Essay: Management of a patient with Heart Failure

The Author intends to identify and discuss best evidence regarding the management of a patient with Heart Failure (HF). After reviewing this evidence the Author will reflect on how subsequent approaches to management of HF will be affected and influenced in accordance with best practice. This essay will consider the case of a 94 year old female, with a confirmed diagnosis of HF, who is having her condition managed by the Author in the community and without the specialist input of the Heart Failure Nursing Team. The Author works within a General Practice (GP) Team and is a registered healthcare professional with the Health and Care Professions Council (HCPC) and will maintain the patient’s confidentiality throughout this essay in accordance with the HCPC Standards of conduct, performance and ethics (Health & Care Professions Council, 2016). The patient will therefore be referred to as Patient X from this point forward. Patient X has been assessed as having capacity to make autonomous decisions regarding her healthcare in accordance with the Mental Capacity Act (Department of Health, 2005) and is fully involved in any decision making regarding management of her condition.
The face of the National Health Service (NHS) is changing as are patient population groups and this can be seen both nationally and locally. In 2014 the NHS Five Year Forward View highlighted the need to address healthcare for an ageing population, including the prevention and management of Long Term health Conditions (LTC) (NHS England, 2014). The more recent NHS Long Term Plan expands on this and specifically refers to an increasing ageing population often living with multiple LTCs; it goes on to highlight that these patients will need to be managed differently to encourage independence and empowerment, often within the community setting (The NHS Long Term Plan, 2019). Data available within the Author’s local area supports this ageing trend having a higher level of patients aged over 65yrs than both the County and National average. In addition it also advocates self help, health promotion, education and joined up care as being integral to managing this group of patients in the future (South Derbyshire Clinical Commissioning Group, 2015). Other companies such as The Health Foundation also recognise the need for the heath care system to work effectively to support an ageing population often with complex health needs (The Health Foundation, 2019) and organisations such as National Voices advocate for person centred care (National Voices, 2019). Reports such as the Marmot Review identifies apparent health inequalities in England and makes recommendations to reduce these with a key objective being to enable all individuals to maximise their capabilities and have control over their lives (Strategic Review of Health Inequalities in England post-2010 (SRHIE), 2010). A recent report in to Multimorbidity, whereby patients live with two or more LTCs also suggests the need to alter the way in which these patients are managed with a shift from simply focusing on their clinical condition(s) to appreciating their lived experience of that condition(s) and how it affects their daily lives (The Richmond Group of Charities, 2018). Companies such as Nesta are also working in partnership with The Department of Health and NHS England, for example, to both offer support making it possible for people to have more involvement in their health and also to ensure that digital technology is in place to underpin this goal. They recognise that the population is living with more LTC and that changes need to be made to make the current health care system sustainable (Nesta, 2019).
Cardiovascular disease is an umbrella term encompassing all diseases of the heart and circulatory system of which HF is one. The British Heart Foundation (2018) states that within the United Kingdom (UK) in excess of 580,000 patients are registered on their GP record as having HF but estimates that the figure is nearer 920,000. 2017/18 data shows a Quality and Outcomes Framework (QOF) prevalence for Heart Failure at the local GP surgery of 1.2% compared to a figure of 0.8% for England (Public Health England, 2018). Data shows a relatively static figure for England since 2009/10 but confirms an upward trend for the local area (Public Health England, 2019). What is not clear from the available data is whether this rising trend in HF prevalence is related to an increasing ageing population, better diagnosis, or a number of inter-relating factors.
HF is a condition where, broadly speaking, the heart is unable to pump enough blood around the body to meet it’s needs due to heart muscle damage. The reasons for this are variable and include the inability of the heart to pump enough blood to the lungs (right sided heart failure); the inability of the heart to pump sufficient oxygenated blood around the body (left sided heart failure); or a combination of both leading to a generalised term of congestive heart failure to be used (National Lung, Heart and Blood Institute, n.k.). The National Institute for Health and Care Excellence (NICE) further distinguishes between Chronic and Acute presentations giving advice for diagnosis and management of both (NICE, 2019). Patients presenting with a particular set of symptoms such as shortness of breath or lower limb oedema may be assessed or investigated for HF. Park, Moser, Griffith, Harring and Johantgen (2019) agree that dyspnoea; particularly on exertion, peripheral oedema and fatigue are common reported symptoms in HF patients but also states that patients may often experience multiple symptoms. They go on to suggest that recognising concurring symptoms or symptom clusters may help diagnose and manage patients more effectively rather than dealing with symptoms in isolation. A study by Sharifi, Rezaei, Khayat and Mohammadinia (2018) discusses how patient and care giver perceptions with regards to the frequency and severity of symptoms may vary but again highlight dyspnoea on exertion and/or at rest, and peripheral oedema as being amongst the highest ranking. If the Author reflects on their own clinical practice it is certainly these presenting symptoms which give rise to considering HF as an initial differential diagnoses in a newly presenting patient, or as a worsening of symptom control in the already diagnosed HF patient, such as Patient X.
