Making Best Practice, Every Day Practice
Heart rate appears to be a marker for optimal medical therapy in heart failure, and a key determinant of hospitalisation. This study compared practices using the local enhanced service (LES) for heart failure against those not delivering the LES. Education and heart rate control seem to influence hospitalisation rates.
We describe a patient with heart failure, diagnosed from clinical history and examination, and with a raised BNP. Despite treatment, her symptoms progressed. Echocardiography, performed after a six-month delay, showed a large mass. After excision of the mass, an atrial myxoma, the patient recovered rapidly and well.
We hypothesised that practice heart failure registers may not be complete or robust due to patients not always being allocated the correct READ codes. We set up a project which improved practice heart failure registers. Ensuring practices have robust registers, by improving clinical coding in general practice, means more accurate prevalence levels can inform planning and commissioning of heart failure services.
Controlling heart rate is a key element of good care of patients with angina or heart failure. In this article we explore the benefit of effective heart rate control to reduce hospitalisation and alleviate symptoms. Measuring heart rate is simple, and can provide valuable benefits for many patients.
Heart failure is characterised by fatigue, breathlessness and retention of fluid. The update of the National Institute for Health and Clinical Excellence chronic heart failure guidelines has simplified its management by using a stepped approach to investigation and treatment. In this article, we focus on the practical aspects of managing the two main symptoms associated with heart failure – oedema and breathlessness.
Managing heart failure requires a holistic approach: as well as optimal medical treatment, patients and their families need to have a sufficient understanding of the condition. There also needs to be a service to deliver this care. Heart failure affects about 0.5% of the population, depending on the age of the population, so each general practice has a manageable number of patients. However, the expertise and confidence needed to deliver optimal care to heart failure patients and their families are not widely held in primary care. There is largely a reliance on secondary care to provide community services, led by consultants and delivered by specialist nurses. Within this system patients are usually well served, but sometimes patients fall between the community service and general practice. In Central Manchester there is no community heart failure service. About one in five patients with heart failure were being admitted each year, indicating that heart failure management in the community needed to improve.
There is emerging evidence that heart rate control is an important element in the management of people with heart failure. The major beta-blocker trials have shown improved mortality and reduced hospitalisation when patients with impaired left ventricular (LV) function are managed with optimal doses. In a meta-analysis of these trials, McAlister et al. have shown a correlation between heart rate control and improved outcomes.1 Beta-blockers may have other actions apart from heart rate control; for instance, they may be anti-arrhythmic or have some other mechanisms for their action. Ivabradine, whose only function is heart rate control, has also shown a reduction in hospitalisation for heart failure.2 Heart rate is additionally an indicator of optimal beta-blockade3, and so may be a proxy for optimal medical treatment.
We hypothesised that practice heart failure registers may not be complete or robust due to patients not always being allocated the correct READ codes. We set up a project which improved practice heart failure registers. Ensuring practices have robust registers, by improving clinical coding in general practice, means more accurate prevalence levels can inform planning and commissioning of heart failure services.
Echocardiography (ECHO) is the “gold standard” test in the diagnosis of heart failure. Brain natriuretic peptide (BNP) can be helpful to rule outpatients who do not require ECHO. This study used an elevated level of Nterminal prohormone BNP (NT-proBNP) as a criterion for referral to a new community heart failure clinic. Results showed that NT-proBNP could be a useful test in the management of heart failure. The researchers propose to institute age- and sex-related cut-offs to refine its place in the patient care pathway.
Mandy Davies, Christine Thomson and their practice team from Elgin provide a ‘how to’ guide on setting up an innovative strategy for managing chronic heart failure, based on their programme that recently won an Innovation in Primary Care Award.
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