it's something that we ask for

523.08 -> specifically in clinic

525.86 -> fatigue is a very common symptom for

529.019 -> again many conditions but it is can be

531.899 -> the presenting symptom of heart failure

534.18 -> patients can feel incredibly fatigued

536.82 -> that they just don't have any exercise

539.279 -> tolerance at all

541.32 -> and they may notice new swelling of

544.44 -> their feet or their ankles they're

545.82 -> finding it more difficult to get their

547.26 -> shoes on

549.3 -> um we look to see whether patients have

551.22 -> been prescribed diuretics water tablets

553.62 -> to make them pass urine to get rid of

555.6 -> fluid and as Tim told us earlier the

559.38 -> most common cause of heart failure is a

561.42 -> history of coronary artery disease so

563.339 -> often patients will have had a heart

565.26 -> attack in the past and so we ask about

567.48 -> that specifically

569.22 -> we also ask about things like have they

571.56 -> had high blood pressure are they

573.18 -> diabetic

575.22 -> um do they have COPD have they had

578.22 -> exposure to chemotherapy drugs and has

580.5 -> more patients survive cancer

582.959 -> um with the chemotherapy agents we ask

585.3 -> about that too because some of these

587.1 -> chemotherapy agents can in fact cause a

589.56 -> problem with the heart function

591.54 -> and and also with radiotherapy and

595.08 -> radiation for for cancer

598.56 -> foreign

601.2 -> so how do we diagnose a heart failure or

604.08 -> actually it's fairly straightforward all

606.36 -> we need is a blood test and it's called

608.64 -> NT pro-bnp and that is released by the

613.2 -> heart as a compensatory mediator when it

617.519 -> knows then the heart knows itself that

619.68 -> it's under strain and that is there to

623.72 -> vasodilate or to open up the heart

626.88 -> arteries and other arteries and so it's

630.06 -> produced very cleverly by the heart and

632.7 -> so we can then measure that in the

634.68 -> bloodstream and very straightforward to

637.68 -> to measure and then we have a cut off of

640.26 -> what is normal and what is what is above

643.44 -> normal

644.7 -> what we can see very

647.64 -> um convincingly is that of the anti-pro

650.339 -> BNP blood test is normal but it's highly

653.7 -> unlikely that the symptoms that the

655.56 -> patient has are due to heart failure so

658.38 -> we call that a very good negative

660.48 -> predictive value

662.22 -> if the antiprope NP blood test comes

665.279 -> back and it's elevated so again above

667.56 -> 300 or 400 then the patient might have

671.279 -> heart failure but that isn't necessarily

674.22 -> absolutely the case because other things

676.86 -> can put the antipropy NP up such as

679.44 -> having a heart rhythm problem such as

681.54 -> atrial fibrillation or having high blood

684.12 -> pressure or having chronic kidney

686.22 -> disease or having infection

689.22 -> etc etc so

691.26 -> um if the antiprope BNP is elevated then

694.62 -> that means that we should go on to do an

697.019 -> echocardiogram to look at the overall

699.54 -> heart function

702.36 -> um and getting access to echocardiogram

706.5 -> um can be a challenge but we have an

709.38 -> open access system at the Royal free so

712.68 -> that GPS can access echocardiography or

716.82 -> they can access it through referring to

720.42 -> one of the Cardiology team

722.519 -> and then we have different cutoffs of

724.44 -> something called the ejection fraction

726.24 -> which is the amount of blood that is

728.519 -> expelled by the heart every time the

730.44 -> heart contracts and these numbers are

733.26 -> the the numbers we look for to see how

735.72 -> much the heart is effective affected by

738.899 -> the heart failure

740.459 -> so if the contraction of the heart is

743.399 -> affected we call that reduced ejection

745.56 -> fraction and that number that we use the

748.079 -> cutoff for is less than 35

751.86 -> my slides have just gone

756.18 -> um and

758.04 -> um if it's mildly reduced then it's

760.74 -> between 35 and 45 and if it's something

763.5 -> called heart failure with preserved

765.06 -> ejection fraction then it's greater than

767.1 -> 45. the reason this is important because

770.04 -> it can affect which

772.079 -> um medications we're going to use to

774.6 -> treat the heart failure

780.98 -> so this is

783.24 -> um an example of the top two slides or

787.079 -> of a normal heart this is an

789.18 -> echocardiogram the slide on the left is

792.48 -> looking down through the heart the left

795.42 -> ventricle the main pumping organ

799.68 -> um main pumping chamber of the heart and

803.04 -> that is normal and then on the right

804.959 -> hand side the top right we can see what

807.42 -> we call the four chamber view that we

809.82 -> can see

810.839 -> um which is also normal so this nice

813.06 -> good contraction of the left heart of

815.579 -> the right heart of the Atria and that's

817.74 -> what we want to see

819.899 -> we can then see examples at the bottom

822.959 -> of the screen of when it is not normal

825.68 -> and this example is someone looking down

829.139 -> through the heart

830.519 -> with an example of severely impaired

834.54 -> left ventricular function and this

838.079 -> patient has what we call half ref or

840.6 -> heart failure with reduced ejection

842.639 -> fraction and the heart is not pumping

845.88 -> well at all

847.44 -> so the echo is very helpful in telling

849.839 -> us how much the heart is pumping and

852.48 -> it's telling us about

855.12 -> um what might be and other problem such

857.7 -> as the thickness of the heart muscle

859.139 -> wall if the valves are working well

862.019 -> Etc

866.36 -> so thankfully we have got good

868.86 -> treatments and

870.42 -> um Tim said earlier on that um the

873.12 -> treatments haven't changed much for

874.8 -> several years and now we it's a bit like

876.899 -> a bus coming along we've got several all

878.7 -> at once and so we've got lots of really

880.32 -> good heart failure medications

881.76 -> thankfully that we can use and these are

883.68 -> definitely impacting on people's lives

886.38 -> on their quality of life and making them

889.019 -> live longer so our aims are to improve

891.899 -> life expectancy but really important is

895.019 -> to improve the quality of life as well

896.959 -> and the relative importance of these

899.76 -> aims do vary between patients and do

903.12 -> vary over time so it's a an ongoing

