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

Table 2: Similarities and differences between HF-PSF and HF-RSF

Elements

HF-PSF

HF-RSF

Epidemiology14, 16-18, 20-21

  • 50% of HF
  • 50% of HF

 
  • More likely to be female and/or elderly
  • More likely to be male

 
  • More likely to have hypertension and/or atrial fibrillation
  • More likely to have coronary heart disease

Prognosis18-22

Similar rehospitalisation, all-cause mortality and five years survival rates

Symptoms and signs5

Breathlessness, ankle swelling, fatigue, reduced exercise capacity, peripheral oedema, elevated jugular venous pressure, hepatomegaly

Diagnosis5-7

Can be diagnosed with trans-thoracic echocardiogram

Management goals5-7

i) relieve symptoms   ii) manage underlying causes and risk factors   iii) improve physical activity tolerance and quality of life  iv) reduce hospital readmissions   v) improve survival

Lifestyle interventions5-6

Fluid restriction <1.5 L/day, sodium restriction <2 gm/day and light exercise (e.g. walking for 20-30 minutes daily, 5-7 days/week)

Pharmacological management5

  • Diuretics – relieve congestive symptoms
  • Diuretics – relieve congestive symptoms

 
  • Empirical use of ACE I, ARB and β-blockers pending completion of more clinical trials
  • ACE I and β-blockers – improve symptoms and survival, and delay progression

 

 
  • ARB – for patients intolerant of ACE I

 

 
  • Aldosterone antagonists – improve survival and reduce hospitalisation

 

 
  • Digoxin – reduce hospitalisation when added to optimal medical therapy, no effect on survival

Table 3: Management recommendations for Madam YW

Case summary

Madam YW, 70-year-old lady was recently diagnosed to have HF-PSF. Her co-morbidities include metabolic syndrome (central obesity, hypertension, type 2 diabetes mellitus, dyslipidaemia), osteoarthritis, frailty and risk of depression. She has an increased HbA1c of 7.5%, TC of 6.1, LDL-C of 3.0 and TG of 2.1. Her RP, LFT and FBC were normal. This lady was discharged to her primary care physician for the up-titration of her medications and long term care. She was given a follow up appointment to be seen at a cardiology clinic in one month.

Role of primary care physician and allied health team

  • Educate Madam YW and her family regarding the diagnosis, potential complications, prognosis and self management goals.
  • Motivate her to change her lifestyle – reduce fluid intake to <1.5 L/day, reduce salt and fat intake, increase fibre intake, perform regular light exercise and reduce weight.
  • Empower her with skills to self care – chart daily weight and seek medical help if there is a change of >2 kg in her weight over 2-3 days.
  • Assess her fluid status at every follow-up – weight change, JVP, lung crackles, lying and standing BP, peripheral oedema.
  • Adjust her diuretic therapy (frusemide) according to her fluid status and kidney function (usual daily dose 20-80 mg).5-7
  • Continue combination with thiazide diuretic (hydrochlorothiazide, usual daily dose 25-50 mg) as these drugs work synergistically to improve diuresis.
  • Titrate her ACE I (perindopril) to target dose (8 mg od.) at 2-4 weekly intervals.5-7
  • Titrate her β-blocker (bisoprolol) to target dose (10 mg od.) at 2-4 weekly intervals.5-7
  • Treat blood pressure to target (<130/80 mmHg).34
  • Monitor side effects (e.g. cough due to ACE I), heart rate and rhythm (bradycardia due to β-blockers) and blood pressure (SBP <100 mmHg requires specialist referral).5
  • Monitor RP 1-2 weeks after initiation and 1-2 weeks after final dose titration (in particular potassium, urea and creatinine).5-7
  • Monitor her glycaemic control (target HbA1c <7% - acceptable in elderly) and consider insulin if glycaemic control remains poor.35
  • Titrate her HMG-CoA reductase inhibitor (simvastatin – maximum dose 80 mg od.) at 4 weekly intervals until her FSL achieve the target levels (TC<4.5, LDL-C<2.6, TG<1.7).35
  • Once targets are achieved and her condition is stable - monitor RP, HbA1c, FSL and LFT at least yearly.5-7
  • Assess adherence to medications, functional capacity, mental state, cognitive functions and nutritional status regularly.7
  • Arrange follow up visits of 2-4 weekly at the initial stage and 1-3 monthly thereafter.7
  • Arrange multidisciplinary home visits where necessary.

Problem solving5-7

  • Increasing congestion – up-titrate dose of diuretics (20 mg/kg of body weight every 3 days) and/or halve dose of β-blockers. Monitor renal function closely.
  • Marked fatigue (and/or bradycardia) - halve dose of β-blockers.
  • Low heart rate <50 beats/minute – stop or halve dose of β-blockers and arrange ECG.
  • Still hypertensive – consider changing to carvedilol (more powerful vasodilator) and/or add other antihypertensive agents (short acting nifedipine and diltiazem are contraindicated as they depress myocardial contractility).
  • Asymptomatic low BP – no change in therapy.
  • Low BP causing symptoms (e.g. dizziness) – discontinue other vasodilators. SBP <100  mmHg requires specialist referral.
  • Increase K+ >5.9 mmol/L and/or creatinine >200 µmol/L or >50% above baseline – halve dose of ACE-I and seek specialist advice.
  • Serious deterioration – seek specialist advice/referral.

Note: β-blockers should not be stopped suddenly – seek specialist advice before discontinuation.

CONCLUSION

In conclusion, long term care of CHF patients involves managing complex interplays between medical, psychosocial, and behavioural factors. This underscores the need for a multidisciplinary primary care team management which usually takes place within the broader context of an integrated chronic disease management programme. Primary care physicians must become the change agent and take a leadership role in system redesign from a grassroots’ perspective. They are ideally positioned to lead multidisciplinary primary care teams to ensure better coordination, continuity and quality of care for patients with chronic conditions. Given the rising epidemic of cardiovascular risk factors in the Malaysian population, preventive strategies at the primary care level are likely to offer the greatest promise for reducing the growing burden of CHF.

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