First person: Helping ease the burden of heart failure

It all started with my best friend, who had been diagnosed with dilated cardiomyopathy in 2001. 

After many years on medication, including an ACE inhibitor and beta blocker, his heart improved and he was immediately taken off them. A year down the line, however, his worsening cardiomyopathy led to heart failure. He had a congestive episode – fluid built up in his chest and lower body and he experienced severe breathlessness and cyanosis – and was blue lighted to the hospital. 

Working out how to help my friend’s wife with his prescription was the start of my journey into heart failure specialism. He is just one of around one million people living in the UK with the condition, according to the British Heart Foundation, with around 385,000 more people undetected or undiagnosed. 

Projections by NICE indicate that hospital admissions for heart failure are set to rise by 50 per cent in the next five years with heart failure the leading cause of admissions in over-65s.

I believe community pharmacists have one of the most important roles to play in coping with the burden of heart failure on the NHS. In my practice in Bridlington, I encounter a large number of people both diagnosed with, and at risk of, heart failure. I play a vital role in optimising their medication and ensuring they are getting the best possible care, in line with NICE guidelines, and therefore improving their quality of life with their friends and family. 

Niche area?

Historically, heart failure has been a very niche area managed by GPs and heart failure nurse specialists in a primary care setting. NHS England reports that 80 per cent of heart failure patients are diagnosed in hospital, despite 40 per cent having symptoms that should have triggered an earlier assessment. With the growing burden of the illness, that has to change. 

A single admission to hospital with the illness can cost the NHS up to £20,000, while late diagnosis is associated with a higher rate of morbidity. Around 10 per cent of heart failure patients admitted to hospital will die within six months. 

There is real momentum across both primary care and the pharmacy sector towards pushing for earlier diagnosis and better management of the condition in the community, with opportunities for community pharmacists to get more involved. 

The Alliance for Heart Failure is an organisation that works with the heart failure community and is supporting a campaign to ensure that community pharmacists play a major role in easing the burden of this illness. 

Teamwork

The gold standard for treating heart failure – as recommended by the European Society for Cardiology (ESC) – is a multidisciplinary team working across primary and secondary care. In order to be part of this, knowing the symptoms (see table), diagnosis pathways and medications for heart failure is crucial. 

This initial knowledge is only half the journey. As the PCN lead pharmacist specialising in heart failure, I work closely with my local GPs to ease the burden of heart failure in my area. I can read echocardiograms, communicate my concerns about a patient’s treatment with other specialists and, most importantly, optimise treatments myself.

This is where all the difference can be made. The ‘four pillar’ approach using angiotensin receptor neprilysin inhibitors (ARNi), beta-blockers, mineralocorticoid receptor antagonists and SGLT2 inhibitors, are the main treatments for heart failure – and getting the right balance can be a case of trial and error. Even though there are specialist heart failure community nurses, it is often very hard to do this in a timely and effective manner once the patient is out of hospital.

After a positive NT-proBNP test, a patient’s diagnosis of heart failure syndrome is confirmed via an echocardiogram. At this stage a pharmacist can play a key role in assessing their medications, symptoms, information about their diagnosis so far and optimise – in collaboration with a multidisciplinary team – an effective titration of their medication. 

One of the most satisfying things about becoming a heart failure specialist was being able to see the impact of my work. Within six months of optimising medicines for the patients in my area, we went from 6 per cent of patients on the heart failure register receiving the four pillars approach to 24 per cent. 

“Jaya, I’ve never seen such high optimisation rates – what’s going on here?” was the response from one of the cardiologists when he saw the results. I was amazed that as a community pharmacist with extra training under my belt I was able to improve the lives of so many people. 

If we are to ease the growing burden of heart failure over the coming years, then it is vital that community pharmacists across the country step up and realise the immense potential they have to make a difference to the outcomes for heart failure patients. 

It took an experience with my friend for me to realise this. I hope many others make the same journey towards transforming their community’s response to heart failure.