How can pharmacists contribute to the care of people with heart failure in Ireland?Senior Fresh Practice of Pharmacy dissertationBsc(Pharmacy) Year 2017Bidemi Afolabi 13318996Table of Contents Abstract. 2Introduction. 3Method. 4Discussion. 5Conclusion. 11References. 12AbstractThis paper discusses the contribution of pharmacists to the treatment of patients suffering from heart failure. The contribution of pharmacists to care for people diagnosed with heart failure involves assessment, education referral, and monitoring. Clinical pharmacists have a substantial effect in a wide variety of roles in inpatient and ambulatory settings, largely through optimization of drug use, avoidance of adverse drug events, and transitional care activities focusing on medication reconciliation and patient education. Meanwhile, it was found that pharmacist in a community setting contributes to the safe and effective use of OTC medication in Ireland. Pharmacists along with the Pharmaceutical Society of Ireland and the Pharmaceutical Healthcare Association continuously strive to ensure better health practices for those suffering from heart failure.IntroductionHeart failure is defined as the inability of the heart to keep up with the demands and specifically , the failure of the heart to pump blood with normal efficiency. 1 When this happens the heart is unable to provide adequate blood flow to the brain, liver and kidneys. Heart failure can be due to failure of either the right or left ventricles or maybe both. Heart failure is a chronic disease which no cure has been found yet.There are many risk factors for heart failure such as coronary artery disease, a previous heart attack, cardiomyopathy and high blood pressure. Some risk factors are modifiable while some are non-modifiable. The modifiable risks are things we can change. These include an unhealthy diet, being overweight and having a lifestyle that comprises of very little physical activity and exercise. Non- modifiable risk factor are those that cannot be changed, these include things like age, gender and race. Both Non-modifiable and modifiable risk factors are taken into account when treating heart failure.Pharmacists have both the opportunity and responsibility of caring for the people with this disease. It is also vital that pharmacists educate these patients in how to look after themselves and reduce those risk factors that are modifiable. It is very important for pharmacists to enhance self-care while promoting the safety and effectiveness of the treatment.Method The majority of the research was carried out through internet searches and through the use of books and journals available in the trinity college dublin hamilton library. Pharmacists ( Kate Byrne) of Leonards corner pharmacy and ( Michelle O’Hagan) Pharmacy Hub were also consulted. When a search was initiated via Google large amounts of results were retrieved, the results were then scanned and a number of these were then read and accessed for quality and relevance to the topic at hand. The results generated , Limitations and number read have been tabulated below.SourceSearch ItemsLimitationsNo RetrievedNo ReadGoogle Heart FailureEnglish101,000,0006GoogleTypes of Heart FailureEnglish74,000,0005GoogleTreatment of Heart failureEnglish103,000,0004GoogleChronic Heart failureEnglish97,000,0007GoogleHeart failure in AfricanEnglish2,600,0002GoogleStages of Heart failureEnglish79,500,003GooglePolypharmacyEnglish860,0008GoogleRisks of polypharmacyEnglish2,440,0005GooglePSI code of conductEnglish2,730,0001GooglePrognosis of Ireland failureEnglish505,0002DiscussionsThe number of people suffering from heart disease in Ireland has been steadily increasing, approximately 90 thousand people are living with heart failure in Ireland today. It can develop at any age but becomes more common with increasing age. Around 1% of people under 65 years of age have heart failure, but 7% of 75-84-year-olds have heart failure and this increases to 15% in people older than 85. Heart Failure is one of the most common causes of hospitalization in patients over 65 years of age. In 2016, there were more than 20,000 patients admitted with heart failure in Ireland, 90% of which were emergency admissions.3 The direct cost of heart failure to the HSE is €158 million annually, which includes hospitalizations, GP visits, nursing home care etc. The total cost of heart failure in Ireland is €660 million, which is made of direct costs (€158 million), cost of informal care and the costs of premature deaths (€502 million)The majority of direct costs (47%) are hospital related. Heart failure patients occupy more than 231,000 hospital bed days each year. Seven percent of all HSE inpatient bed days are due to heart failure. 12There are several types heart failure, left-sided heart failure being the most common type. The left heart ventricle is situated in the bottom left side of the heart. This area pumps blood that has arrived from the lungs to the rest of the body. Left-sided heart failure occurs when the left ventricle pumps ineffectively. This prevents the body from getting sufficient blood of adequate oxygen levels. The blood then backs up into the lungs instead, which leads to shortness of breath and a buildup of fluid known as edema.4 The right heart ventricle is responsible for pumping blood to the lungs to collect oxygen. Right-sided heart failure occurs when the right side of the heart can’t perform its job effectively. It’s usually triggered by left-sided heart failure. The buildup of blood in the lungs caused by left-sided heart failure increases the workload of the right ventricle. This can stress the right side of the heart and cause it to fail.Right-sided heart failure can also occur as a result of other conditions, such as lung disease.5 Diastolic heart failure occurs when the heart muscle more stiff than normal. The stiffness, due to heart disease, means that the heart doesn’t fill with blood as easily as it should do. This is known as diastolic dysfunction. It leads to a lack of blood flow to the rest of the organs in the body. Diastolic heart failure is more common in females than males .6Pharmacists in Ireland play a crucial role as primary health care providers in caring and educating people regarding various health issues. Pharmacists in Ireland are bound to the code of conduct. The code consists of six principles and although