How to support patients being treated for chronic heart failure
Heart failure affects 1–2% of the adult population in the UK with the prevalence rising steeply with age. It is one of the leading causes of emergency medical admissions and readmissions to hospital. Patients with heart failure have a reduced quality of life and many experience severe or prolonged depressive illness.1
The most common causes of heart failure are ischaemic heart disease and hypertension. Other causes include genetic disease of the heart muscle, congenital heart defects, cardiac arrhythmia, alcohol misuse, some cancer treatments and viruses.
The term “heart failure” is used widely and encompasses:
- Left-ventricular systolic dysfunction, also known as heart failure with reduced ejection fraction
- Heart failure with preserved ejection fraction
- Right-ventricular failure
- Bi-ventricular failure
Early and accurate diagnosis of heart failure is crucial for optimal management using evidence-based pharmacological treatment (see Box 1) and implantable devices.
For patients, reducing symptoms of heart failure can have marked effects on quality of life. In clinical trials morbidity benefits are usually assessed by evaluating hospital admissions and readmissions for heart failure or cardiovascular causes. The main symptoms relate to fluid retention which can give rise to:
- An increase in breathlessness, orthopnoea and paroxysmal nocturnal dyspnoea secondary to pulmonary congestion or pulmonary oedema
- Peripheral oedema, which can range from mild ankle swelling to gross oedema including abdominal ascites and at times extending to the genitalia and beyond
Managing the effects of fluid overload can be challenging and include the use of diuretics, fluid and salt restriction, daily weighing and education of the patient and carers on ways to recognise and respond early to deterioration.
Despite the widespread use of diuretics there is no evidence of survival benefits from these medicines. Nevertheless, managing the symptoms of fluid overload is essential in all forms of heart failure. Loop diuretics (most commonly furosemide or bumetanide) form the mainstay of treatment, with thiazide diuretics being used alone only in mild cases or in combination with loop diuretics for a synergistic effect in more severe cases.4
It is important to use the lowest dose of diuretic to manage symptoms (preserving renal function in the longer term) and to review the dose of diuretics regularly in line with symptoms, renal function and electrolyte concentrations. However, there will be some patients for whom diuretics become less effective with time and diuretic resistance is a challenge in everyday clinical practice.
Like for many other chronic conditions, education in self-care strategies is important for the heart failure patient to maintain health.5 Development of multidisciplinary heart failure services in the UK has been important in ensuring patients learn about heart failure, the trajectory of the condition, its management and how to access professional help when things are starting to deteriorate.6 At Brighton and Sussex University Hospitals NHS Trust, this approach has had a positive impact on reducing readmission rates for decompensated heart failure.
Pharmacists can help patients with heart failure by:
- Supporting medication adherence
- Offering lifestyle advice, eg, regular exercise, smoking cessation, fluid and dietary recommendations
- Providing guidance on recognising and responding to symptom deterioration
Information provided can be supplemented by signposting patients to appropriate websites (eg, http://www.heartfailurematters.org/), DVDs and publications (eg, those produced by the British Heart Foundation5). A person-centred approach should be taken, and clinicians should remain aware that patients may experience barriers to self-care, such as depression, anxiety or impaired cognition, which may reduce motivation and adherence.
Although there is much in the media and medical literature about salt intake and its detrimental effects on health for patients with chronic heart failure, studies supporting sodium restriction are limited. In our experience, patients and carers consider this one of the most difficult aspects of self-management.
The recommended daily intake of salt for adults is 6g (or 2.5g of sodium), which equates to only a teaspoon of salt a day. Advice to guide patients is essential, since there is much “hidden” salt in food, particularly in processed foods (see Box 2). Strategies to help patients include education on food labelling, increasing awareness of foods to avoid and how to limit salt intake. Practical suggestions include removing salt from the dining table and using herbs, spices and fresh lemon or lime juice as alternative seasonings.
Importantly, patients should be advised to avoid salt substitutes, which usually contain potassium salts, due to the risks of hyperkalaemia (particularly in the presence of renal impairment or with use of angiotensin-converting enzyme inhibitors or aldosterone antagonists).7
There is a paucity of evidence on the restriction of fluids for heart failure patients and current guidelines advise that routine fluid restriction is of no benefit except in patients with severe heart failure or those with concomitant hyponatraemia.3
Nonetheless, it is important to establish each patient’s usual fluid intake because many (particularly elderly patients) do not have a high fluid intake. It is good practice to review the need for fluid restriction on an individual basis and advise according to severity of symptoms, body mass index, weather conditions, electrolyte levels and presence of diarrhoea, vomiting or fever.
