Pharmaceutical Care Of People With heart Failure

Pharmaceutical
care of people
with heart failure
Course information
Pharmaceutical
care of people
with heart failure
Course information
page
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Introduction
Teaching plan
Lecture: Chronic Heart Failure
Needs Assessment Tool
Aide Memoire – Heart Failure
Questions for Heart Failure
Introduction
Heart failure is defined in the SIGN guideline published in 1995 as
“… an inability of the heart to deliver blood and, therefore, oxygen at a
rate commensurate with the requirements of the metabolising tissues
despite normal or increased cardiac filling pressures.”
It results in significant morbidity, markedly affecting patients’ quality
of life, in addition to having a significant effect on length of life. It is a
major cause of death and its prevalence is increasing as a consequence
of the increasing proportion of the elderly in the population and
as a result of medical advances which have reduced mortality from
myocardial infarction, the survivors however, doing so with significant
myocardial damage.
Prevalence is reported to be between 1 and 2% of the general
population, but rises with age.
Management of heart failure requires both pharmacological and
non-pharmacological approaches. The evidence-base for the former
is extensive and is a useful tool in managing patients. The latter
includes lifestyle changes and the use of medical devices and surgical
techniques.
The evidence base, and subsequent recommendations for the
management of chronic heart failure, have recently been updated and are published in SIGN Guideline number 95.
To update pharmacists on the current management of chronic heart
failure and explore ways to implement pharmaceutical care for this
patient group as part of normal working practice.
Aim
At the end of the session participants will be able to:
• Define the current strategies for the management of patients with
stable chronic heart failure and identify clinical markers suggestive of decompensation.
• Identify pharmaceutical care issues, respond to symptoms in patient
scenarios and identify appropriate management solutions.
• Explore how to implement the principles of a pharmaceutical care
needs assessment tool in practice.
Objectives
Pharmaceutical care of people with heart failure
Implementing the
needs assessment
The Pharmaceutical Care Needs Assessment Tool has been adapted
from the generic tool developed for the hypertension, diabetes
and angina model schemes. Further questions which are useful in
identifying patients with poorly controlled heart failure, or patients who
are at risk of an acute episode, have been added to customize the tool
for this patient group. These additional questions are:
Have you noticed any of the following?
• increase in weight over several days
• development or worsening of ankle swelling
• development or worsening of breathlessness on exertion
• development or worsening of breathlessness at night
• development of a productive cough
New York Heart
Association Classification
References
Useful contacts
The NYHA classification is used to assess the severity of a patient’s
heart failure based on the effect the patient’s symptoms have on
their daily activities. It is therefore a subjective assessment and may
not correlate with the degree of ventricular dysfunction measured by
echocardiography. It is often used during clinical trials as the basis of
inclusion criteria or to identify sub-groups. In day-to-day practice it can
also be used to determine whether there is a change in the patient’s
heart failure status.
Class 1
Evidence of cardiac disease, but
asymptomatic even on exercise
Class 2
Symptoms of HF, but only on
exercise
Class 3
Symptoms of HF, on mild exercise
Class 4
Symptoms of HF at rest
Management of Chronic Heart Failure: A national clinical guideline.
www.sign.ac.uk/pdf/sign95.pdf
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For patients: chronic heart failure www.sign.ac.uk/pdf/pat95.pdf
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• British Heart Foundation – www.bhf.org.uk
• Chest Heart and Stroke Scotland – www.chss.org.uk
• British Cardiac Patients Association – www.bcpa.co.uk
course information
Teaching plan
Introduction to
the evening
10 minutes
Lecture
50 minutes
Comfort break
10 minutes
Workshop
80 minutes
Split the group into smaller groups of about 7 or 8.
There are 4 cases but in the time it is probably only possible to cover
three of these. The three cases to be covered should be chosen in consultation with the local tutors.
Each of the groups should be encouraged to cover all three cases; this
should take about 15 to 20 minutes for each case and then about 10 to
20 minutes for general feedback to cover the main discussion points for
each case.
