Introduction: is a condition where the heart ceases
The aim of this dissertation is to discuss
how pharmacists can contribute to the care of people with heart failure in
Ireland. According to the HSE, heart failure is a condition where the heart
ceases to work as efficiently as expected. Therefore, there is not enough
blood, and in turn enough oxygen, being delivered around the body.1
Some of the common symptoms associated with heart failure include a build-up of
fluid in the lungs, which can result in breathlessness and swelling in the legs
and abdomen.1 As reported by the World Health Organisations,
globally cardiovascular diseases account for 17.1 million deaths every year and
is the number one cause of death across the world.2 According to the
Irish heart foundation there is currently 90,000 people in Ireland suffering
from heart failure, with up to 10,000 new cases presenting every year. Heart
failure is responsible for 20,000 hospital admissions every year, making it one
of the most common causes of hospitalisation in patients over 65 in Ireland.3 In
1998 the total bed days in hospitals relating to heart failure was 261,499
increasing to 291,988 in 2008 and increase of 11.7%.4 With the
exception of lung cancer life expectancy patient with chronic heart failure is
poorer than common cancers.5 Heart failure is now the only major
cardiovascular disease on the increase in Europe.6
Heart failure commonly occurs as a result
of another medical conditions such as
Coronary artery disease
High blood pressure
Previous heart attacks
Other risk factors include smoking, drug
abuse, alcohol abuse, obesity and physical inactivity.7 Diagnosis of
heart failure can be difficult especially in the early stages and requires a
careful history and clinical examination. Diagnosis may require blood tests,
chest x rays, ECG, stress test, MRI, CT scan. Once diagnosed heart failure can
then be classified depending on the severity.8 One method of
classification is the New York Heart Association of heart failure.
Ordinary day to day physical activity
doesn’t cause fatigue or breathlessness or palpitation.
Small limitation of physical activity,
comfortable at rest, ordinary physical Activity causes fatigue,
breathlessness and palpitations
Marked limitation of physical activity,
comfortable at rest, less than ordinary physical Activity causes fatigue,
breathlessness and palpitations
Breathless at rest, unable to carry out
any ordinary activity without discomfort
Table 1. New York Heart Association of heart failure.8
The American heart association guidelines
can also be used to classify the severity of a patient’s symptoms.
A person who has several risk factors
for heart failure but no symptoms i.e. they’re at risk
A person who has heart disease but no
symptoms of heart failure
Has heart disease and experiences signs
and symptoms of heart failure
Advanced heart failure requiring
Table 2. American Heart Association Guidelines8
Once diagnosed heart failure requires
lifelong treatment. The goals of which are to improve symptoms, improve quality
of life, reduce hospitalisation and reduce mortality. There are many drug
classes on the market currently which are used to treat heart failure. The
treatment of heart failure commonly requires a combination of different medicines.
Common medicines used are outlined in the table below.9
Mechanism of action
– converting enzyme inhibitors
Vasodilators, widen blood vessels in
turn reducing blood pressure.
Decreases the workload of the heart
Initial dose is 2.5mg once daily to be
increased gradually over time dependent on patient tolerability.
Target maintenance dose is 10mg once
Taken at the same time each day.
With plenty of liquid.
Food does not affect bioavailability
Can be used as an alternative for
people who cannot tolerate ACE inhibitors
Initial does is 4mg once daily to be
increased by doubling the dose at intervals of at last two weeks.
Maximum dose 32mg once daily.
Bioavailability is not affected by
Reduce the cardiac output in turn
reducing blood pressure
Dose adjusted for each individual
Initial dose 100mg/day
Shouldn’t exceed 400mg/day
Should be taken with breakfast.
Commonly called water pills.
Make urination more frequent
Stops fluid from collecting in the
Solution for injection
Lowest dose that is sufficient to
achieve desired effect.
Usual initial dose is 40mg which can be
adjusted until effective dose is achieved as a maintenance dose.
