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MANAGEMENT OF CHRONIC HEART FAILURE IN PRIMARY CARE: WHAT EVIDENCE DO WE HAVE FOR HEART FAILURE WITH PRESERVED SYSTOLIC FUNCTION?

Management goals and lifestyle interventions

In principal, management goals for HF-PSF are similar to those with HF-RSF. The goals are to i) relieve symptoms ii) manage underlying causes and risk factors iii) improve physical activity tolerance and quality of life iv) reduce hospital readmissions and v) improve survival.^5,6 Lifestyle and behavioural modification are pivotal to the successful management of CHF. Therefore, patients and their families should be educated and counselled regarding the diagnosis, potential complications, prognosis and management goals; and be empowered with skills to self care.^5,6

Management of congestive symptoms should be directed at achieving euvolaemia with diuretics, fluid restriction of <1.5 L/day and sodium restriction <2 gm/day (translated to no added salt to food or cooking).^5,6 It is important to note however, that over-diuresis with diuretic therapy can cause intravascular contraction and deterioration of renal function. Therefore, patients with CHF should be educated and empowered with skills to manage and monitor their volaemic state e.g. by daily weighing and flexible titration of diuretic regimen.⁶ They need to seek medical help if there is a change of more than 2 kg in weight over two to three days.^5,6

Regular physical activity has also been shown to be highly beneficial in patients with CHF.^5,6 It should be tailored to the individual’s capacity, and this may include light exercise such as walking for 20-30 minutes daily, five to seven days per week.^5,6 Participation in a supervised group exercise programme offers the opportunity of additional socialisation, support and education.⁶

Pharmacological management

While the evidence to support pharmacological treatment of HF-RSF is now well established, the enigma surrounding therapeutic options for HF-PSF is continuing. The survival rates of patients with HF-PSF remain unaltered over time as opposed to those with HF-RSF,  despite frequent use of similar pharmacological agents.¹⁸ The CHARM-Preserved trial, which randomised 3,023 patients with HF-PSF to either candesartan or placebo, failed to demonstrate significant effect on cardiovascular mortality, but there were significantly fewer hospital readmissions in the candesartan group.²⁶ The PEP-CHP study showed no difference in mortality and HF hospitalisations when perindopril was compared to placebo in elderly individuals (>70 years) with HF-PSF.²⁷ The I-PRESERVE trial also showed no improvement in mortality and hospitalisation rates when irbesartan was compared to placebo.²⁸ A recent review which summarised all the major outcome trials involving patients with HF-PSF to date concluded that these trials had excessively recruited HF patients with eccentric LV remodelling and ischaemic heart disease compared to patients with concentric LV remodelling and hypertension.²⁹ More clinical trials which adhere to diagnostic guidelines for HF-PSF are needed to form an evidence-based therapeutic decision. Pending completion of these trials, treatment for HF-PSF remains largely empirical with many guidelines recommending the use of similar pharmacological agents as used for HF-RSF.^5,6

In the case of Madam YW, it is important to note that her β-blocker and ACE-Inhibitor (ACE-I) require an up-titration to optimal dose following discharge. An international survey showed that primary care physicians prescribed ACE-I at 50% of the target doses suggested by guidelines and were generally reluctant to use β-blockers in CHF patients.³⁰ Using a guideline-based computerised decision support system was shown to have an impact on primary care physicians’ confidence in the diagnosis and management of CHF.³¹ It is also important to note that her NSAID has been discontinued, as it can cause fluid retention, renal dysfunction and vasoconstriction.⁵

Management of risk factors

Since the evidence-base to support pharmacological management of HF-PSF is not yet established, identifying the underlying cause and aggressive management of risk factors has become the primary focus.^5,6 Hypertension plays a central role in the pathophysiology of HF-PSF.³² In the case of Madam YW, it is clear that her long history of uncontrolled hypertension has induced compensatory hypertrophy of her left ventricular wall (LVH), which in turn contributed to the HF-PSF. Severe uncontrolled hypertension is also a common precipitator for acute cardiac decompensation.³² Treating hypertension to target level has been shown to reduce the incidence of CHF by as much as 50%.³³ Therefore, it is absolutely vital that her blood pressure, lipid level, glycaemic control and weight are managed according to guidelines’ recommendations.^34,35 Antihypertensive agents such as ACE-I or ARB which has been shown to be beneficial in promoting LVH regression should be used.^5,6 ACE-I is also the first line agent of choice recommended for treating hypertensive patients with type 2 diabetes without proteinuria.^34,35

