Heart failure is a complex clinical syndrome characterised by signs and symptoms caused by structural or functional abnormalities of the heart (National Institute for Health and Clinical Excellence (NICE), 2018). Typical symptoms include breathlessness, ankle swelling and fatigue. Signs of fluid overload such as elevated jugular venous pressure, peripheral oedema and pulmonary crackles on auscultation may be present (Ponikowski et al, 2016). Ischaemic heart disease and previous myocardial infarction are the leading causes of heart failure in the UK (National Institute for Cardiovascular Outcomes Research (NICOR, 2018).
The prevalence of heart failure is approximately 1–2% and increases steeply with age (NICE, 2018), reaching more than 10% in those over 70 years of age (Ponikowski et al, 2016). Heart failure accounts for 1 million bed days per year and approximately 2% of the NHS total spend (NICOR, 2018).
The average general practice list in England has over 8000 patients (Bocstock and Oluwunmi, 2018) and therefore the typical practice will care for in excess of 100 heart failure patients. The incidence and prevalence of heart failure are increasing due to a combination of an aging population, improved treatment and higher survival rates after myocardial infarction (NICE, 2018). Patients with heart failure are likely to be well known to practice nurses as they typically have multiple comorbidities, take a large number of medications and attend the practice on average 11.2 times per year – 3.8 of these visits being to practice nurses (Forsyth et al, 2015). With the role of the practice nurse evolving and expanding, practice nurses are increasingly taking on additional roles and responsibilities; therefore it is essential that practice nurses have up-to-date knowledge and skills. This article will discuss the diagnosis, classification and management of heart failure and the opportunities for practice nurses to enhance patient care.
Diagnosis
In most patients, in order to formulate an appropriate treatment plan diagnosis is based on a combination of the following factors:
- Detailed history (eg presence of risk factors such as previous myocardial infarction, atrial fibrillation, hypertension or diuretic use) and clinical examination to determine signs and symptoms
- Measurement of natriuretic peptides
- Electrocardiogram (ECG)
- Echocardiography or alternative imaging (NICE, 2018).
Signs and symptoms
There are myriad signs and symptoms associated with heart failure, which are often non-specific and difficult to differentiate from other conditions, such as obesity, respiratory disorders and aging (Ponikowski et al, 2016). Typical signs of heart failure include elevated jugular venous pressure, peripheral oedema and pulmonary crackles on auscultation. Common symptoms include breathlessness, ankle swelling and fatigue (Ponikowski et al, 2016). Many such signs and symptoms are non-specific to heart failure and therefore further diagnostic tests and imaging are needed to confirm. The underlying causes of heart failure vary and include abnormalities of the myocardium, valves, pericardium, endocardium, heart rhythm or conduction (Ponikowski et al, 2016; NICE, 2018). Identification of the type of heart failure is imperative to determining a correct treatment strategy (eg surgery for valvular heart failure or optimal pharmacological management for heart failure with left ventricular systolic dysfunction). Diagnosis should not be made on signs and symptoms alone (Ponikowski et al, 2016).
Natriuretic peptides
Natriuretic peptides are circulatory hormones, largely of cardiac origin, which are typically raised in heart failure. In patients with no cardiac history or likely cause for cardiac damage, a diagnosis of heart failure is unlikely; however, it cannot be excluded. Natriuretic peptides should be checked in those with suspected heart failure and echocardiography is indicated in patients with a raised result (Ponikowski et al, 2016). Plasma natriuretic peptides can be a useful diagnostic tool, especially in primary care, as patients with normal natriuretic peptide levels are unlikely to have heart failure and should not be routinely referred for further diagnostics. Raised natriuretic peptide levels can help formulate an initial diagnosis and can be used stratify patients where further informative cardiac diagnostics, such as ECGs and echocardiography, are required.
The upper limit of normal in the non-acute setting for B-type natriuretic peptide is 35 pg/ml and for N-terminal pro-BNP it is 125 pg/ml. NICE (2018) recommend referring patients with an N-terminal pro-BNP >400 pg/ml for specialist assessment and echocardiography. However, be aware that other cardiac and non-cardiac conditions can lead to raised natriuretic peptides, including age, renal function and atrial fibrillation (Ponikowski et al, 2016).
