Tag: cardiovascular health

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

Heart Failure – the need to knows

Posted on by Emma

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.

BNP/ NTproBNP

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
Diabetes
> 70 years
Cirrhosis

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. A 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 Cardiovascular system, Chronic disease management, Consultation skills, Diagnosis, Hypertension, Uncategorized

Hypertension – the diagnosis

Posted on by Emma

I’m covering this as it’s a common reason for consulting in primary care. What do you do when you pick up a high blood pressure as part of an examination for another presenting complaint? The answer should not be ‘ignore it and hope it goes away’!

As always, you can read the NICE guidance for all the ins and outs of hypertension diagnosis and management. What I’m going to do is give you some tips on what might be helpful during a consultation where someone has a raised blood pressure but no diagnosis of hypertension.

What I will say (and I can imagine this will become a familiar phrase) is that it is not easy to complete all of this in one 10 minute consultation. So it’s worth planning how to tackle this over a couple of consultations.

Most importantly, you need to know what raised blood pressure is. Here are the definitions to guide you:

  • Stage 1 Hypertension – clinic BP 140/90mmHg or higher AND subsequent 24h BP or home monitoring BP 135/85mmHg or higher
  • Stage 2 Hypertension – clinic BP 160/100mmHg or higher AND subsequent 24h BP or home monitoring BP 150/95mmHg or higher
  • Severe Hypertension – clinic systolic BP 180mmHg or higher OR clinic diastolic BP 110mmHg or higher

I think it’s fair to consider their reason for attendance, and whether this may be impacting upon their BP reading. The other important point is that your patient should be relaxed and quiet whilst the measurement is being taken. It’s a good time for you to complete your documentation. It can be hard to convince a patient to sit and say nothing! Also – make sure you’re using the correct cuff size – this really does impact upon the measurement.

If the BP is high on the first reading then measure it on the other arm also. You should have at least two measurements of BP if the initial one is >140/90. You may take a third if there is a significant difference between the first two. Document the lowest reading taken.

Your first consultation is likely to go as follows if you note a raised BP:

  • You will need to organise 24 hour (ambulatory – ABPM) BP monitoring OR home BP monitoring (HBPM). You might want to discuss these options with your patient. The ideal is ABPM.
  • You can also introduce the idea of hypertension and the lifestyle factors that might impact upon the patient’s BP. It gives them a bit of information to digest in the meantime, and it may allow them to consider how they can alter their lifestyle to make improvements.
  • You can also organise further investigations required to assess for target organ damage (kidneys, heart, eyes), and perform a cardiovascular risk assessment:
    • Bloods – renal function, lipids, HbA1c, liver function (if considering statin)
    • ECG – look for LVH, and REALLY helpful to have a baseline ECG
    • Urine – for albumin: creatinine ratio
    • Fundoscopy – you can look yourself but signposting them to an optician for a detailed check is helpful.
  • To complete a CVD risk assessment (a Q-risk in our case) we will need some information regarding family history of CVD, their height and weight (to calculate BMI), their smoking status, and checking their pulse for AF (which should ideally have been done prior to BP measurement since it can affect electronic BP recording)

You can see that after you’ve taken a history and reached the point of diagnosing a raised blood pressure (which may not have been their reason for attendance) there is quite a lot of explanation and planning to get on with! Don’t forget to address their actual reason for attendance if it wasn’t related to blood pressure.

NOTE – If you diagnose someone with severe hypertension, you need to consider starting an anti-hypertensive there and then. You should probably get on and get some bloods taken on the day to facilitate appropriate monitoring of the medications you have started (e.g. unless you have a recent renal function it is good to get one taken prior to starting an ACE inhibitor, since we need to monitor renal function after initiating said medication). You must also consider referral for same day specialist input if they have signs of papilloedema and/or retinal haemorrhage, or if they have symptoms to suggest an underlying cause e.g. phaeochromocytoma, or referral for investigation if this is possibly secondary hypertension.

The follow-up consultation is hopefully going to be straightforward if you have completed all of the above.

You are going to have the BP monitoring results and be able to diagnose hypertension, and which stage. You will also have the investigation results. This, in turn, allows you to manage the condition appropriately.

What are the lifestyle measures patients’ can take to reduce blood pressure? Did they have a think about these after the last consultation? Are there any changes they think they can realistically make?

  • Diet and exercise (including reducing salt intake, and reducing caffeine intake)
  • Quitting smoking
  • Reducing alcohol intake
  • Relaxation therapies

Who are we giving drug treatment to?

  • Stage 1 hypertension and < 80 years old with:
    • target organ damage
    • established CVD
    • 10-year CVD risk > 20%
    • Diabetes
    • Renal impairment
  • All stage 2 hypertension

Consider referral if < 40 years old with stage 1 hypertension and nil other risk factors, since CVD risk may be underestimated in this population. We need to be looking for a secondary cause in these individuals and offering detailed assessment.

Hypertension should be monitored through clinic readings (unless they have white coat hypertension, in which case home monitoring can be used).

Target BP in clinic is <140/90 if <80 years old or <150/90 if 80 year or older. (home monitoring is <135/85 for < 80years and <145/85 if 80 years or older).

I’m going to stop here.

Do you know which antihypertensives should be used in which groups?

Do you know the stepwise treatment for hypertension?

Do you know how different drugs should be monitored, and what common side effects you might experience with the different medications?

Please use the comments section to try answering some of these questions, or if you have any questions regarding what has been discussed above!