Focus on heart failure

How active is your role in managing heart failure and helping patients stay out of hospital and live better, longer lives?

  • 23 February 2021
Focus on heart failure

When Melbourne GP Dr Andrew Broad recently found out that the prognosis of heart failure is worse than some common cancers, he thought to himself: ‘I didn’t realise how bad heart failure is. I had better start taking it more seriously.’

Research shows that the probability of being alive 5 years after diagnosis is:1

  • 68.3% for prostate cancer and 55.8% for men with heart failure
  • 77.7% for breast cancer and 49.5% for women with heart failure.

‘When a patient is diagnosed with cancer it is usually a call to action and brings on a sense of urgency to do something to ensure the patient can achieve the best possible outcomes’, says Dr Broad.

Dr Andrew Broad, GP
Dr Andrew Broad, GP

‘In contrast, with heart failure, there may often be a degree of resignation that there’s not that much you can do about it’, he says.

‘But heart failure really should be a diagnosis that we give just as much attention and effort to as we do for cancers.’

Learning about the poor prognosis of heart failure was one of a number of ‘Aha!’ moments that Dr Broad experienced when he participated in the development of the NPS MedicineWise program Heart failure: taking an active role, which is launching on 1 March 2021.

Another key moment for Dr Broad related to the management of heart failure.

Dr Broad found that rather than prescribing medicines in isolation to control symptoms, using medicines in combination and up-titrated to their maximum tolerated or targeted doses, can keep people out of hospital and save lives.

‘The big learning for me was that I tended to rely on one or two medications only in low or probably ineffective doses and I often didn’t up-titrate or add the missing medicine to satisfy the big three’, he says.

The ‘big three’ Dr Broad is referring to are:

  • ACE (angiotensin-converting enzyme) inhibitor,
  • heart failure beta blocker,
  • MRA (mineralocorticoid receptor antagonist).

A 2018 meta-analysis and systematic review of heart failure medicines has shown a substantial improvement in mortality when patients with HFrEF (heart failure with reduced ejection fraction) are prescribed a combination of these medicines up-titrated to target doses. It found a 56% reduction in all-cause mortality over 1–3 years, compared to placebo.2,3

HFrEF is defined as left ventricular ejection fraction (LVEF) < 50%, in the presence of symptoms ± signs of heart failure.

 

Compelling reasons to act on heart failure

Dr Broad hopes other GPs will also experience ‘Aha!’ moments like these during the NPS MedicineWise Heart failure: taking an active role program and that these moments will lead to positive changes in the diagnosis and management of heart failure in primary care. 

Heart failure is estimated to affect 480,000 Australians.4

Many people with heart failure in Australia are admitted to hospital with a decompensation episode or another cause, but after discharge, their rate of readmission is 20% within 30 days and 56% within one year. The mortality rate for these patients is 8% within 30 days and 25% within one year.5

And the burden of illness for heart failure is expected to increase with the ageing population. By 2030 it is estimated that as many as 750,000 Australians will be affected by heart failure.4

The NPS MedicineWise Heart failure: taking an active role program, developed in collaboration with the National Heart Foundation of Australia, aims to support health professionals and their patients and carers in primary care in the diagnosis and management of heart failure.

Key features of the program include educational visits to general practices and a suite of online resources including guidelines and clinical resources and tools for health professionals, and action plans, factsheets and booklets for patients and their carers to support self-management.

