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Heart Failure – hope for a dreadful disease

Honorary Clinical Associate Professor Ralph Audehm discusses what can be done to improve the scary statistics of chronic heart failure in Australia

  Every year 30,000 people in Australia are diagnosed with heart failure and as the Australian population ages this statistic is set to increase. Currently, one in four people over 65 years of age have heart failure.

  Chronic Heart Failure places a huge burden on our hospitals – 50,000 people are admitted to hospital annually, one in five will be readmitted in thirty days and 50% readmitted in 6 months! Half of those admitted to hospital with their first episode of heart failure will die within 12 months, and one in three “mild to moderate” heart failure sufferers will die in 3 years.

  Dreadful statistics to see written down.

  The impact on people with heart failure themselves is enormous with over two thirds experiencing symptoms consistent with depression, 40% struggling to socialise or engage in ADLs and 60% having difficulty with recreational pastimes or hobbies.

  So much can be done to improve these statistics. It requires good teamwork between tertiary care and primary care. In fact, research has shown that primary care can be as effective as outpatient care for management of heart failure! The issue is that there are many great treatments for heart failure, but they are not being used early enough or consistently enough.

A myth I would like to bust here and now – there is no such thing as “mild” heart failure. All heart failure needs to be treated aggressively to prevent mortality and morbidity, the earlier the better.

  There currently exist great resources for management of heart failure, as well as good effective medications. These include the foundations medications: ACEI (or ARB if intolerant of ACEI); heart failure specific betablockers (BB); mineralocorticoid-receptor antagonists (MRA).

  In terms of reducing mortality these medications are effective:

 In terms of how well we perform, a NSW hospital heart failure audit showed that on discharge 66% were on an ACEI/ARB; 60% were on a combination of ACE/ARB and a betablocker; and only 19% on the previous and a mineralocorticoid-receptor antagonists (MRA) – all shown to improve mortality, prevent hospital readmissions and improve morbidity!

 Clearly, a lot can be done to improve the outcome for people living with heart failure. General practice is ideally placed (and we always keep hearing this) to support the uptake of best practice therapy for patients with heart failure.

Firstly, identify your cohort of patients. Use the search capabilities in your programs to identify people with heart failure (or alternatively third party programs such as PENCS will identify them).

Secondly, recall them in for a review of their management using care planning item numbers. Develop a check list that the nurse or doctors can use to ensure patients are on the therapy – all should be on ACEI/ARB and BB unless contraindicated.

Thirdly, increase the dose of medication to reach the maximum tolerated doses. Add in MRAs once medication has been stabilized. MRAs can also be used to reduce the burden of frusemide.

 There are also newer medications available for those patients still symptomatic – the new ARNIs. These add a further reduction in mortality of 20%.

 These steps can all be done within general practice, and developing partnerships with local services/cardiologists will enhance the outcomes for our patients. Much can be done for this dreadful disease which has a worse mortality than most cancers, and most importantly for the sufferers and the health professionals assisting them, there is hope.

  To learn more about Chronic Heart Failure, check out the Clinical Audit: Beating Heart Failure.

Breonny Robson Honorary Clinical Associate Professor Ralph Audehm
General practitioner with 30 years experience. He graduated from Melbourne University in 1984 and obtained a Diploma from the Royal Australian College of Obstetricians and Gynaecologists in 1987. He holds a Graduate Certificate in Clinical Research. In 2004 was made an Honorary Research Fellow of the University of Melbourne and in 2015 an Honorary Clinical Associate Professor.