Introduction also the global economy7 (KennellyB., 2014). According


Introduction Heart failure and associated cardiovascular diseases areundeniably some of the most serious conditions currently faced by the populationin Ireland and abroad with an estimated 17.7 million deaths worldwide, and 80%of those being due to heart attacks and stroke1 (World HealthOrganisation, 2017). According to the HSE2 around 90,000people in Ireland suffer from some form of heart failure with most patientsbeing in their 70s. Not only is heart failure one of Irelands greatest causesof death but it is also the cause of 20,000 admissions to Irish hospitals eachyear (HealthService Executive , 2017). The prevalence of heart failure isalso set to rapidly increase due to an aging and ever-expanding populationalthough currently there are over 10,000 new cases each year3 (Irish HeartFoundation , 2017). Not only does the syndrome have a direct and severe impacton the lives of those people who suffer from it but its rampant effects alsoextend into the economic environment in Ireland. The pathophysiology of thiscondition is characterised by numerous traits such as high morbidity, highmortality, frequent readmission to hospitals, and a great reliance on informalcare which in turn creates a great burden for not only the Irish but also theglobal economy7 (KennellyB., 2014).

According to a 2015 study carried out by TheHeartbeat Trust, the annual cost of Heart failure is around €660 million with€158 million being attributed to direct costs with primary care relatedexpenditure accounting for 25% of this figure and drug costs accounting for afurther 16%8 (The Heartbeat Trust, 2015). Heart failure can be described as a complex clinicalsyndrome in which the heart fails to pump blood around the body at a sufficientrate to meet the body’s metabolic demands. Symptoms of heart failure include dyspnoea,fatigue and weakness, and oedema in the legs2 (H.

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Lund L, 2017) (HealthService Executive , 2017)6. Depending on ejection fraction,natriuretic peptide levels, and presence of structural heart disease anddiastolic dysfunction, heart failure can be split into three subtypes. Theseare heart failure with reduced ejection fraction (HFrEF), heart failure withpreserved ejection fraction (HFpEF), and heart failure with mid-range ejectionfraction (HFmrEF)6 (H.

Lund L, 2017). Due to the broad aetiology of heartfailure, there are numerous treatments available in its management. Most commonlyused drugs prescribed for those patients suffering from heart failure includediuretics such furosemide to increase salt and water excretion, angiotensin convertingenzyme inhibitors such as enalapril which reduce vascular resistance, Betablockers such as bisprolol, and aldosterone antagonists such as losartan (HealthService Executive , 2017) (Rang H P)There are of course alternative treatments to heart failure which do notlimit themselves to pharmacotherapy, the most important of which are lifstylechanges.

These include smoking cessation, healthy eating, relaxation, andemotional support. All of these would have a profound reduction on the likelihoodthat another heart attack would occur as well as improvving the patient’scondition. In more serious cases surgica procedures such as implementation of apacemaker, which monitors and corrects heart rate, or an implantablecardioverter defibrillator, a device which detects atrial fibrillation andshocks the heart electrically in order to correct it. The heart may also bemaintained through the use of surgery. If a valve is faulty, it may be replacedwith an artificial one or repaired through a surgical procedure.

Other surgicalapproaches include revascularisation which incloves a coronary angioplasty or acoronary artery bypass graft which would allow blood to flow into the coronaryarteries with greater ease. The final and most drastic solution for heartfailure patients in which medicines or other surgical methods did not help is aheart trnsplant. It involves the replacement of the diseased heart with ahealthy one. This procedure carries great risk as well as there being ashortage of hearts for transplant (Health Service Executive , 2017). Due to its multiple levels of severity, heart failure isclassed according to this severity. The type of therapy and the drugs providedto the patient will depend on the class of heart failure assigned to them. Theclasses range from I to IV with I being asymptomatic and IV being very severe.

Treatmentwith ACE inhibitors has become standard for all classes but treatment stillvaries from patient to patient to the complex nature and aetiology of heartfailure. For example, in Class I, ACE inhibitors are usually used as amonotherapy where systolic dysfunction and an ejection fraction of below 45% isobserved but these patients may also be suffering from atrial fibrillation inwhich case they are given digoxin and warfarin in order to prevent a strokecaused by an embolism from the atria. Amiodarone is given to patients whoexperience ventricular or supraventricular arrhythmia. Treatment regimen addosage must be tailor made for each patient due the varying contributingfactors of heart failure and its broad spectrum of severity.