905.339 -> conversation that we have with patients

907.199 -> about their heart failure treatment

913.62 -> on the left now we don't need to go into

916.32 -> detail about what exactly all of these

918.36 -> different drugs do but suffice to say

920.76 -> that previously we had a very

923.279 -> conventional sequencing of heart failure

925.8 -> medication so that we would start with

927.839 -> one and then increase that up slowly and

931.74 -> then go on to start another one and

933.959 -> increase up the dose of that slowly and

936.6 -> then add another one and then think okay

938.639 -> well maybe that's not working so then we

940.44 -> have to add in a different one and

941.88 -> change the ace inhibitor to an RNA and

944.94 -> see if that will help and then add in

947.519 -> the sglt2 inhibitor right at the end and

950.519 -> that whole process could take six months

952.5 -> or more by the time we've got the

954.18 -> patients back to clinic or risked into

955.92 -> the GDP to help increase the doses etc

959.639 -> etc so that's a long time and and we

963.12 -> know that the quicker we get patients on

966.6 -> effective drugs

968.519 -> they more likely were going to impact on

970.98 -> that ejection fraction and improve the

972.899 -> injection fraction and make patients

974.94 -> feel better and the more recent trials

977.22 -> can see that even within four weeks

979.92 -> there's a big difference between the

982.139 -> those patients on the drug and those

984.3 -> patients who are not on the drug and so

986.88 -> now we are we talk about the four

988.86 -> pillars of heart failure medication and

991.92 -> what we try to do is start all four

995.339 -> as quickly as possible

997.92 -> simultaneously

999.839 -> and get some of them at a lower dose on

1003.199 -> board

1004.04 -> from the outset and then increase the

1006.86 -> doses

1008.12 -> aiming for that to be done within four

1010.88 -> weeks so not six months four weeks

1014.72 -> and we know that that will then make a

1017.899 -> difference because even if we have a

1019.699 -> small dose of each of the different type

1021.8 -> of drug that will help and I'm

1023.72 -> particularly talking about heart failure

1025.579 -> with reduced ejection fraction that

1028.4 -> having a small amount of each of these

1030.5 -> drugs is more helpful than just having

1033.14 -> one of the drugs at a higher dose

1035.72 -> so this is a real sea change in the way

1038.78 -> we are treating heart failure but of

1041.299 -> course we need people to make that

1043.88 -> happen we need heart failure nurses

1046.04 -> specialist nurses we need heart failure

1048.86 -> pharmacists Specialists to Heart Fair as

1051.2 -> well we need heart failure specialist

1053.54 -> Consultants

1055.46 -> um and you know we need physiologists to

1059.12 -> help us with the Echoes to do The Echoes

1061.4 -> to make the diagnosis

1063.22 -> we need nurses in clinic we need people

1066.26 -> to take the phlebotomist to take the

1068.24 -> Bloods Etc so

1070.7 -> um you know we can't we it's all very

1072.86 -> well a saying that we want to do this

1074.539 -> within four weeks but we need a team and

1077 -> it's a team effort to make that all

1078.919 -> happen

1083.08 -> in addition to pharmacological therapy

1086.12 -> there is device therapy and I'm not

1088.76 -> going to talk too much in depth about

1090.5 -> this but in certain types of heart

1092.84 -> failure there are special pacemakers

1094.7 -> which can actually help the overall

1096.679 -> heart function improve

1099.679 -> um so that the patients may go from

1101.539 -> having half ref with that reduced

1103.58 -> ejection fraction to having

1106.34 -> um a recovered left ventricle and a

1110.299 -> normal ejection fraction and with an

1112.58 -> improvement in the quality of life and

1114.74 -> making them live longer and that's

1116.66 -> called CRT or cardiac resynchronization

1119.66 -> therapy in addition to that some

1122.419 -> patients require a defibrillator to

1125.419 -> protect them against malignant

1127.28 -> arrhythmias or heart rhythm problems

1129.679 -> which require a shock

1132.08 -> to save the patient's life so we also

1135.38 -> assess patients for these devices

1138.46 -> to improve life and to save lives

1146 -> so that's quite a lot of technical

1147.799 -> information I want to make it a bit more

1149.72 -> personal now and some of you may have

1152.24 -> remembered the heart failure event we

1154.34 -> did a few years ago before the pandemic

1158 -> um and Abdullah came along with me to

1160.94 -> speak about his experience with with

1163.4 -> heart failure and so I'm going to just

1165.86 -> give an update on abdullah's story with

1168.14 -> his permission of course

1171.98 -> so when I first met Abdullah he was a 23

1175.34 -> year old engineering student in his

1177.559 -> final year

1178.7 -> and he had had breathlessness in the

1182.059 -> lead-up to his finals

1184.1 -> it was felt that his breathlessness

1186.98 -> might be anxiety related

1189.62 -> um whilst revising he thought that

1191.66 -> perhaps he wasn't exercising enough and

1193.76 -> so he had reduced exercise tolerance he

1196.34 -> was feeling tired because of all the

1197.84 -> revising

1199.039 -> but he was admitted to hospital and he

1201.44 -> had an anti-probe NP blood test which

1203.9 -> was

1204.98 -> um significantly elevated

1207.14 -> and he was found to have symptoms of

1211.039 -> heart failure including those important

1212.96 -> ones orthopnea and paroxysmal nocturnal

1215.36 -> dyspnea and

1217.7 -> um I just wanted to highlight that

1219.74 -> because in a 23 year old people don't

1222.86 -> think that they might have heart failure

1224.6 -> and so by asking those specific

1226.34 -> questions it became clear

1228.44 -> um to the admitting doctor that that's

1229.94 -> exactly what was going on and they

1232.1 -> therefore did the anti-probe BNP blood

1234.26 -> test which was elevated and he went on

1237.2 -> to have an echocardiogram which showed

1239.78 -> unfortunately that his heart was

1241.76 -> severely affected and his ejection

1243.799 -> fraction so a measure of the amount of

1246.74 -> blood being expelled was only 12 percent

1249.38 -> so anything normal is above 55 percent

1252.44 -> so it was only working at a fifth of

1254.419 -> what it should have

1257.419 -> um I met him on the coronary care unit

1259.64 -> and I remember very vividly having a

1262.28 -> discussion with him about sending him to

