Transcript: Heart Failure Management In Primary Care

Liz Rohr:

When it comes to heart failure, this is a complex clinical diagnosis that has no real gold standard of like, yes, you have heart failure. It's a combination of a variety of things, both patient symptoms as well as some diagnostic testing. But the moral of the story, especially according to the ACC/AHA guidelines with a new version in 2022 for heart failure, is that it's about either functional or structural abnormality of the ventricles so that they're not as effective in pumping blood. It can feel really unnerving for new grads, and I remember feeling this way too, for being the provider when it comes to heart failure. Even despite having, for myself personally, having multiple years of inpatient adult experience as a nurse working with patients with heart failure, it was a little different and it felt overwhelming sometimes as a new provider.
 

Well, hey there. It's Liz Rohr from Real World NP, and you are watching the Real World NP YouTube channel. We make weekly episodes to help save you time, frustration, and help you take the best care of your patients.

So in this episode, I really want to focus on patients who have established heart failure already as a diagnosis and start with some background information. Next, I'll talk about assessment, like assessing heart failure, the main things that we need to assess in the primary care provider role. I'll touch on management pieces and then as well as referral and co-management with cardiology.

So a couple of pieces of really important background information. And whenever I do any of my teaching, I really start with these foundational pieces because it really informs every other step. These are the things you must know to kind of pass go, continue. And so it may feel like what is the point of this? But I promise you it's important.

So couple of background pieces of information. When it comes to heart failure, this is a complex clinical diagnosis that has no real gold standard of like, yes, you have heart failure. It's a combination of a variety of things, both patient symptoms as well as some diagnostic testing. But the moral of the story, especially according to the ACC/AHA guidelines with a new version in 2022 for heart failure, is that it's about either functional or structural abnormality of the ventricles so that they're not as effective in pumping blood. That's like the main definition of it. And the way you diagnose it, again, is a variety of pieces. So there are symptoms which we'll talk about in a moment, but a couple of diagnostic tools I just want to introduce in broad brush perspectives.

So one is a serum blood test called a BNP. I'm not going to attempt to pronounce it because I'm going to pronounce it wrong. But BNP, N as in Nancy. And NT-proBNP, so this is a hormone. BNP is a hormone that's reduced when the ventricles are overly stretched and it can be a sign of heart failure. NT-proBNP is something that's broken off of that precursor for that hormone. And so that has also been measured for diagnosis of heart failure. That's a test that has a lot of caveats. It is not routinely used for monitoring patients in heart failure. It has some data of correlation of prognosis with higher levels can lead to worse prognosis. However, there's no recommendations for continuously monitoring it, and there are so many caveats in there. If you're going to order that test, please get comfortable with that test before you do so. Please don't just order BNP on somebody and be like, "Oh, great, it's blah, blah, blah." There's a lot of caveats.

And the other test that is used in consideration of the diagnosis initially is echocardiogram, which is important when it comes to the different types of heart failure. And what they're looking for in that echocardiogram is the actual structure of the heart and how it's functioning. We're looking at the ejection fraction of how much blood is leaving the heart. So hold that thought for a moment. So that's some important diagnostic criteria.

The next piece of important background information is the two broad types of heart failure. When I was in school in undergrad, that was over 10 years ago, and we used to talk about systolic and diastolic heart failure. It's sort of still a thing sort of, but heart failure is just, I think the moral of the story is heart failure is a lot more complicated. And the newer terminology is heart failure with reduced ejection fraction versus heart failure with preserved ejection fraction, meaning the ejection fraction measured on an echocardiogram. And just there are actually many shades of this, but reduced ejection fraction is effectively less than 50% on an echocardiogram versus preserved is 50% or greater ejection fraction. Again, there are shades in between and nuances, but I'm going to leave it at that for simplicity.
But the main moral of the story with that is that we need to know when we're seeing a patient is this reduced ejection fraction or preserved ejection fraction because management is different. It's kind of like two different entities. They're similar, but they're very different. And in this episode, I'm really talking about reduced ejection fraction.

Two last pieces about background information. And again, this all ties together when it comes to assessment and management and collaboration with cardiology. So the next piece is about stages and classes. And so probably this is a review for you, but the stages are in the ACC/AHA guidelines. And when it's talking about is the levels of severity of structural impairment and symptoms, and there's levels A through D.

