Posted in Cardiovascular system, Chronic disease management, Diagnosis, Heart Failure, Uncategorized

Heart Failure – the need to knows

Heart failure is a condition we are increasingly seeing as the population ages. According to figures there are approximately 900,000 people in the UK with a diagnosis of heart failure. It is likely many more remain undiagnosed.

Why is it important to a GP? Because it is often our doors that patients arrive at with symptoms of undiagnosed heart failure, or for management of their already diagnosed heart failure. So we need to remember to consider it as a diagnosis, know what other points in their medical history are relevant, how to investigate and how to manage heart failure.

An important learning point – from prior experience – keep heart failure as a differential diagnosis in all patients presenting with symptoms of breathlessness, regardless of age or lack of other risk factors. It is not difficult to include it in your investigations so keep it on the list until you’ve excluded it via tests.

Firstly, we need to think of the way people might present with heart failure. I am not going to cover an exhaustive list of all of the symptoms because you should know this by now. But people often come to see their GP with symptoms of breathlessness ( to differing degrees), fatigue, or very commonly – ankle swelling. All of these symptoms have multiple potential diagnoses, and it is through further questioning and consideration that you are going to consider whether heart failure is on your list of differentials. If it is then your first step is going to be the trusty BNP or NTproBNP blood test.


These peptides are sensitive enough to use as a diagnostic tool for detecting heart failure. But they are not quite as specific. Carrying out a blood test to check the levels of either of these peptides is going to help you both diagnose or exclude heart failure.

But what other factors or conditions can affect the BNP result?

Falsely lower Falsely higher
Obesity Tachycardia
Diuretics LVH
ACE Inhibitors Hypoxaemia
ARBs eGFR < 60
Beta- blockers COPD
> 70 years

Note the above features – this is going to influence the other elements of your assessment. In order to help you interpret the result you need further information. You need their medical history, medication list and some examination findings.

Notably you might need to weigh your patient to look for their BMI. You need to know what their pulse is and the regularity of it. In addition, an ECG isn’t going to go amiss. From that you can look for SVTs, LV strain and signs suggestive of ischaemia.

In addition to the BNP you want to get some additional blood results:

  • Renal function
  • Liver function
  • Thyroid function
  • Lipids
  • HbA1c

*An off-track learning point – I am pretty tough on trainees at times when it comes to requesting bloods and tests. Why? Because they are expensive and you need to interpret them! When I undertook my emergency medicine rotation I worked in a hospital where the pathology lab was off site. During the induction they told us that we shouldn’t be ordering bloods unless we were planning to admit the patient, because the chances were that the results would not be available before the 4 hour see and treat time was up. Unless you’ve experienced this you will not appreciate how liberating it is to go back to using a history and examination to diagnose a patient. General practice has very much the same ethos. It can be really tempting when requesting a blood test to tick a load of other boxes ‘whilst we are at it’. Don’t. Have a rationale for each test you undertake – what are you looking for and why is it relevant. I’m not going to spell it out for you for the above tests but have a think why they might be relevant!

Interpreting the result

We now have a patient with some symptoms suggestive of heart failure and a positive BNP. What do we do now?

Well we need to look for the cause, unless it is glaringly obvious. The chances are we need an ECHO to help us with this. But how urgently do we need an ECHO? We are going to split our patients into three different categories (as suggested by NICE guidance), and this is going to help us treat our patient within an appropriate time frame:

  1. A very raised BNP (> 400pg/ml) or NTpro BNP (>2000pg/ml) – levels like this carry a poor prognosis so refer urgently to the heart failure clinic for further assessment.
  2. past medical history of a myocardial infarction (MI) – refer for an ECHO and specialist assessment within two weeks.
  3. Other patients – need an ECHO within 6 weeks of the abnormal BNP result.

The result of the ECHO is going to split our treat versus refer patients even further. Who will we refer?

  • Patients with a preserved ejection fraction
  • Valve disease – I think there is some scope to be rational with this group of patients. Read the ECHO report and refer sensibly. A very mild aortic stenosis in an 80 something year old may not necessarily require immediate referral.

