Download Heart Failure workshop

Heart Failure workshop 2011
Heart Failure workshop
The learning outcomes for this workshop are:
1. To familarise yourself with the condition and the medicines used to treat it.
2. To be able to review a prescription and recognise that the patient has heart failure and
whether the medicines are being prescribed appropriately, to enable you to make an
intervention if necessary.
3. To understand the medicines management issues for patients in community pharmacy
and hospital.
Introduction
Read the following couple of pages as introduction to the workshop. They are taken from
www.pharmacymag.co.uk which has a CPD programme for pharmacists and technicians. The
article is called Current Thinking on Heart Failure and is written by Mojgan Sani who is a specialist
pharmacist in Cardiology.
Although heart failure is difficult to define, it is easy to recognise in practice. There re two types of
heart failure:
Left ventricular systolic dysfunction (LVSD) which is when the left ventricle which pumps the blodd
around the body work less than optimally.
Heart failure with preserved ejection fraction (HFPEF) which is when the heart has difficulty filling
with blood.
It has been estimated almost a million people in the UK have heart failure. The prevalence
of the disease increases with age, with men at higher risk than women. It is thought to account for
two per cent of all NHS in-patient bed days with a cost of around 1. 8 % of the total NHS budget.
In addition to the NHS costs the disease places a significant burden on other agencies and families.
On average each GP will look after about 30 people with heart failure and suspect the condition in
a further 10 patients each year. The average community pharmacy will be dispensing medicines
for around 80 patients with heart failure.
The patient's quality of life is significantly affected by the physical limitations imposed by the
disease and the emotional problems which arise as a result.
The challenge for the patient and everyone involved in care is managing the other co-morbidities
as well as dealing with polypharmacy and the potential side-effects arising from the multiple-drug
therapy.
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Heart Failure workshop 2011
Causes
The commonest causes for functional deterioration of the heart are damage to or loss of heart
muscle, acute or chronic ishaemia, increased vascular resistance due to hypertension, or cardiac
arrhythmia such as atrial fibrillation.
Causative factors include:
Coronary heart disease - mycardial infarction, ischaemia
Hypertension
Cardiomyopathy
Congenital heart disease
Arrhythmias - tachycardia and bradycardia
Alcohol
Medicines such as calcium channel blockers, anti-arrhythmics, cytotoxic drugs.
Chronic heart failure has two major components: an abnormality of the heart itself and the
response of the body to the diminished ability if the heart to function as a pump. Reduced
function of the heart as a pump is usually caused by an abnormality of the muscle, heart rhythm,
valves or pericardium.
Signs and symptoms
The signs and symptoms of chronic heart failure are mainly a consequence of long term responses
in the body to these two components. For example salt and water retention is the results of
abnormal kidney function while shortness of breath is related to lung dysfunction and fatigue
results from chronic changes in the skeletal muscle.
The classical signs are dyspnoea (difficulty with breathing), ankle oedema and fatigue. Dyspnoea is
also present in chronic obstructive pulmonary disease (COPD) so care must be taken to
differentiate between these two conditions which often occur together. Orthopnoea (shortness of
breath when lying flat) and paroxysmal nocturnal dyspnoea (shortness of breath which wakes the
patient after one or two hours of sleep) are more likely to be related to heart failure.
Systolic and diastolic heart failure
Heart failure has also been defined as “systolic” or “diastolic”.
Systolic heart failure is associated with a reduction in the systolic performance if the heart,
circulatory congestion and progressive activation of various neuroendocrine systems. In later
stages, systolic heart failure is characterised by excessive sympathetic nervous system activity such
as tachycardia, peripheral oedema, ascites and oliguria. Most patients have an enlarged left
ventricle with hypertrophy and remodelling of the chamber, therefore markedly reducing left
ventricular function.
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Diastolic heart failure implies normal systolic function of the heart in the presence of clinical heart
failure. This can be caused by hypertension and results in pulmonary congestion. Chronic heart
failure represents a complex clinical syndrome with both left and right ventricular dysfunction.
Heart Failure Classification
The American College of Cardiology and the American Heart Association have class heart failure
based on structural changes and symptoms. The classification is known as the New York Heart
Association (NYHA) Functional Classification and is routinely used in diagnosis and management of
the condition.
The NYHA classification of Heart Failure
Stages of heart failure based on structure and
damage to heart muscle
Stage A
At high risk of developing heart failure.