pharmacist must abide by all six at all times, there is one in particular that emphasizes the obligation of care to patients of all patients and specifically those suffering of heart failure for this discussion. “The practice by a pharmacist of his/her profession must be directed to maintaining and improving the health, well-being, care, and safety of the patient. This is the primary principle and the following principles must be read in light of this” 2 Pharmacists are obliged to continuous learning in order to be up to date capable of providing the best and relevant care to patients. As patient care evolves more and more of an emphasis is placed on the education of patients. As there are modifiable risks involved in heart disease, modifiable risks being factors such a weight, level of exercise and diet etc, pharmacists must be knowledgeable on these topics in order to impact meaningful knowledge to the patients.In patient healthcare, the assessment of the patient is the first step that occurs. A pharmacy is usually the first contact point of professional healthcare to the public due to the fact that the public can walk into a pharmacy and seek consultation without any prior appointment free of charge. The most common assessment is blood pressure screening, weight /height, and BMI. According to the community pharmacy baseline studies, 47.5% of pharmacies had blood pressure screening facilities and 58.6% had weight/height/BMI assessment facilities.7 Assessment and accurate diagnosis is essential to develop short and long-term plans. This can be very difficult to do in community pharmacy given the limited access to laboratory and sophisticated pieces of equipment. Diagnosis of heart failure is normally conducted by a doctor, a physical examination is performed by the physician. The physician will check for risk factors such a high blood pressure, Diabetes and previous family history of heart failure. The doctor will also listen to the lungs for signs of congestion. Abnormal heart sounds can also be picked up using the stethoscope, legs and abdomen are also accessed for fluid build up. After the physical exam further tests are required to confirm diagnosis. The doctor may take a blood sample to look for signs of diseases that can affect the heart. He or she may also check for a chemical called N-terminal pro-B-type natriuretic peptide (NT-proBNP) if your diagnosis isn’t certain after other tests. Measurements of N-terminal pro-brain natriuretic peptide can be used to differentiate patients with normal and reduced left ventricular ejection fraction.11 An echocardiogram may also be performed, which is a simple test which uses sound waves (ultrasound) to take a moving picture of the heart. It allows the doctor to “see” how the muscles of the heart are working and how the heart valves are behaving. There are 2 main types, trans-thoracic echo (TTE): a doppler probe device is moved over the chest creating sound wave pictures of the heart through the chest wall. Trans-oesophageal echo (TOE): a smaller probe is passed down into the oesophagus allowing detailed pictures of the heart’s structures to be seen because the oesophagus is right behind the heart. A Stress test may also be ordered , this measures the health of the heart by how it responds to exertion. The patient may be asked to walk on a treadmill while attached to an ECG machine, or may receive a drug intravenously that stimulates the heart similar to exercise. Sometimes the stress test can be done while wearing a mask that measures the ability of the heart and lungs to take in oxygen and breathe out carbon dioxideThere are four stages of heart failure Stage A,B,C and D. Stage A is often considered pre-heart failure. This means that there is a risk of developing heart failure due to either family history or medical conditions use as Diabetes, hypertension etc. Stage A patients are often advised on their modifiable risks such as diet,exercise, and smoking. A low sodium diet and active lifestyle are often recommended as they help lower blood pressure and cholesterol. Medication used in treatment are Angiotensin-converting enzyme inhibitors of Angiotensin II receptor blocker if the patient has diabetes or coronary heart disease. Beta blockers such as atenolol are prefered if the patient has high blood pressure. Stage B is also considered pre-heart failure. It means that the patient has been diagnosed with heart failure but symptoms have not yet been presented. It is common for those with stage B to have had an echocardiogram that shows an ejection fraction of 40% or less. Treatment for stage B is really similar to that of A comprising of ACE-1 or ARBs. Beta blockers are used if the EF is 40% and the patient has previously had a heart attack. Atenolol is popular beta-blocker. Atenolol is a beta-adrenergic blocking agent that blocks the effects of adrenergic chemicals, for example, adrenaline or epinephrine, released by nerves of the sympathetic nervous system. Stage C heart failure presents symptoms such as shortness of breath, fatigue and weak legs. Stage C treatment comprises of ARBs and ACE-1 Anlong side hydralazine/nitrate combinations. It is recommended that people of African origin take this even if they are taking other vasodilator medication. Diuretics can only be given to reduce symptoms, Sodium-restricted diets are often employed at this stage.Pharmacists often advise to keep track of weight and inform health care provider of weight gain/loss of 4 pounds. Stage D express advanced symptoms that do not get better with treatment, this is the final stage of heart failure. Stage D treatment is palliative and focuses on the management of symptoms to improve quality of life. Aldosterone receptor antagonists are recommended along with ACE inhibitors, ??adrenergic receptor blockers, and diuretics, unless they are contraindicated.. 13Pharmacists are involved in the managing and follow up care of patients with heart failure. Many decades of research has led to the established effective and well tolerated pharmacological management of heart failure. Pharmacological management of heart failure largely involves the use of angiotensin receptor blockers, angiotensin-converting enzyme inhibitors beta-adrenergic blockers. In the treatment of heart failure polypharmacy is often applied, this is the practice of administering many different medicines especially concurrently for the treatment of a single disease. 