So the other patients, i.e. those with left ventricular systolic dysfunction, are the ones we are going to get on and treat.

Mangement principles

  • Effective communication regarding the diagnosis
  • Lifestyle measures
  • Drug treatment
  • Consider the psychological impact of the disease

Communication – You need to explain the diagnosis clearly and carefully. Heart failure is probably a scary diagnosis to a patient. They are being told their heart is failing. We need a heart to live, and theirs is failing! You need to turn this into a less scary situation with a very good explanation and reassurance that there are ways of helping them. Think about how you might explain this diagnosis, and perhaps try your explanation out in a role play setting.

Lifestyle measures – There are a number of changes patients can make that could help to improve their symptoms and outcomes. Increasing exercise as best they can, stopping smoking, reducing alcohol intake and receiving their annual influenza vaccine.

Drug treatments – Keep this simple in your mind.

  • First line:
    • ACE Inhibitors & Beta-blockers – titrate your ACE inhibitors every two weeks (keeping an eye on the renal function) and start with a low dose and gradually increase (perhaps alongside the ACE inhibitor). Make sure you keep an eye on the heart rate when titrating the beta-blocker. If your patient has a home BP monitor then it is worth suggesting the patient check their blood pressure and pulse if they are feeling dizzy or unwell. An ARB is a suitable alternative if the ACE inhibitor is not tolerated.
  • Second line:
    • At this stage you might wish to consider seeking specialist advice but the following medications can be used in the management of heart failure:
      • Aldosterone antagonist (Spironolactone) – for moderate to severe heart failure, or oedema in congestive heart failure.
      • ARB (Candesartan and Valsartan) – mild to moderate heart failure.
      • Hydralazine + Isosorbide dinitrate – moderate – severe heart failure.
      • Digoxin – will improve the symptoms but will not improve mortality. Use in worsening or severe heart failure where patients are already taking maximal treatment with the above mentioned medications.
  • Diuretics:
    • Use for the relief of congestive symptoms and fluid overload.
    • They can be titrated up and down as required.
    • If a patient is requiring greater than 80mg Furosemide daily then you should refer them onwards.
    • Whilst using diuretics you should monitor every six months via a blood test and medication review.

As with all chronic diseases it is important to consider the psychological impact upon the patient. You should address this at their reviews, and manage as required. Locally in Peterborough the psychological wellbeing service has capacity to provide support to individuals who are suffering from chronic disease such as COPD and heart failure. This part of the management shouldn’t be under-estimated. You can spend your days treating disease and illness, but you can’t lose sight of your patient as a whole.

I hope this has been a helpful summary of how to work up a patient for heart failure, and the basic management approach.

Posted in Consultation skills, Diagnosis, Men's health, Uncategorized

Male lower urinary tract symptoms (LUTS)

This topic seems to crop up fairly regularly as a tutorial request. It’s funny because whenever we go through it I think it actually seems very straightforward. Yet there seems to be this tendency to over think the subject. So I have put together my approach to the male LUTS consultation. My suggested reading for this topic is the hyperlinked BMJ article and the NICE guidance.

A good way to approach male LUTS are to consider the symptoms as storage versus voiding symptoms. Having this in the back of your mind is helpful for data gathering but also gives you information from which to consider the most appropriate management options.

  Storage Voiding
Symptoms Frequency

Urgency (and urge incontinence)



Poor stream

Terminal dribbling

Double voiding

Causes Overactive bladder (if isolated) Benign prostatic hypertrophy

Urethral stricture

Meatal stenosis


Management options Anticholinergics Alpha blockers

5-alpha reductase inhibitors

A mixed picture of symptoms would suggest bladder outlet obstruction, most commonly cause by benign prostatic hypertrophy (BPH).

I take a history of the above symptoms in a systematic manner. I go through all the steps of passing urine to clarify what symptoms they have. It is also important to consider the duration of these symptoms. If these symptoms are acute then you should be considering whether this might be a urine infection, or potentially a bladder cancer.

