Addressing heart failure in primary care

Part 1 – Identifying and diagnosing heart failure

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, the absence of these features 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 (such as arrhythmias or ischaemia) or concomitant medicine use
• If heart failure is still suspected, perform an ECG to check for any obvious underlying abnormalities (e.g. atrial fibrillation, ischaemia) and request a brain natriuretic peptide (BNP) level. Additional investigations can then be considered depending on patient-specific factors, e.g. chest X-ray may be useful to confirm fluid overload and to exclude other causes of dyspnoea.
• A clinical diagnosis can be made if patients have symptoms/signs of heart failure and are not “ruled-out” based on having a low BNP result. Referral for an echocardiogram helps to refine long-term treatment decisions, however, it is not required to make an initial diagnosis.
• Echocardiography can distinguish the type of heart failure, and is particularly useful for identifying associated cause(s); this in turn can guide some treatments (e.g. medical, surgical and devices). The three classifications of heart failure are:
  • Heart failure with reduced ejection fraction (HFrEF) – patients with reduced left ventricular ejection fraction (LVEF) of ≤ 40%
  • Heart failure with mildly reduced (or “mid-range”) ejection fraction (HFmrEF) – patients with a LVEF of 41 – 49%
  • Heart failure with preserved ejection fraction (HFpEF) – patients with a LVEF of ≥ 50%, and evidence of relevant structural heart disease, and/or diastolic dysfunction with a high filling pressure
• If the patient has significant or distressing symptoms at presentation, or an acute cardiac condition is suspected to be causing heart failure (e.g. acute coronary syndrome), consider urgent secondary care referral where further management decisions will be made. 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.

Click here to read the full article “Part 1 – Identifying and diagnosing heart failure”

Part 2 – Initiating and optimising treatment for heart failure

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)
• Rather than sequential treatment escalation in response to symptoms, patients with heart failure should be promptly established on four guideline-directed medical therapy (GDMT) medicines and up-titrated to the highest tolerated or target dose, unless contraindicated. GDMT maximises prognostic outcomes (e.g. risk of hospitalisation and mortality) and limits disease progression. This includes:
  • An angiotensin receptor-neprilysin inhibitor (ARNI; preferred) or an ACE inhibitor/ARB if this is not possible; and
  • A beta blocker (either bisoprolol, metoprolol succinate or carvedilol); and
  • A mineralocorticoid receptor antagonist (MRA); and
  • A sodium-glucose co-transporter-2 (SGLT-2) inhibitor
• Special Authority restrictions may influence the introduction of GDMT. For example, the ARNI and SGLT-2 inhibitor cannot be initiated (funded) without patients first being established on “concomitant optimal standard chronic heart failure treatments” (among other criteria).
  • When an ARNI is introduced, stop the ACE inhibitor (or ARB) before initiating treatment due to the risk of angioedema
  • SGLT-2 inhibitors have been funded with Special Authority approval for patients with HFrEF (regardless of diabetes status) since 1^st December, 2024
• In addition to GDMT, assertive treatment with a loop diuretic is required if the patient has fluid overload. Withhold beta blocker initiation until the patient is euvolemic.
• For patients initially diagnosed in primary care, aim to achieve optimal dosing of all four GDMT medicines within three months where practically possible. If a patient is already taking a GDMT medicine, or is hospitalised for heart failure, aim for optimisation within a shorter timeframe, e.g. within six weeks.
• Regular monitoring is essential in patients with heart failure. Key short-term considerations include medicine adverse effects, clinical/symptomatic status, blood pressure, renal function and serum potassium.
  • Further BNP testing (preferably NT-proBNP) can be considered, but only if it will influence management decisions
  • Repeat echocardiography is helpful to monitor disease progression in the long-term, including consideration for further treatments, e.g. implantable cardioverter defibrillator (ICD), cardiac resynchronisation therapy (CRT) or CRT-defibrillation
• 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
  • HFpEF management focuses mainly on controlling fluid balance using diuretics at the lowest possible dose, in addition to managing associated co-morbidities, especially hypertension and atrial fibrillation
  • SGLT-2 inhibitors are effective in patients with HFpEF, but those with echocardiography-confirmed HFpEF are not currently eligible for Special Authority approval

Click here to read the full article “Part 2 – Initiating and optimising treatment for heart failure”

These publications were supported by an unrestricted educational grant by Novartis NZ Ltd. The publications were independently written and Novartis had no control over the content. The views expressed in these publications are those of the author and not necessarily those of Novartis