NEW treatments and guidelines mean GPs remain central to the frontline management of chronic heart failure in Australia.
Heart failure is a serious and progressive disease in which the heart is unable to meet the body’s metabolic demands. It affects approximately 480,000 patients nationwide (here and here). Heart failure was also identified as the primary or supporting diagnosis in more than 170,000 hospital admissions between 2015 and 2016. Once hospitalized, the patient’s 5-year survival rate is 52-63%, but at each hospitalization, the risk of death of a patient suffering from heart failure increases by 30% (here and here).
Despite these serious statistics, there are a number of therapies for heart failure patients that can reduce hospitalizations and improve survival and quality of life. Most of them can be initiated at the primary care level. As the first and most frequent interaction with the healthcare system, GPs can support and educate patients to improve their awareness of their risk of hospitalization and how best to prevent and manage it. to manage. This article provides examples of how general practitioners can improve the patient experience of managing and living with heart failure.
There are several challenges to successfully managing heart failure.
First, symptoms of heart failure can be nonspecific, with many patients attributing symptoms to aging. Over 80% of patients may not be clinically coded with the diagnosis and symptoms are often treated without identifying the underlying problem.
Second, most heart failure patients also live with a range of comorbid conditions. A 2021 study found that more than 50% of drugs provided to treat these comorbid conditions are contraindicated for heart failure.
Finally, non-compliance with treatment plans by patients, resulting from various causes, can also lead to poor disease management and poor outcomes.
These factors increase the likelihood of cardiac decompensation and hospitalization, which in itself is another big challenge. Not only do hospitalizations significantly reduce patient survival, but they are associated with a deterioration in quality of life and represent a significant financial burden for patients, caregivers and the healthcare system.
Role of new treatments
Our latest work, as yet unpublished, expands on the National Heart Foundation’s 2018 management guidelines and recommends that all patients with heart failure receive all four prognostically beneficial pharmacological treatments, unless contraindicated: an angiotensin receptor neprilysin (RNAI) inhibitor, a β-blocker, a mineralocorticoid receptor antagonist (MRA), and a sodium-glucose cotransporter 2 (SGLT2) inhibitor. Diuretics are a “band aid treatment” and should only be used in the treatment of congestion.
However, due to the significant impact of rehospitalization on heart failure patients and their families, we must also seek solutions that address the cycle of decompensation events, even if patients are currently receiving treatment based on recommendations.
New treatments may play a role in overcoming some of the challenges of managing heart failure and the residual risk of rehospitalization in this patient population.
The Importance of General Practitioners and Best Practices
Typically, patients with heart failure see their GP monthly compared to cardiologists visiting once or twice a year. Therefore, GPs play a fundamental role in meeting the challenges of diagnosing and managing heart failure to help patients feel better, live longer, and stay out of hospital.
GPs are in an ideal position to watch for subtle, cumulative signs of worsening heart failure, such as shoes that are too tight or waking up short of breath.
The main symptoms include:
- shortness of breath – on exertion, at rest or when lying down;
- difficulty doing things they were able to do before;
- possible loss of appetite; and
The main clinical signs include:
- swelling in the lower legs and ankles;
- increased jugular venous pressure;
- crackles in the lungs;
- possible third heart sound; and
- Heart murmurs.
The pharmacological management of heart failure has changed considerably over the past 20 years. Since 80% of patients with heart failure rely on their GP for ongoing management, it is important to maintain a low referral threshold to the cardiologist and re-evaluate the patient’s treatment plan together after each event. . Treatment options can then be targeted and contraindications identified early, leading to better patient outcomes.
Finally, regarding non-adherence, GPs play a central role in keeping patents active and engaged in the management of their disease. Education on fluid retention, salt reduction, regular physical activity, encouragement to weigh yourself daily, the critical importance of not missing medications, and keeping immunizations up to date are essential to maintain quality of life and reduce hospitalizations.
Managing chronic heart failure is a long and often difficult battle that is easily lost. However, many steps can still be taken to minimize adverse effects. Armed with new treatments and proven new management guidelines to reduce mortality, reduce their risk of hospitalization and improve quality of life, there is no doubt that GPs are and will continue to be at the heart of a management success of the disease.
Professor Andrew Sindone is Director of the Heart Failure Unit and Cardiac Rehabilitation Department at Concord Hospital and Head of the Cardiology Department at Ryde Hospital. He teaches medical students, trainees, general practitioners and other specialists, and runs a specialist update program in the management of heart failure.
Statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of WADA, the MJA Where Preview+ unless otherwise stated.