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Hello, everybody. Uh It's, it's nice to see everyone joining on once again. It's nice to be back. I know I had missed a couple of our sessions there as well with work commitments. So it's nice to see the, the number of people steadily rising as it always does. Um Welcome, welcome to this middle primary care network event. Um We are absolutely delighted to have Doctor Patricia Campbell back with us. Um We had heart failure part one just a couple of months ago and all of that catch up content is available. So if you weren't available to see heart failure, part one, I'd encourage you to go and check that out. However, tonight we are doing heart failure part two. Doctor Campbell is a consultant cardiologist in northern Ireland and is lead for heart failure. So we couldn't have a, we couldn't have a more expert. Um telling us about heart failure this evening. As you know, we're going to run with the usual format. We will run Doctor Campbell's presentation. I will harbor off um the questions in the Q and A um to the side and try and avoid any duplicates and we can answer them at the end uh as I have done and as I have been doing, I popped into the chat, just the link to the metal app there for your feedback forms for registration for all your future events and your certificates of attendance. So without any further ado, I am going to disappear into the background off camera and off Mike. Um but Doctor Campbell, I'm here and listening and we will chat to you shortly. Brilliant Tim. Thank you so much for having me back. Um Yeah, as Tim said a couple of months ago, I was on speaking about heart failure with preserved ejection fraction. Um Normally you talk about half ref first and then follow up with half pef but I have a, a big thing that half pef gets overlooked. So we did half pf first. Um and lots of people know a little bit more about he fre but it is always worth going back over. Why on earth? It's so important. So heart failure, reduced ejection fraction, urgency is required. So next slide case is Tim. So yes, you will all be aware of these uh titles that you see across lots of international publications and magazines and newspapers and headlines about the war on cancer. Um And our colleagues in the cancer world have done a great job of letting everybody know just how severe a cancer diagnosis is and that it is a timely intervention required that helps save lives in terms of cancer. Next slide, please, Tim. But actually, if we're to look and again, this is not a slate. And my cancer colleagues work very closely with a lot of our oncology colleagues in the cardio oncology world. Um, but of all of the medications that have really been introduced over the last decade or two to improve outcomes for cancer, they extend lives only by about three months. Right. So let's just keep that figure in mind as we are going forward and talking about heart failure. Next slide, please. Tim. So just a reminder, this is a very simple graphic that we put in heart there last year, just talking about the different types of heart failure. Um And if you're interested, that's a review on He pef and we also did an open access review in the Lancet on he PF just this year. Um and that is aimed at primary care to try and make he pf a little bit more um attainable because it is a difficult subject. But to recap, if you pressed next slide again, Tim, he ref is this bit that we've highlighted here and read. It is signs and symptoms are of heart failure when you have an ejection fraction of less than 40%. So actually to diagnose, he ref is easier than he pef because you just need ABM P plus or minus some signs and symptoms. Um and an ef of less than 40%. So next slide please. Um But it is worth remembering why we care and why I every time you hear me talking about he f ref it is about the urgency of diagnosing it and getting treatment started as quickly as possible. Because the sad reality is that survival in heart failure is worse than most common cancers. Survival for heart failure is often way more abysmal than cancers that we would typically care a huge amount about. So for example, breast cancer in women, and I don't think a lot of women in particular are aware that heart failure is a a thing and b that the outcomes are as bad as they can as they are without good intervention. Um but there is hope because we, we do have medicines that when they're given to the patient and in a timely way, they can dramatically improve outcomes. And when we look at this data, it hasn't really changed over the last several decades. So even though we've got more medicines over the last several decades, we're not doing a great job at getting the right medicine to the right person at the right time. And often that's because there are delays in diagnosis or there are delays in either getting seen by an expert or access to an expert from your primary care setting. Next slide, please. So let's remember if you are admitted to hospital or your patient is admitted to hospital with heart failure, you might think, oh, it's a bit of heart failure with diaries and send them home. The in hospital mortality rate is around 9 to 10%. Now across the UK and across England and Scotland. Um lots of hospitals contribute to the ny core heart failure dataset. And I can tell you that that mortality rate has not budged in years. So we are not doing a better job with that. Um And again, that might be speaking to the fact that patients in hospital really do better when they see a heart failure specialist. And most patients don't get access to that when they are in hospital. But the sad fact is is that you're admitted to hospital with heart failure, you have about a one in 10 chance of dying during that hospital stay and then in a month after your discharge, you have a 15% mortality and a one year mortality. That's around 30%. And that really hasn't changed in many, many years. Those figures are startling next slide, please. Tim. And actually it's not just if you're admitted to hospital with heart failure, heart failure for patients that are in the primary care setting is also high. The one year mortality is 20%. The five year mortality is 50%. So half of all patients have died at five years and the 10 year mortality is 70%. That is way worse than most cancers that we spent a lot of time. And a lot of screening about. So hence the need for urgency for he fre next slide please. But the good news is is that we can dramatically improve event free survival. So this is just a slide that's showing the event free survival impact that we can have on a 65 year old patient if we upgrade them from standard therapy, which would be for example, an ace and a beta blocker and place on full four pillar care, which we'll get to in a moment. But that includes an Mr and an SGLT two inhibitor. We can improve their event free survival by 6.3 years. If we get them on the right medicines, and you can see that those curves start to separate very early, meaning that these medicines work within weeks of being initiated. Next slide, please. Yeah. And for event free survival, it's 6.3 years. But there's also we can improve their quality of life and time out of hospital as well. So it's not just time to death, it's also their quality of life and time spent out of hospital. Next slide, please. And so why does this