Heart Matters: Practical Approaches to Heart Failure Management for Pharmacists
For patients, living with Chronic Heart Failure (CHF) can have a significant impact on quality of life – everyday activities like showering, walking or doing the groceries can be exhausting, as the weakened heart muscle leaves patients fatigued and short of breath. Around 300,000 Australians are living with heart failure and every year approximately 30,000 more are diagnosed1. Pharmacists are ideally placed to provide practical support to patients with CHF, particularly around optimal management of their medications and providing support and advice to patients in managing the daily challenges associated with the disease.
CHF is a complex clinical syndrome that is often characterized by an underlying structural abnormality or dysfunction that impairs the ability of the left ventricle (LV) to fill with or eject blood, most particularly during physical activity1. CHF can be classified as1;
- Systolic heart failure: A weakened ability of the heart to contract (this is the most common form of CHF)
- Heart failure with preserved systolic function (HFPSF): Also known as ‘diastolic heart failure’, impaired filling of the LV of the heart in response to a volume load – despite regular ventricular contractions
Both systolic heart failure and HFPSF can occur together, with the Left Ventricular Ejection Fraction (LVEF) being a clinical distinguisher between the two. The symptoms of CHF can vary according to classification and the extent to which each ventricle (left or right) is affected. As the LV is the major chamber of the heart responsible for pumping blood around the body, when the left chamber fails it causes blood to back up in the left atrium and into the lungs1. This congestion often causes the shortness of breath and orthopnoea (shortness of breath when lying flat) that patient’s experience. Other common symptoms that patients experience with CHF include1;
- Cough (at night predominately)
- Swollen legs/ankles
- Painful/swollen abdomen
Patterns of prevalence for CHF show that incidence is markedly higher with age, affecting approximately 1% of Australians aged 50-59, 10% in over 65’s and over 50% in people aged 85 years or older2.
Table 1 below summarises the main contributing factors to both systolic heart failure and HFPSF.
There are a range of effective strategies to support patients with CHF, both prolonging and improving their quality of life. Management can include best-practice pharmacological interventions, non-pharmacological strategies and surgical procedures. The key management goals of CHF include1;
- Preventing CHF in people at risk and detecting asymptomatic LV dysfunction early
- Relieve symptoms and improve quality of life
- Slow disease progression and prolong survival
- Improve physical activity tolerance
- Reduce hospital admissions
There is limited clinical evidence to guide the management of HFPSF, with aims of therapy focusing on managing the underlying causes (eg. strict BP and glycaemic control) and preventing LV hypertrophy1.
Ace Inhibitors (ACEi): ACEIs have been shown to delay development of symptomatic CHF in patients with asymptomatic LV dysfunction, as well as those without known ventricular dysfunction4. Additionally, ACEis have been shown to improve symptom status and physical activity whilst reducing the need for hospitalisation in worsening CHF5. ACEis form the corner stone of treatment in CHF Doses should be titrated to the maximum tolerated dose to get the maximum benefit4.
Angiotensin II Receptor Antagonists: An overview of studies comparing the use of ACEIs and angiotensin II receptor antagonists in heart failure shows similar outcomes6. Angiotensin II receptor antagonists are recommended as an alternative for patients who experience ACEi-related adverse effects (such as cough)1.
Beta Blockers: beta-blockers inhibit the adverse effects of chronic activation of the sympathetic nervous system acting on the myocardium6. They can prolong survival in patients already receiving an ACEi and symptomatic benefits are also observed with beta blockers as the disease become more advanced6.
Diuretics: Chronic diuretic therapy has not been shown to improve survival and should be reserved for symptom control only1. Combination therapy of an ACEI and a diuretic is usually necessary, as an ACEI is often unlikely to provide adequate relief from congestive symptoms1. Diuretics increase urine sodium excretion and can decrease the physical signs of fluid retention, significantly improving symptom status. In fluid overloaded patients, a loop diuretic is usually used to increase urine output and reduce weight volume to achieve clinical euvolaemia (the presence of the proper amount of blood in the body)1.
