Dr Jacob George and Professor Allan Struthers outline the key recommendations for primary care to provide effective diagnosis and management of chronic heart failure

The management of chronic heart failure (CHF) is increasingly becoming an issue of major concern for both primary and secondary care physicians. The Hillingdon Heart Study estimated that 67,000 new patients are diagnosed with CHF every year in the UK.1 Patients with CHF have the second longest hospital stay, after admissions for acute stroke. In 2000–2001, there were 84,151 admissions to hospital for acute heart failure, at a cost of £378.6 million.2For the same period, there were almost 538,000 hospital outpatient clinic visits for heart failure.2 Patients presenting with heart failure accounted for 7.64 million GP consultations in 2000, at a cost of £104 million.2 Of equal relevance to GPs is the cost of outpatient investigations for heart failure, which was estimated at almost £37.5 million in 2000.2

 

Re-admission rates for heart failure are high and these patients often have multiple pathologies and are being prescribed several drugs. Coupled with this is the fact that many patients are elderly, they often live alone, and have very little social support. It is, therefore, not surprising that the total cost of managing heart failure in the UK was estimated to be £628 million in 2000, although more than 60% of this cost fell within secondary care, with 17% being borne directly by primary care.3 This figure will inevitably rise even further as new treatment modalities become available.

Need for the guideline

It is imperative, therefore, in a system with finite resources, that healthcare professionals engage in judicious and sensible prescribing, based on cost-effectiveness rather than hype. The invaluable input of the Scottish Medicines Consortium in assessing parameters like quality adjusted life years and incremental cost-effectiveness ratios have already set a platform that the Scottish Intercollegiate Guidelines Network (SIGN) committee was able to incorporate into the decision-making process for its guideline on the Management of chronic heart failure.4 In recognition of the current and potential future strain that CHF places on the national healthcare system, increasing numbers of hospital and primary care trusts have employed heart failure specialist nurse teams to follow up on these patients in the community and thereby try to pre-empt potential hospital admissions.

Apart from hypertension, which is probably largely a result of the obesity epidemic that is befalling us, CHF is the only other subset of cardiovascular disease that is increasing in incidence and, despite many advances, overall 1-year mortality rates for CHF remain between 40 and 50%. This has triggered major research into CHF and there have been several large, randomised, controlled trials looking into various aspects of CHF, that have reported yearly in the past decade or so. This has resulted in the treatment of CHF becoming one of the most evidence-based of any medical condition. To a large extent, the order of initiating treatment has been historical but recent trials, like CIBIS III,5 have even addressed this issue. The recently published SIGN guideline4 is aimed at providing the latest evidence-based information to healthcare professionals involved in the management and continuing care of this challenging and increasingly prevalent group of patients. The guideline looks at managing patients with CHF from a multidisciplinary aspect. It contains key recommendations on CHF that impact on GPs and primary healthcare teams, and these are the focus of this article.4 Acute heart failure is dealt with in SIGN 93, which is on acute coronary syndromes.6 The SIGN grades of recommendation will appear in the text in bold print where the recommendations are discussed;4 these are graded from A to D according to strength of evidence on which a recommendation is based.

Initial assessment

It is difficult to make a diagnosis of CHF on purely clinical grounds, but there are several indicative signs and symptoms. For CHF these are of varying sensitivity (%) and specificity [%], and include:4

  • dyspnoea (66), [52]
  • orthopnoea (21), [81]
  • paroxysmal nocturnal dyspnoea (33), [76]
  • history of oedema (23), [80].

Additional signs and symptoms that are more specific to heart failure should be looked for in patients with indications suggestive of CHF. These also vary in sensitivity (%) and specificity [%] and include:4

  • raised jugular venous pressure (10), [97]
  • third heart sound (31), [95]
  • peripheral oedema (10), [93]
  • tachycardia (7), [99]
  • crepitations (13), [91].