matter? Well, it matters because there are lots of patients out there living with her for about 1 to 2% of the of the population across the western world is thought to have a type of heart failure. Many of those have obvious systolic dysfunction. But the sad reality is if we're not getting it. Right. Right now, things are definitely going to get worse. So this is from a think tank in the UK based in Liverpool called the Real Center. And they've looked at lots of chronic diseases and how the impact of population change and comorbidity change should affect those disease statuses. And you can see that there's a prediction for heart rate to heart failure to increase by 92% by 2040. So not only is there a degree of urgency for the individual patient, but there's a degree of urgency that we start working better to make heart failure care better. So that we can deal with this on oncoming onslaught of the increased prevalence of heart failure down the line. Next slide please. Tim and it's on the rise everywhere. Click next, please. So this is just local data from northern Ireland and you can see that there is an increase in our local population. Now this is patients that are on the primary care register um by about 700 patients per year. If you pick next slide, please click next again, please. Yes. So the pre panic picture looked about 808 100 additional people per year being put on the register during the course of 2021 to 2023 that slowed down very significantly. But in the last year, it has taken off dramatically again with 2000 additional people on the register. And for you know, whether that's just the first year post the pandemic and things are just normalizing out and we'll go back to that relatively stable slope or whether it's a true uptick in the incidence of heart failure, I think remains to be seen with time. And Tim, I have lost the slides there. I know I just have your metal. So there you go. You're back. If you just go to full screen there, please. Um You can go to the next slide when you're ready. Bear with me just getting tech. Here we go. Here we go. Apologies. Yeah, and you can click next again. So time is definitely of the essence and we would always say that every single encounter with the person counts. So it's not just oh they're seeing the heart failure, nurse specialist, they're due to see them in six months. She will hang on until then. And the reason for that is, and I will say this probably repeatedly throughout the presentation is that there is no such thing as a stable he ref patient. So heart failure is a progressive condition, but timely optimal medical therapy can prevent the deterioration. And here's why it's important. You probably will have seen this graph presented many times on, you know what you could put it for any chronic disease. There's actually a very similar graph for COPD cases with moderate to severe exacerbations, but this is the heart failure one, we know that every time somebody either has a hospitalization for acute decompensated heart failure, needs intravenous diuretics in the community or just has even an escalation of their oral diuretics, that they have a decline in their cardiac function. And it never quite gets back up to where it's previously started. And with each decline, the time between those exacerbations gets shorter and the the the the regain of function is never quite back to the previous standard. So there is a chronic decline of heart function and overall patient quality of life and ability to stay out of hospital. And you can imagine that if we help prevent a decompensation, then we help prevent that chronic decline. Next slide piece, Tim and what is the evidence that's out there about making an early diagnosis for heart failure? Well, again in this day and age and similar to the data that's been around for 1020 years, we know that lots of patients have been getting their diagnosis of heart failure only when they really decompensate and end up in hospital. Now, the proportion of those patients has been increasing over the last 10, 15 years. And now we know about 80% of patients are getting diagnosed only when they're in the hospital. But if we look back in the trajectory of those patients and their presenting presenting complaints, half of these people had symptoms for up to five years beforehand. And if you have a diagnosis that's made only in hospital and not in the primary care setting, then you have a two fold increased risk of one year mortality. So it's just behooven on us to think, could this person be presenting with heart failure? And if I think they might be check a BNP and get them access to a rapid diagnostic service where you can, um you know, we all think about patients with heart failure being like older men with a previous heart attack or maybe women with uncontrolled hypertension, obesity atrial fibrillation. And yes, they are classic risk factors. What I would say to you is that not all heart failure is the downstream presentation of cardiovascular risks. There are still many people out there with genetic abnormalities and familial events that don't have afib obesity, hypertension, chronic kidney disease, previous heart attack, coronary disease, previous stroke and they, they still are presenting with decline in exercise tolerance. They're treated as asthma and it's years before they get their heart failure diagnosis. So this is particularly for younger women and younger men because they tend to have pretty good peripheral skeletal musculature and they tend to compensate for quite a long time until they don't, until they crash and burn. So if somebody is presenting with a brand new reduction in exercise tolerance and you're not sure what it is. Check a BNP. Next slide, please, Tim. So what do we use for? He ref care? So there are four pills which covers five different pillars as it were. So of the four pills we use one is a pill which combines an ARB with a nerosin inhibitor that's called an Ar. So that's a Valsartan. There's only one in their class. It is superior to what was the previous gold standard? Which is an ace inhibitor but either AR or ace are still class one in the guidelines. Beta blocker is the second pill. The third is an MRA. So that's spironolactone or Aplin. And the fourth is an SGLT two inhibitor and that's either pilosin or dagga flosin 10 mgs once a day. The first three, the beta blocker and Mra all require some up titration usually. But the SGL T two is 10 mg once a day and no further titration needed. So these medicines are all class one indications of being life saving medicines for he fra not only do they approve patients quality of life, reduce their symptom burden, keep them at a hospital but they extend the length of their life. So they are critical medicines in the same way that a chemotherapy or radiation therapy would be critical for the care of cancer. So these are medicines that we shouldn't be kind of saying, oh, I must over the next six months to a year, get this person on these medicines. It cannot be delayed. Next slide, please. Tim. So that's just to highlight that they prevent hospitalization and death. Now to contextualize the risk for patients with heart failure. So I'm just here showing you something that particularly if you're in primary care and you're looking at the Q risk score, Q risk two or three. And you're kind of saying, oh, gosh, I wonder is