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Mdm Teo Ah Mui, an 88-year-old woman, visited your clinic for her regular follow-up, as she had done for the past 20 years. She had just been discharged from the hospital after being admitted for an episode of heart failure last month. She asked about her new medications to protect her heart and regulate her fluid status, wanting to know if they were indeed good for her.
WHAT IS HEART FAILURE?
Heart failure (HF) is a clinical syndrome comprising signs and symptoms that result from a structural or functional cardiac abnormality, causing a compromise in cardiac output and/or elevated intracardiac filling pressures at rest or stress.(1) It is the result of any insult, such as coronary, valvular or arrhythmic, causing a disturbance to cardiac function.
HOW RELEVANT IS THIS TO MY PRACTICE?
HF is extremely prevalent in Singapore. About 20% of deaths in Singapore in 2017 were due to ischaemic heart disease and other cardiac diseases.(2) 4.5% of Singaporeans live with HF, compared to 1%–2% in the United States and Europe.
Many Singaporeans are also at risk of HF, with the most prevalent risk factors being insufficient physical activity (34% of the population), smoking (16%), obesity (35%), diabetes mellitus (10%) and hypertension (14%).(3) These risk factors need to be adequately controlled to minimise the chance of developing HF or, in the case of a HF patient, controlled to retard progression of HF. Management of HF requires the patient’s involvement and a multidisciplinary team approach (
Management strategy for a patient with heart failure:
Common signs and symptoms at presentation
The patient typically develops and presents with fluid overload, which causes dyspnoea, orthopnoea, jugular venous distension, pulmonary crepitations and ankle oedema.(1,6) When there is severely depressed cardiac output, there can be hypotension, cold extremities, decreased urine output and altered mentation when the cardiac output is unable to support adequate tissue perfusion.(1) These patients should be promptly referred to the accident and emergency department.
A medical history of cardiovascular disease or cardiovascular risk factors makes the diagnosis of HF more likely. All stable patients suspected to have newly diagnosed HF should have electrocardiography (ECG) performed and be referred to a cardiologist for early evaluation.
WHAT CAN I DO IN MY PRACTICE?
After diagnosis, the HF patient should ideally be managed in the community, with follow-up to ensure that the patient has few or no symptoms. Repeated hospitalisations for HF is a strong predictor of mortality.(7)
Treatment goals should first be discussed and established with the patient, preferably with the support of caregivers and family members.
HF patients should restrict their salt and fluid intake, albeit to varying degrees based on the individual patient’s profile and severity of HF. They should be counselled on smoking cessation and avoidance of alcohol (especially for alcohol-related cardiac dysfunction), and screened for depression and managed accordingly.(8) Patients should also be taught self-care, symptom surveillance and weight monitoring, and advised to purchase a suitable water jug (e.g. 1-L jug) specifically for regulating water intake and a reliable weighing machine for daily weight measurements and recording. They should try as much as possible to comply with the fluid restrictions, and monitor themselves closely for symptoms such as ankle swelling if they exceed their restrictions on a hot day. Regular aerobic exercise should be encouraged to improve functional capacity and symptoms.(9)
Changes in functional status and/or a rapid gain in weight could herald decompensation. Early intervention, such as by temporarily increasing the diuretic dose, could restore equilibrium and avoid an admission to hospital.
HF patients who are unable to return to previous physically demanding work can be referred to Family Service Centres or Workforce Singapore Career Centres to find suitable employment.
During a routine clinic visit, the physician should document effort tolerance (New York Heart Association [NYHA] class), review weight charts, assess blood pressure and examine the patient’s fluid status, as well as assess medication compliance and side effects. The primary care physician also needs to screen HF patients for depression, for which the Patient Health Questionnaire-9 is a useful tool.(8) HF patients should receive an annual influenza vaccination and a course of pneumococcal vaccination. Advance care planning, as well as work placement and financial help, should be discussed if required.
The dose of diuretics, usually oral frusemide, is patient-dependent (usually affected by cardiac and renal function) and, if required, can be increased temporarily to deal with decompensation episodes, such as doubling the dose for short periods with frequent re-assessment. Disease-modifying drugs for chronic HF are prescribed and titrated based on the patient’s left ventricular ejection fraction (LVEF). Patients are divided into HFrEF (HF with reduced ejection fraction < 40%), HFpEF (HF with preserved ejection fraction ≥ 50%) and HFmrEF (HF with mid-range ejection fraction 40%–49%) groups based on their LVEF on echocardiography.