Electrocardiograms
ECGs are a useful tool in ruling out heart failure – those with a normal ECG are unlikely to have the condition. ECGs can be useful in determining aetiology (eg myocardial infarction) and some treatment strategies (eg anticoagulation in atrial fibrillation and device therapy for broad QRS complex) (Ponikowski et al, 2016). Twelve-lead ECGs should be conducted in all patients with suspected heart failure. Those with a normal ECG are unlikely to have heart failure.
Echocardiography
Echocardiography is the most valuable diagnostic test for patients with suspected heart failure. It is widely available and provides immediate information on chamber volumes, ventricular systolic and diastolic function, wall thickness and valve function, which is crucial in establishing the diagnosis and aetiology. Establishing the aetiology may influence treatment management plans (eg cessation of alcohol in alcoholic cardiomyopathy, family screen in genetic cardiomyopathy etc).
Classification
Type of heart failure
Heart failure can be categorised as preserved, mid-range or reduced ejection fraction according to the measurement of left ventricular ejection fraction (LVEF). LVEF is a measure of stroke volume/end diastolic volume. Heart failure with preserved ejection fraction (HFpEF) is seen in patients with a normal LVEF of ≥50% and another cardiac abnormality, typically left ventricular hypertrophy or dilated left atrium. Heart failure with reduced LVEF (HFrEF) is seen in those with a LVEF <40%; and heart failure with mid-range LVEF (HFmrEF) in those with a LVEF 40–49%.
It is important to differentiate between these categories because the underlying aetiologies, comorbidities and evidence base for pharmacological management differs between them (Ponikowski et al, 2016). The most common cause of HFrEF is ischaemic heart disease. Atrial fibrillation and hypertension are more commonly associated with heart HFpEF (NICOR, 2018). This article will largely concentrate on the management of HFrEF as evidence from clinical trials shows that the morbidity and mortality benefits of pharmacological management are certain in this group. Treatment of HFpEF is largely based on supportive management of symptoms (through diuretics) and of comorbidities; there are no treatments proven to reduce morbidity or mortality (Ponikowski et al, 2016). The evidence base for HFrEF is inconsistent but it is often treated as HFrEF (Lopatin, 2018).
Symptomatic classification
Severity of heart failure symptoms and their effect on exercise tolerance are classified according to the New York Heart Association (NYHA) scale (Ponikowski et al, 2016). This ranges from NYHA I (no limitation of physical activity) through to NYHA IV (unable to carry on any physical activity without discomfort, symptoms at rest can be present) (Table 1). However, NYHA scoring is subjective and can be complicated by other comorbidities, including respiratory disease, poor conditioning and angina. There is a poor relationship between symptoms and severity of ventricular dysfunction (Ponikowski et al, 2016). It is important to establish the effect of exercise on the patient's symptoms, as NYHA score can be used to guide treatment and monitor response. Therefore, NYHA score should be estimated and recorded at each review.
Table 1. Functional classification
| Class | Description |
|---|---|
| I | No limitation of physical activity. Ordinary physical activity does not cause undue breathlessness, fatigue or palpitations |
| II | Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in undue breathlessness, fatigue or palpitations |
| III | Marked limitation of physical activity. Comfortable at rest, but less-than-ordinary physical activity results in undue breathlessness, fatigue or palpitations |
| IV | Unable to carry on any physical activity without discomfort. Symptoms at rest can be present. If any physical activity is undertaken, discomfort is increased |
Management
Although the prognosis of HFrEF remains poor, the disease modifying treatment options and survival rates have improved significantly over the past 30 years (Jhund et al, 2009; Burnett et al, 2017). It is estimated that, when used appropriately, modern pharmacological therapy results in a 63% reduction in all-cause mortality (Burnett et al, 2017). Full guidance can be found in national and international guidelines (Ponikowski et al, 2016; Scottish Intercollegiate Guidelines Network (SIGN), 2016; NICE, 2018). The goals of HFrEF treatment are to minimise symptoms, improve quality of life and reduce hospitalisations, morbidity and mortality (Ponikowski et al, 2016).