Table 3. Medicines used to treat heart failure8,9
Lifestyle changes can also greatly aid
the improvement of symptoms. Smoking has a severely negative impact on the
health of the heart.3 Carbon monoxide present in cigarette smoke
decreases the oxygen carrying ability of blood. Carbon monoxide has a
significantly larger affinity for haemoglobin than oxygen, this reduced the
amount of oxygen that can be carried around the body. Smoking will also cause
blood vessels to constrict further worsening heart failure. A change in diet
can also have a positive impact on symptoms.3 Salt intake should be
reduced if too high. Alcohol intake should also be reduced if the patient is
consuming large amounts.
As of December 2017, there are 1,925
pharmacists registered with the PSI in Ireland.10 This large number mean
the majority if Irish people will have easy access to a pharmacist. This places
pharmacists in a unique position to play a vital role in the care of patients.
Therefore, there is opportunity for the pharmacist to contribute greatly in a
number of ways to the care of patients with heart failure in Ireland. Pharmacists
could monitor patients in a number of ways. Firstly, patient adherence is vital
in the treatment of heart failure. As seen above many of the medicines have
special requirements and it is essential that patients know how to take their
medicines correctly in order to get maximum effectiveness. Pharmacists must
ensure that patients/carers know exactly how and when to take their prescribed
medicine. If the service is available in the pharmacy pharmacists can also
monitor blood pressure of patients. This can be continually monitored ensuring
it doesn’t worsen. They can also offer advice surround diet and lifestyle
encouraging patients to maintain a healthy lifestyle.
Google and google scholar where the main resource
that I used when researching for this dissertation. With the topic of this
dissertation being heart failure, I knew there were some websites that I wanted
to search such as the Irish heart foundation website. I searched key words which I view as relevant
as listed below. I narrowed searches down based on what I saw relevant and
websites I thought were reliable. Using data and other studies that were the
most up to date was also another way of narrowing down the search results, as a
study from 2016 would ultimately be more relevant than data from 1999. What I
searched, and the outcome of those searches are listed in the table below.
Heart Failure Ireland
Heart Failure Ireland Statistics
Leading causes of death in Ireland
What is heart failure
Heart failure pharmacist
Salt intake and heart failure
Table 4. Items searched.
According to the Health Service Executive
(HSE) heart failure can develop at any stage in life, but is more common with
increasing age.1 Approximately 1% of people under the age of 65 have
heart failure. This number increases to 7% in the 75-84 age bracket and a
further increase to 15% in the over 85%.1
with heart failure
5. Age group and percentage with heart failure1
With the life expectancy in Ireland at
its highest ever, due to better health, food supply and nutrition and hygiene.11
Currently in Ireland, heart failure is one of the most common reasons for
admissions to Irish medical services for patients aged 65 and over, accounting
for 30% of cardiologist’s workload.4 There are many factors that
contribute to the increase in heart failure such as the aging population and
better survival rates of heart attacks.4 The graph below shows the
actual population of Ireland in 2014 and the projected population by Eurostat
in 2031. 12As seen there is set to be a significant increase in the
population over the age of 65. This in turn means the number of patients in
Ireland with heart failure will dramatically increase within the next few
years. Therefore, this clearly shows there is a need better care of patients
with heart failure and the introduction of a multidisciplinary care system
across all health care professions will be of benefit.
Figure 1. Actual Population Vs Projected population
of Heart Failure:
An increase in the over 65 age group will
also cause a further burden economically on the Irish government. In a report
carried out by Professor Kenneth McDonald and Dr Joe Gallagher called the Cost
of Heart Failure Report it is said that the estimated cost of heart failure in
Ireland is €660m.4 It is stated in this report that the direct cost
of heart failure to the Health Service Executive (HSE) was €158m in 20124.
