Heart failure: taking an active role

Reference

Summary

Howlett et al, 2018

Clinical practices and attitudes regarding the diagnosis and management of heart failure: findings from the CORE Needs Assessment Survey

This survey was completed by 346 GPs, cardiologists and nurses who manage patients with heart failure in six countries: Australia, Austria, Canada, Spain, Sweden and the UK.

Results revealed multiple gaps over the spectrum of care, including:

• diagnosis (low recognition of the signs and symptoms of heart failure and limited use of diagnostic tests)
• treatment planning (underuse of recommended medicines and sub-therapeutic dosing)
• treatment monitoring and adjustment (lack of adherence to recommendations)
• long-term management (low confidence in providing patient education)

Al-Omary et al, 2018

Mortality and readmission following hospitalisation for heart failure in Australia: A systematic review and meta-analysis

The first systematic review and meta-analysis of all-cause readmission and all-cause mortality for patients hospitalised with heart failure in Australia. Studies included were heart failure hospitalisations in Australia published between January 1990 and May 2016.

The statistical analysis used a random effects model to pool proportions across the 13 included studies, which were 3 randomised controlled trials (RCTs) and 10 cohort studies.

Results:

• The pooled estimated 30-day and 1-year all-cause mortality were 8% and 25% respectively.
• The pooled estimated 30-day and 1-year all-cause readmission rates were 20% and 56% respectively.

The authors advised that ‘urgent action is needed to reduce the human and financial costs associated with such high mortality and readmission rates.’

Jeon et al, 2010

The experience of living with chronic heart failure: a narrative review of qualitative studies

A narrative review of 30 qualitative studies, mainly from the US and Sweden, of the experience of people living with heart failure, written by Australian-based authors. While published in 2010 (and focusing on research from 1990–2008), the general flavour is still considered to accurately reflect the experience of people today.

It found the most prominent impacts of heart failure on a person’s everyday life includes social isolation, living in fear and losing a sense of control.

Reference

Summary

National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand

Guidelines for the Prevention, Detection, and Management of Heart Failure in Australia 2018

Chapter 5 provides a detailed description of the process of differential diagnosis for heart failure, including the Diagnostic Workup algorithm (Page 1145, Figure 2).

5.1 Dyspnoea, which includes a patient history and cardiorespiratory physical examination and blood tests, and Table 6

Table 7: Red flags

5.2 Diagnostic investigations for heart failure, which include blood tests and:

• 5.2.1.1 12-lead ECG
• 5.2.1.2 Chest X-rays
• 5.2.1.3 B-type natriuretic peptide and N-terminal pro-B-type natriuretic peptide (BNP or NT proBNP)
• 5.2.1.4 Echocardiogram
• 5.2.2 Assessment of aetiology
• 5.2.4 Diagnostic tests to guide therapy in heart failure

Parsons et al, 2020.

The epidemiology of heart failure in the general Australian community - study of heart failure in the Australian primary carE setting (SHAPE): methods

The SHAPE study is a retrospective cohort epidemiological study based on analysis of non-identifiable medical records of 1.12 million active patients at 43 Australian general practices in 2013–18.

Results for active patients included:

• 15,468 were classified as having ‘definite heart failure (HF)’, based on having a formal HF diagnosis, HF terms recorded as text in the notes and HF-specific medication
• only 19.5% of patients identified as definite HF had a HF diagnosis recorded in the diagnosis section of their medical records; 52.4% had a diagnostic term recorded as free text in the consultation notes; 26.7% were identified based on HF-specific medication
• classification of heart failure as either HFrEF (heart failure with reduced ejection fraction) or HFpEF (heart failure with preserved ejection fraction) was only found in 19 records
• the age-standardised prevalence of combined ‘definite’ and ‘probable’ HF (the latter defined by medical record data such as ≥40 to < 50% ejection fraction or typical signs and symptoms, and either use of diuretics or more) was 2.199% (95% CIs: 2.168–2.23%)

De Pasquale and Audehm, 2019

Diagnosis of heart failure

This article, published in Medicine Today, is written for a GP audience.

