Diagnosis, management and support
Diagnosis
In primary care, if the patient’s symptoms are suggestive of heart failure, the GP clinical team should request a blood test for natriuretic peptide (usually NT-pro BNP) which is released when the heart muscle is stretched.
If the level is raised this does not confirm a diagnosis of heart failure but it remains a differential diagnosis and the patient should be referred for an ultrasound scan of the heart (ECG) and specialist review. Since extremely elevated levels of NT-pro BNP carry a poor prognosis, patients are triaged for assessment depending on the levels.
Echocardiogram
An echocardiogram (ECG) is the ‘gold standard’ tool for the assessment and diagnosis of heart failure. This ultrasound scan will give a detailed assessment of dimensions of the heart’s chambers, assess valvular function, and determine if systolic or diastolic dysfunction is present.
Importantly it is used to estimate the ejection fraction (the proportion of blood ejected from the heart with each heartbeat) which will determine both diagnosis and treatment pathway. The ejection fraction (EF) of a normal heart is 50-70 per cent. The ejection fraction is sub-divided into:
- Heart Failure with Reduced Ejection Fraction (HFrEF)
- Heart Failure with Mildly Reduced Ejection Fraction (HFmrEF)
- Heart Failure with Preserved Ejection Fraction (HFpEF).
Recent changes in management
Key recent changes in the management of HFrEF are the increased usage of sacubitril / valsartan (Entresto) and the introduction of the sodium glucose co-transportor-2 inhibitors (dapagliflozin or empagliflozin) into the treatment schedule following positive trials.
Until recently, the mainstay of treatment for HFmrEF and HFpEF has been symptom management for congestion with diuretics and management of co-morbidities. However, recent trials with sodium glucose co-transportor-2 inhibitors have led to an extension in the dapagliflozin licence across the spectrum of chronic heart failure with dapagliflozin now recommended by NICE as an option for both HFmrEF and HFpEF. At the time of writing empagliflozin was still under review.
Pharmacy support
Giving general advice regarding cardiovascular health including smoking cessation, healthy eating, exercise, and moderation of alcohol intake. Regular physical activity will improve general health and improve symptoms in heart failure. Heart failure patients should be offered access to cardiac rehabilitation programmes (as recommended by NICE) which are tailored to the patient’s ability to exercise
Strict fluid restriction is not required unless severe fluid overload is present (this would usually be in the hospitalised patient). In patients where congestion is a problem, keeping fluid intake to a sensible level of no more than 2.5 litres/day whilst avoiding dehydration is regarded as a manageable approach. Similarly, strict salt restriction is not required but moderating salt intake is important in managing fluid overload. Patients should be advised not to add extra salt to food and to choose lower salt options where possible. Salt substitutes should be avoided as these contain potassium, which may lead to an increased risk of hyperkalaemia – especially as many of these patients are prescribed an ACEI or ARB or ARNI in combination with a MRA
Ensuring patients are aware of the signs and symptoms of heart failure and the need to make an early self-referral to their GP or heart failure team if they develop worsening symptoms of dyspnoea, oedema, sudden weight gain or nocturnal symptoms of breathlessness or cough
Optimising the use of medicines following hospital discharge under the Discharge Medicines Service to try and prevent unnecessary readmissions. Proactively supporting medicines use for heart failure treatment under the New Medicines Service and general review of medication prescribed for heart failure with referral to the GP or heart failure team for consideration of dose titration or where side-effects or non-adherence have been identified
Patients with heart failure fall into a high-risk group and should be offered the influenza vaccine annually, the pneumococcal vaccine (once) and Covid vaccination and boosters in line with the national programme
Advising on avoidance of prescribed or OTC non-steroidal anti-inflammatory drugs (NSAIDs), effervescent formulations (high salt load) and cough/cold remedies containing a sympathomimetic and to check any herbal remedies with the pharmacist before taking
Supplying patient literature on heart failure or signposting patients to further resources, for example, the British Heart Foundation or Pumping Marvellous websites for patient information.