As the severity escalates,the number of different drugs prescribed and the dosages are also changed andincreased (Greene R.J).Due to the condition’s severity and great number of patientssuffering from it, it is imperative for pharmacists as primary care providersto actively contribute in the management and care of such patients. Heartfailure is a condition which can be treated through the usage ofpharmacological agents as well as lifestyle changes, and surgery allowing thepatient to live their life normally2 (Health Service Executive , 2017) . Therehas been evidence brought up that a multidisciplinary approach to patientmanagement provides an improvement to the patient’s clinical condition with pharmacistsbeing vital members of this team4 (W.

M. Cheng J, 2014). Studies such as the oneconducted by A. Warden et al5 (WARDEN, 2013) showed significant reductions inthe rate of readmission of heart failure patients with an increase in patientsatisfaction when a pharmacy managed program was in place for provision ofeducation and discharge instructions for these patients.   Discussion When describing the role of pharmacists in the care ofpatients with heart failure, the immediate thought of outpatient care inclinical and community settings springs to mind but the pharmacist’s rolesstart in fact before the patient is discharged from the hospital.

One such roleinvolves patient medication reconcilliation and education.  As heart failure mainly effects patients ofthe elderly population, the risk of drug related harm is increases along withthe risk of unwanted effects therefore somewhat complicating the care andpharmacotherapy of these patients (Christensen M, 2016). Certain studies have alreadybeen carried out which conclude that pharmacists’ roles in medicationintervention for these patients can have a great impact on reducing theprobability of these errors and further improving care for patients with heartfailure (W.M.

Cheng J, 2014). One such stuy carried out by Walker P C et al in2009 showed that pharmacist intervention did in fact reduce the number ofmedication discrepencies in patients but unfortunately did not have any majoreffect on readmission rates. During the study a pharmacist was assigned to anintervention group where they actively participated in counselling, educating, assesedappropriatness of discharge medication, and conducted postdischarge phone callswith the patients amongst other important roles. The study showed a 20% drop indiscrepencies in the intervention group but did not totally eliminate itunfortunately  (Walker P C, 2009).  There are other potential roles of the pharmacist in predischarge patientmedication through medication initiation, dosage titration, adjustment, andmonitoring. There are numerous drugs available for the treatment of heartfailure, most notably angiotensin converting enzyme inhibitors, beta blockers,and angiotensin receptor blockers (used in patients who happen to be intolerantof ACE inhibitors.

) (Health Service Executive , 2017). These drugs aregenerally recommended for first line treatement of heart failure. According toa study done by Pitt B et al, the drug spironolactone was found to also berather efficacious in the treatment of patients with heart failure as the drugcaused a 30% drop in mortality as well as a reduction in apparent symptoms (PittB, 1999). Despite the usefulness of these drugs, they are ratherunderprescribed in patients with heart failure espeially in older patients. Notonly are they underprescribed but it was also found that the dosages were lowerin older patients  (Michel K, 2008). Asseen in multiple studies, and protocol driven heart failure clinics driven andmonitored by nurse and pharmacist specialists can positively influence the drugtherapy of patients.

It has been shown that through effective prescription anduptitration of medication doses, the prognosis of heart failure patients can beimproved along with a reduction in systolic blood pressure and and heart ratewith minimal deterioration in renal function or incidence of hyperkalaemia (JainA, 2005).Once patients are discharged from the hospitals, it is the responsibility ofthe medical practitioner that the patient is able to take care of themselvesand maintains a smooth transition of hospital to home. Readmission rates forheart failure are one of the highest at 24 – 44% and are set to rise by morethan 50% in the next 25 years (The Heartbeat Trust, 2015). A large proportion of the 660 million euro costof caring for heart failure patients is incurred through these recurrentreadmissions to hospital. These readmission rates have become invaluable as anindicator in the measurement of  qualityof care in hospitals or the efficacy of certain primary care models. A majorproblem for heart failure patients is poor transition of care which is responsiblefor adverse effects and reduced patient satisfaction (Arora VM, 2010).