No identified structural or functional
abnormality, no signs or symptoms
Stage B
Developed structural heart disease that is
strongly associated with the development of
heart failure, but without signs and symptoms
Stage C
Symptomatic heart failure associated with
underlying structural heart disease
Stage D
Advanced structural heart disease and marked
symptoms of heart failure at rest despite
maximal medical therapy
NYHA functional classification (based on
symptoms and physical activity)
Class I
No limitation of physical activity
Ordinary physical activity does not cause undue
fatigue, palpitations or dyspnoea
Class II
Slight limitation of physical activity
Comfortable at rest but ordinary physical
activity results in fatigue, palpitations or
dyspnoea
Class III
Marked limitation of physical activity
Comfortable at rest but less than ordinary
physical activity results in fatigue, palpitations
and dyspnoea
Class IV
Unable to carry out any physical activity without
discomfort. Symptoms at rest. If any physical
activity is undertaken discomfort is increased
Pharmacological Treatment
Pharmacological treatment aims to improve quality of life as well as length of survival. The
relative importance of these two objectives should be decided on an individual basis and may
change over time in the same patient depending on the stage of heart failure. The British National
Formulary summarises the current approach to treatment as follows:
An ACE inhibitor, titrated to a “target” dose (or the maximum tolerated dose if lower) and a
beta-blocker is recommended to achieve these aims. A diuretic is also necessary in most
patients to reduce symptoms of fluid overload.
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Education and empowerment of patients and their carers regarding medication is an essential part
of therapy as patients with heart failure are often on several medicines which need to be
optimised gradually in order to achieve the best result according to the evidence-based data
available.
Diuretic therapy
Dealing with fluid retention is an important part of managing heart failure patients in order to
minimize breathlessness due to congestion. Loop diuretics such as furosemide or bumetanide are
the main agents used. Thiazide diuretics are not used as often in chronic heart failure as they tend
to be less effective when glomerular filtration rates are below 30ml/min. Metazolone (a thiazide)
may be used in severe, resistant chronic heart failure but may result in rapid fluid imbalance so
needs to be monitored carefully. Electrolyte balance, particularly potassium should be monitored
on a regular basis for all patients with chronic heart failure on diuretic therapy. Renal function
should also be monitored regularly to avoid worsening of renal impairment or acute heart failure.
When the patient is retaining fluid, gut oedema may reduce absorption of tablets and some
patients may require intravenous therapy in order to ensure 100% bioavailability and clinical
effect. This usually requires admission to hospital or a specialist heart failure outpatient setting
for treatment. Diuretics improve symptoms of breathlessness and exercise performance in
patients with heart failure. The NICE guideline recommends using diuretics routinely for the relief
of congestive symptoms and fluid retention in patients with heart failure titrated (up or down)
according to the need following the initiation of subsequent therapies. The initial dose of
furosemide is usually 20 – 40 mg per day but can increase to 250 – 500mg if required.
ACE inhibitors
Angiotensin Converting Enzyme (ACE) inhibitors improve survival in heart failure patients with left
ventricular dysfunction. The benefit is significant in patients with more severe Class IV symptoms
but there is a benefit for all patients with heart failure. There is also good evidence to suggest that
ACE inhibitors reduce the risk of hospitalisation for heart failure. Many of the pathophysiological
abnormalities that characterize heart failure may be reversed by ACE inhibitors. Their main effect
is to block the conversion of angiotensin I to angiotension II, a very potent vasoconstrictor leading
to stimulation of the sympathetic nervous system. ACE inhibitors are therefore arterial and
venous vasodilators that cause “unloading” of the heart. As a result left ventricular mass and
cavity size is reduced and systolic function is improved. Skeletal muscle blood flow is increased,
which in turn improves exercise capacity. ACE inhibitors affect the renal system via
neurohormonal pathways thereby preventing further deterioration in cardiac function and
worsening of heart failure. They also reduce symptoms of fatigue and breathlessness and improve
exercise capacity.
Angiotensin II receptor blockers (ARBs)
This class of drug reduces renin angiotensin activity by blocking the angiotensin II receptor site.
These agents are better tolerated than ACE inhibitors but evidence for their use in heart failure is
much weaker. The CHARM- Alternative clinical trial investigated the use of candesartan in chronic
heart failure patients demonstrated that hospitalization rates as well as all-cause mortality were
reduced significantly. ARBs are usually reserved for patients who are truly intolerant to ACE
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inhibitors. The addition of an ARB can also be considered for symptomatic chronic heart failure
patients who are already taking conventional therapy. ARBs also need careful renal function
monitoring but, unlike ACE inhibitors, do not inhibit the breakdown of bradykynin and therefore
do not show signs of dry persistent cough as a side effect.
