Introduction heart failure and it is very important to



The European Society of Cardiology (ESC) defines
heart failure as ‘an abnormality of cardiac structure or function leading to
failure of the heart to deliver oxygen at a rate commensurate with the
requirements of the metabolizing tissues, despite normal filling pressures (or
only at the expense of increased filling pressures).’ Or .put simply, the heart
does not work as efficiently as it should and therefore, the body does not
receive the oxygen and nourishment that it requires to operate to the best of
its ability.

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Heart failure can occur for many different
reasons however, it is often as a result of other heart conditions such as coronary
artery disease, high blood pressure or a previous heart attack.1
Other causes of heart failure include weakened heart muscle due to either a
heart attack or leaking or narrowed heart valves, alcohol related damage to the
heart muscle, a viral infection in the heart and uncontrolled, irregular heart rhythm.2
These causes either damage the heart or increase its workload which therefore
effects the contraction and relaxation of the heart3
which can lead to a person feeling fatigued and having a build-up of fluid in
the body, two of the most common symptoms of heart failure.2  

There are many different types of heart failure
and it is very important to understand which type the patient has in order to
carry out effective treatment. However, because the symptoms are often quite
similar it is often difficult to correctly diagnose which type a patient has.4
Heart failure can either be left-sided or right-sided. The left side of the
heart supplies the body with most of its blood and so, in left-sided heart
failure the heart must work extremely hard to pump the same amount of blood as
before. There are two different types of left-sided heart failure: systolic
failure and diastolic failure. In systolic failure, the left ventricle has a
reduced ejection fraction meaning it can no longer contract normally to push
enough blood out of the heart. In diastolic failure, there is a preserved
ejection fraction meaning the heart cannot fill properly because of the left
ventricle’s inability to relax normally. This is generally due to the muscle
becoming stiff. Right sided heart failure is usually as a result of left sided
heart failure. The increased pressure in the left side of the heart is
effectively transferred through the lungs and damages the right side. This loss
of pumping power causes blood to get backed up in the body’s veins and cause


Heart failure is a very common condition
worldwide with 1 in 5 people expected to develop heart failure at some stage in
their lives.6
This is no different in Ireland as there are 90,000 people currently living
with heart failure here.7
 The risk of developing heart failure
increases with age with very few individuals diagnosed under the age of 50
compared to 10% of over 75 year olds having the condition. Heart Failure is one of the most common causes of hospitalisation in
patients over 65 years of age.8  In 2008, that there
were more than 20,000 patients admitted with heart failure in Ireland, 90% of
which were emergency admissions The
number of patients with heart failure worldwide is going to increase
considerably in the future due to: the ageing population, the improvements in
treatment and the survival of patients with heart problems. Due to this
predicted increase, it is more important than ever to raise awareness amongst
the public.

In order to attempt to reverse this increase,
it is vital 

Treatment of heart failure is a combination of
both pharmacological and non- pharmacological therapy. The non-pharmacological
methods of treating heart failure are mainly lifestyle changes such as
restricting salt intake in the diet, avoiding the consumption of alcohol, smoking
cessation and having a restriction of fluid intake of < 2 litres per day. It is also important for elderly patients with heart failure to take preventative measures such as routine hand washing, looking after their dental health and maintaining scheduled immunisations to avoid infections which can worsen their health.9 There is a large number of drugs involved in the pharmacological treatment of heart failure. Antagonists of the renin/angiotensin system are the primary drugs of first choice these include: angiotensin converting enzyme inhibitors, angiotensin receptor antagonists and renin inhibitors. Diuretics are extremely important to treat some of the main symptoms of heart failure – peripheral oedema or pulmonary congestion. Glycosides such as digoxin is also used to improve the symptoms bu doesn't affect the mortality. Although they were once thought to be contraindicated in heart failure, beta blockers are now considered first line agents and are used to reduce mortality and decrease hospitalisation.10 Pharmacists play a vital role in the treatment of heart failure – in both the pharmacological and non-pharmacological aspects.