Therefore, it accounted for 1.2% of the healthcare budget in 2012. This number
can further be broken down into sections shown in the table below4
General Practitioner (GP)
Nursing Home care
Heart transplant procedures
Clinical specialist assessment
Table 6. Breakdown of the cost of heart failure in the 2012 Irish
Heart failure is accountable for 7% of
all HSE inpatient bed days, with the average length of a hospital stay for a
patient suffering from heart failure being 11 days.4 Its estimated
that less than 1% of patients are referred on for cardiac rehabilitative services.4
The readmission rate is therefore very high ranging from 24-44%.4 It
suggests that management of patient symptoms isn’t being carried out. It’s
clear that in Ireland there needs to be more of a focus on rehabilitation of
patient which in turn will reduce readmission rates. It’s essential that a
multidisciplinary approach is taken to effectively treat heart failure.
can Pharmacists help in terms of medicine adherence?
In a study carried out by Murray MD et
all (2007) a randomised, controlled trial was carried out to see if Pharmacist
intervention would improve medicine adherence in heart failure.13
The key aspects of the trial are listed below
314 low income patients
All over the age of 50
39% assigned to intervention
61% received the usual care
9 months of multilevel care was provided
by a pharmacist to the select group.
There was a 3-month post study phase
Primary outcomes measured where
Exacerbations that required hospital care
Secondary outcome measures were
Quality of life
Patient satisfactions with pharmacy
Total direct costs
The results of this study concluded that
pharmacist intervention did improve patient adherence and reduce the cost of
heart failure decreased. The graphs below show the results of patient adherence
and taking medicine at the correct time over the course of the 9-month study
and the 3-month post study.
Figure 2. Patient Adherence in Murray et
all study 13
This study showed a clear improvement of
patient adherence in the group that received the intervention over the 9-month
period. There was improvement of 8.2% in adherence, but this improvement was
lost in the 3-month post study. Even though patients received all the
information during their 9-month intervention, once the constant encouragement
from the pharmacist had stopped the percentage of adherence slipped. This
indicates that while pharmacist intervention has a positive effect on adherence
in order for it to be effective it needs to continue for the full duration of
the patient’s treatment.
Figure 3. Medicine taken on schedule in
Murray et al study13
The same result is seen when looking at
the patients taking their medicine on schedule. There is an improvement in the
group who are receiving the intervention during the 9-month study, but this
drops significantly during the 3month post study to the point that it’s below
the group of patients who received no intervention. This once again indicates
that whilst having a pharmacist as part of the multidisciplinary team to care
for patients with heart failure their input and encouragement is required for
the whole duration of treatment.
This study also revealed that hospital
admissions were down 19.4% in the intervention group. This once again
reiterates that pharmacist care has a positive effect on patients resulting in
reduction of symptoms if hospital admission is down. The contribution of
pharmacist also reduces the economic burden of heart failure if hospital
admission is reduced. This study clearly highlights that pharmacist
intervention can improve the adherence of patients and has overall many
positive benefits for both patients and society. The intervention will need to
be continuous over the patient’s durations treatment.
The NMS was first introduced in 2011 in
England. The bases of NMS is that patients taking new medicines show problems
quickly and patients on long term treatment, such as treatment of heart
failure, become non adherent as time progresses. In 2017, the Irish Pharmacy
Union carried out a pilot of the NMS in Ireland. This pilot was carried out by
79 pharmacists throughout Ireland. 394 patients took part in the study, with
data being collected from 224 patients. 111 patients received normal care from
the pharmacist. 113 patients received intervention from the pharmacists.
The results of this pilot showed that the
NMS had a positive effect on 85% of all patients who received intervention. 77%
of patients received a percentage of days covered of 80% or greater. This
accounted for an improvement of 9% of adherence. 8% of the patients who
received intervention back to their GP.
51% of pharmacists thought that NMS had a
positive impact on patient’s engagement with adherence. With 87% of respondents
feeling that NSM should be rolled out as a HSE service. It’s clear there is a
need for pharmacist intervention to improve patient’s adherence. It’s clear
from this pilot that pharmacist intervention in patients improves patient’s
adherence which in turn will only have a positive impact on patients, improving
quality of life and reducing symptoms. This will also reduce the cost of heart
failure with a reduction in the number of hospitalisations.
the pharmacist can help in terms of health and lifestyle?