1264.44 -> harefield for transplant assessment

1267.02 -> which is not a conversation you want to

1269.059 -> be having with a 23 year old

1271.82 -> um he was transferred to hairfield

1275.02 -> the next day

1276.98 -> and we feared that he might require

1279.86 -> either a transplant or Advanced

1282.5 -> treatment with left ventricular sister

1285.26 -> Vice but

1292.78 -> thankfully it did not require Advanced

1296.299 -> heart failure treatment in the means of

1299.059 -> a assist device or a heart failure or a

1302.299 -> heart transplant for that matter

1304.46 -> he was able to have

1306.86 -> um slowly these drugs that I've talked

1309.14 -> about increased while Steve's an

1311.419 -> inpatient and he was discharged later

1314.96 -> that month and it's five years to the

1316.88 -> month that this all happened to poor

1319.94 -> Abdullah and he was diagnosed with a

1321.98 -> dilated cardiomyopathy which means that

1324.74 -> it wasn't related to the heart arteries

1327.14 -> but something that

1329.6 -> um he had been

1331.52 -> um

1332.179 -> uh it was inherited

1335.6 -> so his follow-up was then between

1337.22 -> ourselves and harefield and over time we

1339.38 -> were able to get these important heart

1341.84 -> failure medications on board

1344.059 -> so much so that his antibope NP went

1346.58 -> back to normal and his cardiac Mr showed

1349.94 -> that his heart function had improved

1351.62 -> significantly

1353.96 -> um we increased his medication up and we

1357.32 -> switched them to appropriate medication

1359.32 -> and he thankfully did not then require a

1362.96 -> defibrillator because his heart function

1364.94 -> had improved he's now on those four

1367.7 -> pillars of treatment and has been for

1369.559 -> some time and I saw him last week in

1372.08 -> clinic in his ejection fraction is now

1374.72 -> around 45 so only mildly affected

1378.26 -> and even better news

1382.76 -> as it is now married and he brought in

1386.24 -> his four-month-old lovely beautiful baby

1390.26 -> boy as and as means someone who is

1394.1 -> mightier stronger and more beloved so

1397.28 -> that was such a lovely lovely

1400.82 -> um Clinic last week to to see Abdullah

1403.34 -> and his lovely wife and to meet his

1405.559 -> four-month-old son so really

1408.74 -> um just very special indeed

1414.5 -> and it's really important that we get

1416.36 -> patients on these drugs as I've

1417.98 -> Illustrated hopefully to you

1420.679 -> for their quality of life and to make

1423.74 -> them live longer and we're audited on

1425.78 -> this there's a national heart failure

1427.94 -> audit and we are looked at to see if we

1430.94 -> are prescribing the right drugs for

1432.5 -> patients before they are discharged from

1434.9 -> hospital and we can see the impact of

1437.659 -> these drugs if from this graph you can

1441.2 -> see patients who were discharged so the

1446.659 -> black line is those who were in

1448.34 -> discharge on one job

1450.02 -> the red line is those who are discharged

1453.44 -> on Two drugs

1454.82 -> the green line as if they were

1457.34 -> discharged on three drugs and the bottom

1460.82 -> line the blue line as if they were

1463.34 -> discharged or none of those drugs and we

1465.32 -> can see the survival post-discharge is

1469.4 -> only

1471.2 -> is much better and those who were

1473.84 -> discharged on the three drugs rather

1475.88 -> than no drugs at all and so the one-year

1478.46 -> mortality rate was 15 percent compared

1482.24 -> to 30 percent on those without any of

1484.94 -> the three key drugs that we prescribed

1486.74 -> before discharge

1488.419 -> so it's really important that we are

1490.82 -> audited on this so the patients get

1492.799 -> access to the right drugs and we're all

1495.679 -> doing the same

1497.419 -> we're not only just audited on the drugs

1501.14 -> that we prescribe

1505.58 -> we are audited on many other things too

1508.22 -> and this is taken from the last National

1511.34 -> heart failure audit

1513.52 -> so patients I looked to see whether

1516.98 -> they've had an echocardiogram to

1518.9 -> diagnose the heart failure and this has

1521.6 -> been divided into all patients who are

1523.76 -> admitted with heart failure across the

1525.559 -> UK sorry across England and Wales

1529.039 -> whether they were admitted to A

1532.279 -> cardiology Ward or whether they were

1534.26 -> seen by a heart failure specialist

1536.96 -> and so we can see that

1539.659 -> um

1540.2 -> all patients around 85 percent of them

1542.96 -> received an echocardiogram but more

1545.299 -> patients got an echocardiogram if they

1547.34 -> were admitted to the Cardiology Ward or

1549.14 -> seen by a special heart failure

1550.94 -> specialist

1553.1 -> more patients receive specialist care if

1555.799 -> they were admitted to the Cardiology War

1557.9 -> to sin by a specialist

1559.76 -> and more patients with hefref the

1562.159 -> reduced ejection fraction were

1564.02 -> discharged on all of those disease

1566.299 -> modifying drugs if they were admitted to

1568.82 -> the Cardiology or to sit by a specialist

1571.7 -> more likely to receive Cardiology

1573.799 -> follow-up more likely to see a heart

1576.5 -> failure nurse and have follow-up with

1578.48 -> them more likely to see

1581.24 -> um

1581.84 -> be referred for cardiac Rehabilitation

1584.96 -> and I'm pleased to say that we now have

1587.179 -> at the Royal free heart failure patients

1590.779 -> can now access cardiac rehabilitation

1594.62 -> so um we're hoping that locally our

1597.919 -> numbers of patients with heart failure

1600.2 -> receiving cardiac Rehabilitation will go

1602.179 -> up uh significantly

1604.52 -> and also they're less likely to die in

1607.22 -> hospital if they're on the Cardiology

1609.02 -> Ward and that is very important so

1612.86 -> um I'd like to reassure you that at the

1615.919 -> Barnet

1617.059 -> um both Barnet and the Hampstead sites

1619.039 -> are audited and all of these parameters

1622.039 -> and we're above average for every single

1624.32 -> one that hasn't always been the case but

1626.9 -> the Royal free London has invested in

1629.36 -> the heart failure service and so with

1632.12 -> appropriate heart failure nurse input

1634.4 -> heart failure specialist Cardiology

1636.44 -> consultant input heart failure

1638.84 -> pharmacist input we can make a

1641.48 -> difference

1642.62 -> um so that is really exciting

1650.48 -> so I'm not going to hand over to my

