Medical problem Proposed action Evidence

/ Care issue

Untreated Need for therapy: NICE

indication – HF: ●​ Symptoms:
NG106
-​ Breathlessness (especially on exertion / lying flat), Fatigue, Peripheral oedema
●​ Signs:
-​ Raised JVP, Crackles (fluid in lungs)
●​ Investigations:
-​ BNP ↑, Echo ↓ ejection fraction
●​ Causes / co-morbidities:
-​ Ischaemic heart disease (most common),
Hypertension, CKD, T2DM, AF

Management
1.​ First-line (NICE HF guidance):
-​ ACE inhibitor (e.g. Ramipril) Start low → titrate BNF
➔​ ADR: Dry Cough (ACEI), Dizziness / Syncope, Hypotension, Increased creatinine,
Hyperkalaemia
-​ Beta-blocker (e.g. Bisoprolol) Start low → titrate BNF
➔​ Improves mortality + symptoms
➔​ ADR: Worsening HF, Hypotension, Bradycardia, Fatigue, Bronchospasm, Reduce hypo
awareness, insomnia
-​ MRA (Spironolactone) BNF
➔​ If symptoms persist
➔​ ADR: Dehydration, Hypotension, Increased creatinine, Hyperkalaemia, Gynaecomastia in
males → spironolactone
-​ SGLT2 inhibitor (Dapagliflozin)
➔​ Reduces hospitalisation + mortality
➔​ ADR: Dehydration, Hypotension, Ketoacidosis, Sick day rules, UTI’s
 2.​ Symptom relief - oedema ankle swelling:
-​ Loop diuretic (Furosemide)
➔​ Start: 40mg once daily
➔​ Maintenance: 20 - 40 mg once daily
➔​ Adjust: According to fluid status + based on weight!!
➔​ For fluid overload: monitor med causes urge to pee more often
➔​ ADR: Dehydration, Hypotension, Hypokalaemia, Hyponatraemia, Gout, Impaired glucose
tolerance
To prevent complications:
●​ Control BP
●​ Manage fluid status
●​ Treat comorbidities
●​ Reduce hospital admissions

Monitoring need General:

- HF ●​ U&Es (Na, K, creatinine)
●​ eGFR
●​ BP to avoid symptomatic postural hypotension
●​ Heart rate
●​ Monitor volume status (daily weights & adjustment of diuretic dose as necessary)

Drug-specific:
●​ ACE inhibitor → SPS
●​ Beta-blocker: HR + BP, Monitor worsening HF initially
●​ Spironolactone → SPS
●​ Diuretics: Furosemide → SPS
●​ SGLT2 inhibitor: Renal function, Dehydration
Clinical monitoring:
●​ Daily weight, Oedema, Breathlessness
●​ Screen for:
-​ diabetes (annually); if pt is diabetic, strict glucose control w HbA1c (3-6 months)
-​ coronary artery disease when appropriate
-​ sleep apnoea when appropriate
-​ chronic kidney disease
Counselling Counselling: ESC + NICE
need - HF: ●​ Avoid ibuprofen OTC as it worsens HF
●​ Dapagliflozin reduces HR, & this is how it treats HF.
●​ Sick day rules card & be taught that they should stop taking Dapagliflozin if unwell with diarrhoea or
vomiting & resume after 24 - 48 hrs of normal eating and drinking (esp. ACEi/diuretics/SGLT2i)
●​ ESC: pts hospitalised bc acute HF should be weighed daily & have accurate fluid balance chart completed
-​ pt should have a dry weight determined to help identify how much additional fluid the pt may be
carrying in future exacerbations.
●​ should weight themselves at home daily, after going to toilet but before eating breakfast & getting dressed
-​ if weight goes up 3 - 4lb overnight or over 2 - 3 days, pt should contact HF support nurse asap.
●​ Diet: Alcohol consumption, Overweight, Avoid cachexia & Salt restriction
●​ Exercise, and rest: Avoid muscle deconditioning
●​ Pneumococcal and influenza vaccines
●​ Stress management
Lifestyle advice for stabilising heart failure:
●​ Exercising / cardiac rehab, & advise on salt restriction & Fluid control (if advised) 1.5-2L fluid restriction
●​ Daily weight monitoring → Weight loss (target BMI <25)
●​ Counsel on imp of weight management
●​ Don't pick up smoking again & Adhere to alcohol limits
●​ Monitor HF symptoms: breathlessness, fatigue, swollen ankles, feeling lightheaded / fainting
●​ Daily rest / pacing
●​ Immunisation
●​ Medication compliance
Counselling on Furesomide:
●​ Explain Furosemide is being offered to treat their fluid build-up, and should also treat shortness of breath
●​ med will inherently make them pass urine more often.
●​ Best to avoid taking at night as it could cause u to wake up to need to pee.
●​ Advise nursing staff if become unwell med should be stopped upon dehydration to reduce risk of kidney
injury (sick day rules)
●​ Advise to report any further ankle swelling or SOB to GP so that may be assessed and treated as required
Seamless care Inform GP: NG106
for HF ●​ Furosemide 40mg daily administered for 24 hrs to treat pulmonary congestion & ankle swelling.
●​ (refer to monitoring for furosemide & Dapagliflozin)
●​ SGLT2i started which has side effect of reducing cardiac preload so decreasing fluid build-up in lungs
-​ if pt develops further fluid build-up → may require further treatment with furosemide, this has been
communicated with pt, and they will get in touch if pt notices any shortness of breath or swelling
●​ Pt initiated on dapagliflozin 10 mg OD for HFrEF. GP continue monitoring renal function & volume status

Pharmaceutical Issues/Category of Care Issues to consider:

●​ Untreated indication​ ​ ​ ​ Improper medicine selection​ ​ ​ ​ Sub-therapeutic dose
●​ Overdose​ ​ ​ ​ ​ Failure to receive medicines appropriately​ ​ ADR
●​ Medicine interaction​ ​ ​ ​ Medicine use without indication​ ​ ​ Duplication of therapy
●​ Monitoring need​ ​ ​ ​ Counselling need​ ​ ​ ​ ​ Seamless care need