Co-morbid cardio-respiratory disease: management dilemmas

Part two: Co-morbid cardiac and respiratory disease is common. A new diagnosis can impact on existing disease, creating management dilemmas and necessitating careful, holistic, patient review

The first article in this two part series used a case study approach to explore some of the challenges facing nurses working in an advanced role when dealing with patients whose history, signs and symptoms may be related to new or pre-existing pathology. Many of the symptoms that patients present with are non-specific. The skill of the clinician, nurse or doctor, in assembling the clues gained from careful history taking, assessment and investigation is key to the early, accurate diagnosis that is pivotal in reducing both admissions and complications.

This second article will use the same case study to demonstrate how a new diagnosis can impact on the management of pre-existing disease, and the importance of reviewing patients carefully when new disease is identified.

CASE STUDY RE-INTRODUCING JED

Jed's case is summarised in Box 1. Following his initial presentation with increased breathlessness, tiredness and productive cough he was diagnosed with two new, additional co-morbidities - left ventricular systolic dysfunction (LVSD) and atrial fibrillation (AF). Along with the immediate management of his new conditions Jed also needs a careful review of his existing co-morbidities. Careful consideration needs to be given to how these new diagnoses could affect his current conditions, and a review of both his lifestyle and medication should be carried out.

LIFESTYLE

In terms of a lifestyle review Jed needs advice regarding his new diagnoses and a reminder that maintaining a healthy lifestyle can help improve his symptoms and reduce the risk of exacerbations of his heart failure in the future.¹ Jed, however, may feel there is little point in trying to follow this advice; he may feel somewhat fatalistic about his situation now that he has 'even more health problems to deal with'. Education will therefore be a significant aspect of Jed's ongoing care. He will need encouragement to recognise that there is a lot he can do to keep himself as independent and well as possible, and that many of the things that he can do will benefit several conditions at the same time. For example, he has managed to remain an ex-smoker. This is possibly one of the most important things he can do for his overall health and he should be congratulated about this.

Alcohol

Jed's alcohol intake exceeds the Department of Health's recommended limits for men.² AF is also more common in people who drink 35 units or more of alcohol per week.³ Jed needs advice about reducing his alcohol intake. He should aim to consume no more than 21 units a week with at least one, and ideally two alcohol free days per week, especially after exceeding the daily recommended levels.² Indeed, in view of his AF and heart failure, it would be better if he could reduce his intake even further.

Diet

Healthy eating, with a move away from processed foods that are often high in fat, sugar and salt, should also be encouraged. Jed may also need an explanation of the importance of including more fresh fruit and vegetables in the diet where possible. He may also benefit from referral to a dietician for further advice and education.

Jed's daughter was keen to help Jed improve his diet and suggested that she could prepare his meals with her slow cooker to make life easier for them both. She could leave the food to cook without having to spend time watching it and Jed could eat when he was ready. She was surprised to hear how much added salt there was in some of Jed's staple meals. She had read through the information booklets from the British Heart Foundation she had been given and realised that this could affect his blood pressure and his heart failure. She agreed to make sure that salt was not added during cooking or at the table.

Activity level

Jed had been active, walking his dog twice a day, before the onset of his heart failure and AF. He needs reassurance that exercise remains good for his heart, lungs and general health, and encouragement to regain his previous activity levels.

DRUG THERAPY

Jed was taking metformin 2g and pioglitazone 45mg daily for his diabetes. He was also taking amlodipine 10mg for his blood pressure along with atenolol 50mg, ramipril 10mg, simvastatin 40mg and aspirin 75mg as part of his post MI treatment. For his COPD he was taking a licensed combination inhaler and a short-acting beta2 agonist for occasional symptom relief. However, this treatment regimen will need careful review following the diagnosis of LVSD.

Heart failure management

ACE inhibitors and beta blockers

Jed had already been started on a loop diuretic, furosemide, to reduce his breathlessness and oedema. NICE 1 also advises that patients diagnosed with heart failure due to LVSD should be managed with a combination of an ACE inhibitor and one of the beta blockers licensed for heart failure. Both of these drugs should be prescribed at the maximum tolerated dose in order to:

• Reduce the risk of future exacerbations and admissions
• Improve longevity, and
• Minimise symptoms.¹

Jed is already on an ACE inhibitor, ramipril, at the maximum dose of 10mg. However, although he is taking a beta blocker, atenolol, this is not licensed for heart failure. A change to bisoprolol, carvedilol or nebivolol, is advised.¹

In the past, some clinicians have been reluctant to start beta blockers in patients with a history of obstructive lung disease, such as asthma or COPD. However, the latest NICE guidance on managing heart failure¹ includes the importance of introducing these drugs in patients with COPD as a key performance indicator. The advice when initiating beta blockers in people with COPD is to 'start low, go slow' and to monitor the patients' symptoms, renal function, BP and pulse during the period of up-titration. A history of asthma may necessitate more careful consideration of the risk/benefit ratio as the risk of adverse drug reactions is higher in reversible airways disease. However, many patients with asthma, like those with COPD, will tolerate beta blockers well and will benefit from their effect on mortality rates.