Beta-blockers
Beta-blockers are started at very low doses (e.g. bisoprolol 1.25mg) and gradually increased in
order to achieve optimization. Doses should be titrated slowly over intervals of two to three
months according to each individual patient response, aiming for a resting heart rate of 50 to 60
beats per minute. This slow up-titration is needed because heart failure symptoms may be
exacerbated during the initial period of treatment and patients need to be fully informed of this to
minimise anxiety. These symptoms may include an increase in breathlessness and ankle oedema,
will subside with time. Some patients may require adjustment in the diuretic dose to control these
symptoms. NHS Clinical Knowledge Summaries advises that “temporary deterioration occurs in 20
– 30 % of people during the titration stage. The effects of beta-blockers may take some time to
become apparent and symptoms may improve slowly over three to six months. Beta- blockers
(bisoprolol and carvedilol) demonstrate a significant reduction in heart rate and survival benefits.
NICE guidelines recommend that both ACE inhibitors and beta-blockers should be offered to all
patients with left ventricular systolic dysfunction.
Aldosterone receptor antagonists
Spironolactone and eplerenone (licensed for post-myocardial patients with heart failure) act by
blocking aldosterone, reducing water and sodium retention. The BALES trail in heart failure
patients with NYHA class III and IV demonstrated that spironolactone added to conventional
therapy reduced both frequency of hospital admission and mortality. Patients need to be
monitored for signs of renal dysfunction and gynaecomastia (latter less likely with eplerenone).
Potassium levels also need monitoring due to possible hyperkalaemia, in particular in combination
with ACE inhibitors.
Cardiac glycosides
Digoxin may be used in patients with heart failure who are still symptomatic despite optimised
conventional therapy. Trials with digoxin in heart failure have demonstrated not survival benefits
but the rate of hospitalisation of patients for heart failure was reduced. Care should be taken in
elderly patients who should be monitored carefully for signs of toxicity such as nausea, confusion
disturbance of vision and dysrhythmias.
NICE guidelines for other drugs
The decision to prescribe or continue amiodarone in patients with heart failure should be
reviewed regularly. Patients on amiodarone should be monitored every six months for side effects
as well as liver and thyroid function. Anticoagulation should be considered in patients who have a
history of thromboembolism. Low does aspirin should be prescribed if heart failure patients have
coronary artery disease.
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Lifestyle advice for patients
NICE recommends the lifestyle advice should be given to all patients with chronic heart failure.
 Strong recommendation to stop smoking and refer patients to “stop smoking” advice
 Alcohol consumption should be discussed with patients and those with alcohol related
heart failure should abstain from drinking.
 Annual influenza vaccination should be offered to all patients with heart failure.
 Once only vaccination against pneumococcal disease.
 A supervised group exercise based rehabilitation programme.
In addition www.patient.co.uk provides the following information for patients:
Diet: if you are overweight, try and lose weight to reduce the extra burden on your heart. Do not
have too much salt in your diet, as this can cause water retention. For example, do not add salt at
the table and avoid cooking with it.
Do not smoke: The chemicals in tobacco cause blood vessels to narrow (constrict) which makes
heart failure worse. You make benefit from being referred to a local stop smoking service if you
are finding it hard to stop smoking.
Exercise: For most people with heart failure, regular exercise is advised. The fitter the heart, the
better it will pump. The level of exercise to aim for will vary from person to person.
Weigh yourself each morning: Weigh yourself each morning if you have moderate to severe heart
failure. If you retain fluid, you will gain weight rapidly, so if your weight goes up by 2kg (4lbs) over
three days, you should contact a doctor, as you may need to increase your medication.
Alcohol: You should not drink too much, men should drink no more than 21 units per week (and
no more than 4 units in one day).Women should drink no more than 14 units per week (and no
more than 3 units in one day). One unit is about half a pint of normal strength beer, two-thirds of
a small pub measure of spirits.
End of notes
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Heart Failure workshop 2011
Learning scenario 1
Mrs Patel a 65 year old patient comes into your pharmacy with a new prescription for bisoprolol
2.5mg daily. You are aware that Mrs Patel had a myocardial infarction a couple of months ago and
was discharged from hospital after two weeks. She says she has had an echo and has now been
diagnosed with heart failure. Her regular repeat prescription is:
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Aspirin 75mg daily
Isosorbide mononitrate MR 60 mg every morning
Ramipril 5mg daily
Warfarin as directed on anticoagulant card
Amiodarone 100mg daily
What would be the most important counselling point for Mrs Patel and her newly diagnosed heart
failure?