AldosteroneAantagonists: Aldosterone receptors within the heart can mediate fibrosis, hypertrophy and arrhythmogenesis. Therefore, blockade of these receptors with agents such as spironolactone may provide benefit7.
Digoxin: Digoxin inhibits sodium–potassium ATPase, blockade of this enzyme has been associated with improved inotropic responsiveness in patients with ventricular dysfunction. Digoxin may also sensitise cardiopulmonary baroreceptors, reduce central sympathetic outflow, increase vagal activity and reduce renin secretion8.
Other Agents: Iron deficiency can be quite common in CHF, treatment of iron deficiency may improve exercise tolerance9. Hydralazine and isosorbide mononitrate may be used in patients who are truly intolerant of both ACEis and angiotensin II receptor antagonists10. Calcium channel blockers (particularly non-dihydropyridine type) may be used to treat co-morbidities such as hypertension in CHD patients with systolic CHF11.
Drugs to Avoid in CHF
There are a number of commonly prescribed medications which may cause exacerbation of CHF and should be avoided, these include1;
- Anti-arrythmic agents (other than beta-blockers and amiodarone): May increase risk of ventricular arrythmias
- Non-dihydropyridine calcium channel blockers (verapamil, diltiazem): Negative inotropic effect may depress cardiac function
- Non-steroidal anti-inflammatory drugs (NSAIDs) and Cox-2 inhibitors: May cause sodium and water retention, increase the risk of acute renal failure and increase risk of myocardial infarction
- Tricyclic antidepressants: May prolong QT Interval
- Corticosteroids: May cause sodium and water retention
- Thiazolidinedinones (pioglitazone, rosiglitazone): May cause fluid retention and heart failure by increasing renal sodium reabsorption
- Clozapine: May cause cardiomyopathy and myocarditis
Non Pharmacological Management
Non-pharmacological management in CHF can be just as important as prescribing of appropriate medications. There is strong evidence supporting the benefits of regular physical activity, exercise programs and cardiac rehab in people with CHF. All patients should be referred to a specifically designed physical activity program if possiblespan >12.
Additionally, patients should be educated to monitor and control their fluid balance with CHF. Encouraging patients to limit their sodium intake to less than 2g/day and limit fluid intake to less than 2L/day (or 1.5L/day in severe CHF) is recommendedspan 1. Patients may have an action plan for fluid management and how to self-adjust diuretics when needed.
Due to relative gastrointestinal hypoperfusion, constipation is common and a high-fibre diet is recommended, this will avoid straining at stool, a situation that may provoke angina, dyspnoea or arrhythmiaspan >1. Additionally, a diet low in saturated fats is recommended for all patients who suffer from CHF.
Patient’s should be encouraged to cease smoking (through the use of smoking cessation aids if needed), minimise alcohol intake (should not exceed 1-2 standard drinks per day) and limit caffeine intake to 1-2 cups of caffeinated beverage per dayspan 1.
Supporting Patients in community pharmacy
Providing support for patients with CHF and their carers is an important aspect of overall CHF management. Community pharmacists are well placed to provide education and support to patients through raising awareness and encouraging an understanding of the basic CHF management principles, including recognizing the signs of deterioration and monitoring daily symptoms. Achieve the best in supporting your patients with CHF in community pharmacy by;
- Supporting patients in adopting a healthier lifestyle and taking part in regular physical activity to address the factors/conditions which may contribute to or worsen CHF.
- Help patients understand the effects of CHF on personal issues such as effect on energy levels, mood, depression and sleep disturbance.
- Consider practical items which may be of use to patients with CHF, such as medic-alert bracelets or diaries to log daily weight monitoring
- Encourage patients to access additional support through organizations such as the Heart Foundation, Heart Support Australia and the Cardiomyopathy Association of Australia.
- Help patients understand the importance of adhering to their medication regime and put in place strategies to aid them with managing their medication load (such as Dose Administration Aids).