this person high risk for a future cardiovascular event? So if we're even looking at a very high risk person, so somebody that's either had atherosclerotic cardiovascular disease or multiple events or they've had one event and lots of risk factors. So that would put them in the highest category of risk. You're looking at about a 7% risk of stroke or heart attack over the following year. If you click next, please, Tim, if I then, you know, put a half ref population beside that. So at above 10% that's, you know, you'll start to see that huge risk of 10% per year of cardiovascular death or hospitalization for heart failure. And that is in a stable patient. So that is somebody that's living with hef, they're right in the community, they've had no recent heart failure hospitalizations and they're fairly symptom free. They can live a reasonably good life in their class. N yh A class two, those patients are still at a 10% risk of heart failure, hospitalization or cardiovascular death in the following year. If I had somebody who's had escalation of their diuretics or needed intravenous diuretics or hasn't been able to tolerate as much previous life saving for pillar medicines and they had to be reduced, that puts them into the very extreme risk. And we're talking 40 plus percent risk of heart failure, hospitalization or death in the following year. If you click next, please, Tim. So we care a lot about the ischemic people in the cardiovascular world. But the stable he ref patient has a way higher risk than the very, very high risk atherotic cardiovascular disease. So what I say is there is no such thing as a stable he ref patient, we always need to be looking at our he ref population even if they haven't come to you for symptom worsening in years saying are they actually on the most up to date therapy? Are they on, you know, the old two or three pillars that we used to have or are you on the four pillars now? So next slide please, Tim. So before when we used to kind of just use ace beta blocker plus or minus an MRA, we used to start and then every 2 to 4 weeks of titrate, then add the next one and every two or four weeks of titrate. And you can imagine that if we were now to do that strategy, using these four pillars that we now use, we would really be looking at about half a year to a year before these patients are fully optimized. And during all that time, these patients are exposed to this extremely high risk. So it stands to reason that the guidelines now recommend that we do not any longer. Do this start up trait a start up trait ad because it just takes way too long. Next slide please, Tim. So that's why the guidelines, this is the most recent iteration of the EFC guidelines for heart failure. And you can see this is heart failure with reduced ejection fraction. There is if a patient has a diagnosis of HEF ref they need to be on these medicines. So obviously, a loop diuretic is always gonna be in there as a recommendation for HEF ref because decongestion is critical in these patients. Loop diuretics do not save lives. They do not keep people out of hospitals but they do improve symptoms. However, the beta blocker Mra and SGLT two, all of those medicines are life saving medicines and they're put in this very in this one box, very purposefully to say that they should all be considered to initiate either altogether, are very promptly one after the other and the message is now not to start one up titrate, add another. It's to try and get low dose of all four and then worry about up titrating that the three that need uptitrating. So that's Ar E Mra and um beta blockers. The SGL T twos, as I said are 10 M GS once a day, no titration required. Next slide please. Tim. So I've shown you here the slides on SGLT two effects and how soon they start working but I could have shown you this for RA Mra A beta blocker, they're all pretty much the same. So basically, within about two weeks, we really start to see a significant separation of the curves. And by one month, there is a very statistically significant improvement in patient outcomes with the SGLT twos. The same data stands for RNA beta blockers and MRA. So it stands to reason that the sooner we get these patients on at the time of diagnosis or if they're on older therapies of just ace and beta blocker, the sooner we upgrade them to the four pillars of care, then the better the outcomes for these patients. Hence every encounter with these patients matters, we need to be looking at every opportunity to get them on the appropriate four pillars of care. Next slide please. So there are people out there saying, you know, start them all at once at the very same day. So start an SGLT two and initiate Mra beta blocker and RNA at a low dose all on the same day. And that's because you reduce heart failure, hospitalization by 42% death in total by 25% the combination of two by 37% or a worsening heart failure event, hospitalization or death by 58%. And if you can do this, this is fantastic. This is a great way to go about it. My own feeling in that is there aren't the majority of patients aren't really that hemodynamically robust to start them all on the same day, you may get a very fit 50 year old gentleman with, you know, really good BP, normal renal function, who's never had an AK or hyperkalemic episode, who I would be quite happy to initiate all for on the same day, but most patients have a degree of CKD, they have a degree of hypotension, they've had previous hyperkalemia. There may be some other issues that you may want to start thinking about. Perhaps an SGL two always seems a really easy one to start because it has minimal effect on BP. We we know its effect on the kidney. It will always lower your GFR by four or five MILS. That is the effect of the drug. It is not a nephrotoxic effect. So we know what it's going to do for renal function. We know it has minimal effect on BP. So it's very easy to start that and perhaps a beta blocker on the same day, but it doesn't really matter which, which of them you start. But the message would be try and start more than one when you first see the person. Um next slide please, Tim. Um and there, there's, there's reason behind why we think about starting as many as possible. Yes, it's to reduce that exposure to the increased risk. But also there is some, we know that these medicines work in synergy to improve outcomes for the patients. But there's also some synergy between how they help prevent side effects. So we know that SGLT two S are associated with reduced risk of hyperkalemia. So it's much easier then to start things like an MRA or an R and E if before, you might have had concerns that if the potassium was stay sitting at 4.8 you go, gosh, I'm worried this potassium might go up if I start this MRA. But actually, you can start the S DLT two and the MRA at the same time. And you're much less likely to get a hyperkalemic event. We also know that they slow the progression of D and therefore it's much easier to get an Mr and an R on board where before you may have been a little reluctant to start those in somebody with CKD alone. But the combination is a, is somewhat protective and again, they have minimal or no effects on BP. So it's very easy then to start a beta blocker or somebody who doesn't have a postural drop in their BP to start an R. So, you know, there is ability to start more than