Managing Heart Failure in the Community
What is Heart Failure (HF) and how prevalent is it in Singapore?
HF is a clinical syndrome complex that results from cardiac function impairment. HF is divided into 3 categories based on cardiac left ventricular ejection fraction (LVEF): HF with Reduced Ejection Fraction (HFrEF), HF with mid-range Ejection Fraction (HFmrEF) and HF with Preserved Ejection Fraction (HFpEF) (1).
In HFrEF, LVEF is </= 40%. It is predominantly due to abnormal cardiac pump (systolic) function. In HFpEF, LVEF is >/=50%. It is predominantly due to abnormal cardiac relaxation (diastolic) function. HFmrEF straddles the border with LVEF 41-49%. The HFmrEF cohort with characteristics, treatment patterns, and outcomes appear similar to those of patients with HFpEF.
There is no single diagnostic test for HF. Integral to the diagnosis of HF is the search for the underlying aetiology and precipitant(s) for HF.
Heart failure (HF) is a common cardiac condition with high mortality and morbidity burden on the patient and family. With an ageing population, increasing prevalence of risk factors for HF, and improved management of HF itself, this burden in Singapore will only grow.
What are the common causes and precipitants of HF?
Common causes of HF are Coronary artery disease (CAD), which includes acute coronary syndrome (ACS), chronically poorly controlled hypertension (HTN), atrial fibrillation (AF), cardiac valve disease (e.g. significant aortic stenosis), and thyro-cardiac disease. These common causes of HF are also prevalent in the community. Diabetes mellitus (DM) is also commonly linked to HF via CAD or directly as diabetic cardiomyopathy. Diabetic cardiomyopathy causes abnormal cardiac relaxation insidiously, and if unchecked worsens to pump weakness then failure, manifesting itself as overt HF.
In a Singapore study, up to 35% of patients presenting with HF were found to have ACS as a HF precipitant (1). Other common HF precipitants are infections, non-compliance to medications, diet or fluid restrictions, and gout flares in chronic HF.
What are the common presentations of HF and what are the differential diagnoses?
The cardinal manifestations of HF are dyspnea and fatigue, which may reduce effort tolerance, and fluid retention, which in turn may lead to dyspnea, abdominal distension and leg swelling. They can present in different combinations. Differentials to consider in HF presentation include lung disease (e.g. asthma, lung fibrosis) in dyspnea, and kidney and liver disease in abdominal or leg swelling presentations. Fatigue itself has very broad differentials.
What are the investigations for a patient suspected of having HF?
ECG and serum NT Pro BNP biomarker are important investigations in the diagnosis of HF. In an appropriate clinical context, if the ECG is normal and serum NT Pro BNP is not above a rule-out diagnostic threshold, the likelihood of HF as the cause of presenting symptoms is low. Important investigations include those needed to exclude lung, renal, liver and hematological causes for the symptoms.
It is also very important to identify the cause (aetiology) and trigger (precipitant) for the HF episode. Red flags will need to be excluded. Subsequently an echocardiographic evaluation and further investigations will be needed to stratify, and assign aetiology and precipitant of HF.
What are the stages of HF and how do they affect management?
The American College of Cardiology (ACC) and American Heart Association (AHA) has classified HF into 4 broad stages, with asymptomatic Stage A and B, and symptomatic Stage C and D. For symptomatic HF patients, their functional status is further classified according to the New York Heart Association (NYHA) system. These different stages, together with LVEF stratifications, have their specific management strategies. The ACC/AHA staging with their broad management outlines are shown in Table 1.
The vast body of evidenced-based therapeutics with medications or devices are within the HFrEF cohort (see Table 1). Relative risk of reduction of mortality or morbidity is 15-40%. However, evidenced-based therapeutics is sparse in the HFmrEF cohort, but encouragingly, it is emerging in the HFpEF cohort, with many studies on-going.
In the community, we must reinforce heart healthy lifestyle-safe physical activity and moderation in diet, provide appropriate vaccinations, and motivate our patients to comply with management plans.
We also need to avoid medications that may tip patient with ACC/AHA Stage C or D HF into decompensated HF. Common culprits are NSAIDs, verapamil etc.
Is there a role for GPs to manage HF patients in the community?
Family physicians have an important role in the management of HF patients in the community. A suggested outline of this role is shown in Figure 1. It is important to recognize HF, identify the precipitant(s), and aetiology, and assess the patient’s volume status, before proceeding to specific management.
In new HF cases, it is most prudent to refer to the hospital for expeditious management.
In Chronic HF cases, the Family physician can manage decompensated HF. However, when there are red flags, do refer to the Accident and Emergency for prompt management. Working with the cardiologist is important. Early reviews may be needed. If there is no improvement despite initial management, it is best to refer onwards.
(1) 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). Eur Heart J. 2016 Jul 14;37 (27):2129-2200.
(2) Heart failure cohort in Singapore with deﬁned criteria: clinical characteristics and prognosis in a multi-ethnic hospital-based cohort in Singapore Leong K T G, et al. Singapore Med J 2007; 48 (5) : 408
A Specialist’s Point of View – Written by Dr Leong Kui Toh Gerard
Dr Leong Kui Toh Gerard
MBBS (Singapore), MRCP (UK), FRCP (Edin), FAMS (Cardiology), FACC (USA) ASCeXAM, Diplomate (ts) (National Board of Echocardiography, USA)
Dr Gerard Leong is a specialist in cardiology, subspecialising in advanced heart failure and transplant and echocardiography imaging in cardiology. He is an experienced cardiologist with more than 10 years as cardiologist, and more than 15 years as a physician in public hospitals in Singapore. Prior to his appointment as Medical Director and senior consultant cardiologist of Thomson Cardiology Centre, Dr Leong was a senior consultant in the department of cardiology in Changi General Hospital (CGH) from 2012 and the Director of the CGH Heart Failure Program since its start in 2006 to 2017.
Thomson Cardiology Centre
Thomson Medical Centre
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