1. Be aware of patients at highest risk
Around 68,000 new cases of heart failure are diagnosed each year in the UK. The general population prevalence is around 1%. Heart failure occurs predominantly in the elderly, in patients with cardiovascular risk factors such as hypertension or diabetes and is particularly prevalent in those with a history of MI. Bear it in mind that the symptom profile of co-morbid conditions, such as COPD, can overlap. CKD is also prevalent and can limit heart failure treatments. Patients with heart failure and other co-morbidities require close monitoring and holistic care.
2. Suspect heart failure in patients with signs and symptoms, and a history of MI
In patients with symptoms and signs suggestive of heart failure, a history of MI makes a diagnosis of heart failure extremely likely, so refer directly for an echocardiogram. According to the European Society of Cardiology, heart failure is a clinical syndrome in which the patient has symptoms, signs and objective evidence of a structural or functional abnormality of the heart.
Echocardiography is the most commonly used investigation to establish ‘objective evidence’ of cardiac dysfunction in routine clinical practice.
3. Measure natriuretic peptides to determine if an echo is indicated
B-type natriuretic peptide (BNP) and NT-pro BNP (the inactive cleaved fragment of the pro-BNP molecule) are released in response to volume and pressure overload and are raised in heart failure. BNP relaxes vascular smooth muscle to reduce ventricular pre-load and also acts on the kidney to increase sodium excretion and induce diuresis. Natriuretic peptides are raised in heart failure and can be used to determine if and when an echocardiogram is indicated.
4. Remember that ‘heart failure’ can be a scary phrase for patients
‘Heart failure’ can be a frightening term for patients so it is crucial to explain what the diagnosis means and the treatment options available. It is also important to address and, where appropriate, modify cardiovascular risk factors.
5. ACE inhibitors and ß-blockers should be used in left ventricular systolic dysfunction (LVSD)
LVSD is the most common cause of heart failure. Evidence supports the use of ACE inhibitors and ß-blockers in the treatment of heart failure because of LVSD. Trials showed these agents improve quality of life and reduce mortality.
6. Diuretics are helpful for symptom control in LVSD
7. Risk-factor modification is crucial in heart failure with preserved ejection fraction (HFPEF)
HFPEF occurs because of abnormal cardiac muscle relaxation, which results in reduced left ventricular filling. Trials of ACE inhibitors and ß-blockers have been disappointing and guidance suggests modification of risk factors – particularly blood pressure and diabetes control – is the mainstay of treatment.
8. Refer patients with moderate or severe valvular disease
A surgical opinion is indicated in moderate-to-severe valvular disease. Once the valve lesion or rhythm problem is resolved heart function may improve.
9. Heart failure has a worse prognosis than many types of cancer
Recent data from an English population study suggests the 10-year survival rate for patients with a diagnosis of heart failure is around 30%1. Use of ACE inhibitors and ß-blockers should be optimised to improve outcomes.
10. Discuss palliative care early
Given the poor prognosis of heart failure, palliative care provision is vital – but regional approaches vary. The point where active treatment should be changed to palliative can be difficult for clinicians to gauge. Patients can deteriorate suddenly, but equally a few days of intravenous diuretic in hospital can make a dramatic difference. Discussions at an early stage with the patient and their family can ensure the patient’s wishes are met.
Dr Clare Taylor is a GP in Birmingham and a clinical research fellow in cardiovascular disease at the University of Birmingham
Dr Taylor is involved with delivering a four-day course on heart failure management in primary care at the University of Birmingham in February 2013. For more information go to: tinyurl.com/heartbirmingham
References
1 Taylor CJ, Roalfe AK, Iles R and Hobbs FDR. Ten-year prognosis of heart failure in the community: follow-up data from the Echocardiographic Heart of England Screening (ECHOES) study. Eur J Heart Fail 2012; 14(2): 176-84
Further reading
- NICE. Chronic heart failure: management of chronic heart failure in adults in primary and secondary care. August 2010, CG108
- Dickstein K, Cohen-Solal A, Filippatos G et al. European Society of Cardiology guidelines for the diagnosis and treatment of acute and chronic heart failure. European Heart Journal 2008, 29: 2,388-442