A: To remember to take all her medicines in the morning
B: To ask the patient what she has been told about the benefits and possible effects on
symptoms of the new medication
C: To enquire what other tests she has had carried out
D: To remember to take the bisoprolol at a different time of day to the other medicines
Answer and rationale
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Learning Scenario 2
Mrs Patel comes back to your pharmacy two weeks later with her next repeat prescription as
follows:
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Aspirin 75mg daily
Isosorbide mononitrate MR 60 mg every morning
Bisprolol 5mg daily
Ramipril 5mg daily
Warfarin as directed on anticoagulant card
Amiodarone 100mg daily
She is feeling breathless and does not want to have the bisoprolol dispensed as she say that she
felt really ill on the medicine in the previous two weeks. She did not see the doctor when she
collected her prescription from the surgery and even she had, she would not have felt able to tell
her than she did not want to continue with the new tablets.
How would you handle Mrs Patel’s decision not to take the bisprolol?
A. Agree with her and say that she can stop taking the drug as it is making her heart failure
worse and causing increased breathlessness
B. Encourage her to persist with the medication as prescribed as it has been show to
improve survival. Reassure her that the side-effect will diminish with time
C. Ask her if it would be ok to have a discussion with her GP to make her aware of the
breathlessness at the 2.5mg dose and suggest a slower increase in dose in order to
minimise worsening of symptoms
D. Contact the prescriber while she is waiting for the prescription and explain about her
intended non-compliance
Answer and rationale
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Heart Failure workshop 2011
Learning Scenario 3
Mrs Patel enquires about her annual influenza vaccination and is worried about whether she will
still be offered it because of her diagnosed heart failure. She has also heard that she may need
another vaccination.
How would you respond to her queries?
A. Reassure her that she can continue with her annual influenza vaccination and that's the
only vaccination she needs
B. Suggest that she goes back to her GP for further advice
C. Offer to give her the flu vaccination privately as she will no longer be able to get it on the
NHS
D. Advise her that she can continue to get her annual influenza vaccination. You enquire if
she has ever had vaccination against pneumococcal infection and say that it is advisable
to have a one-off pneumococcal vaccine if she has never had it before
Answer and rationale
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Heart Failure workshop 2011
Learning Scenario 4
Mrs Nicholson is 61 years old and a regular customer in your pharmacy. Her medical history
includes ischaemic heart disease, COPD, and she was recently diagnosed with heart failure. She is
overweight at 85kg.
Her PMR includes the following:
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Aspirin 75mg daily
Bendroflumethiazide 2.5mg every morning
Spironolactone 25mg daily
Simvastatin 40mg at night
Ramipril 10mg daily
Imdur 60mg daily
Salbutamol inhaler 2 puffs qds prn
Ipratropium inhaler 2 puffs 8 hourly
Beclometasone 250microgram 2 puffs bd.
This month carvedilol 6.25mg twice daily has been added to her prescription
Which of the following statements is correct?
A. Carvedilol 6.25mg twice daily is an appropriate starting dose in heart failure
B. The GP needs to be contacted to check that the beta-blocker has been initiated by the
heart failure specialist clinic
C. Beta-blockers are contra-indicated in patients with COPD
D. There is an interaction between carvedilol and ramipril
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Heart Failure workshop 2011
Learning Scenario 5
Mrs Nicholson comes in four weeks later and asks to purchase some Gaviscon liquid. She has used
it before for heartburn and found it to be effective.
What would you do in response to this request?
A. Refuse to sell the Gaviscon because its high sodium content should be avoided by
patients with heart failure
B. Recommend an antacid with a low sodium content and counsel Susan about restricting
her sodium (salt) intake
C. Recommend an antacid with a low sodium content, counsel Susan about restricting her
sodium (salt) intake and suggest she uses a salt substitute
D. Refer Susan to her GP for further clinical assessment and advice
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Learning Scenario 6
You have got to know Mrs Nicholson well over the last few months and have regularly had
discussions about her medication. You invite her to have a MUR, during which she tells you that
her doctor has talked to her about losing weight to help with her breathlessness.
What further information could you give to Susan?
A. You want to be sympathetic and supportive but feel it would be better not to offer any
further advice about her weight as it may conflict with the monitoring and support she is
already getting from her GP and hospital specialist
B. Sell her an OTC weight loss product
C. Enquire if there has been any discussion about her being referred to a dietician for advice
and, if not, encourage her to ask for this advice from her GP or at her next hospital
appointment. Alternatively you could speak to her GP yourself.
D. Encourage her to join a local exercise class for older people at a nearby gym
End of workshop
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