NICE (2014) recommends taking a detailed history, clinical examination and tests such as an Electrocardiogram (ECG), chest xray and bloods as a means of helping to diagnose both acute and chronic HF. In both instances a measurement of serum natriuretic peptides; either B-type natriuretic peptide (BNP) or N-terminal pro-B-type natriuretic peptide (NT-proBNP) should be used to aid diagnosis (NICE, 2014). In accordance with the Author’s local procedures it is the NT-proBNP that is measured with a value of <300 ng/litre ruling out a diagnosis of heart failure in an acute presentation. For chronic HF a value in excess of >400ng/litre is considered raised with >2000ng/litre being significantly raised and carrying a poor prognosis (University Hospitals of Derby and Burton NHS Foundation Trust, 2017). These cut off points are also recommended by NICE (NICE, 2014 & NICE, 2018). SIGN (2016) concurs that a diagnosis using a set of symptoms alone is problematic and therefore early investigations are essential to confirm diagnosis including a measurement of serum natriuretic peptides to help decide if echocardiography is required or not; and if so how soon specialist assessment should be sought. Whilst these thresholds are widely recognised as being a reliable indication of when to refer on to Secondary care several other studies have questioned this. Taylor et al. (2016) used a set of pre-determined clinical decision rules (CDRs) along with a measurement of NT-proBNP to identify patients likely to have HF. This diagnosis was then confirmed (or not) by echocardiography. They found that CDRs, in isolation, were not helpful and additionally that a HF diagnosis was confirmed in 77% of patients with an NT-proBNP >400ng/litre compared to 94% using a lower threshold of 125ng/litre. They therefore concluded that with the current threshold advised by NICE perhaps 1 in 5 patients may be misdiagnosed. This lower threshold is also recommended in the European Society of Cardiology (ESC) guidelines (Ponikowski et al, 2016). Other studies such as Verdu et al. (2012) similarly conclude that a lower threshold may be more appropriate but Taylor et al. (2018), who conducted a systematic review of the available literature concluded that B-type natriuretic peptide has variable ability to exclude chronic heart failure in patients. They therefore suggest that all positive results should be confirmed by cardiac imaging and an appropriate follow up. They also identified that more studies were required in the Primary Care setting where data was lacking.
NICE, SIGN and ESC guidelines all recommend the use of cardiac imaging to definitively diagnose HF with ESC guidelines stating that imaging is central to achieving a diagnosis (NICE, 2018; SIGN, 2016, Ponikowski et al., 2016). SIGN (2016) guidelines highlight how imaging, which is relatively cheap, helps to establish the underlying cause for the HF. For example, left ventricular systolic function (LVEF) and an estimation of pulmonary artery systolic pressure can both be measured, along with detection of any significant valve disease. Ponikowski et al. (2016) goes on to point out that imaging should only be performed when there is an expected meaningful clinical consequence. This is something that the Author considers within the scope of their day to day practice. The Author often assesses frail, elderly patients with multiple co-morbidities who may present with symptoms of HF. In conjunction with these individuals, and at times, with their families discussions take place to determine an appropriate level of investigations dependent on their wishes and expectations. The Author has certainly concluded on occasions that a diagnosis of HF is likely based on the clinical picture and a raised NT-proBNP blood result, but has stopped short of referring in to Secondary care for an echocardiogram. This decision has been taken for multiple reasons such as patient wishes, the ability of the patient to tolerate the imaging and whether or not the results of the test would significantly alter management of the symptoms.
