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NEW treatments and guidelines mean GPs remain at the centre of frontline management of chronic heart failure in Australia.
Heart failure is a serious and progressive condition, where the heart is unable to meet the metabolic demands of the body. It affects around 480 000 patients nationally (here and here). Heart failure was also identified as the main or additional diagnosis in over 170 000 admissions to hospital between 2015 and 2016. Once hospitalised, the patient’s 5-year survival rate is 52–63%, but with each hospitalisation, the risk of death of a patient with heart failure increases by 30% (here and here).
Despite these serious statistics, there are a number of therapies for patients with heart failure which can reduce hospitalisation and improve survival and quality of life. Most of these can be initiated at the primary care level. As the first and most frequent interaction with the health care system, GPs can support and educate patients to improve awareness of their risk of hospitalisation and how best to prevent and manage it. This article provides examples of how GPs can improve the patient experience of managing and living with heart failure.
Management challenges
There are several challenges to address in order to achieve successful management of heart failure.
First, symptoms of heart failure may be non-specific, with many patients attributing symptoms to ageing. Over 80% of patients may not be clinically coded with the diagnosis and symptoms are often addressed without identifying the underlying issue.
Second, most patients with heart failure also live with a range of comorbid conditions. A 2021 study found that over 50% of medications supplied to treat these comorbid conditions are contraindicated for heart failure.
Finally, patient non-adherence to treatment plans, stemming from a variety of causes, can also result in poor disease management and outcome.
These factors increase the likelihood of heart failure decompensation and hospitalisation, which in itself, is yet another great challenge. Hospitalisations not only drastically reduce patient survival, they are associated with worsening quality of life and pose a significant financial burden to patients, carers, and the health care system.
Role of new treatments
Our latest, as yet unpublished, work extends upon the 2018 National Heart Foundation management guidelines, and recommends that all patients with heart failure should be on all four prognostically beneficial pharmacological treatments, unless contraindicated: an angiotensin receptor neprilysin inhibitor (ARNI), 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 re-hospitalisation on patients with heart failure and their families we also need to look for solutions that address the cycle of decompensation events, even if patients are receiving current guideline-based therapy.
New treatments can play a role in overcoming some of the challenges to heart failure disease management and the residual risk of re-hospitalisation in this patient population.
The importance of GPs and best practice
Typically, patients with heart failure see their GPs every month compared with visiting cardiologists once or twice a year. Therefore, GPs play a fundamental role in addressing the challenges in heart failure diagnosis and management to help patients feel better, live longer and stay out of hospital.
GPs are in an ideal position to monitor for subtle and cumulative signs of heart failure deterioration, such as shoes being too tight or waking up in the night short of breath.
The mains symptoms include:
- shortness of breath – on exertion, at rest or when lying flat;
- fatigue;
- difficulty doing the things that they used to be able to do;
- possible loss of appetite; and
The main clinical signs include:
- swelling of the lower legs and ankles;
- elevation of the jugular venous pressure;
- crepitations in the lungs;
- possible third heart sound; and
- heart murmurs.
Pharmacological management of heart failure has changed dramatically in the past 20 years. As 80% of patients with heart failure rely on their GP for ongoing management, it’s important to keep a low referral threshold to the cardiologist and together reassess the patient’s treatment plan after every event. Treatment options can then be targeted and contraindications identified early, leading to better patient outcomes.
Finally, regarding non-adherence, GPs play a pivotal role in keeping patents active and engaged with their disease management. Education on fluid retention, salt reduction, regular physical activity, encouragement to weigh themselves every day, the critical importance of not missing their medications, and keeping up to date with vaccinations are vital to maintaining quality of life and reducing hospitalisations.
Managing chronic heart failure is a long and often difficult battle that is easily lost. However, there are still many steps that can be taken to minimise adverse outcomes. Armed with new treatments and new management guidelines proven to reduce mortality, lower their risk of hospitalisation and improve quality of life, there is no doubt that GPs are and will continue to be at the heart of successful disease management.
Professor Andrew Sindone is Director of the Heart Failure Unit and Department of Cardiac Rehabilitation at Concord Hospital and Head of Department of Cardiology at Ryde Hospital. He teaches medical students, trainees, GPs and other specialists, and runs a program to update specialists in the management of heart failure.
The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.