Heart Failure (HF) Nurses and Allied Professionals Specialists Contribute to Differential Diagnosis of Patients with HF and Comorbidities

Abstract

Patient presentation: A 76 years old male patient with Heart Failure (HF) enrolled in the nurse-led management program ‘Support Heart’ is presented in the current clinical case. Even though he was well educated and supported through the program, he had several deterioration and re-hospitalizations, during a few months period. The symptoms remained after his discharge and specialist nurses of the program advised him to visit a cardiologist specialist on HF and other specialists as well who diagnosed amyloidosis. Initial work-up: The patient was introduced to the management program ‘Support Heart’ after he was diagnosed with HF with preserved Ejection Fraction (HFpEF). ‘Support Heart’ program includes specialist nurses and physiotherapists on HF who collaborate with cardiologists; and provide monthly follow-up meetings in which the patients are educated, ask questions, do exercise, walking etc. During the pandemic and the lockdowns (a few months period), the patient was admitted three times within the cardiology ward with dyspnea NYHA III and swelled legs with ulcers. The first meeting of the program after the lockdown was only a few days after discharge. HF nurses during his assessment found that the symptoms were not better and undertook a more detailed medical history when they found out that his brother died from a liver disease. The family history with the unknown disease and the continuing symptoms were the reasons that nurses referred the patient to a HF cardiologist specialist. The cardiologist suspected amyloidosis and asked for further evaluation tests. Diagnosis and management: The scintigraphy and hematological tests suggested transthyretin amyloidosis. His therapy then was optimized and upgraded with disease specific treatment (tafamidis) for amyloidosis and the clinical presentation of the patient was improved. His NYHA stage became II and the ulcers were much better. The nurses of the ‘Support Heart’ program were informed by the cardiologist about the new therapy and the necessary follow-up treatment. Follow-up: Amyloidosis is an increasingly recognized but too often underestimated cause of HF. It is often underdiagnosed due to the lack of clinical manifestations. The new possibilities of imaging and tests along with a careful clinical assessment and medical history provide the opportunity for early diagnosis, optimization of the therapy and improved clinical outcomes. The HF nurses of the ‘Support Heart’ program explained to the patient about cardiac amyloidosis and how it changes his treatment and follow-up of the multi-disciplinary team. Then, they made together with the physiotherapist of the program a new program of physical activity since his physical condition along with his mental condition were improved. Conclusion-Learning points: Specialist nurses and physiotherapists in HF and supportive nurse-led management programs may contribute to differential diagnosis of patients with HF and comorbidities and improve the outcomes of the patient and the coordination of health professional specialists. Patients with HF who are mostly older people with comorbidities need continuing support, evaluation and optimization of therapy.