Self-care in patients suffering from
heart failure is vital in the management of conditions, typically patients are
expected to partake in daily weighing, restriction of fluids and diet, monitor
their own symptoms and comply with multidrug regimes.15 With
encouragement to comply with all these, it would be expected that there would
be a decrease in readmission to hospital. In the breakdown shown above for
hospital spending the amount spent on rehabilitation is worrying small when
thinking of the life time effect that heart failure has.
The pharmacist has the ability to assist
patients in many ways in the management of their heart failure.
weighing: If the service of a weighing machine is
available in the pharmacy, the pharmacist can keep track of a patient’s weight.
It may not be practical for daily weighing to take place in the pharmacy but
once weekly or bi monthly would aid the patient to stay on track in maintaining
a healthy lifestyle.
Diet: The pharmacist can offer patients advice on maintaining a
healthy lifestyle. In a study carried out by Prof Pekka Jousilahti over a 12-year period which was presented to the European
society of cardiology in 2017
revealed that the risk of heart failure is doubled in patients who have a salt
intake of 6.8g daily compared to patients who had a daily intake of 13.7g.16
Pharmacist should educate patients on the risk of a high salt diet and
recommend they avoid processed food which will have a high salt content.
Patients should also be encouraging to have a high fruit and vegetable intake.
Regimes: Many patients who suffer from heart
failure will be taking multiple drugs in order to treat the disease.8
In the table shown in the introduction it shows many of these drugs have
special requirements such as time of day to be taken and whether or not to be
taken with food. In order for these drugs to be most effective they need to be
taken correctly. Pharmacists need to encourage patients to take them right and
to take them continually. Patients should be aware of the benefits of taking
their medicines correctly.
to the Healthy Ireland survey carried out by the Department of Health in 2017,
22% of people surveyed were smokers, a decrease on 2016 where 23% were smokers.
1 = GP
2 = Hospital doctor
3 = Nurse
4 = Dentist
5 = Other
6 = Pharmacist
Figure 4: Smokers who have discussed quitting with health care
As seen above 10% of people have
consulted a pharmacist in relation to quit smoking, this is significantly lower
than the 35% who have consulted their GP. There is an opportunity for
pharmacist to start the conversation with people themselves educating them on
the effect smoking has on heart failure and the advantages of quitting.
Heart failure is a prevalent disease that
is affecting Irish society, with the number of people it is affecting yearly
only set to rise. It’s clear from the discussion that the treatment of heart
failure would benefit largely from multidisciplinary care. Due to the
complexity of the treatment of heart failure, it is not just a disease where
you can take the prescribed medicine and see a positive impact. Patient
adherence to medication is invaluable in the treatment of heart failure. This
teamed with many lifestyle changes that need to be monitored on a daily basis. The
intervention of the pharmacist would aid patients by easing symptoms and
increasing quality of life. Multidisciplinary care will also have a positive
impact on the economic burden that heart failure has on Ireland and the
increase. With the introduction of the New Medicine services pilot in 2017 it
is clear that the need for intervention from the pharmacist is something that’s
going to been seen across Ireland not only to aid patients with heart failure
but to aid patients with all chronic diseases.
The Oireachtas Committee on the Future of
Healthcare’s Sláintecare Report (2) recommended that in order to provide
healthcare at the lowest level of complexity in a safe and efficient manner
that the use of all mechanisms and processes is essential. It also recommends
that there is priority given to preventative care and health promotion and that
a strong focus be placed on medicine management. Studies have shown that
pharmacist intervention only serves to have a beneficial effect on patients who
are currently suffering from heart failure. An improvement in the wellbeing of
patients who are suffering from heart failure will reduce the burden this
disease has on hospitals freeing up many day beds and would reduce the number
of patients being hospitalised. Its clear from all stated above that the
contribution of pharmacist in the car of patients wot heart failure will only
serve to benefit patients.