 

GPs are ideally placed to diagnose and manage heart failure

Diagnosis and management of heart failure are complex. Several practice gaps that can contribute to poorer patient outcomes have been identified, including:

  • low confidence among GPs about diagnosing and managing heart failure6
  • missed opportunities for earlier diagnosis of heart failure7 and diagnostic delay compounded when signs and symptoms go unrecognised7-9
  • failing to see echocardiography testing as relevant or necessary for heart failure diagnosis10
  • gaps in service provision arising from poor communication between hospital staff and community-based health professionals7
  • sub-optimal dosing of medicines that have been shown to significantly improve outcomes for people with heart failure.11

Self-care strategies, such as physical activity programs recommended for heart failure, are complex and often challenging for patients to maintain.12 Gaps in patient education and poor health literacy have also been identified as key issues.10,13

Qualitative interviews and surveys with GPs found low confidence in interpreting investigation results and initiating heart failure medicines and a reluctance to increase dosages to target or maximally tolerated doses when patients are stable.6

‘GPs have an important role in heart failure.’ 

Professor Andrew Sindone, Director of the Heart Failure Unit and Department of Cardiac Rehabilitation at Concord Hospital, and Head of Department of Cardiology at Ryde Hospital in Sydney.

Professor Andrew Sindone

‘GPs are ideally placed to identify their patients with heart failure and provide effective life-saving therapy’, says Professor Sindone, who is co-author of the National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand Heart Failure Guidelines 2018.

‘I would say to all GPs that you should do this.’

The NPS MedicineWise Heart failure; taking an active role program aims to reinforce and put into practice Professor Sindone’s message to GPs of the important role they can play in helping patients with heart failure live better, longer lives.

 

References

  1. Mamas MA, Sperrin M, Watson MC, et al. Do patients have worse outcomes in heart failure than in cancer? A primary care-based cohort study with 10-year follow-up in Scotland. Eur J Heart Fail 2017;19:1095-104.
  2. Burnett H, Earley A, Voors AA, et al. Thirty years of evidence on the efficacy of drug treatments for chronic heart failure with reduced ejection fraction: a network meta-analysis. Circ Heart Fail 2017;10:e003529.
  3. Atherton JJ, Sindone A, De Pasquale CG, et al. National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand: Guidelines for the prevention, detection, and management of heart failure in Australia 2018. Heart Lung Circ 2018;27:1123-208.
  4. Chan YK, Tuttle C, Ball J, et al. Current and projected burden of heart failure in the Australian adult population: a substantive but still ill-defined major health issue. BMC Health Serv Res 2016;16:501.
  5. Al-Omary MS, Davies AJ, Evans TJ, et al. Mortality and readmission following hospitalisation for heart failure in Australia: a systematic review and meta-analysis. Heart Lung Circ 2018;27:917-27.
  6. Smeets M, Van Roy S, Aertgeerts B, et al. Improving care for heart failure patients in primary care, GPs' perceptions: a qualitative evidence synthesis. BMJ Open 2016;6:e013459.
  7. Hsieh V, Paull G, Hawkshaw B. Heart Failure Integrated Care Project: overcoming barriers encountered by primary health care providers in heart failure management. Aust Health Rev 2020.
  8. Ivynian SE, Newton PJ, DiGiacomo M. Patient preferences for heart failure education and perceptions of patient-provider communication. Scand J Caring Sci 2020.
  9. Segan L, Nanayakkara S, Mak V, et al. Enhancing self-care strategies in heart failure through patient-reported outcome measures. Intern Med J 2018;48:995-8.
  10. Howlett J, Comin-Colet J, Dickstein K, et al. Clinical practices and attitudes regarding the diagnosis and management of heart failure: findings from the CORE Needs Assessment Survey. ESC Heart Fail 2018;5:172-83.
  11. Guirguis K. Prescribed heart failure pharmacotherapy: How closely do GPs adhere to treatment guidelines? Res Social Adm Pharm 2020;16:935-40.
  12. Ho TH, Caughey GE, Shakib S. Guideline compliance in chronic heart failure patients with multiple comorbid diseases: evaluation of an individualised multidisciplinary model of care. PLoS One 2014;9:e93129.
  13. Australian Commission on Safety and Quality in Healthcare. The Second Australian Atlas of Healthcare variation Sydney: Australian Commission on Safety and Quality in Health Care,, 2017 (accessed 1 February 2021).