Faces of Heart Failure - The GP

Dr Joe Gallagher is a GP in Gorey Co Wexford and Clinical Lead for Cardiovascular Disease with the Irish College of General Practitioners(ICGP).    

The GP is one of the first people you may meet on your heart failure journey as they are the ones that make the primary diagnosis which, as Dr Gallagher explains, is not always that easy as the symptoms of heart failure mimic many other chronic conditions.

Q. As a professional specialising in heart failure what does a typical day look like in your practice?

A. No two days are the same is the good news. As a GP I work with nursing, physician associate, pharmacy, and administration colleagues to help care for people of all ages with a variety of acute and chronic conditions. I also interact with heart failure specialist teams who are caring for my patients.

Although heart failure is not the most common chronic condition we see in general practice it has a major impact on both the person themselves, those that care for them, and the health system.  A study in Galway showed that a person living with heart failure attends their GP on average 14 times per year, has four other chronic conditions, and is on an average of 11 medications.  It is overwhelming.

My role as a GP is to take a holistic overview of the care of the patient and their multiple conditions and work with them to develop the best care plan for them. I also liaise with specialist colleagues involved in their care to help achieve the appropriate goals for each patient.

The HSE has recently developed a chronic disease programme in general practice which, for the first time, provides structured care for people with a number of chronic conditions, including heart failure, in general practice.  This is an innovative programme and has won an award from the UN and WHO for its contribution to preventing and treating chronic disease.  The clinic I work in also links with a hospital in Malawi, Africa which is seeking to improve the management of people with chronic disease, and each week we discuss the management of patients with heart failure.

Q. There are currently more than 90,000 people in Ireland living with heart failure, do you think this is an underestimate?

A. Heart failure is underdiagnosed across the world. It is a difficult diagnosis to make because the symptoms overlap with many other conditions and often present gradually. Also, access to the diagnostic tests needed has been very difficult from a general practice perspective but that is improving now as the HSE is providing funding to ensure direct access to these tests for GPs.

" Heart failure happens when the heart cannot pump blood sufficiently around the body to meet the body’s needs."

Dr Joe Gallagher, GP

Q. What is heart failure?

A. Heart failure happens when the heart cannot pump blood sufficiently around the body to meet the body’s needs. This means that there is not enough oxygen and nutrients reaching the other organs leading to symptoms and signs such as shortness of breath, fatigue, and ankle swelling.

Q. What causes heart failure? 

A. There are a number of causes of heart failure with the commonest being high blood pressure, diabetes and coronary artery disease.  For some people, there may be genetic conditions that cause it and in younger people, they may have had heart problems when they were born that led to heart failure.

Q. How is heart failure diagnosed?

A. There are many conditions that can cause similar symptoms to heart failure so when someone comes to their GP he/she will also try to look for other causes of these symptoms such as lung disease or anaemia.

One of the tests we use to see if heart failure is likely is a blood test called NTproBNP or BNP.  BNP is a protective hormone produced by the heart if it is under stress so, if the level is normal it means the heart is not under stress and heart failure is unlikely. If the level is elevated the person can be referred for an echocardiogram (ultrasound of the heart) which will look to see if there is evidence of heart failure.  Access to tests such as NTproBNP and echocardiograms has been limited meaning GPs often had to refer the patient to an outpatient clinic to get these tests done which could lead to delays.  However, the HSE is working to make these tests more widely available across the country to ensure people get diagnosed as soon as possible.

Q.Is heart failure easy to diagnosis? 

A. Heart failure is a difficult condition to diagnose. Previously it often presented with sudden onset shortness of breath. However, the prevention of cardiovascular disease is much improved and many people are on medications to help manage their blood pressure, diabetes, and cholesterol. This means that people often present with a very different range of symptoms now which can be difficult to pick apart from other medical conditions.  They may complain of fatigue, for example, that has been gradually increasing over time rather than shortness of breath.  We have also found that because people often have a number of other medical conditions they may have put their symptoms down to getting older or one of their other medical conditions and may not even mention it to their GP or other healthcare professionals.

" I have had patients from a few days old to more than 100 years who have been diagnosed with heart failure."

Dr Joe Gallagher, GP

Q. What are the most common symptoms of heart failure?

A. Heart failure presents with a variety of symptoms and these vary from person to person. Common symptoms are shortness of breath, fatigue, coughing or wheezing, and signs such as weight gain and swollen ankles. However, the problem is that these symptoms can also occur in people with a variety of other conditions making it difficult to diagnose.

Q. How is heart failure treated?

A. A major part of heart failure care is providing education for the person with heart failure so they can understand and manage it better themselves. For the majority of people heart failure is managed with medications. There are a number of medications now that have a dramatic impact on improving both symptoms and outcomes. Some people with heart failure may have other therapies such as pacemakers, stents or a bypass, they may even need a heart transplant.

 Q. Have the treatments for heart failure improved over the past twenty years if so in what way?

A. Treatments have improved dramatically over this time. Firstly, healthcare systems are becoming better organised at managing people with heart failure and other chronic conditions. Systems such as the HSE GP Chronic Disease Management Programme and hospital heart failure programme are important to ensure that people receive regular checks and appropriate treatments.

The medications used to treat heart failure are also improving leading to better quality of life and they also have a major impact on life expectancy for people with heart failure. However, more research is needed as the treatments for a type of heart failure called heart failure with preserved ejection fraction are not as good despite the fact that it affects 50 per cent of people with heart failure.

 Q. What age groups are most affected by heart failure, and does it impact more women than men?

A. Most people with heart failure are in the older age group. However, it can affect people of all ages. For example, approximately 1 per cent of people under 65 have heart failure compared to 7 per cent of 75-84 year olds and 15 per cent of people aged over 85.

Q. Do young people get heart failure?

A. Yes, I have had patients from a few days old to more than 100 years who have been diagnosed with heart failure.

" Heart failure is very different for different people. Learn as much as you can about your condition and let your healthcare providers know what your goals and preferences are. You are the expert in you."

Dr Joe Gallagher, GP

Q.Does heart failure mean your heart is failing?

A. It is probably not the best description. It really is that the heart is not functioning as well as it should but for most people this is managed with medications and does not mean that their heart will stop or fail totally. It is just not working as efficiently as it could

Q. Is it possible to live well with heart failure?

A. Yes for the majority of people heart failure is a manageable condition. It is important to learn about it and know what can make it worse. Stopping smoking, regular exercise, and even light exercise, is good it is also important to attend medical appointments and take your medication regularly.

 Q. What is the best and worst part of your job?

A. The best part is the people I get to interact with every day – people with heart failure, their families, and my colleagues in both primary and secondary care who work hard to provide a great service.

The worst part is the difficulty in accessing care for people in a timely manner. It is very frustrating to know what someone needs and to also know that they will have to wait a long time for it and that this delay could result in an emergency hospital admission. I hope that will change soon.

 Q. If you could give one piece of advice to the general public regarding heart failure prevention, what would it be?

A. Prioritise your own health on a daily basis. Exercise regularly, don’t smoke, drink alcohol in moderation, and eat healthily. Life is really busy but no one else will look out for your health. What you do today sets the scene for the future even for children and young people.

Q. If you could give one piece of advice to people living with heart failure, what would it be?

A. Heart failure is very different for different people. Learn as much as you can about your condition and let your healthcare providers know what your goals and preferences are. You are the expert in you.

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