Management of chronic HF is guided by the aetiology of the condition so at initial diagnoses a specialist multi disciplinary team (MDT) consultation should be offered to the patient to discuss their specific diagnosis, prognosis, treatment options and any other concerns they may have (NICE, 2018). Pharmacological management of HF involves the use of diuretics to alleviate symptoms of congestion and oedema with doses being titrated up and down to achieve optimum results (NICE, 2018 sign and european too??). Thiazides such as bendroflumethiazide or loop diuretics, for example, furosemide may be used; in some cases where there is resistant oedema, combined diuretic therapy may be indicated (NICE, 2019). Commonly used diuretics such as Furosemide actively transport sodium out of the cells leading to a subsequent increase in water excretion in order to maintain the osmotic balance (Neal, 2015). Hypokalaemia and hyponatraemia may occur (Joint Formulary Committee, 2017) therefore it is necessary for kidney function to be monitored with a regular urea and electrolyte blood test (NICE, 2018). Braunwald (2014) supports the view that in patients with chronic HF diuretics can successfully reduce symptoms of dyspnoea and fluid retention but they do not necessarily extend survival in this patient group. Vaduganathan, Kumar, Voors & Butler (2015) discuss diuretic resistance in clinical practice and link a reduced diuretic response with poorer patient outcome but go on to conclude that there is no current standardisation or definition as to what a ‘poor diuretic response’ looks like with measurements of weight increase and urine output being unreliable. Braunwald (2014) states that this resistance is often associated with repeated diuretic use agreeing that it leads to poorer outcomes but goes on to state that more research is required to determine whether the resistance is simply an indicator of future adverse clinical outcome or an actual cause of it. Decompensation and fluid retention often lead to hospital admissions for intravenous (IV) diuretics when oral therapy has become ineffective. Quinn and Read (2014) explored the potential benefits of developing a safe and effective service to deliver IV diuretics in the community with a view to reducing hospital admissions and achieving an improved patient experience. They concluded that a small pilot scheme had had positive outcomes for both the patient and carers but highlighted significant limitations such as a lack of an out of hours service, problems recruiting suitable patients due to stringent selection criteria. Additionally cost effectiveness required further evaluation as whilst hospital admissions were reduced the demand on the local community HF nursing team was significantly increased.
In HF patients with reduced ejection fraction first line treatment is to offer an angiotensin-converting enzyme (ACE) inhibitor and a beta-blocker (which is licensed for use in HF) starting at a low dose and titrating upwards ensuring that blood pressure and kidney function is regularly monitored (NICE, 2018). Introduction of a beta-blocker should be gradual with regular pulse and blood pressure checks taking place until optimum tolerated therapy is achieved (NICE, 2018). Doses may need reviewing and adjusting in patients with Chronic Kidney Disease (CKD) and in patients with an eGFR below 30ml/min/1.73m2 liaison with a renal specialist may be required; in any case patients with existing CKD will require close monitoring due to an increased risk of hyperkalaemia (NICE, 2018). Cole et al. (2014) discuss how the addition of an aldosterone antagonist, in conjunction with both an ACE inhibitor and a beta-blocker; known as Triple Therapy may improve life expectancy but raise concerns that Clinicians tend to focus on the perceived risks of such therapies, rather than the benefits. Horwich, Smooke, Hamilton and Fonarow (2003) state that beta-blockers, ACE inhibitors and aldosterone antagonists all play an important individual role in managing HF but identify that effectiveness of combining these three medications has yet to be fully evaluated in clinical trials. They concluded after completing their own small trial that the combination of these three medications provided benefits and improved survival. This opinion is again confirmed by Werner, Poss and Bohm (2010) which cite two larger trials RALES (Randomized Aldactone Evaluation Study) (Pitt et al., 1999) and EPHESUS (Pitt et al., 2003) which concluded that the addition of an aldosterone antagonist was beneficial, reducing both morbidity and mortality. In fact many papers raise the same point but the Author struggled to find information as to why such therapy is not routinely implemented or recommended in management guidelines; instead it is only offered as an additional recommendation to treat patients with persistent symptoms of heart failure (NICE, 2018 and SIGN, 2016).