one because there is um some synergy between them in preventing side effects. And similarly, for an R and when you start an R and you're much less likely to get the hyperkalemia that you previously would have had with an MRA and an ace inhibitor. So combination of R and Mra causes much less hyperkalemia than the previous iteration of ace inhibitor and Mra. So again, look to the combinations and see which you can start that might help prevent side effects that you previously might have been concerned. About. Next slide, please, Tim. And have we had any data to say that you know other ways of implementing them in a fast fashion but perhaps not all on the same day leads to improved outcomes. Yes, we do. And this has been put in the most recent version of the guidelines. So this was strong. HF and these were patients with acute decompensated heart failure. They were in the hospital and they were either on no failure, therapies or out of date or suboptimal heart failure therapies. And they had a high BNP. So they were um it was a randomized trial. They were randomized to either usual care, which is just whatever the normal was to high intensity care. So they tried to introduce half dose of all of the pillars of care before they went out of hospital. And then they checked them the first week to make sure that they were tolerating those. And then thereafter, they went up titration. And by week three, week four, we're looking at full optimal doses, tolerated doses of heart failure therapy and they followed them up for 90 days and then followed up outcomes for 100 and 80 days. Now, when we first heard about this trial. We all as heart failure, experts thought holy smoke that is fast and they're probably not gonna see, you know, if there's outcome benefit in such a short period of time. But next slide please, Tim. But what we did see is that a lot of these patients were very likely to be able to get on and stay on the fully uh uh optimal dose of these heart failure meds. Next slide please. Tim. And that there was a very significant reduction in heart failure, hospitalization and all cause death. Now it's hard in a half a year to show that. But that is that's the outcome that they had. They also showed that weight went down consistent with appropriate decongestion. CP measurements went down, peripheral edema grades went down. N yh A class went down and NT PRO BMP went down very significantly. So they're all kind of medical markers. What about how the patient felt? There was a statistically and clinically significant improvement in the patient's quality of life score. So not only did patients tolerate it, not only were they able to stay on these medicines but it dramatically improved their outcomes. So we now have lots of data to say as many of the four pillars as quickly as possible will cause downstream beneficial effects in patient outcomes. Next slide please. Tim. But real in the real world, we're not doing such a great job at this next slide please. If we look at titrate HF and this was, you know, a long term registry of heart failure patients from the Netherlands. Now, I'm from Northern Ireland. We are fairly data free world. We just did a big heart failure mapping project here which we announced yesterday and I was standing up telling them the small bits of data that we were able to tell them about heart failure care in Northern Ireland because we don't really have a robust health care data set. But other countries like Sweden and the Netherlands have fantastic heart failure data sets. And even in, in countries like this, that have really quite sophisticated medical care for heart failure. When they looked at patients with, he fre only 44% of patients were prescribed quadruple therapy and only 1% got the target doses for all classes of drugs. That's not fantastic. Now, those who attended a dedicated heart failure clinic did much better at attaining that than those that went to a general cardiology clinic. Um but I suppose some of the inability to get to the target doses were due to intolerances. And so some of it could have been seen as an exception. So we need to get better at recording, you know, whether this is something that we just didn't try or whether it's truly that this patient cannot tolerate it. Next slide, please. Um Here's some of our own local data which is quite striking and shows that the care setting does matter. So in my own trust, that's one of our health care regions within Northern Ireland, we looked at over 5000 patients with a heart failure diagnosis he diagnosis and we looked at their clinical follow up over the course of their entire um heart failure care. Next slide, please. And unsurprisingly, they were an older age group, the median age was 75 and they were multi morbid and over half the patients had more than three comorbidities, which generally reflects what we know about he patients next slide. But what we do know was that? So this was looking at patients who were being seen by our heart failure nurses. So the heart failure nurses were the specialists. But when they were referred to the heart failure nurses, what we did know was that you were much less likely to be on life saving therapies such as ace inhibitors, beta blockers, MS and RNS and more likely to be on diuretics if you referred by non the teams. So that was either by the medical team or by primary care teams. Now, remember it's great that you're in diuretics to try and help improve the patient's symptoms. But that's not so great when those medicines are not life saving, but you're not getting those patients on the life saving medicines. I apologize here because I'm looking to, I'm seeing my battery flashing. It's telling me to plug in my computer. I just don't want to get cut off, I'll pause one second, Tim, just to make sure I'm plugged in properly. Is that all right? No problem at all. And in the meantime, in the meantime, I will just remind everyone. I've got one question for you so far. Um, I'd encourage everybody on the chat if there's any other things springing to mind as you're listening to Doctor Campbell, this is your chance to, to get questions answered. Pop them in the chat. I will harbor them off to the side and we'll address as many as we can at the end. Yeah. Sorry to him. I don't know what's happening here saying that my battery is not great. But so we'll keep going and I'll log in on my phone if there's a problem. Apologies, problem at all. Ok. So, so if you were referred by a non cardiology team, you are less likely to be in these life saving therapies. So like I say, diuretics are great for, you know, relieving decongestion, but they do not improve the length or the quality of life for that patient. And the next slide please. And the next thing that was really striking is that if you were referred by a non cardiology team, your survival was half. Now, we're not really able to say why that is, but it's probably that the patient's diagnosis was delayed or that they were not on these life saving therapies. So what I think this speaks to and you can click to the next slide is that for anybody who isn't a heart failure specialist, it really is an international recommendation. And here in the UK, we've got the NC pod report for inpatients stating that all inpatients do better when they see a heart failure specialist. But we have now got data to say that that exact same