This part of the conversation needs to be based on what you have found out about where the patient is on their heart failure pathway and on the new medicine/s they have been prescribed.

Ultimately, the lowest dose of diuretic should always be prescribed. For some patients this will mean dose reduction or discontinuation while, for others, it will mean that the diuretic is a long-term treatment to prevent fluid retention. 

For other HF medicines the intention is to up-titrate doses. The target doses are listed in Table 1. Side-effects, some of which are transient, may limit the tolerable upper dose.

Possible exploratory follow-up questions are:

• Have you been asked to record your weight? How is that going? Is someone contacting you/when is your next review?
• Have you been asked to measure your blood pressure at home? How is that going? Do you have any concerns over doing this or the readings you are getting?
• Have you been told that you need to have any blood tests while taking this medicine? When are these?

Most HF medicines need to be taken long-term with the exception of diuretics, which may be reduced or stopped altogether depending on fluid retention or, conversely, may need a dose increase or be reintroduced if congestion increases. 

Patients’ experiences of side-effects from HF medicines differ markedly. A realistic explanation about this, and that some side-effects will improve and some may not, is helpful. For example, some patients feel tired when they first take beta-blockers and for some this may gradually improve or they find they are able to tolerate it.

Many of the medicines lower blood pressure. To avoid symptoms patients may find it helpful to be careful when getting up quickly (lying or sitting to standing), especially if they are starting a new medicine or after a dose increase. 

Increased urination is a common side-effect of the SGLT2 inhibitors and some patients find this settles down after a few weeks. Advising the patient about good ‘genital hygiene’ is also helpful to reduce the risk of urinary tract infection and genital fungal infection (e.g. candida).

Healthy heart advice for HF does not differ from other CVD conditions: a good diet, exercise, weight management, sensible alcohol intake and smoking cessation should be encouraged. 

Enquiring about fluid intake can be helpful. In general 2-2½ litres a day is a reasonable intake. Many people think this means ‘how much water do I drink?’ and forget that it should include all fluids – so they need to add in all the cups of tea or coffee, soups and alcohol consumed.

Salt intake is also important in managing fluid overload (high salt intake will lead to fluid retention). Advise patients not to add salt to food, to check food labels and learn how to choose lower salt options.

Most people know that microwave meals, takeaways and snacks like crisps are high in salt. They might be surprised to know that a lot of other foods are also high in salt such as cheese; breakfast cereals; canned soups; bread, pastries and pizzas; biscuits, cookies and cakes; processed meats – sausages, bacon and ham; sauces – gravy, ketchup, mustard, brown sauce and soy sauce.

The amount of salt will vary between different brands and varieties, so patients should check the food labels to help choose the healthiest option.

Make sure the patient knows when their next appointment is, including any blood tests.