Overview
Heart failure (HF) may be described as the inability of the heart to pump blood around the body effectively. This medical condition usually presents as a function of the heart becoming too weak to undertake its biological function. Typical symptoms arising from HF include fatigue, breathlessness, palpitations and angina. Clearly, the development / presentation of this medical condition can have a significant impact on the quality of life for the patient. The extent of such impact can be considered by reference to ‘functional limitation’ as per the New York Heart Association. Within this model, four classes of HF are described ranging from Class I to Class IV encompassing increased impact on normal activity with progressive symptom severity across the scale. Several strategies are available to manage HF in the clinical healthcare setting. This Clinical Digest will consider self-management, drug therapy, practical implications (i.e. driving) and end of life discussions.
1. Self-management
Patient education surrounding the management of HF is key because this will help to go some way to improve quality of life. For example, on diagnosis the patient may be advised to lose weight, improve their diet, stop smoking and ensure that their vaccinations are up to date (i.e. pneumococcal immunisation). Although HF may result in fluid retention, sodium or fluid intake should not routinely be dramatically changed however excessive fluid consumption should be avoided (i.e. due to the potential for dilutional hyponatraemia) and excessive salt intake should be avoided to prevent hypernatraemia. Self-weighing is important for the patient to lead on such that fluid balance can be closely monitored. Here, the healthcare professional should be notified if there is a gain of more than 1.5 – 2.0 kg over a 2 day period; in this case the dose of diuretic may be increased to combat the raise in fluid retention. Naturally, the diagnosis of HF, which is chronic and progressive, may result in the reduction of the patient’s mood. Therefore, depression should be monitored for and treated accordingly in this patient population.
2. Drug Therapy
On diagnosis of HF, drug therapy should be initiated at an appropriate time point. At the outset, an ACE Inhibitor (i.e. Enalapril 20mg OD) and licensed beta-blocker (i.e. Bisoprolol 10mg OD or Carvedilol 50mg OD) should be used. If ACE Inhibitors are not tolerated, then ARBs (i.e. Losartan 50mg OD) may be employed as an alternative. In the rare event of these drug classes not being acceptable then advice from a consultant should be sought, where Hydralazine and a Nitrate combination may be considered. Diuretic therapy (i.e. Furosemide 20mg OD) should be started in those patients who have fluid overload and titrated accordingly.
If the patient still exhibits symptoms, then a Mineralocorticoid Antagonist (i.e. Spironolactone 100mg OD) can be added in to the treatment regimen. However, in this case there might be an elevation in the level of potassium in the blood leading to hyperkalaemia and related fatal cardiac arrhythmias; here effective monitoring is crucial. In the case where the HF does not respond to such therapy then the patient should be referred to a consultant who may consider Dapagliflozin, Digoxin, Ivabradine, Sacubitril Valsartan or Amiodarone.
In general, all drug substances should be started at lower doses and up-titrated carefully with relevant monitoring (i.e. HR and BP). Importantly, the assessment of renal function is critical and blood panels should be acquired 1-2 weeks after drug initiation and after each dose increase. Typical blood monitoring would be over the 3 month / 4 month, 6 month and 12 month periods.
Clinical reviews may consider:
· Capacity of the patient in terms of the HF (i.e. symptoms and rhythm checks)
· Fluid status
· Renal function
· Medicine side effects
· Related issues such as anxiety and depression
3. Practical Implications
Clearly, the symptoms experienced by the HF patient can have a significant bearing on normal daily activities (i.e. exercise and tasks). A prime example of this is driving a vehicle. In this case, official guidance changes with time and the driver / healthcare professional is always best to consult the most up to date DVLA regulation set for advice. In terms of the New York Heart Association classification scheme, those drivers with an ordinary licence who rank in Class I do not need to inform the DVLA, those in Class II and Class III do not need to notify the DVLA if symptomatically stable, however those individuals who fall into Class IV cannot drive and must inform the DVLA and agree to have their licence revoked.
4. End of Life
With regards to HF, end of life is difficult to predict. Discussions with the patient on this subject are important and do need to happen. Towards the end of the course of the disease, quality of life can be significantly affected due to symptom presentation as detailed above. Co-morbidity is common in this patient sub-set and polypharmacy is often noted. Moreover, HF patients often present with a degree of frailty meaning that their resilience to this medical stressor is significantly reduced. A key issue for the patient / clinician is the uncertain course of the disease where often there are times of disease stability followed by sudden exacerbations. Patients tend to overestimate their life expectancy, particularly during the stable phases of HF, and therefore they may not be ready to discuss end of life issues when those conversations are required. Thus, it is very important that healthcare professionals display excellent communication skills when interacting with patients and demonstrate appropriate understanding as the patient progresses through their journey in life.
