I hope you are all enjoying the burst of sunshine in the UK even though it can be challenging to work in such heat!
I personally love the heat, the hotter the better, and I love donning my sunglasses and going for a run.
This month’s blog focuses on heart failure patient review.
As you are aware in England and Northern Ireland we have the quality and outcomes framework (QOF), which not only encourages general practice to maintain their heart failure registers, but also to ensure patients are on some of the basic therapies for HFrEF (LVSD) and to conduct an annual heart failure (medication) review.
Wales and Scotland have different quality improvements initiatives to improve care for such patients.
As you will have read in my previous blogs, validating the heart failure register is the first step before we review these patients.
Of course, the HF register includes all patients with heart failure not just those with HFrEF; there will be patients with HFpEF (LVDD), right heart failure, valvular heart failure cases.
This blog will focus on those with HFrEF and the four pillars of modern-day heart failure management (Straw et al. 2021).
For some practices reviewing patients with HF this may be the first QOF year that they have involved themselves directly.
It’s essential that the multidisciplinary team (MDT) conducting the reviews are aware of the rationale for managing HFrEF and the differences to other types of heart failure which should not be confused with.
Training and education is key to successful patient outcomes and I have been involved in virtual MDT meetings that have enabled primary care clinicians to become more involved in prescribing key pharmacological treatments.
The MDT approach provides not only mentoring but a joint-working approach which improves communication amongst the wider team.
If your practice needs coaching and clinical support in conducting patient reviews there are some excellent training programmes available to support this across the Country.
As a passionate educator I am more than happy to help where I can!
So, back to HFrEF patient reviewing – what do you need to know?
- First stop, look at the patient’s diagnosis, looks at their echo/coding – check the diagnosis, make sure you have enough evidence and information to base your review and recommendations on!
Check your evidence. - It is helpful if the patient has had their annual bloods before the clinical consultation.
Make sure they have had the basics requested: FBC, U&Es, LFTs, HbA1c at least.
Many patients are iron deficient so further haematinics may be required.
All patients with HFrEF should have an ECG performed annually, why?
Patients with HFrEF may be considered for cardiac resynchronisation therapy (CRT/biventricular pacing) to improve symptoms and patient outcomes.
The key finding we are looking for here are patients in sinus rhythm who have a prolonged QRS duration.
These patients can be discussed with the HF cardiologist team.
So your patient arrives, what next?
Assess current symptoms – focus on breathlessness (NYHA status – ask the patient they are far more accurate than us!), night time symptoms (orthopnoea/PND), exercise tolerance (changes), presence of peripheral oedema, cough, wheeze, chest pain, dizziness, angina, palpitations, syncope, falls, confusion, anxiety and depression.
Has they been any hospital admissions (HF or any cause) in the last year?
Has there been any medication changes since the last review?
Note their social living arrangements – we know those who live alone are higher risk of re-hospitalisation.
Note their co-morbidities!
- Examine the patient, vital signs recordings and chest auscultation, assess for presence of oedema. Review renal function.
- Review medication, note previous discussions on titration of medication, is there a good reason why they have not been optimised, don’t assume.
- Look for evidence-based therapies – ACE/ARNI/ARB, BB, MRA, SGLT2i; the four pillars.
- Review blood pressure and pulse rate when optimising their medications. Where do we start?
- We know that symptomatic hypotension can be a challenge in this group of patients; ensure they are not too dry to start with.
- We know that having a balance of medications can work very well for patients rather than large doses of say an ACEI and no BB – if blood pressure is challenging then try for low doses of all medication drug groups.
There is research emerging as to how to guide us further in how we should initiate all the 4 pillars of treatment going forward and this is worth watching this space on this (Shen & Jhund et al. 2022).
- Don’t forget to arrange any renal monitoring and vital sign review following optimisation where appropriate.
- Always document clearly the plan of action, it can not all be done at once, if the plan is visible to all then the whole team benefit of knowing what is the next step.
- Don’t forget to reset the patient’s HF recall on the clinical system and ‘code’ heart failure annual review and heart failure medication review (England only) in the clinical system.
- Don’t forget the non-pharmacological advice – what do I mean by this?
- Individualised advice if appropriate on fluid and salt intake
- Symptom recognition and when to ask for help, using self-care plans
- Weight monitoring (fluid) if appropriate
- Exercise, sexual activity and dietary advice
- Smoking cessation and alcohol advice
- Immunisation for pneumonia, flu and coronavirus
- Travel, climate advice and driving restrictions (if applicable)
- Sick day rule advice for medication
- Carer support needs/financial benefits such as carer’s allowance
- Is this patient deteriorating despite maximum intervention? Refer back to the HF cardiology team.
These patients may be suitable for device therapy or it may be time to be considering and documenting end of life palliative care needs.
Finally, I would like to wrap up this month’s blog by raising awareness of using a heart failure template to guide the patient review process.
HF templates are helpful to clinicians as an aide memoire and offer a systematic standard approach for all patients.
Oberoi are currently using their experience to develop a new template to support clinicians in reviewing patients.
Please do get in touch if this is something you would like to consider in your practice.
There are other templates available that local teams have customised across the Country in addition to other industry template packages.
Thanks for reading my July Blog!
If you would like to discuss reviewing heart failure patients, audit, coding and or your educational requirements please feel free to email me on: Amanda.Crundall@oberoi-consulting.com
McDonagh et al. (2021). ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. European Heart Journal. Sep 21; 42 (36): 3599-3726. https://pubmed.ncbi.nlm.nih.gov/34447992
NICE (2018) www.nice.org.uk/guidance/ng106
Straw et al (2021) Four pillars of heart failure: contemporary pharmacological therapy for heart failure with reduced ejection fraction. British Medical Journal. http://dx.doi.org/10.1136/openhrt-2021-001585