They are the most accessible healthcare professional to people living with
heart failure and so, it is essential they use the opportunity they have to
encourage a healthy lifestyle



























pharmacist is the most easily accessible healthcare professional for most
people in thie country. In a survey carried out for the PSI it was found that 67%
of people aged 55-64 and over 80% of those aged over 65 visit their pharmacy


play a vital role in the care of people living with heart failure.


medication and ensure drug compliance.


One of the
most obvious and important roles a pharmacist has while caring for a patient
with heart failure is dispensing their medication and counselling the patient or
their carer on their treatment plan. There are many different types of heart
failure medication including: ACE inhibitors, aldosterone antagonists,
angiotensin receptor blockers, beta blockers, diuretics, digoxin and isosorbide
dinitrate. Due to the wide range of drugs available, the treatment plan for
patients is often multifaceted and complex11
meaning it is crucial the pharmacist counsels the patient concisely and in a
manner that they understand completely. Pharmacists can educate the patient about
the importance of their medications and the side effects as well as why they are taking them. Rate of
adherence to heart failure medication varies however, most authors have noted
an average of 40-60%12
Studies have found that poor adherence to medication makes patients two
times as likely to be admitted to hospital and three times as likely to
experience death compared to patients who were adherent to their regimens.13 Therefore,
encouraging patient adherence is one of the most vital aspects a pharmacist
should focus on while counselling a patient in order to ensure they get the
best results from their medication.



Drug – Drug interactions


As previously mentioned, patients with heart failure are on
multiple medications and often following complex dosing regimens. Heart failure
patients take, on average, 6.8 prescription medications per day, resulting in
10.1 doses a day not including over the counter medication or complementary and
alternative medication. As a result of this complicated tratemnet plan,
pharmacists play a vital role in ensuring there are no drug-dug interactions.

This can be done by regularly reviewing all of the medication the patient is
taking – not only the prescription ones.


Many drugs can have negative effects on heart failure in
many ways such as: by causing direct myocardial toxicity; by negative
inotropic, lusitropic, or chronotropic effects; by exacerbating hypertension;
by delivering a high sodium load; or by drug-drug interactions that limit the
beneficial effects of HF medications.14  In order to avoid this it is important a
pharmacist is aware of the drugs that can cause these effects. These include: analgesics,
anaesthesia medications, antidiabetic and antihypertensive medications,
anti-infective medications, anticancer medications, hematologic medications,
psychiatric medications and urological medications. Over the counter NSAIDS,
which are used by approximately 17% to 23% of the population once a week,15 can
exacerbate HF and increase the risk for HF hospitalization particularly when
taken at higher doses.16
Because this medication is so easily accessible, pharmacists play an important
role in educating patients about the risks associated with the medication.




When a patient is diagnosed with any chronic illness it can
be an extremely stressful, worrying and traumatic time for patients, their
family and their care giver. Heart failure in particular can be difficult to
patients to deal with because the name heart failure insinuates a much more
serious disease than in actually is. Pharmacists are therefore, vital in the
first few weeks of being diagnosed to act as a source of information for
patients and to answer any questions and queries. In the “Future pharmacy
practice in Ireland’ report created by the PSI the first part of the
pharmacists role in supporting patient’s with chronic disease is information
and awareness. This report states that when newly diagnosed with a disease
patients receive large amounts of information at once and this can lead to
confusion about their condition and the medication they must take. Pharmacists
are easily accessible and so, they have many opportunities to ensure that the
patient understands their condition and to improve their knowledge, the more
knowledgeable the patient is, the more likely they are too comply with their
medicine regime.










1 (ahf)

2 Irish heart




6 Lloyd-Jones
DM, Larson MG, Leip EP et al. Lifetime risk for developing congestive heart
failure: the Framingham Heart Study. Circulation 2002;106:3068–72.


7 hse

8 Management
of chronic heart failure in the older population



9 Treatment for chronic heart failure in the
elderly: current practice and problems


10 same as 8

11 Improving
medication adherence of patients with chronic heart failure: challenges and


12 Improving
medication adherence of patients with chronic heart failure: challenges and


13 Impact
of Medication Nonadherence on Hospitalizations and Mortality in Heart Failure


14 Drugs
That May Cause or Exacerbate Heart Failure


15 OTC
analgesics and drug interactions: clinical implications


16 same as 14