Overview

Ensure you are familiar with the principles outlined in Managing cardiovascular disease in frail older people.

Managing congestive symptoms and fluid retention

Diagnosis is not always straight forward as many of these patients have co-morbidities including hypertension, diabetes, chronic kidney disease, ischaemic heart disease, airways disease or cognitive impairment.  It is not unusual for patients to attribute their symptoms to ‘getting older’ and adapt their activity levels accordingly.

The most common symptoms of heart failure are:

• breathlessness – this may be after activity or at rest. It may be worse when lying down and may cause night time waking needing to catch the breath or a persistent cough
• swollen ankles and legs, caused by a build-up of fluid (oedema)
• fatigue – feeling tired most of the time and finding exercise exhausting

Heart Failure classification

Heart failure is a broad term and the treatment pathways are based on the type of heart failure present.  The following two classification are used to stratify heart failure:

• heart failure with reduced ejection fraction
• heart failure with preserved ejection fraction

NICE Guideline for chronic heart failure provides a good overview of the treatment pathways.

Heart failure with reduced ejection fraction (HFrEF)

There is a substantial evidence base to support the use of medicines to reduce both mortality and symptoms. In the absence of contra-indications, all patients should be considered for a combination of the following classes of medicines:

• an angiotensin converting enzyme inhibitor or alternatively an angiotensin II receptor antagonist if side effects such as cough occur
• a beta-blocker licensed for heart failure (bisoprolol, carvedilol or nebivolol)
• if still symptomatic, a mineralocorticoid receptor antagonist (spironolactone or eplerenone) can be added

Initiate and titrate

These medicines are introduced at low doses and up titrated to the maximum dose or the maximum tolerated dose with careful monitoring of:

• renal function
• electrolytes
• blood pressure
• heart rate
• symptoms

Improving symptoms is the priority because many frail older people will not make it to the recommended evidence based ‘target dose’ to reduce mortality and it is more likely their renal function will decline.

Continue medicines

These medicines should be continued wherever possible, even if doses need to be reduced due to co-morbidities or frailty. This is because they affect both mortality and symptoms even in the later stages of life expectancy.

Further information

The following resources on managing renal function in these patients may be helpful:

• ‘Think Kidneys’
• ‘Change in renal function associated with drug treatment in heart failure: national guidance’ (2019)

Heart failure with preserved ejection fraction (HFpEF)

Clinical trials in HFpEF have not identified any specific treatments to reduce mortality.

The aim is to control the symptoms of heart failure and ensure good management of co-morbidities that may co-exist such as hypertension, atrial fibrillation, diabetes and chronic kidney disease in line with current NICE guidance.

Conducting a consultation

The following points should be considered when managing CHF in older people with frailty:

• establish the diagnosis –is this HFpEF or HFrEF?
• take a comprehensive history to establish what specific symptoms the patient is experiencing
• take a comprehensive medication history – in particular in relation to diuretic therapy as patients may find the diuresis difficult to manage and omit doses or discontinue altogether
• monitor for adverse effects such as symptomatic hypotension or postural hypotension or bradycardia
• review other medication – is this adding to the effects on blood pressure and heart rate? Could it be causing fluid retention? Is it affecting renal function or heart failure symptoms (e.g. NSAIDs)
• during goal setting, establish the impact of these symptoms on the patients daily functioning so that drug therapy can align with the patient’s goals
• consider how you might carry out a face-to-face or virtual review of a patient with heart failure

When to refer

Consider referral to specialist care if symptoms persist of for further advice.