A study carried out by Donaho et al (Donaho EK, 2015) found that when a multidisciplinaryallied health clinic including a nurse and a pharmacist were tasked withproviding protocol driven post discharge evaluation and management, 30 day allcause readmissions did in fact drop by 44.3% in comparison to the regular  30 day all cause readmission rate at thishospital. The protocol used involved a planned follow up within 1 week andbetween 4-6 weeks post discharge. The follow ups included physical examinations, medication education and reconciliations,medication up?titration per protocol, individualized HFdisease education emphasizing symptom recognition and reporting, coordinationof outpatient health care resources, and a comprehensive discharge plan.Another study made by Warden BA et al (WARDEN,2013) further proved that the involvement ofpharmacists in medication education and discharge instruction had a verypositive impact on outpatient medication adherence and readmissions, mortality,and length of hospital stay. The study also showed a significant relative riskreduction of 55 to 69% which can be attributed to more than just the use ofproper drug therapies but also enhanced patient understanding of andimproved adherence to proven medications, rec-cognition and proper managementof exacerbation symptoms, and a strong emphasis on and frequent reminders forfollow-up.

Pharmacists have the potential to play a vital role not only in the drugtherapy of heart failure patients but also in their education. Varma et al (Varma S,1999) conducted a study evaluating a structured pharmaceutical approach in theprovision of education from a pharmacist on the disease state as well asmedication and management of the heart failure symptoms. The patients had also receiveinformation booklets on the discussed topics. The patients were assesed oncertain criteria at baseline and 3,6,9 and 12 months after. The patients receivingthe education exhibited a much greater drug compliance to the drug groupresulting in lower readmission rates as well as improved physical capabilitiesand exercise capacities.

Those patients who received the intervention also hadextensive knowledge of their drug therapy. Thoughdirect intervention with patients does bare rather promising results, amultidisciplinary approach can be just as if not more succesful. This can beseen in the article written by George et al (George J, 2011) which describesthe community pharmacists role. The article found that community pharmacistsplay a vital role in the screening of patients for cardiovascular disorderse.

g. heart failure. The pharmacists would be responsible for detecting theearly signs of these disorders in some harder to reach demographics increasingthe detection rates and allowing these patients to receive necessary treatmentas soon as possible. The pharmacists in this case can be seen to collaboratewith medical practioners sa once the disease was detected, the patient wasreferred to the general practitioner in order to receive a more in depthanalysis and evaluation of their condition. This shows how a collaborative careprocess can improve the efficacy and outcome of treatment in heart failurepatients.

This can be further seen in reviews such as the one published byOmboni et al (Omboni S, 2018) which shows multiple studies done showing thatpharmacist intervention through multidisciplinary care efforts has a ratherpositive outcome on hospital readmissions, quality of life, patient wellbeing,and length of hospital stay. These interventions generally consist ofmedication reconcilliation, patient education, and collabarative medicationmanagement. Apotential role for pharmacists in the future may include management andmaintenance of a ventricular assist device. According to Givertz MM (Givertz,2011) there are currently a great range of devices being developed for pateintswith advanced heart failure. These devices reange from fully artificial heartsto ventricular assist devices. These devices have recently been approved forthe use of lifetime support for patients suffering from end stage heart failurethough before they were exclusively used temporarily as a bridge to heartrecovery or heart transplant.

VADs assist the heart in its function and canimprove the quality of life for many patients. A study by Jennnings et al (JenningsDL, 2011) found that pharmacists could contribute to the maintenance of thesemechanical devices through the provision of antimicrobial agents. The studyshowed how pharmacists assisted the patients with dose, frequency or route ofadministration, ordering lab tests or discontinuing the therapy. It is believedthat as this medical field expands and develops, pharmacists will have more ofa prominent role in the use and management of these mechanical devices inpatients with end stage heart failure.   Conclusion  Elucidating from the information acquired from the aforementionedstudies, articles, and sources of information, it can be confidently said thatpharmacists have a great many vital roles in the care of patients with heartfailure.

It can be seen that as active participants in the care of thesepatients, they have a significant positive impact on a number of therapeuticoutcomes including decreased hospitalisations and readmissions to hospital, andan improved sense of wellbeing amongst the patients accompanied by a muchgreater improvement in the quality of life.  Pharmacist roles in management and care ofheart failure patients is categorised into three main areas which are the mostdocumented in literature. These are medication reconciliation, patienteducation, and collaborative medication management. 

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