The other important information you need to know are whether they have (or could have) any other medical conditions that may be causing their symptoms. E.g. is this a presentation of diabetes if they have increased frequency of micturition. Also, the medications that they take for other medical conditions could cause side effects that mimic LUTS. So check with them and check their medication list. You also need to consider taking a sexual history if they have any dysuria or penile discharge.

One of the important questions to ask, as with all consultations:

Why is this man presenting now? What are his concerns?

This is the golden question because it is going to guide your management plan. I often see men who wish to discuss their urinary symptoms because they are concerned about the possibility of prostate cancer. But once this is discussed and investigated they don’t feel the need to take medication for their symptoms. So ask them about expectations – it might save an unwanted prescription!

You need to examine your patient:

  • Abdominal examination
  • Genital examination
  • Digital rectal examination (DRE)
  • Look for peripheral oedema
  • Neurological examination – if there is anything in the history that creates suspicion

A note about DRE and Prostate specific antigen (PSA). You need to undertake a DRE at some point during your assessment of the patient presenting with LUTS. Unless the patient is having their blood test very soon after the DRE it is unlikely to impact upon the PSA results. However, you could undertake the PSA testing, advise them they will need this examination at their follow up consultation and then perform it at the review. That is down to your preference. As long as it is completed in good time.


  • Urinalysis – can look for infection, diabetes, or possibility of malignancy.
  • An input/output diary – if they have storage symptoms or nocturia. Make sure they note caffeine intake.
  • PSA – You need to counsel the patient prior to offering a PSA test. I really like this website for providing a man with information about PSA testing.

It is also very helpful to ask the man to complete the international prostate symptom score (IPSS) questionnaire. The man’s scoring on this questionnaire can direct the management plan put in place.


First line should be information. About their condition and the lifestyle measures they can make that may improve their symptoms e.g. fluid modification. I really like this patient information leaflet from BAUS

Drug treatments. This is where the IPSS can be helpful.

Mild LUTS (IPSS <8)

Enlarged prostate

5 Alpha reductase inhibitor
Moderate – Severe LUTS (IPSS >7)

Normal sized prostate

Alpha blocker
Moderate – Severe LUTS (IPSS >7)

Enlarged prostate

Alpha blocker +

5 Aplha reductase inhibitor

Overactive bladder (isolated storage symptoms) Anticholinergics

(if fails or not tolerated Beta 3 agonist)

Consider the common side-effects of these medications when explaining them to patients:

  • Alpha blockers (e.g. Tamsulosin) – reduced ejaculation, postural hypotension (it is advisable to suggest the patient takes these last thing at night)
  • 5 Alpha reductase inhibitors (e.g. Finasteride or Duasteride) – Reduced libido, Erectile dysfunction, gynaecomastia. With this treatment it may take several months for it’s benefit is seen. It is worth explaining this to the patient up front.
  • Anticholinergics (e.g. Oxybutynin) – dry eyes, dry mouth, constipation, confusion (in the elderly).
  • Beta 3 agonist (e.g. Mirabegron) – Tachycardia

Organise follow-up:

It is useful to review they patient at 4-6 weeks post initiation of treatment. They you can review at 6-12 month intervals. If it is Finasteride only that you have initiated then you may wish to lengthen the first review to around 3-6 months to allow time for it’s effects to have been seen.

Who to refer?

  • Failure of medical treatment after a couple of reviews
  • Severe LUTS (IPSS 20+)
  • DRE suggests malignancy
  • Elevated age-specific PSA
  • Recurrent UTIs
  • Persistent non-visible haematuria or any visible haematuria
  • Urinary retention

This is the British Association of Urological Surgeons (BAUS) age adjusted PSA guide:

Age Maximum PSA (ng/ml)
40-49 years 2.7
50-59 years 3.9
60 – 69 years 5.0
70-79 years 7.2
80-84 years 10
85+ years 20

If your patient has a raised PSA then this is a really nice web page to direct them to or print off to explain what this means and what might happen next.

I really hope this has shown you how straightforward a male LUTS consultation can be. If you have any questions then just as and I will answer as best I can.