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Heart failure (HF) is a common condition in primary care with 1% of the population self-reporting this condition. Mortality is substantial, approaching 40% to 50% over 5 years. Heart failure is a complex syndrome in which abnormal heart function results in, or increases the subsequent risk of, clinical symptoms and signs of low cardiac output or pulmonary or systemic congestion.1 This article will present some practical tips for managing HF.2
C.C. is a 67-year-old woman with a long history of dilated cardiomyopathy and chronic atrial fibrillation (since 1992), type 2 diabetes requiring insulin (since 1994), stage 3 chronic renal insufficiency (since 2005), and gastroesophageal reflux disease. She has an extensive list of medications: 160 mg of valsartan once daily; 10 mg of ramipril once daily; 40 mg of furosemide twice daily; 0.25 mg of digoxin once daily; 20 mg of atorvastatin once daily; 30 mg of nifedipine extended release once daily; 81 mg of acetylsalicylic acid once daily; 7.5 mg of warfarin once daily; 24 units of Novolin ge NPH in the morning, 30 units at supper; 10 units of Novolin ge Toronto in the morning, 5 units at night; 1000 mg of metformin twice daily; 150 mg of ranitidine once daily; 420 mg of magnesium oxide once daily; 500 mg of calcium carbonate once daily; and 300 mg of ferrous sulfate once daily.
After 16 years of stability, her lifestyle has deteriorated, with a poor diet and cessation of her cardiac rehabilitation exercise program. During 5 hospital admissions, 5 different cardiologists suggested differing treatment regimens, modifying doses or agents in the same class. Metabolic investigations reveal poor control of her diabetes, with a glycated hemoglobin A1c of 8.1%. Results of complete blood count and electrolyte measurement are normal, but her creatinine level is 160 mmol/L (estimated creatinine clearance 40 mL/min). Cardiac investigations reveal new triple-vessel coronary artery disease. She declines revascularization and wishes to be treated medically. Her atrial fibrillation is well controlled. Echocardiography shows systolic dysfunction with an ejection fraction between 18% and 28%. The cardiothoracic surgeon indicates that cardiac pacing or an implanted cardioverter defibrillator are not options for C.C. Her treatment is challenged by the family medicine resident who questions potential inconsistencies between her treatment regimen and HF management guidelines. The patient’s understanding of her condition is inadequate for her to comply effectively with lifestyle changes, and communication among her caregivers has been inadequate, given the complexity of her case.
The management algorithm for chronic HF is summarized in Figure 1.2 Both aggressive use of medication to target doses and patient education are required for effective management of HF1; however, the foundation for all HF therapy includes nonpharmacologic management (Box 1).2
Data from Jin et al.2
Dietary, lifestyle, and over-the-counter nonsteroidal anti-inflammatory drug indiscretions are common sources of HF exacerbations.2,3 Lifestyle measures facilitate HF management. Communicating information about exercise and salt and fluid intake to patients is essential for optimal management.
Diuretics are useful in providing symptom relief, especially acutely, but do not prevent long-term mortality.3 Overreliance on diuretics often results in hypotension and electrolyte abnormalities, limiting the use of other agents that reduce mortality.
Other agents can help if symptoms persist after maximizing the most beneficial agents.
While patient dietary indiscretions often occur, we must also be aware of prescriber indiscretions that can exacerbate HF. Specifically, medications such as nonsteroidal anti-inflammatory drugs, antiarrhythmic agents, diltiazem, verapamil, stimulants, glitazones, corticosteroids, tumor necrosis factor blockers, and numerous cancer chemotherapeutic agents are implicated.1,3
Steps are taken to improve C.C.’s treatment regimen. The first step is communication with her HF clinic physician, who agrees to be the primary consultant for cardiac therapy changes. She participates in an intense educational program on HF. In the year after her therapy is changed, C.C. avoids any admission to the hospital for HF. Her medications are adjusted and better reflect the evidence-based treatment guidelines: 10 mg of ramipril once daily; 10 mg of bisoprolol once daily; 0.125 mg of digoxin once daily; 25 mg of spironolactone once daily; 80 mg of furosemide twice daily; 2.5 mg of metolazone on Monday, Wednesday, and Friday; 420 mg of magnesium oxide once daily; 60 mg of isosorbide mononitrate at bedtime; 600 mg of Slow K once daily; 5 mg of warfarin once daily; 40 mg of atorvastatin once daily; 81 mg of acetylsalicylic acid once daily; 40 units of Novolin ge NPH twice daily; 24 units of Novolin ge Toronto 3 times daily; 20 mg of rabeprazole once daily; 1000 IU of vitamin D once daily; 300 mg of ferrous sulfate once daily; and 500 mg of calcium carbonate once daily. Metformin, which had been held during periods of acute congestion, was restarted at 500 mg twice daily, in line with current recommendations.3
Important concepts in management of chronic HF are summarized in Box 2.2 Educating patients on lifestyle measures supports medication management. Ensuring patients approach the maximal tolerated target doses for ACEIs and BBs improves mortality and morbidity. Adhering to the targets of treatment, combined with patient education and communication between family physicians, cardiologists, pharmacists, and dietitians, will lessen the burden of this disease on patients, caregivers, and the health care system.
ACEI—angiotensin-converting enzyme inhibitor, ARB—angiotensin receptor blocker BB—β-blocker, HF—heart failure.
Data from Jin et al.2
RxFiles is an academic detailing program providing objective comparative drug information. RxFiles incorporates information from family physicians, other specialists, and pharmacists with an extensive review of the literature to produce newsletters, question-and-answer summaries, trial summaries, and drug comparison charts. The RxFiles Drug Comparison Charts book and website have become practical tools for evidence-based and clinically relevant drug use information throughout Canada. For more information, go to www.RxFiles.ca.
*The full version of the RxFiles heart failure overview and treatment chart is available at www.cfp.ca. Go to the full text of the article online, then click on CFPlus in the menu at the top right-hand side of the page.
RxFiles and contributing authors do not have any commercial competing interests. RxFiles Academic Detailing Program is funded through a grant from Saskatchewan Health to Saskatoon Health Region; additional “not for profit; not for loss” revenue is obtained from sales of books and online subscriptions.