So stage A is, and these are broad, and definitely look at the guidelines if you want to learn more. But the broad overview is that A is for people who are at risk for heart failure. So they have diagnoses like diabetes, hypertension, patients with obesity fall into this category. There are some cardiac abnormalities that predispose somebody's risk for heart failure. Those patients are considered stage A.

Stage B is still considered "pre-heart failure". However, it's patients who have signs of structural cardiac impairment, structural disease, cardiac disease, but they do not have symptoms.

Stage C is patients who have both signs of structural cardiac disease and now have symptoms. And stage D is called advanced heart failure. And those are patients that both structural changes and symptoms so severe that they're interfering with their daily lives or leading to recurrent hospitalizations.

So why does that matter? That sounds very tedious, Liz. Now it's really not, I promise. The rationale for that is that because inside the guidelines, the treatments correlate with what stage we're talking about. And so just to orient you, when you have a patient coming into your clinic, that's one of the questions you need to think about. What stage are we talking about here?

Last pieces of background that's really important, again, this all ties together with the management pieces, is that there are classes. It's NYHSA, I believe. I always get the acronym messed up, so I'm not going to say it. But it talks about the classes of heart failure. And this one, whereas the stages are really static, the classes are a bit mobile. Meaning it's really describing the state of their symptoms as they are currently. So somebody can go from stage one to stage four and back to stage one again. And it's really, it just depends on what their... It's helpful to determine what their clinical baseline is to shoot for. And also if we're having a worsening state of their symptoms, how do we classify that?

So there are four stages. So the first one is that there's no symptoms with both physical activity or rest. The second one is that you're starting to get some symptoms with activity, but you're still feeling okay when you're resting. The third stage is that you're having pretty significant symptoms when you're doing physical activity, but still, when you're resting, you're doing okay. Stage four unfortunately is when patients have both severe symptoms with physical activity and they also have symptoms at rest. Like I said, it's not a fixed state to be in those classes of symptoms. Those can change. But those are just things to watch out for.

So again, just to kind of recap, you want to think about are we talking about reduced ejection heart failure, HFrEF versus HFpEF, which are just the cutest names. So if you talk about HFrEF versus HFpEF, what stage of heart failure are we talking about and what class of heart failure are we talking about in this visit, because that one changes. 

Last piece is what are the goals of care for heart failure? Just to orient you or reorient you about that, the goals are to prevent complications, reduce morbidity, meaning hospitalizations, reduced quality of life, et cetera, and reduce mortality and prevent progression. We're really trying to keep, like can we optimize what we have, prevent it from getting worse, and prevent patients from dying. Those are really important, crucial parts of the management of heart failure.

So next I want to talk about the assessment and just really kind of put it in context. So the typical context is that you're a new grad or maybe you're returning to primary care or you just want a refresher. Beautiful. So you have a person who's in front of you or on your schedule and you're like, "Oh gosh, they're coming in for follow-up of heart failure. What do I do?" It's like, okay, take a deep breath, first of all. Second of all, let's think about some assessment pieces. So things you can start before the patient even comes in the room. So looking at their chart, when were they last seen in your clinic? By who? Was it one of the other primary care providers? Was it a chronic care follow-up three months ago or were they last seen two years ago?

Another question, have they seen cardiology before, ever, hopefully? If somebody has a diagnosis of heart failure, the hope is that they at least have seen cardiology on that initial diagnosis. Spoiler alert for referrals. But have they seen cardiology before? When was that last appointment? Was it a year ago because they're stable? Was it six years ago because they're just not really interested in their care right now, and now they're really short of breath? Other pieces. What tests have been done before? Have they had an echocardiogram done before? Have they had a BNP done before or NT-proBNP? Again, that's kind of for reference. We don't really continually monitor that BNP test. We do continually monitor those echocardiograms though. Typically it's annually.

And then also while you're looking at that cardiology note, likely they're going to say those things that I just talked about, HFrEF, HFpEF, what's their rejection fraction percentage? Is it less than 50, greater than 50? What number is it? Do they talk about their baseline? Do they talk about how they're feeling at that visit? What the expectations are? What is their care regimen and what is their recommended plan of care? Follow up in three months, follow up in six months, follow up in a year? So that's all before the patient walks in the door, before you're in front of them.