The need to change his atenolol was explained to Jed and he agreed to be switched to bisoprolol. As Jed was already on a medium dose of atenolol he started on bisoprolol 5mg, which is also in the middle of the dose range. Beta blockers can cause a deterioration in symptoms in approximately one third of patients who start on them and, if Jed had been beta-blocker naive, the advice would have been to 'start low, go slow'.¹

Jed had already had an ECG but if he had not, an ECG should be carried out to ensure there was no evidence of heart block or other abnormalities which might contraindicate the use of beta blockers.⁴ After approximately 2-4 weeks, Jed's renal function, blood pressure (lying/sitting and standing in order to detect possible postural drop) and pulse rate would need to be checked to ensure that they remained at a safe level (BP > 90/60 and pulse >50bpm) before up-titrating the bisoprolol further to 7.5mg, and eventually to 10mg. It is worth noting that NICE advises that asymptomatic hypotension does not necessitate dose reduction of beta blockers and/or ACE inhibitors.¹

Calcium channel blockers (CCB)

Jed is also taking amlodipine, a CCB, for hypertension. Care is needed when using CCBs in heart failure as they can cause fluid retention, which can make heart failure symptoms worse.⁴ CCBs are, however, very useful for hypertension and are now considered to be first or second line treatment, based on the age of the patient.⁵ In Jed's case the pros and cons of continuing the CCB need to be considered by his health care team. Discussions should also include Jed and, perhaps, his daughter if he would prefer this. It may be that he can carry on with the treatment as long as he is monitored carefully.

Diabetes management

Metformin

There is no reason why Jed should not continue with metformin as long as his renal function is monitored. Metformin is the first line recommended treatment for type 2 diabetes according to NICE,⁶ but there is a small risk of lactic acidosis in metformin-treated patients who have renal impairment. Careful monitoring is therefore advised.⁶ Primary care clinicians may need specialist advice if the estimated glomerular filtration rate (eGFR) falls below 45ml/min/1.73m2 and/or creatinine rises above 150mol/l. Local guidance may, however, vary from these figures, so these guidelines should be checked.

Pioglitazone

Although it is safe to continue Jed's metformin, with ongoing monitoring, the same cannot be said for his pioglitazone. Pioglitazone is a thiazolidinedione and this class of drugs is not recommended for use in people with heart failure as they can cause fluid retention.⁴

In addition, the Medicines and Healthcare products Regulatory Agency (MHRA) updated advice in 2011 on the use of pioglitazone, based on possible concerns regarding bladder cancer risk.⁷ Although Jed does not have additional risk factors for bladder cancer, his heart failure diagnosis makes pioglitazone unsuitable for continued prescription.

Other options

There are several therapy options to replace Jed's pioglitazone. He could try a sulfonylurea, a dipeptidyl peptidase-4 (DPP-4) inhibitor such as sitagliptin, vildagliptin, saxagliptin or linagliptin, or he could be considered for insulin or a glucagon-like peptide-1 (GLP-1) such as exenatide or liraglutide. Not all of these options may be appropriate for Jed, however, so again, careful discussion of the licensed indications and the pros and cons of each should take place with Jed, his daughter and other health care team members.

COPD management

Exacerbations of COPD may lead to worsening heart failure and may necessitate a hospital admission, which Jed is keen to avoid. It is important to review his COPD management to ensure that he is on the most appropriate treatment regimen, in line with NICE guidance.⁸

Jed's symptoms and lung function parameters suggest that a combination therapy should be prescribed.⁸ Although inhaled steroids may be useful in treating COPD, particularly in terms of preventing exacerbations, they are only licensed for use as a combination product of an inhaled corticosteroid and long-acting beta2 agonist. There are only two combinations that currently have this licence - Symbicort at a dose of 400/12mcg via the Turbohaler and Seretide 500mcg via the Accuhaler. Both of these can be used with the long-acting once daily anticholinergic, tiotropium.

Concerns have been voiced regarding the use of inhaled anticholinergics, including tiotropium, in patients with a history of heart problems.⁹ The current advice is that the risk/benefit ratio should be considered and discussed with the patient before deciding whether or not to proceed with treatment. It is worth remembering that NICE 8 advises that a lack of symptomatic response to any treatment may mean that the drug should be discontinued. The exceptions to this are the combination therapies, which are prescribed primarily to reduce exacerbations.

Jed has a self-management plan but this should also be reviewed to ensure that he is aware of his current treatment regimen along with ways of preventing exacerbations - such as avoiding extremes of temperature, maintaining adequate supplies of medication and keeping up to date with his flu and pneumococcal protection.

Atrial fibrillation management

Jed's diagnosis of persistent AF will mean that he needs treatment and advice regarding this, based on NICE guidance.¹⁰

Stroke risk reduction

Both aspirin and warfarin can be used to reduce the risk of stroke in patients with AF. The decision regarding which to use should be based on the NICE guidance,10 although the patient should also be included in the decision-making process. Aspirin can be prescribed at a dose of 75mg daily and requires no ongoing monitoring, whereas blood tests will be required to ensure that the correct dose of warfarin is prescribed. The combination of aspirin and warfarin has been shown to reduce risk further but the benefits of this regimen are offset by an increased risk of bleeding.