recommendation should be made for the primary care setting. And the general medical setting is that if you are diagnosed by a heart failure specialist and cared for by a heart failure specialist from the outset, you do much better. So I think it speaks to us that our heart failure service planning needs to not just involve people like me sitting at the top tier. Um but it also needs to involve patient people in health care systems all across the patient care journey. And certainly here in northern Ireland, we are advocating for a much more dynamic link between primary care and secondary care. And I'll get to that next slide, please, Tim. So we can help prevent the hospitalization. And you will remember from my previous slide where this curve goes up and down but never quite makes it back up to the top is that we can impact patient outcomes by intervening earlier. So for I, you can keep going, just press next again. Ideal streamlined heart failure care, you can keep going should involve ideally screening those at high risk. There should be a very easy electronic referral. If somebody has got a high BNP and symptoms of heart failure, there should be a very quick way to get that patient referred. Patients need to be prioritized. According to their BNP, we know patients with a much higher BNP do much worse. So there's a red flag referral service recommended for heart failure. If you have ABM P greater than 2000, you need to be on a two week pathway for a diagnostic confirmation and a specialist heart failure review. And if it's between 402,000, you need a six week pathway. Again, much like the cancer pathways. We all know about heart failure pathways should be exactly the same. We all talk about how you need excellent clinical care. You need rapid medicine optimization. If you're in hospital, you need an early post discharge review. You ideally need specialist heart failure care in hospital and a way for you to self refer by patient initiated follow up. If your symptoms decline in the future, we know that heart failure rehab improves outcomes for patients, helps people out of hospital as often as the medicines do. But importantly, the vulnerable times for patients are when they're going between secondary care, inpatient care and primary care. That's where they sometimes fall through the cracks or when they're out in primary care, which is they spend most of their lives in the community and not in the hospital that they're not getting access to the heart failure, specialist care. Now oftentimes the secondary care, heart failure teams are at capacity or they're unable to take on more patients on their books. But what we have done to try and work with that is do a virtual multidisciplinary team, outreach to primary care to get access for those patients living in the community with heart failure. Next slide please, Tim. So we do a virtual clinic in the Southern Trust here in Northern Ireland. Next slide. And so we have 72 primary care practices here in my own trust. Um Not all of them have engaged because it takes a little bit of work in the primary care side. So 80% say that time is a bit of a challenge, but all of those who have become engaged state that it is brilliant for getting really quick patient um advice, clinical advice from an expert. Um a really rapid turnaround of tests where tests are needed, but also a massive improvement in their knowledge and upskilling in heart failure care and increased confidence in that. Because when we tested confidence and ability, pre and post say a year, there has been a dramatic uptick in confidence and knowledge for heart failure care management. Next slide. And when we look at hard data, we're able to show that we dramatically reduce the times that these patients out in the community would be waiting for a heart failure specialist opinion. And we dramatically increase the percentage of those patients who are on optimal medical therapy. Next slide piece, Tim. And then again, because commissioners are the people who fund these services. We have to show that this is cost saving that we should be doing an outreach to primary care from the secondary care setting. And we have to show our commissioners in the secondary care setting that this is cost effective. And it is because we are preventing additions to the cardiology waiting list, the heart failure, nurse specialist waiting list, but also referrals into the ed and um acute medical units. But worryingly, lots of the primary care team said that if they hadn't had access to this multidisciplinary heart failure clinic, then lots of them would have done nothing. And I've already shown you the graph that when we don't optimize patient care, the progression of decline gets much more rapid with much more frequent decompensations leading to increased mortality and heart failure hospitalizations. And similarly a quarter of these um primary care teams who had no confidence in heart failure management at the initial initial relationship that we started with this heart failure clinic were going to do an unsupervised change. So, you know, they, they were, they were doing things that they weren't really confident about knowing what to do, how to follow. Um And that was a worry to them and yes to us to for these patients that are complex. Next slide, please tim a word on for those of you who er, particularly sit in the primary care setting, we can prevent heart failure. Next slide, please, we know that there was a trial like many years ago by my wonderful colleagues in Dublin called Stop HF If we look at patients with diabetes and other risk factors such as hypertension and obesity, that if we impact on their risk factors, we are able to prevent all cardiovascular events down the line, but particularly heart failure events. Next slide please. And I sit in the British Society of heart failure. Um but they have done a multinational initiative um last year called 25 and 25 which is a plan to reduce the trajectory of heart failure by reducing the mortality by 25% over the next 25 years. And that's because we know can prevent the onset of heart failure for patients with cardiovascular risk factors by impacting early on their cardiovascular risks or diagnosing the heart failure earlier than we otherwise would have to try and get away from this. 80% of people being diagnosed only when they're in hospital screening isn't really part of primary care work here in northern Ireland and some of the cardiovascular risk work and heart failure work isn't really commissioned in primary care anymore. So it is something that we all need to advocate for very strongly. Next slide, please. So some take home messages and I start, I'm seeing some questions starting to come through here and thank you very much for them for heart failure with reduced ejection fractions, outcomes are worse than many cancers. We can optimize care for patients to try and improve these outcomes. But the real world data shows that we're not doing a great job at that right now, I would stress to you that if you have a patient with heart failure with reduced ejection fraction just because they're not coming to see you does not mean that they are a stable patient. Um A patient with a low ef class two N yh A symptoms still has an excess of a 10% risk of cardiovascular death and heart failure hospitalization every year. So we've had many primary care