Pharmaceutical care of people with heart failure
Pharmaceutical Care Needs Assessment
Heart Failure
Name
Doctor’s name
Date of birth or CHI no.
1
2
3
Date
Can you tell me what medical condition(s) you have?
dose
5
What, if any, side-effects do you experience from your medication?
8
9
10
yes
no
yes
no
Do you ever forget or choose not to take your medication?
If yes, how often – weekly/monthly?
Do you know what to do if you have missed a dose of your medication?
7
no ordered monthly
What is/are the name(s) of the medication you take
for your condition(s) and how do you take it/them?
4
6
frequency
Do you feel that your medication is controlling your symptoms
or have you noticed any changes since you started taking your
medication? Do you know the trigger signs?
Do you have a regular check/blood test/review?
Can you tell me when that was, and the outcome?
Would you like any information/advice on anything about
your condition/medication/health promotion areas?
Do you smoke?
Specific Heart Failure questions
Have you noticed any of the following:
• increase in weight over several days
• development or worsening of ankle swelling
• development or worsening of breathlessness on exertion
• development or worsening of breathlessness at night
• development of a productive cough
Note any follow up action required and any outcome
Issue or action
Understanding
Effectiveness
Safety
Compliance
Health/self help
Referral
Other
course information
Pharmaceutical Care Needs Assessment
Aide Memoire – Heart Failure
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Can you tell me what medical condition(s) you have?
This helps to clarify their understanding of their condition(s). Length
of diagnosis can be important. People are provided with lots of support
and information at initial diagnosis – the amount of information
and support received at diagnosis will vary, also they may or may not
be attending appropriate clinics. Over time, people can forget key
information or the messages may change over time.
Note answer and offer patient general information on conditions.
Action
2
What is/are the name(s) of the medication you take for your
condition(s) and how do you take it/them?
Check with prescription or patient medication records. Confirm that
the patient is taking the medication as instructed on the prescription
with any appropriate counselling instructions, e.g. swallowed whole.
Note how person takes medication and offer appropriate advice.
Action
3
Do you ever forget or choose not to take your medication?
If yes, how often – weekly/monthly?
Clarify which drugs are missed and when.
Offer appropriate verbal advice depending on response.
Action
4
Do you know what to do if you have missed a dose of your
medication?
Document response.
Offer appropriate verbal advice depending on response.
Action
5
What, if any, side effects do you think you are experiencing from
your medication?
Adverse effects are common; most are dose-related and predictable. Idiosyncratic adverse effects are potentially dangerous and usually
occur in the first weeks of treatment. Some people erroneously link
medication to adverse effects and this can affect their adherence to
their regimen. It is possible to manage some adverse effects.
Action
Note any adverse effects and confirm that they are as a result of their
medication and reassure patient accordingly.
Pharmaceutical care of people with heart failure
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Do you feel that your medication is controlling your symptoms
or have you noticed any changes since you started taking your
medication? Do you know the trigger signs?
Document response. Consider and offer appropriate advice.
Action
7
Offer appropriate verbal advice depending on response.
Do you have a regular check/blood test/review? Can you tell me when
that was, and the outcome?
Document response.
Action
8
Offer appropriate verbal advice depending on response.
Would you like any information on anything about your condition/
medication/health promotion areas?
This helps to identify any self-help or health issues.
Action
9
Offer advice and support on how the person can manage their lifestyle
more effectively or signpost them to other organisations. Offer general
healthy eating advice as appropriate.
Do you smoke? How many cigarettes do you smoke and how long
have you smoked?
Smoking exacerbates respiratory conditions by causing damage to
the airways and increasing the risk of an attack. All patients should
be encouraged to stop smoking. Identify what stage they are at in the
“cycle of change” model. In patients suspected of having COPD, it is
important to have a smoking history as this may help to confirm the
diagnosis.
Action
Offer appropriate support or refer to local support agency depending
on local arrangements.