8 This is often associated with negative side effects due to interactions between the drugs applied, however, in the treatment of heart failure research has shown that polypharmacy leads to prolonged survival and decreased morbidity. As previously mentioned there is a risk of severe side effects due to the interaction between drugs, this can become dangerous if there is no dedicated team to manage this. This is where pharmacists come in, pharmacists can easily assume this role due to their ability to promote safe use of drugs and minimising prescribing errors. Different drugs target different pathophysiological aspects of heart failure. Pharmacists have knowledge of clinical pharmacology, pharmacokinetics, and pharmacogenomics thus enabling them to design dosing regimes that give patients the best results. Pharmacists also play an important role in the medical team managing patients with acute heart failure. They may contribute meaningfully regarding factors such as nonadherence to therapies, intake of drugs that may worsen heart failure and may also suggest dosing adjustments that may be necessary in light of changing renal or hepatic function. Pharmacists can also effectively monitor patient response to intravenous therapies. The pharmacist has a knowledge of drug dosing, pharmacokinetics, and drug interactions is an excellent contribution to support teams, where managing immunosuppressive, antithrombotic, and anti-infective agents can be highly complex.9It is very common for patients with heart failure to have other comorbidities. Theses comorbidities must be taken into account as these they will carry in themselves treatment with pharmacological drugs. This leads to an increased risk of potential drug-drug interactions. As mentioned previously pharmacists have a vast knowledge of drugs and their interactions, this places pharmacists in a position to advise prescribers on which drugs are contraindicated in combination and on when dose adjustment may be necessary. It is not uncommon for drug interaction disease to occur, some of the drugs prescribed to treat other comorbidities to exacerbate heart failure. Pharmacists play a key role in the avoidance of such situations as they can have fatal consequences. Particularly for over the counter medication, pharmacists are the first point of contact and play a role key in educating patients on readily available medication such as domperidone and pseudoephedrine which can interact with their heart medication. NSAIDs may cause sodium and water retention, peripheral vasoconstriction, worsen heart failure, and decreased renal function. Acute renal failure may be more likely when these agents are used in combination with an ACE inhibitor (ACEI) / angiotensin receptor blocker (ARB) and/or diuretic. Effervescent preparations such as Sola- Extra and Berocca may cause increase fluid retention due to high salt content.WIthout professional advice it is unlikely that patients would be aware that these common readily available medication can have a detrimental impact on their health.14 The common mnemonic WWHAM although simple is very effective and helps pharmacists and OTC staff to obtain more information about the patient and know whether the medication will interact with medication or health in a negative way. WWHAM covers key points of patient identity, What symptoms are being experienced, how long the symptoms have lasted, action taken and probably most important other medication being used by the patient.Perhaps the biggest role pharmacist play in heart failure treatment is that of education. It is important for patients to understand that having heart failure does not mean that their heart is about to stop. Rather, their heart is not able to pump enough blood to meet the body’s demand, or it is not filling up quickly enough. The blood may back up and cause swelling in the feet, ankles, and legs, and it may also cause some shortness of breath and fatigue. It is a slow process and usually caused by diseases that affect the heart, such as high blood pressure, coronary artery disease, and diabetes. Understanding of their condition can help with medication adherence. Adherence is very important when taken medication, studies have shown that patient education is a key factor in medication adherence. Pharmacists are often viewed as approachable and accessible by patients. This is one of the reasons that pharmacists patient education improves medication adherence and reduces adverse side effects.Pharmacists have been trained to communicate drug specific education to patients in language that is understandable to the patient. Information provided include of the purpose of each drug within their regimen, how to take it safely, potential adverse effects, and best approaches to managing side effects should they occur.10 There are times where other reasons to non-adherence come into play,such as the inability to afford, physical or cognitive impairment. Pharmacists may be in a position to help overcome these problems eg. substitution with a cheaper equivalent version. Many approaches to improving adherence are available such direct education, electronic reminders, daily/weekly pill boxes and pharmacists would tailor adherence interventions to meet the needs of individual patients.10ConclusionPharmacists have an important role in the care of patients with heart failure in Ireland. Their role can come in form of being a part of a team providing primary care or as an independent practitioner.Pharmacists as active participants in Heart failure patient care lead to a positive change in therapeutic outcomes. Polypharmacy management and patient education are two areas best documented in this literature of which pharmacists have a positive impact on patient outcome. The important contribution of pharmacists to heart failure care is increasingly being recognized. Their attention to the optimal and safe deployment of evidence-based therapies can reduce hospitalizations for heart failure, improve the quality of care, and decrease resource burdens on physician providers and health systems. Considerable advances have been realized in the integration of clinical pharmacy services into heart failure management, and efforts should continue to achieve broader penetration of clinical pharmacists as vital members of the heart failure management team.