1652.46 -> colleague Amit bakai who's going to talk

1654.5 -> more about

1655.88 -> um the services that we're providing and

1658.039 -> how digitizing the heart failure pathway

1660.679 -> has really helped us to achieve what

1662.96 -> we've managed to achieve so far

1666.5 -> thank you so much Carol and this has

1669.02 -> been a really nice elegant demonstration

1671.419 -> of the complexity of managing people

1673.76 -> with weakened hearts and more

1675.919 -> interestingly all the work that we're

1677.539 -> doing and as you've rightly said already

1679.7 -> Carol that we're we've been blessed that

1681.799 -> we're above average and in fact amongst

1684.32 -> and we'll see why we're above average uh

1686.779 -> with the digitization support that we

1688.94 -> need because managing heart function uh

1691.82 -> is is never easy uh even the detection

1694.58 -> so the title is a slightly um it's not

1698.059 -> managing it's actually we're going to be

1699.74 -> finding and sending them home earlier

1702.32 -> because Carol's already done the

1704 -> managing so well and particularly the

1706.22 -> four pillar approach so if we look at

1708.74 -> the next slide before 2019 we had this

1712.88 -> incredible journey where we all sat as a

1716.12 -> cardiac team but also the a e team also

1719.059 -> the nursing staff the pharmacists uh the

1721.46 -> emergency colleagues and medical

1722.6 -> colleagues and actually said let's look

1724.58 -> at all the guidelines and what would be

1726.2 -> the best way for patients to have a

1728.779 -> journey through heart function at the

1731.24 -> Royal free and Barnett and Chase Farm

1733.52 -> hospitals and what would be the ideal

1735.74 -> scenario and one of the things we

1737.659 -> recognize is that they often present

1739.52 -> with new onset breathlessness or Nuance

1742.7 -> leg swelling so fluid being retained in

1745.4 -> the legs that's particularly something

1747.2 -> we'll see in the heat where people are

1748.76 -> drinking a lot more fluid and then if

1750.919 -> they're not clearing that fluid from the

1752.72 -> body one of the reasons for that can be

1755.059 -> one of the commoner reasons can be a

1757.159 -> weakened heart not passing that water

1759.38 -> through to the kidneys to pass out in

1761.48 -> the urine and so we sat we spent 50

1764.539 -> hours Carol and I uh LED these meetings

1767 -> uh so many times and and came to the

1770.299 -> best conclusion that actually if anybody

1772.88 -> presented to any of our hospitals with

1775.399 -> Nuance at breathlessness or leg swelling

1777.44 -> why don't we automatically include in

1780.02 -> their routine Bloods that NT probe NP

1782.84 -> bio marker that Carol's told us about

1785.179 -> which is actually a hormone that the

1787.279 -> heart secretes when it's under strain so

1789.86 -> the heart has a sensation of oh my God

1791.96 -> I'm too full I've got too much blood in

1794.12 -> the system I'm actually overloaded I

1796.7 -> must push it diuretic to try and make

1798.86 -> myself pass more water out so we

1801.44 -> actually measure that level and that

1803.36 -> level actually tells us if it's above

1805.039 -> normal it may be because the heart is

1807.5 -> under strain next slide please

1810.039 -> and what happened is that our new

1813.02 -> electronic system from Cerner came

1815.72 -> through to Barnet in the first instance

1818.24 -> in December 19 prior to the pandemic and

1821.659 -> we were lucky enough to be the first

1823.279 -> site in not only Europe but I believe in

1826.22 -> the world to have a digitized heart

1828.799 -> function pathway with not only for

1831.26 -> people diagnosed with heart failure but

1833.539 -> people suspected of heart failure and

1836.12 -> this is consecutive patients being

1838.1 -> admitted putting through that data into

1840.559 -> our pathway we identify them the minute

1843.08 -> the blood test is elevated they are on

1845.299 -> the digital pathway electronically

1847.1 -> without any manual intervention and so

1850.46 -> far because of this pathway we have over

1853.399 -> 40

1854.539 -> 000 patients episode Journeys that have

1857.12 -> gone through that same pathway with the

1858.86 -> data being collected and during the

1861.44 -> pandemic it became really evident that

1863.659 -> actually if that blood test marker was

1865.159 -> elevated it was also a marker that you

1867.5 -> may not survive covered and we were the

1869.6 -> first amongst the London group to

1872.96 -> recognize that as a marker of of poor

1875.659 -> prognosis even with covid because the

1878.36 -> strain on the lungs was putting strain

1880.1 -> on the heart and we could see that in

1881.899 -> the blood test Mark in the digital

1883.22 -> pathway

1884.48 -> so some of the things that that led to

1886.399 -> we even re when the new system at the

1889.34 -> Hampstead site came through as well the

1891.44 -> Cerner pathway immediately the digital

1894.08 -> pathway was built into it and on the day

1896.6 -> of go live hamster patients already had

1899.24 -> this pathway built into it and we'd

1901.82 -> modified it and learned some key aspects

1904.22 -> from Barney next slide will show you the

1908 -> things that we achieved when we did this

1910.46 -> with this digitization of the suspicion

1912.799 -> of heart failure

1914.899 -> just trying to press there we go one of

1917.72 -> the things that we found at the Barnet

1919.279 -> site immediately when this pathway was

1921.62 -> switched on we our nursing staff our

1925.039 -> clinical nurse specialists that and and

1927.14 -> told and informed and given awareness of

1929.659 -> patients suspected to be at heart

1931.399 -> failure when the pathway was switched on

1933.44 -> every single week thereafter we went

1936.559 -> from 29 patients being considered and

1939.74 -> referred to us with a suspicion of heart

1941.659 -> failure to 52. now at the Barnet site

1944.96 -> already we've done a lot of work in a e

1947.36 -> to try to reach in and find heart

1950.12 -> function patients so for us if this was

1952.7 -> like okay two-fold increase threefold

1954.679 -> increase my goodness will we cope with

1956.539 -> the Manpower will we cope with the echo

1958.22 -> demands Etc so we did a lot of

1960.14 -> preparation and realized that this would

1962.96 -> be something that would happen also at

1965.059 -> the Hampstead site and so we were ready

1967.039 -> that when we switched this on at the

1968.659 -> Hampstead site where we do a lot more