The diagnostic challenge is to determine the actual cause of breathlessness in a patient who may have underlying lung disease or when that is combined with heart failure. In many cases, time spent taking an accurate initial history and making a thorough examination of the patient will save spending time and money on multiple investigations, which could lead the GP down the wrong diagnostic pathway.

Diagnostic tests

Once there is a strong suspicion of heart failure, the diagnosis must be confirmed with documented clinical signs. The following tests should be carried out:4

  • electrocardiogram (ECG)
  • serum urea and electrolytes
  • full blood count
  • fasting glucose level
  • thyroid function
  • brain natriuretic peptide (BNP) or N-terminal brain natriuretic peptide (NT-proBNP) [B]
  • chest X-ray [B].

Either a high BNP/NT-proBNP sample or an abnormal ECG makes the diagnosis of heart failure more likely and patients with abnormalities in either test should undergo an echocardiogram.4 An office-based near-patient BNP testing machine similar to a glucometer for patients with diabetes is available commercially and may be a useful, quick, initial test in primary care. Figure 1 contains an algorithm of the diagnostic route for CHF.

Figure1: Diagnostic algorithm for patients with suspected chronic heart failure

Diagnostic algorithm for patients with suspected chronic heart failure

CHF=chronic heart failure; BNP=brain natriuretic peptide; NT-proBNP=N-terminal BNP; ECG=electrocardiogram.
This algorithm was reproduced from Management of chronic heart failure by kind permission of the Scottish Intercollegiate Guidelines Network.

Management of patients with chronic heart failure

Investigations for CHF are not only important in order to provide baseline parameters for future reference, the identification of underlying causes of CHF also has implications for management. Most patients with CHF will have ischaemic heart disease as the underlying pathology, but there is an increasing awareness of patients with diastolic heart failure or diastolic dysfunction/heart failure where normal systolic function is preserved, and patients with valvular heart disease. Diastolic dysfunction has an estimated prevalence of about 35% of the total heart failure population,7 while valve disease may be amenable to surgery.

Although studies show that about 40% of patients with CHF have a clinically significant improvement in their left ventricular ejection fraction after revascularisation8 and 50% have fixed perfusion defects on multigated acquisition (MUGA) scans,9 there is no evidence to suggest that routine angiography will improve the prognosis of patients with CHF. The exception to this would be in patients who continue to complain of exertional angina. In these cases, a myocardial perfusion scan or an angiogram may reveal stenotic lesions that are amenable to revascularisation and therefore, myocardial salvage. There are clinical trials underway to assess whether routine assessment of viable myocardium will improve prognosis in patients with CHF.4

There is some evidence that magnetic resonance imaging (MRI) is superior to coronary angiography for patients with dilated cardiomyopathy. However, routine use of MRI to detect patients who will benefit from revascularisation is not recommended by the guideline.4 Clues from the patient’s clinical history will indicate the likelihood of a cardiomyopathy. These will include:

  • high alcohol intake (11 units/day for more than 5 years)
  • women who are peripartum or postpartum
  • acute preceding history of cold/viral infection, especially in young patients.

Behavioural aspects of management

Depression

Depression is common in CHF but there is debate as to whether or not it is related to increased mortality.10,11 The British Medical Association quality and outcomes framework recommends screening all patients with chronic heart disease, but not specifically CHF, for depression.12 One of the most widely used questionnaires is the hospital anxiety and depression scale.13 If an antidepressant is to be prescribed, tricyclic antidepressants should be avoided because of the possible side-effects of negative inotropic effects on the heart and QT prolongation.14,15

Smoking

All patients should be encouraged to stop smoking and should be offered smoking cessation advice and support. [B] Nicotine replacement patches may not be suitable for patients with severe CHF and/or renal impairment.16

Alcohol consumption

Patients with alcoholic cardiomyopathy should be strongly advised to stop drinking alcohol. All other patients with CHF should be advised to refrain from excessive alcohol intake.4 [C] They should also be made aware that hospital re-admissions are lower among patients who abstain from alcohol,17 and that excessive alcohol consumption will result in directly toxic effects to the myocardium.18

Salt intake

Dietary salt intake should not exceed 6 g/day. In practice, this is often difficult to achieve because of ‘hidden’ salt content, especially in ready-made meals. Patients should be advised that ‘low salt’ substitutes have a high potassium content, which might increase their risk of hyperkalaemia when combined with other concomitant medications for heart failure.

