What are the recommended monitoring parameters for patients on heart failure medications in primary care?

For patients on heart failure medications in primary care, recommended monitoring parameters include both general clinical assessments and specific monitoring for individual drug classes ².

• General Monitoring for all Heart Failure Patients:
  • A clinical assessment of functional capacity, fluid status, cardiac rhythm (minimum of examining the pulse), cognitive status, and nutritional status ².
  • A review of medication, including the need for changes and possible side effects ².
  • An assessment of renal function ².
  • Monitoring of symptoms and signs of heart failure, such as palpitations, shortness of breath, presence of oedema, and syncopal or presyncopal symptoms ¹.
  • Checking the person's pulse rate and rhythm and examining the heart ¹.
  • Consider monitoring N-terminal pro-B-type natriuretic peptide (NT-pro-BNP) levels in people less than 75 years of age to guide optimum drug treatment, especially for those with a higher baseline NT-pro-BNP level (greater than 2114 pg/mL) ¹.
  • The frequency of follow-up should be short (days to 2 weeks) if the person's clinical condition or drugs have changed, and at least every 6 months if the person's condition is stable ¹.
• Specific Medication Monitoring:
  • Angiotensin-Converting Enzyme (ACE) Inhibitors and Angiotensin-II Receptor Antagonists (AIIRAs/ARBs):
    • Measure serum sodium and potassium, and assess renal function, before and after starting the medication and after each dose increment ².
    • Measure blood pressure after each dose increment ².
    • Once the target or maximum tolerated dose is reached, monitor treatment monthly for 3 months, then at least every 6 months, and at any time the person becomes acutely unwell ².
  • Beta-blockers:
    • Assess heart rate and clinical status after each titration ².
    • Measure blood pressure before and after each dose increment ².
  • Mineralocorticoid Receptor Antagonists (MRAs):
    • Measure serum sodium and potassium, and assess renal function, before and after starting the MRA and after each dose increment ².
    • Measure blood pressure before and after each dose increment ².
    • Once the target or maximum tolerated dose is reached, monitor treatment monthly for 3 months, then at least every 6 months, and at any time the person becomes acutely unwell ².
    • Monitor closely for hyperkalaemia, especially in people with chronic kidney disease ².
  • Digoxin:
    • Routine monitoring of serum digoxin concentrations is not recommended ².
    • A digoxin concentration measured within 8 to 12 hours of the last dose may be useful to confirm a clinical impression of toxicity or non-adherence ².
    • The serum digoxin concentration should be interpreted in the clinical context, as toxicity may occur even within the 'therapeutic range' ².
  • Amiodarone:
    • Offer liver and thyroid function tests, and a review of side effects, as part of their routine 6-monthly clinical review ².
    • Review the need to continue the amiodarone prescription at the 6-monthly clinical review ².