A guide on heart failure (HF) management for primary health care physicians in Nigeria

• Heart failure is a clinical syndrome manifesting with typical symptoms of dyspnoea and signs in keeping with poor perfusion and /or ventricular filling at elevated pressures. 

• The single MOST important investigation in heart failure is an echocardiogram. 

• The classification of HF rests on the ejection fraction. With a score of > 50% qualifying for HFpEF and HFrEF less than 50% respectively. 

• In patients who can’t easily access an ECHO a BNP test can give you a sensitive differential from other causes of dyspnoea. Always check the JVP; it’s a valuable clinical sign. 

• ABNP level below 100pg/ml or 200pg/ml (in renal Failure) essentially rules out HF. 

• HF is a chronic condition, it is not reversible, however, progression can be altered. 

• In the black population, several studies have shown differing prognosis between HFrEF and HFpEF. Generally, HFpEF tends to have a slightly better prognosis. 

• Patients with HFrEF can improve to HFpEF, but should still be classified and managed as the former. 

• A key to managing HF includes patients adherence to therapies, Daily weights or twice weekly (They can get a bathroom weighing scale), self-titration of diuretics with weights >2kilos from dry weight, (A kilogram is = to 1L of fluid), Fluid and salt restriction therapy, and prompt treatment of complicating medical issues. 

• Most studies have not shown any major benefits with pharmacologic therapies in HFpEF, a key management is control of hypertension, other cardiac risk factors and a trial of ACEi/ARB and MRA if tolerable. 

• Frusemide helps with fluid congestion; it plays no role in improving prognosis or mortality. The only useful diuretic prognosis wise is the class of MRA (Spironolactone/Eplerenone). It should be in the cocktail of every patient with HF if tolerable, (Hyperkalaemia a common SE). 

• Digoxin is NOT helpful in prognosis or mortality and should not be routinely prescribed, can play a small role in maintaining ventricular rate in AF (Especially in the elderly). (Digoxin toxicity is worse with hypokalaemia). Some studies have shown increased mortality in patients on digoxin. 

• Standard management of HFrEF should include a beta-blocker, (Cardiac specific,e.g Metoprolol XR, Nebivolol, Bisoprolol or Carvedilol), an MRA e.g Spironolactone, and an ACEi or ARB ( Ramipril/Valsartan) as tolerable doses as possible. 

• Most patients with COPD can tolerate beta-blockers, asthma is a moderate contraindication, watch out for acute breathlessness after initiating therapy, preferably start them when clinically stable. 

• Non-dihydropyridine calcium channel blockers e.g diltiazem are bad in HF, should be avoided. 

• NSAIDs are bad, causes fluid retention and hyponatremia, avoid in HF. 

• Weight loss (Cardiac cachexia) due to high metabolic rate in HF and hyponatremia are bad prognostic signs in heart failure. 

• Iron deficiency is common in HF and worsens prognosis, it should always be replaced to ferritin levels >100, or transferrin saturations >20%. If you can’t get iron studies done, the MCH (mean corpuscular HB) which is reported in FBE analysis is a close and sensitive guide to iron stores. 

• In diabetics with HF, aside using metformin, the SGLT2 e.g. Empagliflozin, significantly helps in cardiovascular health. (Note euglycaemic DKAs as SE in SGLT2). Avoid the thiazolidinediones e.g pioglitazone as they worsen HF. 

• Worsening HF symptoms in diabetics, despite adherence to all therapies might be a sign of worsening ischemic heart disease, remember the “silent MI”. Aspirin if tolerated is key for primary prevention. 

• In acute decompensation of HF, an intravenous diuretic is more potent than oral therapy. 

• A clue to acute pulmonary oedema is elevated blood pressures from the usual baseline in addition to the ABCDE signs of heart failure. 

• The commonest reason for deterioration in HF is non-adherence to therapy; always educate patients, especially when they feel better. 

• Persisting low blood pressures in patients with HF with elevated JVPs despite the cessation of antihypertensive/diuretic dose reduction is a sign of a drop in ejection fraction/ worsening HF, get an ECHO ASAP. 

• A review of general blood work, ECHO and ECGs should be done at least yearly and preferably 6 monthly in patients who can afford. 

• An annual review by a cardiologist is essential if available.

Written by Dr. Femi Afolayan

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3 thoughts on “A guide on heart failure (HF) management for primary health care physicians in Nigeria

  • September 11, 2019 at 9:03 am

    Very helpful guide!

  • September 11, 2019 at 2:57 pm

    Thank you for this beautiful article Dr. Afolayan. I think all internists need to read this. Very well put together! Well done!

  • September 14, 2019 at 4:29 pm

    A well written summary. Kudos Dr Femi

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