Follow-up and monitoring

In our experience, patients prescribed oral diuretics who are discharged home would, almost always, have been receiving intravenous diuretics during the acute decompensation phase of their illness. It is, therefore, crucial that their urea and electrolyte levels are monitored closely by their GP or, more probably, by a designated heart failure nurse. Depending on diuretic dose and concomitant medication, it is our practice to request a renal function sample to be taken between 1 and 2 weeks after discharge and then at 1 month. Most patients will be followed up at clinic between 6 and 12 weeks following discharge and any issues regarding their medication dosage can then be resolved on an informed basis when the serial blood results post-discharge are available to the clinician in clinic.

Although no study has explicitly evaluated whether daily weight monitoring is associated with lower mortality, improved quality of life, or fewer re-admissions19 and it remains controversial,20 daily weights are thought to offer a simple yet useful guide to impending fluid retention. A simple daily weight chart, completed at a set time of day, will enable the primary care physician to determine the degree of deviation from the patient’s ‘dry’ weight, which often correlates well with the degree of oedema and/or breathlessness. It is important to make patients aware that if they notice an increase in their weight of between 1.5 and 2.0 kg within 2 days, they should contact their GP.

Most patients discharged from hospital should be on ‘standard’ heart failure therapy such as an angiotensin-converting enzyme inhibitor, a beta blocker and, possibly, an aldosterone receptor antagonist, in addition to aspirin, statin, and diuretics. There may be reasons, such as hypotension, renal artery stenosis, or reversible airways disease, that preclude some patients from receiving these agents. Healthcare professionals, at follow-up specialist clinics, usually aim to up-titrate these medications to as close to the target dose as tolerable. It may be necessary for GPs or heart failure nurses to monitor the response to the up-titration. In particular, renal function and blood pressure should be monitored.

All patients should be given the pneumococcal vaccine once and offered an annual influenza vaccination [D], as many patients who present with an episode of acute decompensation have a pulmonary infection.21,22

Follow-up post-discharge should fulfil several functions. These are:

  • renal function monitoring
  • nurse-led assessment of weight and symptoms
  • lifestyle and dietary advice reinforcement
  • titration of diuretics (with renal monitoring) if fluid retention
  • administration of a one-off pneumococcal vaccination and an annual influenza vaccination
  • referral for specialist advice early if in doubt
  • initiation of palliative care measures if appropriate.

Nurse-led follow-up

In a trial evaluating the effectiveness of a nurse-led follow-up service, it was found that patients in the active intervention group had fewer re-admissions, were more compliant with medications, and had a better quality of life than the control group.

The main aims of the specialist nurse service are to pre-empt admissions by detecting worsening symptoms at an early stage and to titrate diuretic doses to effect, usually for short periods of time.23,24 Education is also essential, as heart failure is not a disease that is well understood by the public.

Palliative care

Issues surrounding death and dying are complex, involving symptomatic relief and psychosocial issues. The GP will have invaluable information about the patient’s circumstances and can play an important role in initiating palliative care measures, including supplying oxygen for use at home, facilitating hospice admissions, as well as administering appropriate discontinuation of treatments. This should be done by liaising with the heart failure specialist in secondary care and the palliative care team.

Summary

While the guideline is not all-encompassing nor is it intended to serve as a standard of care, it should provide healthcare professionals at every level with guidance on the currently available evidence-based management options.4 Issues relevant to other aspects of heart failure are covered in the cardiac arrhythmias (SIGN 94),25 risk estimation (SIGN 97),26 and acute coronary syndromes (SIGN 93)6 guidelines. The current guidelines will be reviewed in 3 years.

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