Addressing medication adherence

Madam YW also admitted to have poor adherence to her medications and follow up appointments prior to her hospital admissions. With the additional morbidity of having CHF, this lady is now on polypharmacy of ten different medications. Only 50% of patients with chronic diseases have been reported to adhere to their medications.³⁶ Non-adherence significantly contributes to increasing morbidity and mortality, as well as wastage of health care resources.³⁷ A Cochrane systematic review shows that interventions which were effective in improving medication adherence for long term care were complex and multifaceted; including combinations of more convenient care, information, reminders, self-monitoring, reinforcement, counselling, family therapy, psychological therapy, crisis intervention, manual telephone follow up, and supportive care.³⁸

Bridging the gap in long term heart failure management in the community

In summary, this case illustrates the complex interplay between medical, psychosocial, and behavioural factors in the management of patients with CHF. This underscores the need for a comprehensive health care delivery in long term management of these patients in the community.

There is now substantial evidence that multidisciplinary strategies in CHF management reduce HF hospitalisation, improve quality of life and save costs.^39-42 A systematic review suggests that patient education to enhance self care, follow up monitoring by specially trained staff, and access to specialised HF clinics are the most efficacious approaches.³⁹ Strategies which employed telephone contact and advised patients to attend their primary care physicians in the event of deterioration were shown to reduce hospitalisations.³⁹ Home visits by pharmacist are pertinent in optimising medication adherence,⁴³ and the inclusion of a pharmacist in the multidisciplinary team has been shown to reduce HF hospitalisation.⁴⁴ Multidisciplinary care teams, centred on primary care, are highly effective in improving coordination of care, disease control and health outcomes.⁴⁵ Therefore, long term care of CHF patients in the community warrants a multidisciplinary team management involving primary care physician, nurse, pharmacist, physiotherapist and psychologist; and it must be well supported by the secondary care services.^7,46

In primary care, multidisciplinary management of CHF usually takes place within the broader context of an integrated chronic disease management. Numerous models of care have been developed and the most notable is the Chronic Care Model (CCM).⁴⁷ Primary care practice redesigned in accordance with the CCM has been shown to improve the quality of care and outcomes for patients with various chronic conditions.^48,49

However, chronic disease management in the Malaysian primary care settings, be it in the public or private sector; is still largely being done in a sporadic, unplanned and uncoordinated manner.⁵⁰ There is an urgent need to address this issue, and the CCM provides a useful framework for the restructuring of healthcare delivery across all levels of service provision.⁵¹ The recently announced proposal by the Malaysian government to establish a national health financing scheme which will integrate all public and private primary care clinics under a common network of care, offers the promise of better coordination and quality of care for chronic conditions.⁵²

In response to this, Malaysia has now produced more than 400 highly trained specialist primary care physicians, who are in an ideal position to champion patient-centred chronic disease care and take a leadership role in system redesign from a grassroots’ perspective. These numbers, however, are far from adequate. Imperative measures are currently being undertaken by the public universities and the Academy of Family Physicians Malaysia (AFPM) to produce more primary care/family medicine specialists in order to meet the country’s demand. Availability of highly trained allied health personnel is also critical to support the deployment of multidisciplinary teams in primary care. There must be a constant endeavour to increase the numbers of highly skilled nurses, pharmacists, dieticians, physiotherapists, psychologists and other allied health personnel to deal with the challenge of managing chronic conditions. Primary care physicians must ultimately become the agent of change and lead multidisciplinary primary care teams to ensure that better coordination, continuity and quality of care is delivered for patients with chronic disease across time and settings.

A case for prevention

The incidence of CHF is likely to escalate in the Malaysian population as hypertension, type 2 diabetes and coronary heart disease remain the most common risk factors. The prevalence rates for hypertension and diabetes in Malaysian adults >30 years are reaching epidemic proportion at 42.6% and 14.9% respectively.⁵³ The overall control rates for both conditions however, have remained alarmingly poor over the past 20 years,⁵³ despite the existence of succinct clinical practice guidelines and improved availability of pharmacological agents in primary care. If this trend continues, Malaysia would not be able to cope with the impending burden of treating complications of these conditions; which is already causing strain to its health system. Preventive strategies at the primary care level, directed towards an early and aggressive management of cardiovascular risk factors, effective patient education and lifestyle change, improved prescribing habits; and efficient delivery of multidisciplinary care, are likely to offer the greatest promise for reducing the burden of HF morbidity and mortality.

Summary and recommendations

This case illustrates a common presentation of HF-PSF in primary care. While its epidemiology, pathophysiology and prognosis are well established, the enigma surrounding its therapeutic options is continuing. Table 2 summarises the similarities and the differences between HF-PSF and HF-RSF, while Table 3 summarises the management recommendations for Madam YW.