This aide memoire is for guidance and the pharmacist should use their
professional judgement at all times.
course information
Questions for Heart Failure
The management of decompensated heart failure is not covered in
the core teaching material. However, it is important that patients with
heart failure, and health professionals caring for them, recognise the
signs and symptoms of worsening heart failure.
The additional questions included in the needs assessment tool help
pharmacists recognise, during a patient consultation, whether the patient may need adjustment of their medication, or referral to a GP or heart failure specialist.
These questions are:
1
Have you noticed an increase in weight over several days?
Patients with heart failure should be encouraged to regularly check
their weight. Rapid increases in weight, 1.5-2kg over 2 days, should
prompt a review. Weight can increase prior to, or in the absence of,
obvious oedema.
If patient is self-managing diuretic therapy, prompt them to adjust
dose. If patient is not self-managing, advise patient to seek advice from
their GP or heart failure specialist.
Action
Have you noticed the development or worsening of ankle swelling?
2
This may be an indication of worsening fluid retention. The development, or worsening (e.g. swelling extending to the calf, knee or further)
of peripheral oedema will require an increase in the dose of diuretic,
which the patient may have been instructed to do, or may require adjustment by a health care professional.
Ankle swelling may be precipitated by drug therapy. Dihydropyridine
calcium-channel blocker causes ankle swelling independent of heart
failure, while other medicines, e.g. NSAID, glitazones, do so by worsening heart failure.
If patient is self-managing diuretic therapy, prompt them to adjust
dose. If patient is not self-managing, advise patient to seek advice
from their GP or heart failure specialist. If the patient is currently being
treated with a medicine that could worsen fluid retention, this should
be brought to the attention of the prescriber.
Action
Pharmaceutical care of people with heart failure
3
Have you noticed the development or worsening of breathlessness
on exertion?
The NYHA classification grades heart failure by symptoms. A reduced
exercise tolerance due to breathlessness would change a patient’s
NYHA class and consequently may change the choice of drug therapy.
Action
4
The patient should be encouraged to seek advice from their GP or heart
failure specialist for review of their treatment.
Have you noticed the development or worsening of breathlessness
at night?
Increasing breathlessness at night can take two forms: Orthopnoea results from redistribution of peripheral oedema to the
lungs when the patient lies flat. Patients often need 2, 3, 4 or more
pillows to sleep. This ensures that their chest is not the lowest part of
their body and consequently fluid will accumulate elsewhere, e.g. the
buttocks. Paroxysmal Nocturnal Dyspnoea (PND) also results from redistribution of fluid. However, redistribution is into the vascular space,
which increases blood volume and consequently cardiac return. This
increase in preload can precipitate acute heat failure. Breathlessness
due to PND is more acute, severe and distressing for the patient.
Worsening orthopnoea, or the presence of PND, require adjustment of
diuretic therapy.
It should be noted that patients with heart failure often wake up at
night but this is commonly caused by the need to pass urine rather than
breathlessness.
Action
5
The patient should be encouraged to seek advice from their GP or heart
failure specialist for review of their treatment.
Have you noticed the development of a productive cough?
Patients often develop a cough that is unrelated to heart failure. However, a cough that is productive of yellow/green sputum may indicate a
chest infection that will require antibiotic treatment. Chest infection is
a common cause of decompensation.
A cough that is productive of clear watery sputum that may be frothy or
blood stained may be due to worsening pulmonary oedema and such
patients need to be referred to a GP or heart failure specialist.
Action
The patient should be asked to describe whether or not the cough is
productive and the nature of any sputum. Sputum that may be infected
should prompt a referral to the GP. If the sputum could indicate pulmonary oedema, the patient should be advised to seek advice from their
GP or heart failure specialist.
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Pharmaceutical care of people with heart failure
3rd Floor, 2 Central Quay
89 Hydepark Street
Glasgow G3 8BW
Tel: 0141 223 1600
Fax: 0141 223 1651
www.nes.scot.nhs.uk/pharmacy