So when it gets to being in front of the patient, you want to do a couple of assessment questions. You want to assess how their symptoms are. There's a whole bunch of symptoms for heart failure with a variety of sensitivity and specificities. However, let's touch on some of the main ones. So we want to ask questions about dyspnea, chest pain. Are we having either dyspnea or chest pain with activity, at rest? Again, talking about the classes. Activity? Are they fine at rest? Are they not well when they're resting? Those are important. Do they have edema, lower extremity swelling? Do they have a cough? Do they have paroxysmal nocturnal dyspnea? Meaning waking up in the middle of the night, suddenly waking up because they're short of breath. Do they have orthopnea, meaning they can't lay flat? All of those things have various sensitivity and specificity for heart failure, including weight gain, which, hold that thought for one second. I'm going to touch on that.

But last kind of physical assessment piece, if you're looking at a person, aside from assessing their subjective symptoms, are listening to their lungs for rales. That can be associated with heart failure worsening, or maybe their baseline, hopefully not their baseline. But anyway, listening to their lungs, looking for edema in their lower extremities. How far up does it go on their legs if they do have it in their feet? Is it pitting? Is it not pitting? Is it three-plus pitting up to the shins? Do they have generalized anasarca? Like hopefully not, pretty terrifying.

And then the last really tricky assessment piece for physical exam is that JVD, the jugular vein distension. I know it's really tricky. You can Google it. You can take a look and see what the steps are. From a cardiologist's mouth, the most important piece is assessing for it, less so how many centimeters or inches or however you measure it above... So moral of the story, that's the one where you lean back about 45 degrees. You can press on the patient's or on their liver and it can lead to some reflux back up into their jugular veins. And then you measure how tall it is above that line. Anyway, the moral of the story is that you're trying your best to assess it. It doesn't have to be perfect. You don't have to get those exact measurements. You're just trying to get a picture of what's going on. Cardiologists do this all day every day. So they're very good at it. All you got to do is practice.

So I do want to touch on weight because this leads into the patient assessment, like assessment slash counseling. So one of the pieces you want to assess is weight gain. I felt really uncomfortable with this as a new grad. And I think it's really dependent on the patient as well as the cardiologist that you're collaborating with in the co-management of this patient. But typically, patients who have heart failure with reduced ejection fraction, they want to check their weight at home every day, ideally. Ideal world, they check it every day. And there's various parameters, whether they have worsening symptoms or they have a certain amount of weight gain in the course of overnight versus in the course of a week.

So for an example, I had a patient who if they had worsening dyspnea, shortness of breath and dyspnea, the same thing, but like coughing, worsening of their edema, they had more than three pounds of weight gain within one day to the next or five pounds over the course of a week, they were directed to call the office, either the cardiology office or our office to get guidance about their medication management, any education, any diuresis that they might need, things like that. Or guidance to go for hospitalization, for example, to the ER. So weight measurement is really important. Having those conversations, seeing what cardiology recommends, coming up with a plan for that patient, reinforcing it at that visit.

And also talking about lifestyle management. So reducing sodium intake. The 1500 to 2000. They may need fluid restriction as well, depending on their staging, their symptoms. We definitely want to talk about alcohol use and tobacco use, reducing those as best we can. And just overall kind of healthy diet as well as preventative measures.
 

So when it comes to management, most of our role in primary care is assessment. Where are we at? When do they see cardiology? What is the regimen supposed to be? What's their baseline? Baseline weight, baseline symptoms so that we can establish if there's been a deviation. And on that note, I actually want to add about the symptom variety is that a lot of times patients will get diuresis when they are having signs of fluid overload. And that is an art more than a science. And it is normal if you feel very uncomfortable with that. And what I would do, and I still do, is call the cardiologist themselves and say, "Hey, I have our mutual patient, blah, blah, blah, blah, blah. Here's all the information. They're taking all of these meds. Here's what is going on. Do you have guidance about adjusting their furosemide?" for example. And it was a very collaborative conversation, but I digress.
 