HFrEF (HF with reduced ejection fraction < 40%)
While many evidence-based disease-modifying drugs are available for the treatment of chronic HF, HFrEF patients are notoriously undertreated.(3) An angiotensin-converting enzyme (ACE) inhibitor (or angiotensin receptor blocker [ARB])(10) and beta-blocker(11) are recommended for a patient with symptomatic (NYHA Class II–IV) HFrEF. A mineralocorticoid receptor antagonist(12) is recommended in symptomatic patients with LVEF ≤ 35%. These drugs should be administered at the target dose as long as the patient does not experience symptomatic hypotension (i.e. blood pressure remains > 90/60 mmHg). Starting at a lower dose with judicious up-titration could help encourage acceptance and minimise adverse drug effects. Should the patient still have HF symptoms, the ACE inhibitor (or ARB) can be replaced with an angiotensin receptor-neprilysin inhibitor (ARNI). The PARADIGM-HF trial showed that sacubitril/valsartan (an ARNI) is superior to enalapril in reducing morbidity and mortality in HFrEF patients.(13) Renal function, and in particular potassium levels, should be monitored 1–2 weeks after initiation or dosage change, then 3–6 monthly in patients on ACE-inhibitor/ARB/ARNI to ensure stability.
Beta-blockers are the first-line therapy in controlling the heart rate of a patient with chronic HFrEF. A target heart rate of 50–70 beats per minute (bpm) is advised. Adding an If-channel blocker is reasonable if the patient is in sinus rhythm and has a heart rate that is persistently > 70 bpm despite being on the maximum tolerated dose of beta-blocker.(14)
For diabetic patients with HFrEF, metformin(15) and a sodium-glucose cotransporter-2 (SGLT-2) inhibitor(16) should be included in their drug regimen. Both the EMPA-REG OUTCOME trial(17) and DECLARE-TIMI 58 trial(18) showed significant mortality and morbidity benefit of SGLT-2 inhibitors over placebo in HFrEF patients. However, thiazolidinediones,(19) saxagliptin,(20) nonsteroidal anti-inflammatory drugs and COX-2 inhibitors(21) are not recommended in HF patients.
An automated implanted cardioverter-defibrillator device should be considered in patients with LVEF ≤ 35% and NYHA Class II–III after optimising medical therapy for prevention of sudden cardiac death.(22) Cardiac resynchronisation therapy should be considered in symptomatic patients who are in sinus rhythm, with left bundle branch block on ECG, who have QRS duration ≥ 150 ms and LVEF ≤ 35% despite optimal medical therapy.(23) Commonly used drugs for HFrEF are shown in
Commonly used drugs in HFrEF and their appropriate target doses.(1)
HFmrEF (HF with mid-range ejection fraction 40%–49%)
Patients with HFmrEF are a distinct group for whom there is currently no evidence-based medication to reduce mortality or morbidity. However, in the recent PARAGON-HF trial, the therapeutic benefits of ARNI vary by LVEF and appear to extend to HFmrEF patients, particularly for hospitalisation for HF.(24)
HFpEF (HF with preserved ejection fraction ≥ 50%)
HFpEF is on the rise in Southeast Asia due to the high prevalence of rapidly ageing societies and hypertension.(3) Compared to HFrEF, HFpEF patients tend to be older and female, have hypertension and atrial fibrillation, and less likely to have myocardial infarction.(25)
Currently, no specific pharmacological treatment has been shown to reduce mortality and morbidity in HFpEF patients. Several studies are ongoing. The current aim of treatment is to alleviate symptoms and improve quality of life, such as by prescribing diuretics to congested patients,(1,26) as well as aggressive control of comorbidities such as hypertension.
In conclusion, HF is a common problem in Singapore and requires a multidisciplinary approach. A combination of appropriate disease-modifying drugs, lifestyle modifications, and accessibility to care can help to reduce morbidity and hospitalisation rates.
TAKE HOME MESSAGES
Newly diagnosed, clinically stable HF patients require early specialist evaluation, while unstable or hypotensive patients need emergency attention.
Treatment goals should be discussed and agreed on with patients before being clearly documented in a care plan.
Decompensation should be detected early and treated with a temporary increase in diuretics.
Fluid and salt restrictions should be encouraged and enforced, with measurement of fluid intake and daily weight.
Smoking cessation and regular exercise should be encouraged.
Patients with HF should receive influenza and pneumococcal vaccines.
Patients can be screened for depression at clinic visits.
Diabetes mellitus, hypertension and lipid control should be optimised.
In patients with in HFrEF, disease-modifying drugs should be optimised to achieve appropriate target doses or at least maximally tolerated doses.
Patients should be encouraged to re-integrate into society with help from community resources.
Advance care planning:
Family Service Centres:
Mdm Teo was happy to learn what her two new medications ‒ beta-blockers and ACE inhibitors – were for. Her domestic helper, Mary, would help to prepare a small 1-L water flask and monitor her fluid intake, chart her weight daily and remind her to take her medications. You also reminded Mary to chart Mdm Teo’s diet and drop by your clinic 2‒3 days later after her morning walk to hand her charts to your clinic assistants.
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