Addressing heart failure in primary care

Key practice points:

• The presentation of people with heart failure in primary care can vary substantially, ranging from mild and non-specific symptoms, e.g. a reduced exercise capacity and malaise, through to those with classical key features, e.g. ankle swelling, shortness of breath, orthopnoea
• Clinical examination can help to identify more specific signs of heart failure, e.g. elevated jugular venous pressure (JVP), positive abdominojugular reflux, S₃ (gallop rhythm) and a laterally displaced apical impulse; however, their absence does not exclude the possibility of heart failure
• The patient’s history should be reviewed to:
  • Identify whether they have made behavioural changes to compensate for symptoms, e.g. reducing physical activity in response to shortness of breath
  • Assess for other factors that may be an underlying cause or exacerbate symptoms, e.g. co-morbidities or concomitant medicine use
• If heart failure is still suspected, perform an ECG to check for any obvious underlying abnormalities and request a brain natriuretic peptide (BNP) test
• A clinical diagnosis of heart failure can be made if patients are not “ruled-out” based on their BNP result; they should also be referred for an echocardiogram to help refine long-term treatment decisions, however, this is not required to make an initial diagnosis
• If the patient is clinically unstable consider referral to secondary care, where treatment will likely be commenced. Treatment for patients initially managed in primary care is guided by the severity of symptoms, the presence and type of co-morbidities and relevant laboratory investigations.

Key practice points:

• Following clinical diagnosis, pharmacological treatment for patients with heart failure should immediately proceed under the assumption they have reduced left ventricular ejection fraction (HFrEF); in general, this initially involves:
  • Assertive treatment with a loop diuretic if the patient has fluid overload
  • Initiation of an ACE inhibitor (or ARB) as soon as practically possible, and a beta-blocker once any symptoms of fluid overload have settled; these should subsequently be titrated to the maximum dose tolerated
• Spironolactone (or eplerenone) can be considered if patients remain symptomatic; in some patients with severe symptoms, spironolactone may be used concomitantly alongside the ACE inhibitor and beta-blocker immediately
• The combination product of valsartan (an ARB) and sacubitril (a neprilysin inhibitor) – class name ARNI; brand name Entresto – can also improve clinical outcomes in patients with ongoing symptomatic HFrEF despite optimised standard treatment
  • Sacubitril + valsartan is fully funded with Special Authority approval
  • Stop the patient’s ACE inhibitor (or ARB) before initiating sacubitril + valsartan due to the risk of angioedema
• There is increasing evidence that sodium-glucose cotransporter-2 (SGLT-2) inhibitors can improve prognostic outcomes in patients with heart failure, with or without diabetes. However, this medicine is currently only funded for patients with type 2 diabetes who meet the Special Authority criteria.
• If heart failure with preserved ejection fraction (HFpEF) is confirmed based on echocardiography at any point, a cardiologist should generally be involved to refine treatment, which mostly focuses on control of fluid balance using diuretics at the lowest possible dose, in addition to managing associated co-morbidities

Article supported by the South Link Education Trust