Okay, so when we talk about management, I'll get back to that. So management is effectively assessing the patient, doing patient education. Are they at their baseline or are they not at their baseline? Are they worse, better? Are they the same? And then what is their medication regimen? Because just because we prescribe something doesn't mean somebody's taking it. And then the other piece is that even if we prescribe a medicine, it doesn't mean that they tolerate it. So this is a little too much to get into for one episode. I do feel like this would be helpful course content, but I make no promises. But to be continued.
 

Talking about guideline-directed medical therapy, GDMT. You may see this in the guidelines or in heart failure conversations in general. Effectively when we talk about those stages, the ABCD, in the guidelines, it takes the stages and it gives you exactly what those people are supposed to be taking for guideline-directed medical therapy. So if you're at risk, there's recommendations. If you have pre-heart failure but you have structural changes, there's other recommendations. And if you're at that stage C of, you know what, you have both structural changes and symptoms, you get a whole cocktail of medications.
 

And without getting too much into it, the moral of the story is that there are medicines that are life-preserving, mortality-preserving, meaning these medicines are demonstrated over time to reduce a patient's mortality with heart failure. And then other ones that are symptom reduction and quality of life improvement and reducing hospitalizations, however, have no effect on their long-term mortality. So what's really important to take away is that take a peek at those guidelines, take a look at that kind of medicine cocktail that goes with each of the classes.
 

I really want to focus on just a snapshot of those patients who are at stage C, the ones who have both structural changes and symptoms. Because the majority of patients that I'm seeing in primary care are having that. So just as a broad overview, there's a cocktail of medications for those patients that they should be on. And I want to be clear that there are medications that we choose for heart failure because they, number one, can improve their ejection fraction or reduce mortality. And then there are other medicines that we choose because it's important for their symptom management and to do things like reduce hospitalizations. However, those do not have that mortality benefit. And the reason I'm stressing that is because sometimes in the real world, just because we prescribe a medication for somebody doesn't mean that they tolerate it. And so sometimes we have to do things that are not exactly the way that they "should" be because a variety of reasons.
 

So just as a brief overview snapshot, it gets a lot more detailed than this, but you want to think about what medicine classes is this person taking. Beta blockers, ACE-inhibitors and diuretics are the main three. Those first two, ACEs, ARBs and beta blockers actually, those ones are mortality improving. Diuretics are important for symptom management and preventing hospitalization. However, those are not necessarily linked to reduction in mortality. After that, there's actually been some updates too, whether it's reduced ejection fraction or preserved ejection fraction. And definitely check out the details of the guidelines as it applies to your practice and your patients. But there's more included now about those SGLT2 inhibitors.
 

Regardless of patients who have diabetes or not, there are recommendations about using dapagliflozin. I'm probably not saying that right. I'm going to include it down below, some links in the guidelines as well. But that's definitely consideration for patients who have heart failure, both reduced and preserved. And then they also, we want to think about antimineralocorticoid receptor antagonist. So spironolactone, eplerenone. Those are also diuretics, but those are more linked to the prolongation, reduction of mortality, prolongation of life.
 

From there, there's a whole other host of things, but really that's just like a snapshot overview of there is a cocktail of medications, guideline-directed medical therapy, GDMT, that patients should be on, depending on their stage and their classes and all of that. So definitely take a peak at that in conjunction with the notes from cardiology.
 

And then your next steps are really kind of seeing if they've ever seen cardiology. So if this is an established diagnosis, they should have seen somebody from cardiology before and they should have some guidance from them about when to follow up and further adjustments. I really work collaboratively with my cardiologists that work with my patients because it's really high risk for patients. And I think the other bottom line for real world practice is that in primary care we only get 15 minutes and there are a whole bunch of tests, there's a whole bunch of education, there are a whole bunch of all these different things to be thinking about, as well as guideline updates and new studies and new medications and all of this stuff that really should be in the hands of cardiology.
 

We can absolutely continue them in primary care, but I am definitely a stand for us to get the support that we need to give the best care to our patients. And there's so much to be offered when we can co-manage patients. And I didn't talk about all of the medicines in heart failure. Like I said, that's a huge topic. But hopefully this is a helpful primer for you to feel more comfortable walking into those heart failure visits.
 

So thank you so much for watching.

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