Patients require education on recognising the signs and symptoms of deterioration (see Box 3, p55) and the daily recording of weight is central to this. Such signs and symptoms tend to indicate fluid retention — adjustment of diuretic dose along with the monitoring of renal function can often resolve the situation or prevent further deterioration.
Over-diuresis may also occur alongside fluid and electrolyte loss and risk of deterioration in renal function. Early signs include excessive urination, weight loss, tiredness, muscle weakness, dizziness and dry skin. Patients who are new to diuretic therapy, those with a recent increase in diuretic dose and those with diarrhoea and vomiting should be particularly vigilant; early recognition, with diuretic adjustment and renal function monitoring, is crucial.
Patients should also be given advice on what to do if they experience:
- Chest pain
- Acute shortness of breath
In addition, patients should be made aware that their condition can destabilise if they develop an infection.
It is a misconception that patients with heart failure will not be able to participate in exercise programmes. Physical conditioning through exercise has been shown to increase exercise tolerance, improve health-related quality of life and reduce hospital admissions among patients with heart failure. The European Society of Cardiology recommends regular aerobic exercise, ideally as part of a multidisciplinary care programme, to improve functional capacity and symptoms.3
Signposting the patient to local programmes designed for cardiac patients can improve uptake and ongoing participation.
Pharmacists should be alert to medicines-related issues among heart failure patients, especially those prescribed complex regimens. It may be necessary to:
- Adapt labelling for visually impaired patients
- Simplify treatment regimens
- Engage family members or care providers to assist with administration
Patients should be aware that any change to their medicines, or the addition of a new treatment (for short-term or ongoing use), may require closer monitoring of their heart failure. Box 4 lists some common medicines to be avoided or used with caution for patients with heart failure. Of particular note is the detrimental effect of non-steroidal anti-inflammatory drugs, which can cause fluid retention and renal impairment with resulting decompensation of heart failure that can lead to hospital admission.
Community pharmacists are well placed to support the patient in the long-term use of medicines and to help identify those patients who are experiencing difficulties.
For patients and clinicians, managing the symptoms of chronic heart failure can be complex and challenging — particularly in older people and those with comorbidities.
Pharmacists, as members of the multidisciplinary team, can support and empower patients with heart failure around matters relating to self-care and medicines management.
Box 1: Medical management of heart failure
National and international guidelines for heart failure should be followed for pharmacological management of left-ventricular systolic dysfunction (LVSD). In other forms of heart failure the evidence for pharmacological intervention is lacking and treatment tends to focus on the management of comorbidities — in particular hypertension and diabetes in patients who have heart failure with preserved ejection fraction.2,3
According to the National Institute for Health and Clinical Excellence,2 all patients with chronic heart failure due to LVSD should be offered both an angiotensin-converting enzyme inhibitor and a beta-blocker, and dosages should be optimised. If a patient is still symptomatic, the clinician should seek specialist advice and consider adding one of the following:
- An aldosterone antagonist licensed for heart failure
- An angiotensin-II receptor blocker licensed for heart failure
- Hydralazine in combination with a nitrate (especially if the patient is of African or Caribbean origin)
Box 2: Hidden salt
National Salt Awareness Week takes place on 11–17 March 2013. The campaign aims to encourage people to eat less salt and, in particular, focuses on raising awareness of the “hidden” salt in ready-meals and food prepared by restaurants and fast food outlets (Pharmaceutical Journal2013;290:113).
Box 3: Signs and symptoms of worsening heart failure
The following signs and symptoms can indicate deterioration of a patient’s heart failure:
- Increased shortness of breath with a decrease in exercise tolerance
- Weight gain of more than 2kg in two days
- New orthopnoea
- Paroxysmal nocturnal dyspnoea
- Development or worsening of peripheral oedema or ascites
Box 4: Drugs to avoid
Common medicines to avoid in patients with heart failure include:
- Non-steroidal anti-inflammatory drugs (including selective cyclo-oxygenase-2 inhibitors)
- Corticosteroids (use lowest dose for shortest possible period)
- Antacids with high sodium content
- Soluble analgesics with high sodium content (eg, co-codamol, paracetamol)
- Calcium-channel blockers (amlodipine or felodipine can be used if essential)
- Antiarrhythmic medicines (including flecainide and dronedarone)
- Pioglitazone, metformin (avoid in concomitant renal impairment)
Alison Warren is lead cardiac pharmacist, and Carolyn Kenny and Karen Murphy are clinical nurse specialists in heart failure, all at Brighton and Sussex University Hospitals NHS Trust.
Citation: Clinical Pharmacist DOI: 10.1211/CP.2013.11117606
Recommended from Pharmaceutical Press