1970.279 -> angioplasty and stenting where the focus

1972.799 -> on function hadn't been there as deeply

1976.1 -> when we switch this on we had an

1978.26 -> increase at that site right up to 59

1981.32 -> again similar numbers from nine and so

1984.02 -> we had a four to five fold increase in

1986.36 -> the number of people suspected with

1987.62 -> heart function and fortunately we were

1989.84 -> prepared we'd already got the Manpower

1991.82 -> in place we've got the echo Services

1993.2 -> we'd already got the trainee in place to

1995.72 -> cope with this and we have seen that as

1998.419 -> a sustained effect so the pathway

2000.76 -> immediately allows you to find more

2003.279 -> patients with heart function and we'll

2004.779 -> give you a simple case study straight

2006.34 -> after this the other amazing thing we

2009.64 -> saw is that the pathway nudged people

2012.22 -> we've designed it to nudge people to use

2014.98 -> those medications that Carol's told you

2016.84 -> about and to change that prognosis that

2019.96 -> Tim has told you about the cancer

2021.34 -> equivalent prognosis and let's see what

2024.159 -> that shows you

2025.419 -> here are some of the things that the

2027.34 -> pathway did in terms of saving lives it

2029.679 -> automated the process of echo requests

2031.779 -> automated the nudged towards more

2033.7 -> prescribing

2035.559 -> just struggling to move the slides

2037.84 -> forward easily George I don't know thank

2040.24 -> you so much and and here on this Slide

2042.779 -> the gray lines are from that National

2046.72 -> audit the nikor audit which is 62 000

2050.139 -> patients before the pandemic 2021 data

2053.379 -> that Carol showed you the gray lines are

2056.08 -> where average the country is on

2058.54 -> prescribing these medications and what

2060.639 -> you'll see from the blue and orange

2062.44 -> lines are the two Hospital sites Barnet

2065.44 -> and Hampstead now interlinking on

2068.5 -> exactly those therapies because of a

2070.359 -> pathway and on every single class of

2073.54 -> medications for heart function beating

2076.419 -> the national average and if you look if

2079.119 -> you look at the second bar that line

2081.04 -> goes up to 120 it should only go up to

2082.96 -> 100 we're already at 95 for something

2086.56 -> called Ace and arbs we're already over

2089.32 -> 95 for beta blockers and the mras which

2094.06 -> are a type of diuretic that help the

2096.46 -> heart relax and lower blood pressure the

2099.04 -> country barely ever gets over 60 percent

2101.38 -> and on both hostile sites we're at 70 to

2105.4 -> do this on every single drug class the

2107.859 -> probability is so low it has to be a

2110.38 -> real effect of our pathway next slide

2113.079 -> we've already shown

2114.88 -> um that we're reducing mortality and a

2117.16 -> simple case study here is an example of

2119.68 -> a 60 year old lady who came to casualty

2122.44 -> she was a a dinner school a school

2124.96 -> dinner lady she's been told that much of

2127.48 -> a breathlessness was anxiety much of a

2129.88 -> breastless was asthma because she'd been

2132.339 -> wheezing and the CT scan when she came

2134.92 -> to casualty did show some lung disease

2136.96 -> and it was thought she might have a

2138.88 -> respiratory problem and she was given a

2140.92 -> respiratory outpatient but because of

2143.14 -> the automated pathway the number being

2145 -> over 2 000 immediately our nursing teams

2147.94 -> picked her up arranged an echocardiogram

2150.4 -> within eight days this was managed no

2153.88 -> intervention for the GP to be do

2155.8 -> anything no intervention for the patient

2157.78 -> to do anything our digital pathway

2159.88 -> nudged our nurses to arrange an

2161.98 -> echocardiogram echocardiography

2164.079 -> physiologists at the Barnet site saw and

2167.74 -> detected this heart function and the

2169.9 -> valve across the heart is really tight

2171.88 -> it wasn't opening properly there's a big

2174.16 -> lump of calcium sitting in the middle

2176.38 -> there at three o'clock in that top

2178 -> picture and that was stopping the heart

2180.76 -> valve opening so she couldn't get blood

2182.859 -> out even though the heart was strong and

2184.96 -> trying to beat really hard even just

2187.24 -> being told this information as she

2189.28 -> reached a e and she actually her anxiety

2192.76 -> kicked in and she actually passed out

2195.339 -> she actually collapsed she had a cardiac

2197.02 -> arrest and we were fortunate enough to

2199.18 -> be able to resuscitate her speak to our

2201.22 -> cardiac surgeon colleagues at Barts and

2203.74 -> we transferred her overnight and a few

2206.2 -> days later she had that valve

2207.64 -> replacement so from being told she had

2210.4 -> anxiety asthma respiratory problems the

2212.92 -> pathway actually brought to our

2215.44 -> attention the valve disease that was so

2218.44 -> bad that that anxiety episode alone that

2221.2 -> caused it to have a cardiac arrest

2223.3 -> like and this is just one of many

2225.16 -> stories and this and because of this

2227.68 -> wonderful pathway and the guidelines and

2230.14 -> the optimization we can do we were able

2232.48 -> to do more we created a virtual award

2234.7 -> where we're able to discharge people

2236.44 -> early and look after them and we have

2238.78 -> consultant colleagues like Dr Amaral now

2241 -> who are looking after patients virtually

2243.28 -> 40 to 50 patients any one time we're

2246.28 -> discharging them earlier and they're

2247.96 -> being looked after for the next 18 days

2249.7 -> we were also having a diuresis Lounge

2252.099 -> for some patients that just needed to be

2253.66 -> here for a day to get diuretics and they

2256.42 -> sit in an armchair and they go to the

2258.4 -> toilet back and forth and pee out the

2260.5 -> fluids with an injection so so many

2262.72 -> different innovations that the most

2264.82 -> interesting Innovation is of course for

2267.4 -> research studies that are coming along

2268.9 -> we have already made group of patients

2271.599 -> for the next level of optimization and

2274.599 -> so we've been able to put patients into

2276.88 -> newer research studies on newer

2278.44 -> medications thanks to the pathway work

2280.839 -> that Carol others and many of us have

2283.24 -> have participated in bringing to the

2285.52 -> Forefront and so we are now sharing this

2288.4 -> work with our other partners and Cerner