Diuretics
Diuretics are used for symptomatic relief of fluid overload. Loop diuretics such as furosemide and bumetanide are generally used as a first-line treatment, with doses being adjusted to achieve euvolaemia with the minimum effective dose. Patients can be educated by the specialist heart failure team to alter doses according to symptoms and daily weights. Thiazides can be used synergistically with loop diuretics in resistant oedema; however, this combination should be monitored closely due to the risk of adverse effects (Ponikowski et al, 2016).
Angiotensin converting enzyme inhibitors and beta-blockers
Angiotensin converting enzyme inhibitors (ACEIs) and beta-blockers (BBs) are recommended for all patients with HFrEF in the absence of contraindications. The use of higher doses is associated with lower mortality and hospitalisations for heart failure (Packer et al, 1999; Konstan et al, 2009). Where possible, there should be an attempt to titrate these agents to target dose (Table 2).
Table 2. Target doses of cardiovascular medication
| ACE-inhibitor | Starting dose | Target dose |
|---|---|---|
| Captopril | 6.25 mg three times daily | 50 mg three times daily |
| Enalapril | 2.5 mg twice daily | 10–20 mg twice daily |
| Lisinopril | 2.5 mg once daily | 20–35 mg once daily |
| Ramipril | 2.5 mg once daily | 5 mg twice daily |
| Beta-blocker | ||
| Bisoprolol | 1.25 mg once daily | 10 mg once daily |
| Carvedilol | 3.125 mg twice daily | 25–50 mg twice daily |
| Nebivolol | 1.25 mg once daily | 10 mg once daily |
| Angiotensin receptor blocker | ||
| Candesartan | 4 mg once daily | 32 mg once daily |
| Valsartan | 40 mg twice daily | 160 mg twice daily |
| Losartan | 25–50 mg once daily | 150 mg daily |
| Mineralocorticoid receptor antagonist | ||
| Eplerenone | 25 mg once daily or on alternate days | 50 mg once daily |
| Spironolactone | 25 mg once daily | 25–50 mg once daily |
ACEIs are initiated at a low dose and up-titrated every 2 weeks to the recommended target dose with careful monitoring of blood pressure, renal function and potassium after each dose increment. Angiotensin II receptor blockers (ARBs) may be used in patients intolerant of ACEIs (eg for ACEI-induced dry cough). BBs are used in a similar manner, being initiated at a low dose and gradually up-titrated at intervals, no less than every 2 weeks after monitoring blood pressure, heart rate and clinical status (increasing breathlessness, fatigue, oedema or weight gain).
It is important to monitor fluid status when up-titrating BBs as they can initially worsen congestion. Patients should be euvolaemic and stable before initiating and up-titrating (SIGN, 2016). For sinus rhythm patients, BBs are usually titrated to a resting pulse of around 60 bpm. However, the mortality benefits of BBs are less certain for patients with atrial fibrillation and a pulse of around 80 bpm is usually the accepted target (Kotecha et al, 2017).
Mineralocorticoid receptor antagonists
Mineralocorticoid receptor antagonists (MRAs) are indicated in patients with an LVEF ≤35% and who remain symptomatic (NYHA classes II–IV) despite treatment with ACEIs and BBs, or in post-myocardial infarction patients with LVEF ≤40% and evidence of heart failure. Renal function and potassium should be closely monitored due to the risk of renal dysfunction and hyperkalaemia (SIGN, 2016). Patients should also be encouraged to seek medical advice should they develop diarrhoea or vomiting.
Ivabradine
Ivabradine is indicated in patients with:
- NYHA class II–IV symptoms
- LVEF ≤35%
- Heart rate ≥75 bpm sinus rhythm, despite BBs or in those who cannot tolerate BBs, or it is contraindicated.
It is only effective in patient in sinus rhythm and is not used in atrial fibrillation (SIGN, 2016; NICE, 2018).
Angiotensin-II receptor/neprilsyn inhibitor
Sacubitril/valsartan is the first angiotensin-II receptor/neprilsyn inhibitor (ARNI) used in patients who remain symptomatic (NYHA classes II–IV) despite optimal medical therapy (typically ACEIs, BBs, and MRAs). In such patients it is superior to ACEI for morbidity and mortality reduction (McMurray et al, 2014). Its use is restricted to specialist initiation in patients with an LVEF ≤35% in England and Wales (NICE, 2018) and LVEF ≤40% in Scotland (SIGN, 2016). There is a risk of angiodema when used in combination with ACEIs. A 36–48-hour washout period is recommended when switching from an ACEI (electronic Medicines Compendium, 2018). Patients require careful monitoring of blood pressure and renal function.
