Angela Graves with her top tips for heart failure management in primary care
1 The older the patient, the more likely they are to have heart failure
Heart failure is on the increase because the population is ageing and comorbidities are increasing. The older the person, the higher the incidence and the more likely they are to have other conditions. However, early diagnosis and the introduction of evidence-based practice can delay mortality and improve symptoms. NICE guidance was updated in September last year and provides useful algorithms for diagnosis and treatment.1
2 Patients with underlying cardiovascular disease, chronic hypertension and previous myocardial infarction are more likely to have heart failure
At annual review or incidental appointment, ask patients if they are experiencing new or worsening breathlessness, especially at night, or extreme lethargy or fatigue. Check for peripheral oedema.
3 Be aware of the unusual causes of heart failure such as myocarditis, excess alcohol intake, deranged thyroid function, anaemia and a family history of cardiomyopathy
Take a detailed history, perform an ECG, take routine bloods, urinalysis, peak flow or spirometry, and measure NT-pro BNP. If NT-pro BNP is >2000ng/l (>236pmol/l) refer urgently for review within two weeks for a specialist clinical assessment that includes echocardiogram. If NT-pro BNP is 400-2000ng/l (47-236pmol/l) the patient should be referred for review within six weeks. If NT pro BNP is <400mg/l (<4pmol/l) heart failure is less likely and other causes of symptoms should be considered.
4 Initial management should be by the heart failure multidisciplinary team (MDT)
First-line drug treatment consists of ACE inhibitors, ß-blockers and, if symptoms persist, mineralocorticoid receptor antagonists (MRA). Depending on clinical status, further treatment may consist of sacubitril-valsartan, ivabradine, or complex cardiac device therapy of cardiac resynchronisation or implantable cardioverter defibrillator. Make use of the heart failure MDT. Complex drugs and regimes can be difficult to manage and the heart failure MDT, especially the heart failure specialist nurse, can help. Place your patient on your heart failure register – QOF code HF 001 for holding a register, HF 002 for a confirmed diagnosis by specialist and echocardiography, HF 003 for prescribing of ACE inhibitor or ARB, HF 004 for additionally prescribed ß-blocker.
5 The care plan should be made available to the patient
The heart failure MDT should produce a summary of diagnosis and aetiology, medicine management and the patient’s functional and social status. This should be the basis of a care plan, which should also be available to the patient.
6 The primary care team should take over the management as soon as the patient has been stabilised and management optimised
Review in primary care at least every six months.
7 Ask the patient how much they wish to know when discussing their heart failure
Telling patients they have heart failure can be a daunting task. The term alone can be devastating. The prognosis of heart failure remains poor, but with the right care and treatment things have improved significantly. The patient community frequently say that the way they received their diagnosis had a huge bearing on how they adjusted to their condition. Ask the patient how much they know or wish to know and use their answer as your guide. Give them time to reflect. Use the Pumping Marvellous Foundation charity, which offers a wide range of information and a digital platform where patients talk about their lives with heart failure.
8 Self-care has a strong role to play
A symptom checker is a handy tool for patientsto monitor their symptoms and take early action to prevent deterioration – available at pumpingmarvellous.org.
9 Refer patients for cardiac rehabilitation
These programmes should offer physical activity, education and psychological support.
10 Use the Gold Standard Framework to decide when to introduce advance care planning
Identifying when to introduce advance care planning can be complex in this situation. Look at the document Difficult Conversations from the British Heart Foundation, which was developed with patients and carers who have experience of end stage heart failure. Use the Gold Standard Framework and be aware of local palliative care services for heart failure patients.
Angela Graves is a heart failure specialist nurse and the clinical lead for the Pumping Marvellous Foundation
1 NICE. NG106: chronic heart failure. NICE: 2018