The Pharmaceutical Journal Vol 267 No 7169 p510-525
13 October 2001

BPC 2001 summary

Optimising the management of heart failure

Joe Asghar, pharmaceutical adviser, Northern regional drug and therapeutic centre, Newcastle, discussed the management of chronic heart failure. “Heart failure is still misdiagnosed, still underinvestigated and still undertreated,” he said.

Heart failure is a multifactorial syndrome: a cluster of issues cause the heart to fail. It is a progressive condition and accounts for 5 per cent of all hospital admissions in the United Kingdom. Readmission rates in the elderly are between 29 and 47 per cent within three to six months of discharge. On average, every GP has 20 people with heart failure and it accounts for 1 per cent of health care expenditure in the UK. Diagnosing heart failure is not easy, he said. Only 32 per cent of people with suspected heart failure have the diagnosis confirmed. There is a lack of agreement over what constitute the clinical features of heart failure and different scoring systems are used.

A large number of drugs are used for heart failure, he said. Thiazide and loop diuretics have been around for a long time and do help with symptoms but there is no randomised controlled trial evidence that they improve prognosis in people with heart failure. Mr Asghar said that he was going to concentrate on angiotension converting enzyme (ACE) inhibitors, spironolactone and b-blockers.

ACE inhibitors

Evidence showed that ACE inhibitors work: treatment results in lower mortality, a lower risk of myocardial infarction and lower rates of hospital admission than placebo in patients with left ventricular dysfunction. “They should be used as part of routine practice,” he said. However, a study in 1998 revealed that only 60 per cent of GPs were currently treating patients with heart failure with an ACE inhibitor. There were also difficulties in getting GPs to use reasonable doses. “ACE inhibitors are often prescribed at doses lower than those used in the main mortality trials,” he said.

Until recently, b-blockers had been considered to be contraindicated in heart failure because they could worsen symptoms by decreasing the contractility of the heart. However, the latest studies in patients with mild to moderate heart failure had shown that hospital admission and total mortality are reduced by treatment with b-blockers. “Beta-blockers make a real difference, but the problem will be convincing doctors to treat heart failure with a b-blocker,” he said. He thought that b-blockers should be a part of routine practice but only for patients with class I-III heart failure, who are clinically stable and who are already taking an ACE inhibitor, diuretic and possibly digoxin. Therapy should generally be initiated by a specialist rather than a GP, he added.

In and out of favour

The potassium sparing diuretic spironolactone was “continuously in and out favour,” said Mr Asghar. A study, published in 1999, of patients with treatment failure at the severe end of the spectrum showed that a daily dose of 25mg spironolactone reduced risk of all-cause mortality by 11 per cent. He recommended that this dose should be used in patients with moderate to severe heart failure (grade III to IV) who are still symptomatic despite ACE inhibitor, loop diuretic and digoxin therapy. However, monitoring of adverse effects was vital — in particular, hyperkalaemia, and also gynaecomastia and breast pain, effects that can occur in up to 10 per cent of men.

Digoxin was another drug that went in and out of favour, he said. Evidence showed that digoxin reduced the rate of admissions to hospital when added to other therapies but was not effective on its own.

There was no evidence that calcium channel blockers were of benefit in heart failure and there was no information on use of anticoagulant/antiplatelet therapy.

“In conclusion, heart failure is associated with significant morbidity and mortality and despite good evidence, not all patients are adequately treated. “Apart from ACE inhibitors, there is clear evidence that both b-blockers and spironolactone increase survival. However, we do need more head-to-head studies to confirm the precise order in which therapies should be used. We also need clear monitoring arrangements in primary care.”

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