2290.859 -> uh our electronic record system is

2293.26 -> really Keen this is integrated into all

2295.9 -> of their Cerner Pathways in the future

2297.7 -> so this is the sort of things that we've

2299.98 -> been doing uh we've been

2301.92 -> pre-emanating or trying to do

2304.839 -> preventative work by finding people

2307.06 -> Upstream even before the diagnosis and

2310.119 -> then managing after the inpatient stay

2312.64 -> where we get them on all the right

2313.9 -> medications to allow them to go home

2316 -> earlier but Carol I'm going to hand back

2318.4 -> to you to say the bigger picture of how

2320.68 -> we're connecting this all up across the

2322.72 -> region if that's okay

2325.24 -> thanks amid

2326.92 -> um so yes with it having the heart

2329.5 -> failure Hub at the center of our heart

2332.74 -> failure service we can then have

2336.28 -> patients come to us who have been

2338.44 -> admitted to hospital and then discharged

2341.14 -> so we then see them early in their

2343 -> Outpost discharge to help prevent them

2346.06 -> being readmitted to hospital we can see

2348.76 -> them if they've attended Ed and rather

2351.4 -> than

2352.72 -> um go home to then have the GP have to

2355.96 -> refer them back to the hospital because

2357.76 -> they might have heart failure we're

2359.32 -> picking up that anti-pro BMP result and

2362.079 -> arranging to see them urgently to have a

2364.24 -> One-Stop shop in the heart failure heart

2367.66 -> failure Hub where we can do an

2369.7 -> echocardiogram at the same time as the

2372.099 -> consultation and then get them started

2373.96 -> on these drugs that are so important

2376.42 -> we're then working with

2378.94 -> um our GPS in the community

2381.46 -> and our community heart failure nurses

2383.94 -> to identify patients who are at risk of

2387.76 -> heart failure and asking them whether

2390.16 -> they may have one of those symptoms such

2392.14 -> as breathlessness fatigue or new

2394.24 -> swelling of ankles and if so

2397.06 -> um respond then responding to a text if

2399.28 -> they're an increased risk group

2401.46 -> they respond to a text and then we

2403.72 -> arrange for them to have an antipore BMP

2405.7 -> blood test if that's elevated then they

2408.04 -> get an echocardiogram and review by one

2410.68 -> of the consultants in the heart failure

2412.359 -> Hub so we're screening at risk patients

2415.18 -> trying to identify them earlier on so

2417.52 -> that they're not being admitted to

2419.26 -> hospital in acute heart failure we're

2422.32 -> also looking at patients who are known

2425.14 -> to have heart failure who for one reason

2426.88 -> or another haven't been able to come up

2428.56 -> to the hospital because they've not

2431.02 -> wanted to come into the main hospital

2432.76 -> because of covid

2434.68 -> um or they they haven't come for their

2436.78 -> appointment or they've had telephone

2437.98 -> appointments and haven't been seen face

2440.079 -> to face and this heart failure Hub and

2442.54 -> they're all free is separate to the main

2444.28 -> entrance to the hospital and so the

2446.14 -> patients are feeling more comfortable

2447.82 -> going into

2449.68 -> that space and so they can be seen and

2452.98 -> have a data collected as part of a heart

2456.339 -> failure math clinic and then we can look

2458.8 -> to see are they on the right drugs are

2460.9 -> they on the four pillars that we were

2462.46 -> talking about earlier

2464.26 -> um should they be getting a device and

2466.9 -> looking at there

2468.64 -> um where they are with their heart

2469.78 -> failure Journey are they needing input

2471.579 -> from palliative care

2473.38 -> um for example

2475 -> um are they need to needing help with

2476.56 -> social prescribing so looking at all

2479.26 -> these different aspects

2481.119 -> um and it's so the heart failure Hub

2483.04 -> being Central to that working with

2485.8 -> Community working with local GPS and

2488.68 -> working with palliative care to make

2490.42 -> sure that the right patient is being

2492.82 -> seen in the right place at the right

2495.04 -> time and if you could just go back a

2497.02 -> slide please

2499.72 -> we can see from our sort of one team

2502.06 -> approach

2503.5 -> um some call it integrated we want to be

2505.18 -> seen as one team that we're not having

2507.16 -> to integrate care and we're all all just

2509.8 -> one team working together with GPS and

2512.079 -> Community teams that when we did our

2515.14 -> math Clinic we looked in um with our

2517.42 -> pilot we found that 40 of patients had a

2520.06 -> heart failure medication change that 12

2523.38 -> had a newer updated

2526.359 -> um care plan

2528.4 -> um seven percent were referred for a

2530.2 -> device

2531.16 -> um consideration and some of the

2533.32 -> patients who are known to have had half

2535.48 -> ref heart failure with reducive

2538 -> rejection fraction their up-to-date Echo

2540.579 -> had shown that their heart failure had

2542.02 -> recovered didn't mean to say that we

2544.06 -> would stop the medication of course but

2546.28 -> the great news of the patient that they

2548.56 -> were had recovered heart function as a

2551.8 -> result of their medication so it may be

2555.7 -> that as we go forward that this might be

2558.18 -> a more effective active way of looking

2560.98 -> after heart failure patients across the

2563.02 -> community

2563.88 -> having mdts to discuss all the patients

2567.579 -> with the GPS and since then I find that

2570.579 -> more GPS are contacting me directly to

2572.98 -> Ask advice or speak about medication

2575.619 -> changes Etc so so that relationship is

2580.24 -> improving all the time and you can see

2582.88 -> this word cloud which Rachel Brady who I

2585.579 -> have to say has been amazing in helping

2587.38 -> us with all of this

2589.359 -> um she did this word cloud and it's

2591.64 -> quite small but you can see there that

2593.38 -> patients were feeling worried anxious

2595.3 -> nervous before coming to the heart

2596.859 -> failure Hub and afterwards they were

2599.14 -> feeling good feeling calm feeling

2600.819 -> reassured feeling happy so that was

2603.16 -> really positive feedback from our

2604.78 -> patients which of course is absolutely

2606.76 -> Central to everything that we do

2611.859 -> so if you just then go on

2614.56 -> so

2616.119 -> um

2616.66 -> we've been able to celebrate the work

2618.64 -> we've been doing with recent Oscars and