Devices
An implantable cardioverter-defibrillator (ICD) is a device implanted inside the body of a patient that is able to perform defibrillation, cardioversion or pacing in certain life-threatening arrhythmias. An ICD may be suitable for primary prevention of sudden cardiac death for patients who remain symptomatic (NYHA classes II–III), despite optimal medical therapy with an LVEF ≤35%, to reduce the risk of sudden cardiac death. They are also indicated for secondary prevention (eg those with previous ventricular tachycardia or arrest) in NYHA classes I–III.
Cardiac resyncronisation therapy (CRT) is a complex type of pacemaker that aims to improve the co-ordination of ventricular contraction and can be useful in patients with heart failure and a bundle branch block. CRT therapy may be suitable to reduce morbidity and mortality in NYHA classes I–IV patients despite optimal medical therapy with an LVEF ≤35% and a broad QRS, depending on exact QRS width and morphology (Ponikowski et al, 2016; NICE, 2018). Patients suitable for a device should be referred to the specialist heart failure multidisciplinary team.
Specialist heart failure multidisciplinary teams and primary care
The importance of multidisciplinary teamwork and collaboration with primary care is well recognised (Ponikowski et al, 2016; SIGN, 2016; NICE, 2018). Typically, specialist heart failure multidisciplinary team input is needed at diagnosis for aetiology investigation, initial management plan formation and treatment optimisation, in decompensated patients and when device therapy or advanced treatment options are needed (NICE, 2018).
NICE states that the role of primary care (including when the patient is under the specialist heart failure multidisciplinary team) is to ensure effective communication links between different care settings and clinical services involved in the person's care. This is in order to lead a full holistic review of the person's heart failure care, which may form part of a long-term conditions review. This review aims to recall the person at least every 6 months and update the clinical record to arrange access to specialist heart failure services where necessary.
Heart failure management is usually taken over by primary care once symptoms are stabilised and management is optimised. The specialist heart failure multidisciplinary team should provide a care plan that includes details on monitoring medication and symptoms to look out for which may indicate deterioration, and a process for accessing the specialist team if needed (NICE, 2018). The structure, role and functionality of the specialist heart failure multidisciplinary team will differ across the UK. The majority of heart failure nurses are employed in one sector of care, with only 28.5% working cross-sector (Pumping Marvellous, 2018). Heart failure nurses form an integral part of the specialist heart failure multidisciplinary team and have been shown to improve patient outcomes (Blue et al, 2001). Approximately 40% of heart failure nurse specialist teams only see HFrEF patients, therefore in some areas there may be a gap in delivery of care to patients with HFmrEF and HFpEF (Pumping Marvellous, 2018). It is important that practice nurses are aware of the category a heart failure patient has and the services offered by the specialist heart failure multidisciplinary team in their area to ensure that all appropriate patients are referred to and reviewed by the specialist heart failure multidisciplinary team. For patients with HFrEF this will help ensure that they receive optimal pharmacological and device management with morbidity and mortality reducing agents. For those with HFmREF or HFpEF, who may not be under the care of the specialist heart failure multidisciplinary team, there may be a role for practice nurses in providing care to improve quality of life.
Specialist heart failure nurse services in the UK are under increased demand and are managing ever increasing case loads without extra resources (Pumping Marvellous, 2018). With the increasing prevalence of heart failure, there are opportunities to reshape primary care services to ensure that the needs of this ever increasing population are being met. This may include cross-sector collaborative working to ensure that patients are reviewed and up-titrated in a timely manner (Pumping Marvellous, 2018).
Opportunities for practice nurses
The role of the practice nurse in the management of heart failure is likely evolve to include cross-sector collaborative working to meet the needs of this patient group. This may involve opportunities for practice nurses to enhance care for patients with heart failure from diagnosis to long-term condition reviews, through to end-of-life care. The practice nurse may be the first health professional to encounter a patient displaying signs or symptoms of heart failure. Practice nurses are often responsible for carrying out long-term condition reviews for patients at high risk of developing heart failure, such as ischaemic heart disease, atrial fibrillation and diabetes. It is important that practice nurses are alert for signs and symptoms of heart failure in such patients and are aware of the diagnostic referral pathway in their local area.