When reflecting on their own practice the Author recognises that pharmacological management of LTCs is not the only avenue which needs to be explored with the patient to achieve good symptom control and improve outcomes. Social prescribing and referral of patients to other non-clinical services recognises that supporting a patient’s social, emotional or practical needs can greatly benefit the individual and enable them to take greater control over their own health (The King’s Fund, 2019). This view is supported by Mendes (2018) who agrees non-pharmacological approaches also have an important role to play. Other factors such as education, rehabilitation and self-management strategies need to be explored along with the patient’s general well-being. Self-management aims to reduce symptoms, slow disease progression and thereby improve overall quality of life but most patients will require support in making lifestyle changes in addition to encouragement to engage in self-management activities (Barley & Lawson, 2016). Supporting such self-management requires education, motivation and empowerment of the patient and can take many forms, for example, provision of written materials, attendance at peer support groups or one to one counselling (De Silva, 2011). However, De Silva (2011) goes on to suggest that providing information alone is unlikely to be enough to promote behaviour or lifestyle changes therefore more pro-active behavioural interventions may be required to promote the necessary change. Motivational Interviewing (MI) is now widely recognised as an appropriate counselling technique that can be used to positively impact on lifestyle changes by helping to determine what motivates the patient to make those changes (Soderlund, Madson, Rubak & Nilsen, 2011). Miller, Foran-Tuller, Ledergerber and Jandorf (2017) explain that MI is a patient centred approach enabling individuals to acknowledge and deal with any ambivalence they may have to the proposed change be it lifestyle or otherwise. Soderlund et al. (2011) conclude that MI does help to build patient motivation and results in improved communication and more favourable outcomes but acknowledges that more research is required with regards to how Clinicians are trained to use and deliver such techniques. They also identify time restrictions in busy healthcare settings and the complexity of learning the required techniques as potential barriers to success. Day (2018) takes this one step further stating that mental health is inextricably linked to physical health with depression being two to three times more prevalent in patients with a LTC. Day (2018) suggests that both mindfulness and cognitive behavioural therapy (CBT) can help with the psychological care in this group of patients.
The NHS Long Term Plan underpins the need to focus on person-centred care; that is care tailored to the individual, in addition to engagement of the patient in any decision making process (NHS, 2019). This fosters a relationship between patient and clinician which is based on a shared responsibility for health (NHS, 2019). Empowerment can be defined as “the process of gaining freedom and power to do what you want or to control what happens to you” (Cambridge University Press, 2019). In terms of healthcare provision the empowered patient will use a variety of resources to seek information with regards to the effective management of their LTC and the healthcare professional involved should be on hand to support this process of empowerment (Mendes, 2018). The King’s Fund (2015) states that both the empowerment of, and the active engagement of patients, underpins the priorities for action to help develop and deliver a sustainable healthcare system going forward and is therefore essential. The Expert Patients Programme (EPP) is an example of a self-management programme. Here, the emphasis is placed on developing the individual’s confidence and self-efficacy to enable them to control the day to day management of their health condition, rather than just providing them with education materials, or simply telling them what they need to do (Kurien, 2014). Barley and Lawson (2016) discuss the importance of ‘self-efficacy’; the patient’s confidence and ability to manage a specific situation effectively, and highlight how improvements in self-efficacy correlate with improvements in patient attitudes, behaviours, quality of life and appropriate use of healthcare services. Healthcare professionals need to view the patient / clinician relationship as a partnership to harness the patient’s assets to achieve a common goal, rather than focus on their deficits which only reinforces dependency (Morgan et al., 2017). Birtwistle et al. (2019) identifies ‘the motivation to do something’ as being an intrapersonal factor; one that influences behaviour change. Kurien (2014) discusses the idea of motivation and that it needs to be present so that people are able to utilise their existing skills and abilities to take on board new information enabling them to engage in learning new skills. In a study by Marcinko (2015) the complicated link between motivation, well-being and physical health was considered and results suggested that the higher the degree of self-determination, and the greater the levels of well-being, the more positive the impact on physical health. Those with low self-determination had poorer physical health in comparison. Initiatives such as the ‘Realising the Value’ campaign aims to support people to have the knowledge, skills and confidence to take control of their health but recognises that this also requires a wider shift culturally and in terms of behaviour for any change to be meaningful (Nesta, 2016). An earlier study by Hewitt-Taylor (2004) looked at patient empowerment and how this may be achieved; it was noted that power can not simply be handed over to the patient as problems arise an example being the Clinician being reluctant to give up the power. In a more recent study by Ross et al. (2014) it was suggested that patients want to be involved and take on more responsibility in relation to their care and despite Health Professionals being generally supportive of this they often raise concerns about the legal implications should something go wrong. Further difficulties were also raised by Nafradi, Nakamoto and Schulz (2017) who looked at the link between self-efficacy and medication adherence. They suggested that this is an area where patient empowerment may have a negative effect on outcomes with highly empowered patients often believing that they can ignore the Clinician’s advice leading to potential non-compliance with regards to their medications. It is therefore clear that this process of empowerment and achieving successful self-management is multi-factoral and complex with various barriers that need to be overcome to achieve success.