2621.88 -> the work done for digitizing the heart

2624.76 -> failure pathway came out top in the

2626.74 -> outstanding contribution to research

2628.66 -> category

2630.22 -> um and the heart failure clinical

2631.78 -> practice group across site was also

2634.119 -> nominated in recognition of the

2635.98 -> Fantastic work that everybody is doing

2641.8 -> um I mean mentions clinical research and

2643.839 -> clearly everything that we do has been

2646.119 -> driven by clinical research

2649.319 -> patients participating in Trials

2651.76 -> allowing us to see what drugs work what

2654.52 -> their Works don't what drugs don't work

2656.68 -> what devices work what we should be

2659.14 -> doing for patients should we be starting

2661.72 -> um medications all at once should we be

2664.06 -> only starting one at a time all of that

2665.8 -> has all of that information is

2667.839 -> evidence-based through clinical trials

2669.76 -> and of course there may be some of you

2671.98 -> listening in this evening who might want

2674.319 -> to take part in clinical research and

2676.78 -> therefore the email addresses is here

2679.78 -> for you

2682.5 -> and indeed some of you may wish to

2685.839 -> consider helping us with our heart

2687.579 -> failure pathway and being involved and

2689.859 -> sort of as a patient advisor and so that

2692.56 -> we're getting it right we do look for a

2694.66 -> feedback as you can see from our

2696.7 -> patients making sure that what we're

2698.38 -> doing

2699.4 -> um is impacting in a positive way this

2702.16 -> is us taken when the Marlborough Clinic

2704.579 -> opened for the first time in 2021

2709.48 -> um and it already feels dated thankfully

2712.119 -> in terms of having the masks on

2715.06 -> um but uh yes we certainly have space

2718.18 -> there so patients do feel more

2719.859 -> comfortable they're not in a very busy

2722.56 -> outpatient

2724.68 -> area and so it does feel a bit more calm

2728.8 -> and relaxed in the heart failure hub

2734.26 -> so we're now going to move on for the

2736.3 -> last 10 minutes to a question and answer

2738.76 -> session and we have got a few questions

2742.06 -> already so a meeting and Tim

2746.319 -> um

2748.66 -> and also like to introduce Alison who

2752.38 -> thankfully has made it on

2754.24 -> um with us

2755.8 -> um Allison thank you very much for

2757.42 -> joining us

2758.56 -> um uh this evening

2760.66 -> um for this heart failure session

2767.7 -> so um there are a few questions which

2770.8 -> hopefully we have answered

2772.96 -> um what is the definition of heart

2774.64 -> failure I think we've we've answered

2776.44 -> that

2778.119 -> um Can atrial fibrillation lead to heart

2780.579 -> failure um I think we've we've answered

2782.56 -> that that heart rhythm problems can lead

2784.54 -> to heart failure

2786.7 -> um

2787.8 -> shortness of breath excuse me

2792.64 -> it's shortness of breath and mild chest

2794.92 -> pain always a sign of heart failure

2797.26 -> I mean maybe you could answer that when

2799.18 -> I did sip of water yeah of course

2801.099 -> absolutely absolutely not not always we

2803.98 -> can have things like plots on the lung

2806.02 -> that can cause shortness of breath and

2808 -> sharper chest chest pain and we have

2810.7 -> different blood tests if you've just

2812.38 -> come off a airplane flight for example

2814.599 -> in the last couple of weeks and you

2815.98 -> suddenly get short of breath with chest

2817.48 -> pain we will do something called a

2819.22 -> D-dimer to see if you might have a clot

2821.619 -> on the lung and then there were a couple

2823.54 -> of tests about the NT probe NP uh if you

2826.9 -> want uh Carol I can just quickly nip

2828.88 -> that one off the NT probe NP blood test

2831.579 -> can be lower than suspected and if it's

2835.839 -> low doesn't mean you haven't got a heart

2837.88 -> failure 98 of the time it is accurate

2841.48 -> that you don't have heart failure if

2842.98 -> it's in the normal range but there are

2845.14 -> people who are high body mass index so

2847.54 -> people with a lot of subcutaneous fat

2849.94 -> and so then the anti-propion P level is

2853.18 -> artificially lowered afro-caribbean

2855.7 -> origin colleagues patients and people

2857.859 -> will also have a a falsely lower

2860.38 -> anti-bromo B so the range needs to be

2862.48 -> adjusted and then people who are already

2864.4 -> on medication such as water tablets or

2867.099 -> taking a lot of caffeine drinks and so

2869.079 -> forth which can also be diuretics so

2871.06 -> those things can lower spuriously the

2873.52 -> antibody MP and then accidentally hire

2876.4 -> any chest infection anything that causes

2878.68 -> strain on the lungs will also cause

2880.66 -> strain on the heart but that doesn't

2882.4 -> mean the heart is failing it could be a

2884.079 -> temporary strain and so you can have a

2886.839 -> false positive with chest infections

2889.48 -> clots on the lung where the heart attack

2891.46 -> not meaning that the heart is weakened

2893.26 -> but transiently it's under strain if we

2896.02 -> do a procedure such as an operation

2897.7 -> coronation bypass grafting or a

2899.98 -> cardioversion those sorts of things will

2902.02 -> also Elevate that blood test but the

2904.06 -> antibody will come back down when the

2906.22 -> heart is recovered

2908.02 -> thank you so I think you're just

2910.06 -> illustrating that if someone

2912.28 -> um the GP suspects that the patient has

2914.38 -> heart failure and it's not quite fitting

2915.819 -> because the antibi is low that they

2918.339 -> should still seek advice and see whether

2920.38 -> their patient might fit into that

2923.319 -> um less common category where the

2925.3 -> antiprobe MP is low but they do actually

2927.28 -> have heart failure and this is very

2930.579 -> um uh appropriate question to be asking

2933.28 -> given the the current weather should

2935.74 -> patients be advised to reduce or emit

2938.8 -> diuretics during the extremely hot day

2941.8 -> periods

2943.599 -> it's a really good question is it and

2945.94 -> the answer to that is and one of the

2947.74 -> things that you and I have always done

2949.06 -> with patience Carol is said that please

2951.4 -> look at the color of your urine and if

2954.28 -> you have three dark urines in a row you

2957.28 -> are at risk of getting dehydrated and so

2959.98 -> you either need to be drinking a little

2961.48 -> bit another extra half a liter that day