teams work with us to look at their heart failure population to try and see. Gosh, are they actually on the right treatment for their disease? And if they're not working with us through our heart failure, virtual clinic to try and optimize their outcomes, timely care matters because these medicines, all the four pillars for he for f care all work within weeks of being initiated. The target is to initiate as many as possible of these pillars at a low dose and then worry about a titration thereafter. And if I could urge any of you to either vouch for or champion for the use of a heart failure, multidisciplinary team between primary and secondary care, we can show that in many instances, it's been shown to improve patient outcomes. And it's certainly something we're fighting for here in Northern Ireland and I'll leave it there and we'll hand over back to Tim for some questions. That was absolutely fantastic. Captivating as always, Doctor Campbell. Absolutely fantastic presentation. I hope everybody enjoyed that as much as I did. I certainly did. I'm going to take the slides down off just to make our beautiful faces a little bit bigger. Um, Do I'm going, I'm going to jump in selfishly with, with one question because I'm interested in this as well. It's I in the interest of full disclosure, slight conflict of interest in that. I worked in the same trust area as Doctor Campbell in my f one year, um which is our sort of first year out of medical school in Northern Ireland and in the UK. Um And I had really, really good um experiences with the heart failure nurses with community heart failure teams as well. But is there one thing that you apart from timely referral for GPS or for primary care physicians? Is there one thing that you would say could make the biggest difference for patients apart from timely referral or is it getting the heart failure patients seen by a specialist? So that's a difficult one, Tim because you know, II was up in Stormont. So for anybody that doesn't know that is the seat of parliamentary power here in northern Ireland last week. And of course, the Health Minister rightly says, if you could do one thing for you, what's the one thing that I could do that's going to fix this? But as you know, heart failure is a chronic lifelong condition. So there isn't one thing that changes entirely the trajectory for these patients. Timely, diagnosis matters massively and a delay in diagnosis undoubtedly dramatically worsens that patients outcomes. So if you're sitting in primary care and somebody's coming to you with undifferentiated shortness of breath or reduced exercise tolerance. What I would say is just consider, could this be heart failure? And here locally, a BNP costs about 12 to 14 lbs. We do blood tests that cost way more, that mean much less in terms of outcomes. Vitamin D costs a huge amount more than that. I know it is, it's important but you know, it doesn't have the huge urgency or mortality that comes along with a heart failure diagnosis. So I think timely diagnosis is critically important. I think the other thing I would say is that don't forget about your, you know, your heart failure population that you have out there already. Certainly, you know, when the guidelines changed and it went from just being an ace and a beta blocker, maybe an MRA to all four as quickly as possible. We then had to go. Ok. Well, we've discharged thousands of patients in our time who were at home. Now on these old out of date pillars of care. And just because we're not seeing them does not mean that they're not at risk. Now, obviously, we didn't have the capacity to bring all those people back to see us all face to face. And that's part of the reason why we set up this heart failure virtual MDT to try and get access to those people in a way that, you know, my physical clinic couldn't. Um So I would say there is no such thing as a stable patient. The guidelines say that they need at least yearly review in primary care, which happens variably across the UK and the world. Um But at each of those yearly reviews, there should be, let's see what treatment treatment that you're on. Now. Actually, your ef is only 30% and you're only on an ace and the beta blocker, we need to do something about that. And if you don't know how to do it, then you need to reach out to somebody who does know how to do it. And if that's your heart failure, nurse specialist to get them back in to see them, that's it. But you know, if you have somebody who's a heart failure champion who doesn't stop talking, then, then you get those. Um I think, you know, we all need heart failure. We need, we need champions in all of these chronic conditions which are all on the uptick. COPD is massively on the uptick in northern Ireland and across the UK and the world and it is associated with increased cardiovascular mortality, including heart failure. So, you know, I think there's a lot of speaking to the shift left of medicine to try and doing a lot more in the primary community setting so that we're preventing the patient coming to hospital. Because you and I know the reality of the hospitals are, they are often overcrowded. Patients will report after coming in from a heart failure, decompensation after like a day or two and just getting one or 2 kg off. Do you know what? I feel so much better? And we'll send, have them sent out without their medicines yet because you just, there's an urgency for beds. The ed is packed, we need to clear some space. Um but we haven't actually optimized their treatment and they just come in a couple of weeks later um or, or they could die out in the community. So the short answer, I'm not sure if we maybe lost you there. Doctor Campbell, did we potentially bear with us folks? I think we're just having a little bit of a technical glitch. Um Give us a couple of seconds. I'm sorry about that, Tim and the audience. No, you're absolutely, you're absolutely grand. I suspect I was trying to just get your number there, but I suspect that that's exactly what happened. No, I was, I was just going to come back to that myself and say that maybe instead of those daily C RP tests to look at how someone's chest infection is getting better. Maybe, you know, three of them would make up the cost of a single BNP. So if we're looking at cost, maybe that would be a more effective investigation for the patient who comes in with recurrent chest infections. Or you agreed and look um just as you mentioned, BNP there, the use of BNP, it's probably worth going over. We talked about it a little bit at the last meeting, but BNP is a great diagnostic indicator for heart failure. A high BNP doesn't necessarily mean heart failure, but it is a sign that you need to be investigated for potential heart failure. There's lots of things that put your BNP up. Um So it doesn't necessarily mean, you know, a BNP of 2000 doesn't necessarily mean this is true heart failure. Um But it does mean red flag needs investigated for same. Um How we else use BNP is a predischarge BNP for somebody who's been in hospital, helps me prioritize the urgency of that person. So if they come in with ABM P of 2000 and I'm sending them home with ABM P of 200 I've done a wonderful job and I'm not very worried about that person if they come in with ABM P of 2000 and I send them home with ABM P of 1800. You know, that person is tentative and