Improving Management of Heart Failure Patients
Heart failure (HF) is a chronic condition that affects millions of people worldwide and reduces their quality of life. HF occurs when the heart cannot pump enough blood to meet the body’s needs, causing symptoms such as shortness of breath, fatigue, swelling, and reduced exercise capacity. HF can be caused by various factors, such as coronary artery disease, hypertension, diabetes, valvular heart disease, cardiomyopathies, and arrhythmias.
HF is a complex and challenging condition to manage, especially in primary care settings where most patients receive their care. General practitioners (GPs) play a key role in HF management, but they face many barriers and difficulties in providing optimal care for their patients. These include uncertainty about diagnosis, treatment, communication, and advance care planning; lack of access to specialized care and knowledge; and poor interprofessional collaboration (Smeets et al., 2016).
Therefore, it is important to identify strategies for improving HF management in primary care and enhancing the quality of life of HF patients. In this blog post, we will discuss some of the evidence-based strategies that can help GPs and their patients achieve better outcomes.
### Prevention of HF
One of the first steps in improving HF management is to prevent its occurrence or progression. This can be done by addressing the modifiable risk factors that contribute to HF development, such as smoking, alcohol consumption, obesity, physical inactivity, and poor diet. GPs can provide counseling and education to their patients on how to adopt healthy lifestyles and avoid harmful substances. For example, quitting smoking can reduce the risk of HF by 36%, while moderate alcohol intake (no more than one drink per day for women and two drinks per day for men) can lower the risk by 22% (ESC, 2021).
GPs can also screen their patients for common conditions that can lead to HF, such as hypertension, diabetes, dyslipidemia, and atrial fibrillation. These conditions can be detected by simple tests such as blood pressure measurement, blood glucose testing, lipid profile testing, and electrocardiogram (ECG). GPs can prescribe appropriate medications and monitor their effectiveness and side effects. For example, angiotensin-converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs), beta-blockers, mineralocorticoid receptor antagonists (MRAs), sodium-glucose cotransporter 2 inhibitors (SGLT2is), and sacubitril/valsartan are recommended for patients with HF with reduced ejection fraction (HFrEF) to improve survival and reduce hospitalizations (UpToDate, 2021).
### Diagnosis of HF
Another crucial step in improving HF management is to diagnose it accurately and timely. HF diagnosis can be challenging for GPs because its symptoms are nonspecific and can mimic other conditions. Moreover, some diagnostic tests are not readily available or accessible in primary care settings. Therefore, GPs need to have a high index of suspicion for HF and use a combination of clinical assessment, biomarkers, and imaging to confirm or exclude the diagnosis.
Clinical assessment involves taking a detailed history and performing a physical examination of the patient. GPs should ask about the onset, duration, frequency, severity, and triggers of the symptoms; the presence of risk factors or comorbidities; the use of medications or supplements; and the impact of the symptoms on daily activities and quality of life. GPs should also look for signs of fluid overload or congestion, such as jugular venous distension, crackles in the lungs, hepatomegaly
or ascites.
Biomarkers are substances that can be measured in the blood or urine that reflect the function or damage of the heart. The most commonly used biomarker for HF diagnosis is natriuretic peptide (NP), which is released by the heart in response to increased pressure or stretch. NP levels are elevated in patients with HF and correlate with its severity and prognosis. GPs can use NP testing to rule out HF in patients with low levels (<125 pg/mL for B-type NP [BNP] or <300 pg/mL for N-terminal pro-BNP [NT-proBNP]) or to support HF diagnosis in patients with high levels (>400 pg/mL for BNP or >900 pg/mL for NT-proBNP) (UpToDate, 2021).
Imaging is the gold standard for HF diagnosis and assessment of its cause and type. The most widely used imaging modality for HF is echocardiography, which uses ultrasound waves to create images of the heart’s structure and function. Echocardiography can measure the ejection fraction (EF), which is the percentage of blood pumped out of the left ventricle with each heartbeat. EF can be used to classify HF into two types: HFrEF (EF <40%) and HF with preserved ejection fraction (HFpEF) (EF ≥50%). Echocardiography can also identify the presence and severity of valvular heart disease, cardiomyopathies, pericardial disease, and pulmonary hypertension, which can cause or complicate HF. However, echocardiography is not always available or affordable in primary care settings, especially in low- and middle-income countries. Therefore, GPs may need to refer their patients to specialized centers or use alternative imaging modalities, such as chest X-ray, ECG, or cardiac magnetic resonance imaging (MRI), to diagnose HF and its etiology. ### Treatment of HF Once HF is diagnosed, GPs need to initiate and optimize the treatment of HF and its underlying causes. The treatment of HF aims to relieve symptoms, improve quality of life, prevent complications, and prolong survival. The treatment of HF depends on its type, severity, and comorbidities, and involves pharmacological and non-pharmacological interventions. Pharmacological interventions include medications that target the neurohormonal pathways that are activated in HF and cause further cardiac damage and remodeling. These medications include ACEIs, ARBs, beta-blockers, MRAs, SGLT2is, sacubitril/valsartan, ivabradine, digoxin, and diuretics. GPs should prescribe these medications according to the current guidelines and evidence and titrate them to the optimal doses. GPs should also monitor the response and adherence to these medications and adjust them as needed. GPs should also prescribe medications that treat the underlying causes or comorbidities of HF, such as anticoagulants for atrial fibrillation, statins for dyslipidemia, or antiplatelets for coronary artery disease. Non-pharmacological interventions include lifestyle modifications and device therapies that can improve the symptoms and outcomes of HF patients. Lifestyle modifications include dietary sodium restriction (<2 g/day), fluid restriction (<1.5 L/day), weight management (body mass index [BMI] 20–25 kg/m2), regular physical activity (at least 150 minutes/week of moderate-intensity aerobic exercise), smoking cessation, alcohol moderation (no more than one drink per day for women and two drinks per day for men), and stress management. Device therapies include cardiac resynchronization therapy (CRT), implantable cardioverter-defibrillator (ICD), mechanical circulatory support (MCS), and cardiac transplantation. These devices can improve the function or rhythm of the heart or replace it with a mechanical pump or a donor organ. However, these devices are not widely available or accessible in primary care settings and require referral to specialized centers. ### Education and Support of HF Patients A key component of improving HF management is to educate and support HF patients and their caregivers about their condition and how to manage it. Education and support can help HF patients understand their diagnosis, treatment plan, prognosis