Once a diagnosis is made, heart failure will form part of a patient's long-term condition review. At each review signs and symptoms of heart failure should be assessed, including NYHA, to monitor response to treatment and stability. Practice nurses should be aware of the classification of heart failure and be proactive in ensuring that patients are on optimal medical therapy, relative to their symptoms and degree of left ventricular impairment. Where possible, doses should be titrated to target dose and there may be a role for nurse prescribers in the titration and monitoring of ACEIs, BBs and MRAs. This will include checking blood pressure, pulse, renal function and potassium as per guidelines. Full blood count and iron studies should be periodically monitored in symptomatic HFrEF patients and those with iron deficiency should be discussed with the specialist heart failure multidisciplinary team for consideration of intravenous iron (SIGN, 2016). Vaccination status should be checked to ensure that patients have received a one-off pneumococcal vaccination and are up-to-date with annual influenza vaccination (NICE, 2018).
When undertaking a long-term conditions review, it is important to monitor and act on worsening symptoms, such as the need to double a loop diuretic dose, as symptomatic worsening is a key marker of increased risk of hospitalisation or death (Okumura et al, 2016). Such worsening is often under-played but these patients need prompt attention (Ponikowski et al, 2016). Persistent symptoms may indicate the need for additional therapies that require specialist initiation such as ivabradine, ARNI or device therapy (Ponikowski et al, 2016). Worsening symptoms and congestion should be communicated to the specialist heart failure multidisciplinary team.
As patients with heart failure are well known to practice nurses, a long-term conditions review provides a good opportunity to provide holistic care relative to the needs of the individual patient. This may include ongoing education and lifestyle advice, screening for depression, monitoring medication compliance and addressing the need for social support. In woman of childbearing age, it is appropriate to have a sensitive discussion around contraception and pregnancy as left ventricular systolic dysfunction increases the maternal morbidity and mortality risk to varying degrees and some medications can be harmful to the fetus. Women contemplating a pregnancy should be referred for joint cardiac and obstetric assessment and pre-pregnancy counselling so they understand the potential risks of a pregnancy to make an informed choice whether to proceed (Regitz-Zagrosek et al, 2018). In others it is important that they know how to access effective contraception that is safe to use with their cardiac condition and who to contact in the event of an unplanned pregnancy.
Due to the trajectory of heart failure, there is an important role for practice nurses in the identification of palliative care needs. This should include anticipatory care planning, co-ordination of care, referral to palliative services, multidisciplinary team working and good communication between sectors and good end-of-life care (SIGN, 2016).
Conclusion
Heart failure is a complex clinical syndrome that is increasing in prevalence. Practice nurses have a vital role to play in the delivery of care to patients with heart failure, from diagnosis to providing long-term condition reviews and through to end-of-life care. Collaborative working with the heart failure multidisciplinary team can bring new opportunities for practice nurses, ensure sustainability of heart failure services and enhance care and improving outcomes for heart failure patients.
KEY POINTS
- Heart failure is a complex syndrome caused by structural or functional abnormalities of the heart and is characterised by fluid overload, breathlessness and fatigue
- Heart failure can be categorised as preserved, mid-range or reduced ejection fraction according to the measurement of left ventricular ejection fraction on echocardiogram
- In heart failure with reduced ejection fraction disease-modifying medications including angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, beta-blockers, mineralocorticoid receptor antagonists, ivabradine and angiotensin-II receptor/neprilsyn inhibitor have been shown to reduce morbidity and mortality
- The National Institute for Health and Care Excellence suggests delivery of care through collaborative working between the specialist heart failure multidisciplinary team working and primary care
- Practice nurses play a vital role in the delivery of care to patients with heart failure from diagnosis, to providing long-term condition reviews and through to end-of-life care
CPD reflective practice
- What is the differences between heart failure with preserved EF (HFpEF); heart failure with reduced LVEF (HFrEF); and heart failure with mid-range LVEF (HFmrEF) and how should these be coded on clinical systems to differentiate between them?
- What factors should be taken in consideration when seeing a young, female patient with HFrEF for their long-term management review?
- What is the remit of the heart failure nurse service in your area and how do you or patients access this service?