they need a lot closer follow up. So that's the two big times that we use it. The third time that I typically recommend, particularly for people sitting in a primary care setting is a yearly BMP as part of that yearly heart failure review because, you know, sometimes you want to know what their baseline is because if they come in, particularly the elderly patient with half ref or even half pe, they come in and they're just newly confused or they've got new nocturia or something is new or different off their feet, then it might be a heart failure. You know, heart failure isn't the obvious all the time. It's not always p and it's not always pitting edema up to the stomach. You know, it may just be particularly for the very elderly and frail a decline in function. So having a baseline BNP is a good place to reference when you're not sure what the presenting symptoms are. So that's kind of the three times a year. So, absolutely fantastic. Fantastic. I I'm just finishing a job in the kind of other aspect of primary care um in emergency medicine in A&E. And I think some of my consultant colleagues maybe don't like whenever I go, I will just send ABM P as well. But I hope that I hope that that is, is a useful thing to do. Look, I'm gonna, I'm going to jump into some of our listeners questions. So um hopefully these are popping up on the screen. But Mary Ann has said that um has observed a marked increase in heart failure. Um also in the emergency department in younger people since the introduction of the COVID vaccine. Um commenting about stress responses in spice and glucose as well. Um Is that something that has been on your radar at all? Doctor Campbell, um any awareness of that. So um the data is very clear on this so far that there is a tiny increased risk of myocarditis related to the COVID vaccine, but it pales into insignificance to the myocarditis related to COVID itself. So personally speaking, I have seen one possible vaccine related myocarditis, but I've seen a massive uptick in COVID related myocarditis. Myocarditis is inflammation of the heart muscle, myocardium itis. Um and it's often very difficult to prove what caused that inflammation. We don't have a test, we don't biopsy all these hearts and get them sent off for genetic and viral testing. So we often never find out what it is. But we definitely have seen an uptick in myocarditis related just just inflammation but also myocarditis related decline in alb systolic function related to COVID. So we are not recommending patient to not go for the COVID vaccine. We are recommending patients all to go for the COVID vaccines, especially if you've got heart failure. Because if you get heart failure, if you get COVID with the diagnosis of heart failure, your outcomes are definitely much worse. So the short answer is it is a very tiny risk with the vaccine and a much higher risk with COVID with the, with the disease itself. Thank you. Um Sine has mentioned about the rationale behind choosing an A slash A RB or re um what should be the first nine? I think there's a fairly straight answer there. So for me, it's very easy. Um RNAs are superior to ace inhibitors. They were compared to ace inhibitors for heart failure with reduced ejection fraction. So this is the ef of 40% and below. So for me, why would I start with an ace inhibitor when I've got a medicine that's superior to it. So it caused AAA more than 20% reduction in cardiovascular death and heart failure, hospitalization when compared to the gold standard from before, which was an ace inhibitor. So for me, it's r first line and only if somebody has got, you know, I don't know a significant drop of BP with the RA because they've got borderline hemodynamics that they can't tolerate it. For whatever reason would I then use an ace or an ARB a second line. Lots of the guidelines that have come, you know, for primary care, people with a specialist interest in heart failure have said we start with an ace. If they tolerate that, they will change to an R and, and I can kind of see why that came about. It's because nice initially said should only be initiated, initiated by a specialist. But I think we all now have many years of experience with an R and we know that the hemodynamic profile, it might cause a very slight increased reduction in BP over an ace inhibitor. But the renal effects are the same. And actually you get less hyperkalemia with an RN than you would with an ACE inhibitor. So for me, it's definitely first all the way. Um and I think lots of people are trying to get away from that ace first, then Arnie because again, I'm just adding more time until I'm getting the patient on the right medicine. So why would I add more weeks to what's already a critical situation? Absolutely. And so much about what you had shared, there was about getting all the drugs started with the changes in the guidelines, getting them all going as such. Um I know as mentioned, um I guess it maybe is slightly um out there a little bit about the role of Everard in he, I know that's not maybe forefront in the guidelines but any but it's there. No, it is there. So if Aberdeen definitely has a role. Um So if Aberdeen is an add on medicine, so it is not a first line medicine. It is for patients who despite the four pillars of ongoing symptoms and their heart rate is above 70 despite being on a beta blocker or because they can't get on more beta blocker. So it's for those patients sinus rhythm, heart rate above 70 despite of a beta blocker or because they can't tolerate more or any of a beta blocker, it's an add on therapy. It's usually a special, it's usually started by some of us. Um in the heart failure world, I would say if you're sitting in the primary care, general medical setting, only if you're really particularly comfortable with heart failure care. If you have a specialist interest in it, go for it. Um But to me that's typically done in the heart failure specialist setting something that's a little bit more down the line. Um Yeah, let me move on to Anthony's question. Then we've one more after that and that will probably wrap us up for this evening. So, um we try not to be very patient specific because obviously the, the uh the platform itself is educational and not for um specific cases. But I suppose we could generalize Anthony's question in the sense of a housebound patient with BNP findings that would suggest the need for investigation for he f ref or for heart failure in general. Um but they're unable to attend for those physical investigations being housebound. What would the advice there be in regards to um primary care physicians doing something about the four pillars without a definitive diagnosis? Yeah. So look, I mean, if you've listened to the last talk and you've listened to this talk, you'll see that loop diuretics are for everybody, right? So if somebody's got signs and symptoms of heart failure and you've got a BMP that looks suggestive of heart failure, well, then loop diuretics definitely relieve patients symptoms. Um And if somebody is housebound, what are our goals of care for this patient? You know, our goals of care are to make this patient feel better and decongestion is definitely a cornerstone of heart failure care. In fact, we know that patients when they are adequately decongested, do better, but most patients are not aggressively decongested well enough. Um