A quality improvement model to identify undiagnosed heart failure at chronic obstructive pulmonary disease annual reviews
Authors: Hamad H , Maroof S J , Steward C 
Published: November 2024

Abstract

Introduction
Heart failure (HF) is a common comorbidity in people with chronic obstructive pulmonary disease (COPD). The estimated prevalence of HF comorbidity in patients with COPD is up to 40%1. COPD and HF have overlapping symptoms which could delay the diagnosis of HF. Studies have shown that in UK primary care, HF treatment for COPD patients is delayed by almost twelve months compared to patients without COPD2. Early diagnosis and management of HF for COPD patients in primary care could reduce risk of recurrent exacerbation and subsequent hospitalisation. HF screen is not currently emphasised in the primary care COPD annual reviews. NICE guidance for COPD diagnosis mentions the use of serum natriuretic peptides to aid differential diagnosis of HF3. Pharmacists in general practice are the patients’ first point of contact, they are able to take leading roles in the holistic management of long-term conditions such as HF and COPD.

Aim
Reduce HF related complication including exacerbations and subsequent hospital admissions for COPD patients through early HF identification programme at COPD annual review.

Methods
Electronic Emis search was conducted on the practice database to identify patients on the COPD register. Patients with existing diagnosis of HF or NT-ProBNP in the last 12 month were excluded. Patients were invited for COPD annual review and screened for HF symptoms (breathlessness, fluid retention, fatigue, lightheadness) as per NICE guidance for HF identification. NT-ProBNP test was added to routine annual blood test for patients experiencing any of the HF symptoms. Patients with elevated NT-ProBNP &gt;400ng/L were referred for further assessment for suspected HF. The project was a small scale service improvement project, it did not require ethical approval, this was confirmed with the Broad Street Health Centre clinical lead.

Results
Twenty six patients were screened out of 48 (54 %). Six patients (23%) had NT-pro BNP results over 400ng/L and were referred for further investigation for suspected HF. Diagnosis was confirmed for three patients 11%. Two of the newly diagnosed patients had an MRC score of 3, while one had and MRC score of 2. No patients with MRC score 1, 4 or 5 where among the newly diagnosed group.

Discussion
Results analysis correlates with published data regarding the prevalence of HF in COPD patients. Screening for HF in primary care might be most beneficial for patients with MRC of 2 or 3. Patients with score of 1 might have milder symptoms however annual screening will allow early detection of future deterioration. There were no newly diagnosed patients from the MRC score of 4 and 5 groups as they might have already been diagnosed if their symptoms were related to underlying HF. The three patients diagnosed with HF were treated for HF as per NICE guidance. Patients’ spontaneous feedback was positive regarding the new management approach.

Conclusion
Pharmacists in general practice can play a dynamic role in early identification of existing co-morbidities while conducting annual long-term conditions reviews. This in return facilitates vital early interventions to improve prognosis and reduce further complications along the way.

References
1. Pirina P, Martinetti M, Spada C, Zinellu E, Pes R, Chessa E, Fois AG, Miravitlles M, Pais A, Cosseddu S, Dessì MA. Prevalence and management of COPD and heart failure comorbidity in the general practitioner setting. Respiratory Medicine. 2017 Oct 1;131:1-5.
2. Axson EL, Bottle A, Cowie MR, Quint JK. Relationship between heart failure and the risk of acute exacerbation of COPD. Thorax. 2021 Aug 1;76(8):807-14.
3. National Institute of Health and Clinical Excellence. Chronic Obstructive Pulmonary Disease. June 2023 [Online].