- Review patients for medications which may exacerbate or worsen CHF, in-pharmacy medicines reviews (MedsChecks) or Home Medicines Reviews (HMRs) might be a suitable options for many patients
The assessment questions below can be found at the Guild Pharmacy Academy myCPD e-learning platform. Login or register at: www.mycpd.org.au
- Which of the following is not a common symptom of Chronic Heart Failure?
d. Swollen ankles
- Which of the following is a common contributing factor to Heart failure with preserved systolic function (HFPSF)?
a. Aortic Stenosis
b. Non-ischaemic idiopathic dilated cardiomyopathy
c. Type 2 Diabetes
d. Thyroid dysfunction
- Which of the following statements is true regarding the pharmacological management of Chronic Heart Failure?
a. Angiotensin II receptor antagonists have been shown to have similar outcomes to ACE inhibitors, and can be used in patients who have experienced side effects with ACE inhibitor therapy.
b. Angiotensin II receptor antagonists have been shown to be superior to ACE inhibitors, and should be prescribed for all patients with Chronic Heart Failure
c. Beta Blockers inhibit sodium–potassium ATPase, blockade of this enzyme has been associated with improved inotropic responsiveness in patients with ventricular dysfunction
d. In fluid overloaded patents, an aldosterone antagonist should be used to achieve euvolaemia
- Which of the following drugs should be avoided in patients with Chronic Heart Failure?
c. Isosorbide mononitrate
- Which of the following statements regarding the non-pharmacological management of Chronic Heart Failure is FALSE?
a. Patients should limit sodium intake to less than 2g per day
b. Patients with severe Chronic Heart failure should limit fluid intake to less than 1.5L/day
c. Patients should aim for a diet that is low in saturated fats and low in fibre, to avoid constipation
d. Alcohol consumption should be limited to 1-2 standard drinks per day and caffeine limited to 1-2 cups of caffeinated beverage per day.
1. National Heart Foundation, Cardiac Society of Australia and New Zealand. Guidelines for the prevention, detection and management of chronic heart failure in Australia, updated October 2011, 2011.
2. Australian Institute of Health and Welfare (AIHW) and the National Heart Foundation of Australia (NHFA). Heart, stroke and vascular diseases—Australian facts 2004. Canberra: National Centre for monitoring cardiovascular disease; 2004; p.140
3. McMurray JJV, Stewart S. The burden of heart failure. Eur Heart J 2003;5:I3–I113.
4. Nicklas JM, et al. Effect of enalapril on mortality and the development of heart failure in asymptomatic patients with reduced left ventricular ejection fractions. N Engl J Med 1992;327:685–91.HF Number 141
5. Pitt B, et al. Effect of losartan compared with captopril on mortality in patients with symptomatic heart failure: randomised trial—the Losartan Heart Failure Survival Study ELITE II. Lancet 2000;355(9215):1582–7.
6. Merit-HF Study Group. Effect of metoprolol CR/XL in chronic heart failure: Metoprolol CR/XL Randomised Intervention Trial in Congestive Heart Failure (MERITHF). Lancet 1999;353:2001–7
7. Pitt B, Zannad F, Remme WJ. The effect of spironolactone on morbidity and mortality in patients with severe heart failure. N Engl J Med 1999;341:709–17
8. Packer M, Gheorghiade M, Young JB. Withdrawal of digoxin from patients with chronic heart failure treated with angiotensin-converting-enzyme inhibitors. RADIANCE Study. N Engl J Med 1993;329:1–7.
9. Anker SD, Comin Colet J, Filippatos G, et al; FAIR-HF Trial Investigators. Ferric carboxymaltose in patients with heart failure and iron deficiency. N Engl J Med. 2009:361(25):2436–48.
10. Cohn JN, Archibald DG, Ziesche S. Effect of vasodilator therapy on mortality in chronic congestive heart failure. Results of a Veterans Administration Cooperative Study. N Engl J Med 1986;314:1547–52.
11. Packer M. Primary results of the PRAISE II Study. Presented at the Annual Scientific Meeting of the American College of Cardiology; 2000; Anaheim, CA, USA.
12. Flynn KE, Pina IL, Whellan DJ, Lin L, Blumenthal JA, Ellis SJ, et al. Effects of exercise training on health status in patients with chronic heart failure: HF-ACTION randomized controlled trial. JAMA 2009;301(14):1451–9