It is accessible via a subscription or once-only payment.

It provides an easy-to-read overview of the diagnosis of heart failure, largely based on the Guidelines for the Prevention, Detection, and Management of Heart Failure in Australia 2018.

Reference

Summary

National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand

Guidelines for the Prevention, Detection, and Management of Heart Failure in Australia 2018

Chapter 7 provides a detailed description of the pharmacological management of heart failure, including the HFrEF Management algorithm (Page 1155, Figure 3).

7.1 Heart failure with reduced ejection fraction (HFrEF) (pages 1154 to 1161) includes medicines recommended for:

All patients

• Angiotensin converting enzyme inhibitors (ACEI)
• Heart failure beta blockers
• Mineralocorticoid receptor antagonists (MRAs)

Selected patients

• Diuretics
• Angiotensin receptor blockers (ARBs)
• Angiotensin receptor neprilysin inhibitors (ARNIs)
• Ivabradine
• Hydralazine plus nitrates
• Digoxin
• Nutraceuticals

7.2 Heart failure with preserved ejection fraction (HFpEF), which is a much briefer section (half a page) including 5 points of practical advice.

Burnett et al, 2017

Thirty years of evidence on the efficacy of drug treatments for chronic heart failure with reduced ejection fraction: A network meta-analysis

This meta-analysis of 57 included randomized controlled trials (RCTs) found hazard ratios for medicines including ACEI, ARB, ARNI, heart failure beta blocker and MRA, either alone or in combinations of two or three versus prescribed to target doses versus placebo for all-cause mortality and 95% confidence intervals for patients with HFrEF (presented in Figure 5).

The meta-analysis highlighted that the combination of an ACEI + heart failure beta blocker + MRA for patients with HFrEF had a 56% reduction in all-cause mortality compared to placebo: (hazard ratio 0.44 [95% CI 0.26 to 0.66]).

This compared, for example, to 17% for ACEI alone and 43% for ACEI + heart failure beta blocker.

Sindone and Driscoll, 2019

How to optimise therapy for heart failure with reduced ejection fraction

This article, published in Medicine Today, is written for a GP audience. It is accessible via a subscription or once-only payment.

It provides an easy to read overview of pharmacotherapy and device therapies that improve the prognosis for patients with heart failure with reduced ejection fraction (HFrEF).

It is largely based on the Guidelines for the Prevention, Detection, and Management of Heart Failure in Australia 2018.

Reference

Summary

National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand

Guidelines for the Prevention, Detection, and Management of Heart Failure in Australia 2018

Chapter 8 provides a detailed description of non-pharmacological management for heart failure. The main takeaways are the ‘Recommendations’ and ‘Practice Advice’:

8.1 Systems of Care to Reduce Rehospitalisation

8.2. Models of Care to Improve Evidence-Based Practice

This section includes guidance on:

• multidisciplinary heart failure disease management programs
• nurse-led titration
• non-pharmacological heart failure management and multimorbidity

8.3. Frequency of Follow-up

8.4. Self-management

This section includes self-monitoring education (see Practice advice)

8.5. Fluid Restriction and Daily Weighing

8.6. Sodium Intake

Note that the guidance for heart failure applies the sodium intake guidance for the whole Australian population. If sodium intake is > 2 g/day for a specific patient, then intervention is recommended to reduce intake for that patient.

8.7. Exercise Training and Heart Failure

Jonkman et al, 2016

Do self-management interventions work in patients with heart failure? An individual patient data meta-analysis

An individual patient data meta-analysis of 20 included RCTs assessing the effectiveness of self-management interventions for people living with heart failure.

It found reduced risk of time to the combined endpoint of heart failure-related hospitalisation or all-cause death (HR 0.80; 95% CI, 0.71 to 0.89) and time to heart failure-related hospitalization alone (HR 0.80; 95% CI 0.69 to 0.92).

The Guidelines for the Prevention, Detection, and Management of Heart Failure in Australia 2018 state that this meta-analysis shows that ‘self-management interventions significantly prolonged the time patients spent out of hospital and stayed alive.’