Warfarin is first line therapy to reduce stroke risk in persistent AF. Jed had no contraindications to warfarin and agreed to start on this treatment. He continued to be monitored at the warfarin clinic with regular blood tests and review of his dosing regimen, with the aim of keeping his INR between 2 and 3, aiming ideally for 2.5.

Heart rate reduction and rhythm control

Bisoprolol, the beta blocker Jed is taking for heart failure, will help to reduce his heart rate. There is, however, some debate over whether to aim to reduce heart rate or correct the arrhythmia in AF and this is not a straightforward decision in Jed's case. Jed is over 65 and has a history of cardiovascular disease. This puts him in the 'rate control' category, as defined by NICE.¹⁰ However, his diagnosis of heart failure also puts him in the 'rhythm control' category.

Restoring sinus rhythm is thought to be the most effective goal, but is harder to achieve than reducing the heart rate. Correction of the arrhythmia may be attempted through the use of cardioversion, once the patient is properly anticoagulated and assuming they are suitable for this. Medical correction would involve the use of drugs such as standard beta blockers, or, failing that, sotalol, amiodarone or flecainide.

Rate control can be achieved using betablockers OR a rate-limiting calcium channel blocker (CCB) such as diltiazem or verapamil.¹⁰ As Jed is already being prescribed bisoprolol, this will help with the management of his AF in terms of both rate and rhythm. The combination of a beta blocker and a rate-limiting CCB such as verapamil or diltiazem should, however, be avoided.¹¹

PSYCHOLOGICAL CARE

Jed's multiple medical problems have potential to severely impact on his quality of life. His mood should be regularly monitored to ensure that he does not become depressed. An accredited tool such as the PHQ912 can be used for this. It is also important that Jed should be made to feel that he is central to his consultations and any decision making process. He may also be offered outside help, such as cognitive behavioural therapy, through the 'Improving Access to Psychological Therapies' (IAPT) initiative13 and through referrals to a pulmonary and/or cardiac rehabilitation programme.

CONCLUSION

Overall, Jed's new diagnoses, with new treatments and lifestyle interventions to consider, are clearly going to have an impact on his life. However, with education and support from his family and health care team, he should be able to continue to live independently once he is on the correct and optimised treatment regimen and has made the necessary lifestyle and behavioural changes.

REFERENCES

1. National Institute for Health and Clinical Excellence. Chronic Heart Failure: management of chronic heart failure in adults in primary and secondary care. CG108. 2010 http://www.nice.org.uk/nicemedia/live/13099/50517/50517.pdf

2. Department of Health. Alcohol advice. 2011 http://www.dh.gov.uk/en/Publichealth/Alcoholmisuse/DH_125368

3. Mukamal KJ, Tolstrup JS, Friberg J, Jensen G, Gronbaek M. Alcohol consumption and risk of atrial fibrillation in men and women. Circulation 2005; 114: 1736-1742.

4. Electronic Medicines Compendium. 2012 http://www.medicines.org.uk/emc/

5. National Institute for Health and Clinical Excellence. Hypertension. CG127. Quick reference guide. 2011 http://guidance.nice.org.uk/CG127/QuickRefGuide

6. National Institute for Health and Clinical Excellence. Type 2 diabetes - newer agents. CG87. 2009 http://www.nice.org.uk/CG87

7. MHRA. Pioglitazone risk of bladder cancer. 2011 http://www.mhra.gov.uk/Safetyinformation/DrugSafetyUpdate/CON125962

8. National Institute for Health and Clinical Excellence. Chronic obstructive pulmonary disease: management of chronic obstructive pulmonary disease in adults in primary and secondary care. London: National Clinical Guideline Centre. 2010 http://guidance.nice.org.uk/CG101/Guidance/pdf/English

9. Singh S, Loke YK, Furberg CD. Inhaled anticholinergics and risk of major adverse cardiovascular events in patients with chronic obstructive pulmonary disease: a systematic review and meta-analysis. Journal of the American Medical Association 2008; 300(12): 1439-1450

10. National Institute for Health and Clinical Excellence. Atrial fibrillation. 2006 http://www.nice.org.uk/nicemedia/live/10982/30054/30054.pdf

11. Clinical Knowledge Summaries. Angina - stable - management. 2011. http://www.cks.nhs.uk/angina/management/detailed_answers/poor_smptom_control_on_treatment/drug_management

12. Gilbody S, Richards D, Brealey S, Hewitt C. Screening for Depression in Medical Settings with the Patient Health Questionnaire (PHQ): A Diagnostic Meta-Analysis. Journal of General Internal Medicine 2007; 22(11): 1596-1602.

13. Improving Access to Psychological Therapies programme. 2012 Available at: http://www.iapt.nhs.uk/