Non-Covid clinical crises: Heart failure
Pulse’s series on how to manage non-Covid subacute problems when you’re out of your comfort zone and there’s minimal help available
In general, the principles around diagnosis and management of heart failure during this pandemic should remain aligned to those outlined in the NICE 'Chronic heart failure guideline' 2018.
People with heart failure are amongst those at the highest risk of poor outcomes both in general and in relation to Covid-19 infection. Evidenced based treatments (RAAS drugs/beta blockers) make a significant difference to outcomes in those with heart failure due to reduced ejection fraction (HFrEF) but our ability to safely monitor and optimise these therapies may be reduced during the Covid-19 crisis. Importantly these therapies should not be routinely stopped during the pandemic as there is no clear evidence of harm and even some suggestion that RAAS drugs may be beneficial during COVID-19 infection.
First and foremost, where a patient presents (by telephone triage and /or subsequent consultation) with acute haemodynamic compromise and clinical features of heart failure then consideration should be given to directly admitting the patient urgently to secondary care whatever the underlying cause of their cardiac decompensation including Covid-19 infection
In breathless patients presenting with a suspected new diagnosis of heart failure (orthopnoea/PND/new or worsening peripheral oedema) then ideally, they should be seen and assessed in a face to face consultation with where possible, an NT-proBNP and relevant bloods (including renal function) measured and an ECG recorded. Symptoms and signs of fluid retention can be addressed using oral loop diuretics (bumetanide/furosemide OD or BD). Those with an NT-proBNP over 400 pg/ml should be referred urgently to specialist services using existing pathways with the expectation that they will be triaged according to current Covid-19 recommendations. The subsequent use of evidence-based therapies will be based on the outcome of further investigations and ideally supported by specialist teams. Specialist advice should be sought urgently for patients with severe or worsening symptoms.
Patients with known heart failure and symptoms/signs of decompensation should where possible re-engage with the specialist HF services directly. Where this is not possible then primary care clinicians can again address symptoms/signs of decompensation using loop diuretics and ideally arrange for relevant bloods (renal function and electrolytes) and an ECG to be performed while seeking advice urgently from existing HF/Cardiology services.
Covid-19 infection may contribute directly or indirectly to the development of heart failure or associated decompensation. GP’s should seek specialist advice urgently for patients with suspected /known heart failure and concomitant Covid-19 infection.
Dr Jim Moore is president of the Primary Care Cardiovascular Society