So loop diuretics are always the first treatment of choice. But if you're thinking, I would like to try and get some guideline directed medical therapy on board for this patient. But I don't know what sort of heart failure they have because I can't get an echo because they're housebound. Well, if you listen to the last talk and then this talk, you will have heard that there's one medicine that crosses all the ejection fractions, it doesn't matter what type of heart failure that you have. If your ef is 10% 20% 50% 60% the SGLT two of DS and, and SIN 10 mg once a day are a class one indication regardless of your ef Now, some people might say, well, look, they might have heart failure failure symptoms that turns out to be critical aortic stenosis. I mean a physical exam really should help you determine whether you've got really critical aortic stenosis or not. But, but also it's probably not going to do a huge amount of harm. The only time I would say not to use it is if somebody has frank clear contraindications to it or they have previous severe pancreatitis or they have an indwelling catheter with recurrent septic uti. So the occasional uti is not a reason not to give an SGLT two inhibitor. Again, it's important to remind people if they're not used to using it, it doesn't matter whether patients are diabetic or not. Um For the diabetic patient, I suppose you tend to have a little bit of care about starting it. If their HBA1C is really tightly controlled and they've got good renal function. If both of those things are true, then you may want to consider reducing some of their other medicines. I don't know who's putting balloons up there, but it looks great. Um So you may want to think about reducing their insulin or some other medicine, they're on reducing their Metformin dose if their HBA1C is really tightly controlled and their renal function is good. The SGLT two is only good hypoglycemic agents if somebody's got really robust kidneys. So if the GFR is 45 and below, they're not really going to cause hyperglycemia. But you have none of those concerns. For the non diabetic patients, they do not cause hyperglycemia, what we would say for all patients is that they must be able to, or their carers must be able to follow the sick day rules. So that's probably what I would do. The other thing that I would be doing in my own trust because we can do it is why don't you call into the heart failure virtual clinic and we can talk through this and we can give you advice today and you can back to us next week and say, well, that didn't go, go so well or it worked a little bit but not enough. What do I do next? And then you've got dynamic access to heart failure care. And I think given that the disease prevalence is going up and up and up and comorbidities are going up and up and up. We're going to see and hear a lot more of these cases. And I think having access to specialist care is really important. One of those key things for sure. I also am not sure where the balloons are coming from. I have to be honest. Um It's not me. I'm going to move on to our, our last question this evening that comes from Richard. Um He is questioning about patients who are already on established pillars of heart failure management and this is such a common difficulty, I guess for um folks in primary care in general practice who do their annual review of their heart failure patient or their asthma patient or their chronic disease patient and the patient turns around and says, but what's wrong? I'm fine. I'm ok. What is wrong? How do you have you any advice for clinicians who are trying to approach that conversation and try and get the patient back on site? So I either show them the graph that I showed you guys about adding. So the 65 year old man gets 6.3 years of event free survival, event, free survival mean he's not in hospital. I'm adding quality and quantity of life to him. So it's not just you're fine now, but this is going to keep you as good as you are now for much, much longer. Um And if I don't have that slide, I'll just draw that slide and that data is true for a 55 year old, for an 85 year old. Now the time gets a bit less than 85 you're only adding about 3.5 years and then it's a discussion between you and the patient again. You know, I am not telling the patient what to do. It is a discussion and if they refuse, they refuse, they are within their rights, but they need to understand that by refusing the upgrade, you know, they are putting themselves at risk. And I think when you explain it in terms like that, most people kind of go well, should I give it a go? And when you, when you particularly when you explain that the medicines that we're using can be used synergistically and often without side effects or we can reduce the effect incidence of side effects by how we combine them. I think it's, I think it's I I've rarely had a patient say no on the basis of that, but I think you have to let them know that by continuing as you are, you are exposing yourself to earlier risk of coming to harm just about being up upfront and honest. Really, data is very powerful. Data is so powerful. Um Doctor Campbell, can I say an absolutely massive thank you on behalf of everybody who has joined, not only tonight but back in since September when we did heart failure, part one as well. Um For everyone who's joined tonight who maybe didn't see that scroll up in the chat, I posted the link to that talk there as well and we will have tonight's talk up very shortly after the event. Um Thank you so much for giving up your time. It's December, it's manic, it's busy. I know that you've been flat out. But trust me, whenever I say that the people from the primary care network here at me, really appreciate your expertise. Um I'm going to just quickly plug a couple of upcoming events tomorrow night. We are back with probably a colleague that Doctor Campbell know um Doctor Jane mcauley, one of the palliative care consultants that I've worked with as well. We're going to be looking at diabetes in palliative care and I posted the link for that. That's tomorrow night at our usual time. Um, and then following on just next week, we have a familiar favorite back. It actually spiked in my head. Um, Doctor Campbell, whenever you were talking about or people with niche interest in these specific chronic disease management. Well, we're back next week with Doctor Steve Holmes who's a GP with an interest in CO PD. Um But this time he's going to be talking about asthma diagnosis and he, he's one of those kind of folk who have a real interest in a chronic disease management. The link for both of them are in the chat there as well. I'm going to share tonight's feedback form which should go both to your email and on the chat. Please take a minute to fill that out. Not only because you get your certificate of attendance at the end of it, but because feedback is such a crucial part for our speakers, it forms. Um So so much help whenever it comes to doing appraisals and revalidation and things. So I know our speakers really appreciate your comments in those. It's after half eight, I am going to park us there for this evening. Um Hopefully we'll see some of the audience again tomorrow night and I'll finish by saying another massive thanks to Doctor Campbell for tonight and for September as well. Have a great evening. Folks talk later on.