2963.46 -> or as you rightly say if you've been

2966.28 -> educated advised by our cardiac research

2968.98 -> nurses who are very good at helping you

2970.839 -> you can Flex the dose of the diuretics

2973.359 -> if you believe that you're at risk of

2975.819 -> getting dehydrated but the education

2978.28 -> that our team give on looking at the

2980.619 -> colored urine so we say three dark

2982.48 -> urines in a row and you may be at risk

2984.76 -> of getting dehydrated so either call us

2986.619 -> contact your heart function nurse

2988.78 -> Etc or please drink an extra half a

2991.48 -> liter or you might drop a half a dose of

2994.3 -> a diuretic like frozen might not be

2995.92 -> metanoid you might lower the dose in

2997.48 -> this heat but you're absolutely right

2999.099 -> people have been getting low blood

3000.839 -> pressure and dehydrated because they

3003.3 -> have their own diuretics there's a great

3005.339 -> topical question

3007.74 -> thank you

3009.359 -> um and another theme from some of the

3013.14 -> questions

3014.46 -> um is are there any screening programs

3017.099 -> for people with a family history of

3019.38 -> heart failure

3021.54 -> Yeah Tim do you want to did you want to

3023.64 -> take that one or Carol you you probably

3025.44 -> want to talk about Gabby's work even

3027.24 -> even more closely you know that than I

3029.4 -> do as I expect

3032.7 -> yeah so um Gabby captor is one of our

3035.7 -> consultant colleagues who um runs the

3039 -> cardiomyopathy

3041.16 -> um service at the Royal free so

3044.119 -> cardiomyopathy can be inherited and so

3047.579 -> she runs a screening program for

3049.94 -> patients and for their relatives to look

3052.98 -> to see if they have any genetic

3055.619 -> um type of heart failure and screams the

3058.319 -> family members as well so she's a very

3060.9 -> welcome addition to our heart failure

3063.24 -> team and and does very specialized work

3066.3 -> with cardiomyopathy patients so yes

3069.24 -> there so it's a short answer is yes

3071.28 -> there there are screening programs and

3073.8 -> for certain types of of heart failure

3077.339 -> so one of the questions that's come up

3081 -> um we are asked about the cost to

3084.24 -> perform anti-probe NP

3086.819 -> um and the extra cost per year for

3088.74 -> screening with the anti-profenp and a e

3092.579 -> um and

3094.14 -> um going back to your slide I mean

3097.14 -> comparing

3098.7 -> um referral rates at Barnet and the

3101.4 -> Royal free the referral rates were

3104.059 -> higher considerably higher at Barnet

3107.78 -> pre-epr being switched on than the Royal

3110.4 -> free and people may have wondered why

3112.26 -> that was well before

3115.44 -> um the epr was switched on the

3117.9 -> turnaround time for the antipropian pier

3120.18 -> Barnett was in a couple of hours so the

3123.42 -> blood test result was available to the

3126.059 -> Ed doctors to then refer the patient

3128.579 -> home whereas at the Royal free it was

3131.46 -> taking at least two days to come back so

3133.68 -> not helpful for the Ed doctors and so

3137.339 -> that coincided with then epr and with

3140.7 -> the pandemic and you know the pandemic

3143.04 -> caused lots of problems but we did

3144.96 -> manage to switch on a much quicker

3147.119 -> turnaround for the anti-probe EMP

3148.74 -> results and hence is sort of starting to

3151.26 -> see that increase in referral rates but

3153.48 -> really it was the epr that provided that

3156.18 -> fantastic

3158.099 -> um you know referral rates uh to the

3160.559 -> numbers that we have now

3162.359 -> so I guess the answer we we might want

3166.8 -> to give is that

3168.54 -> um identity Pro BNP blood test cost is

3171.599 -> certainly much lower than someone being

3174.599 -> admitted with heart failure

3176.88 -> um and uh but maybe I should let you

3178.92 -> answer that

3180.079 -> no thank you so much Carol but first of

3182.88 -> all we were we were the first sight ever

3184.92 -> from Abbott uh to be able to have NT

3187.38 -> probe NP sorry BNP uh this was in 2014

3191.579 -> uh in the country and and so we were the

3194.579 -> first to even make it available to our

3196.319 -> Primary Care colleagues that they could

3197.88 -> actually request at the NP and so we

3200.099 -> have 10 years of experience even before

3201.72 -> the pathway was uh 10 years of

3203.76 -> experience on the NP and NT program be

3206.16 -> testing and so we'd actually done we'd

3208.92 -> actually undertaken a lot of research on

3211.079 -> the health economic benefits on the

3213.599 -> selected patients that you suspect heart

3216.119 -> failure of having that diagnosis early

3218.28 -> and actually be able to focus where the

3220.14 -> echo went so it's a great sophisticated

3223.14 -> question about the return on investment

3224.819 -> the health economic benefits it's not a

3227.22 -> screening tool generalized it's a

3229.38 -> screening tool specified by the symptoms

3232.02 -> we were very careful weren't we care

3233.88 -> when we said actually not everybody gets

3235.859 -> an antibody MP because there'll be so

3237.48 -> many things that will pick up as false

3239.7 -> positive that it should be Nuance at

3241.68 -> breathlessness or Nuance bilateral leg

3244.02 -> swelling and that stood Us in good stead

3246.3 -> and and so the return investment there

3248.099 -> is is worthwhile

3250.74 -> well I think we might be drawing to a

3253.92 -> close

3255.359 -> um if you do have any additional

3257.28 -> questions then you can send these two

3264.599 -> are of dot membership nhs.net

3270 -> um and over to Allison thank you thank

3273.359 -> you very much Carol and thank you to uh

3275.819 -> to Tim and and Amit also as our speakers

3278.76 -> for a fascinating set of presentations

3280.559 -> and discussion this evening and thank

3282.599 -> you to all the attendees who joined us

3284.64 -> this evening online

3286.68 -> um if you want to contact the Council of

3289.14 -> Governors who run these sessions please

3291.78 -> email our governor inbox and the uh

3295.74 -> the email again the emails just come up

3297.66 -> there so you feel free to uh to email

3300.3 -> that um that Governor's mailbox and uh

3303.48 -> it just leaves me to say thank you very

3305.099 -> much for everyone to joining us and I

3307.079 -> look forward to the next session thanks

3308.64 -> very much thank you

3313.079 -> foreign

Source: https://www.youtube.com/watch?v=pRM8_Gjx8N0