heart%20failure%20-%20chronic
HEART FAILURE - CHRONIC
Treatment Guideline Chart
Heart failure is a clinical syndrome due to a structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood in order to deliver oxygen at a rate commensurate with the requirements of the metabolizing tissues.
Symptoms are caused by ventricular dysfunction secondary to abnormalities of the myocardium, pericardium, endocardium, valves, heart rhythm and conduction.
Chronic heart failure is a state where patient's signs and symptoms have been unchanged (stable) for at least a month but may decompensate suddenly or slowly when stable chronic heart failure deteriorates leading to hospitalization.

Heart%20failure%20-%20chronic Patient Education

Patient Education

 General Counseling

  • Patient counseling tends to improve patient compliance and outcomes
  • Educate the patient and caregivers about chronic HF
    • Discuss the nature of HF, treatment goals, drug regimens, dietary restrictions, symptoms of worsening HF, what to do if these symptoms occur and prognosis

Medications

  • Inform patients about the drugs’ indications, dosage, side effects and precautions
  • Emphasize the importance of treatment adherence
  • Assist patients in dealing with complicated drug regimens and in accessing affordable medications
  • Avoid NSAIDs including cyclooxygenase-2 (COX-2) inhibitors
    • Patients are at increased risk for fluid retention and renal failure especially those with decreased renal function or who are on ACE inhibitors
    • NSAIDs can cause sodium retention, peripheral vasoconstriction, decrease the efficacy and increase the toxicity of ACE inhibitors and diuretics

Pregnancy and Contraception

  • Low-dose oral contraceptives have a small risk of causing hypertension or thrombogenicity, but these risks need to be weighed against the risk of pregnancy
  • Advise patients with LVEF <30% and those in NYHA Class III-IV to not get pregnant; if HF occurs during pregnancy, use beta-blockers, Digoxin, diuretics, Hydralazine and/or nitrates judiciously

Travel

  • Discuss travel plans with the physician for patients with HF are at increased risk of deep venous thrombosis (DVT)
  • Air travel is preferred than other means of transportation, especially on long journeys
    • Long flights may predispose patients to accidental omission of medicines, edema of lower extremities, dehydration and DVT
    • DVT prophylaxis with a single injection of low-molecular-weight Heparin and/or graduated compression stockings plus calf stretching during the flight are recommended
    • Pharmacotherapy may be added if there is significant risk of DVT
  • Avoid high altitude destinations of >1500 meters because of relative hypoxia

Lifestyle Modification

Weight Monitoring

  • Increase in body weight is associated with deterioration of HF and fluid retention
  • Patients should weigh themselves regularly to monitor weight change
    • If a patient has sudden unexpected weight gain of >2 kg in 3 days, the physician should be informed and diuretic dose may need to be adjusted
  • Patients who are obese need to lose weight to decrease symptoms, improve well-being and prevent progression of HF
    • Goal body mass index (BMI) is 25-27 kg/m(22-25 kg/m2 for Asians)
    • Goal waist measurement for men is <94 cm and <80 cm for women
  • Weight reduction should not routinely be done in patients with moderate to severe HF since unintentional weight loss and anorexia are common problems
  • Cardiac cachexia, defined as involuntary non-edematous weight loss ≥6% of total body weight within the previous 6-12 months, is an important predictor of decreased survival
    • Possible treatments are appetite stimulants, exercise, anabolic agents and nutritional supplements

Diet Modification

  • Sodium restriction
    • Restrict sodium intake to <2 g/day (~1/4 teaspoon of table salt)
  • Potassium reduction
    • Advise patients regarding a low potassium diet since hyperkalemia and/or abnormal renal function hinders the ability to reach target medication doses
  • Fluid restriction
    • Should be individualized, though generally may limit fluid intake to 1-1.5 L/day in patients with normal renal function
    • Routine fluid restriction in all patients with mild to moderate symptoms is probably not beneficial
    • Weight-based fluid restriction (30 mL/kg body weight if body weight ≤85 kg or 35 mL/kg if body weight >85 kg) may cause less thirst
  • Caffeine
    • Excessive caffeine intake may increase heart rate, increase BP and exacerbate arrhythmia
    • Limit caffeine beverages to 1-2 cups/day
  • Saturated fat
    • Limit saturated fat intake in all patients with HF
  • Omega-3 fatty acids
    • Supplementation with omega-3 polyunsaturated fatty acids is a reasonable adjunctive therapy in chronic HF
    • A trial showed reduction in mortality or hospital admission for a CV event
  • Fiber
    • High fiber diet is recommended to prevent constipation secondary to relative gastrointestinal hypoperfusion
    • Helps avoid straining in stool which may provoke angina, dyspnea, or arrhythmia
  • Frequent small meals may prevent shunting of the cardiac output to the gastrointestinal tract, thus decreasing the risk of angina, dyspnea, dizziness or bloating

Alcohol

  • Alcohol is a direct myocardial toxin and may impair cardiac contractility
  • May have negative inotropic effect and may be associated with BP elevation and increased risk for arrhythmia
  • Limit alcohol intake to 10-20 g/day (2 units/day in men or 1 unit/day in women)
    • A standard drink of 14 g of pure alcohol is equal to 12 oz of beer (5% alcohol content), 8-9 oz of malt liquor (7% alcohol content), 5 oz of table wine (12% alcohol content), 1.5 oz of 80-proof distilled spirits or liquor, eg gin, rum, vodka, whiskey (40% alcohol content)  
    • 1 unit is equivalent to 10 mL (8 g) of pure alcohol [⅓ pint of beer (5.2% alcohol content), half a standard glass (175 mL) of wine (12% alcohol content), or 1 measure (25 mL) of spirits (40% alcohol content)]

Smoking Cessation

  • Primary goals: Complete smoking cessation and avoidance of passive smoking
  • Provide counseling, cessation programs and pharmacotherapy (eg nicotine replacement, Bupropion)

Physical Activity

  • Regular physical activity or aerobic exercise is strongly recommended in patients with chronic HF (NYHA Class I-III)
    • It should be individualized based on the patient’s capacity
    • Promote adherence to an exercise goal of 30 minutes of moderate activity or exercise, 5-7 days a week with warm up and cool down exercise
  • When clinically stable, patients should be encouraged to carry out daily physical activities and leisure activities that do not induce symptoms

Sexual Activity

  • Counsel patients to defer sexual activities if they are in NYHA Class III-IV but may resume when their cardiac condition is stabilized  
  • Sexual activity is likely to be safe in patients who are able to achieve approximately 5-6 metabolic equivalents of exercise (eg can climb two flights of stairs without stopping due to angina, dyspnea or dizziness)
  • Advise patients regarding the use of sublingual nitroglycerin as prophylaxis against dyspnea and chest pain during sexual activity
    • Drugs used in erectile dysfunction (eg Avanafil, Sildenafil, Tadalafil) are contraindicated in patients receiving nitrates or those who have hypotension, arrhythmias or angina pectoris
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