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HEART FAILURE - CHRONIC
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.
New onset heart failure refers to the first presentation of heart failure.
Transient heart failure refers to the symptomatic heart failure over a limited period of time although long-term therapy may be indicated.
Chronic heart failure is stable, worsening, or decompensated heart failure.

Patient Education

Medications

  • Inform the patients about the drugs’ indications, dosage,side effects and precautions
  • Emphasize the importance of treatment compliance
  • Assist patients in dealing with complicated drug regimens
  • Avoid nonsteroidal anti-inflammatory drugs 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 angiotensin converting enzyme (ACE) inhibitors
    • Nonsteroidal anti-inflammatory drugs (NSAIDs) can cause sodium retention, peripheral vasoconstriction, decrease the efficacy, and increase the toxicity of ACE inhibitors and diuretics

Lifestyle Modification

Weight Monitoring

  • Increase in body weight is associated with deterioration of heart failure (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/m2
    • 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 tsp of table salt)
  • Fluid Restriction
    • Limit fluid intake to 1.5-2 L/day in patients with severe HF to relieve symptoms and congestion
    • 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 body weight >85 kg) may cause less thirst
  • Caffeine
    • Excessive caffeine intake may increase heart rate, increase blood pressure and exacerbate arrhythmia
    • Limit caffeine beverages to 1-2 cups/day
  • Saturated Fat
    • Limit saturated fat intake in all patients with heart failure
  • 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 cardiovascular event
  • Fiber
    • High fiber diet is recommended to prevent constipation secondary to relative gastrointestinal hypoperfusion
    • Helps avoid straining in stool withc 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

Cardiac Rehabilitation

  • Useful in patients who are clinically stable
  • Several meta-analyses demonstrated cardiac rehabilitation improves functional capacity and exercise duration and decreases hospital admission and mortality

Alcohol

  • Alcohol is a direct myocardial toxin and may impair cardiac contractility
  • May have negative inotropic effect and may be associated with blood pressure (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)
    • 1 unit is equivalent to 10 ml of pure alcohol (1 glass of wine, 1/2 pint of beer, or 1 measure of spirit)

Smoking Cessation

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

Activity

  • Regular physical activity is strongly recommended in patients with chronic heart failure
    • 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

  • Sexual activity is likely to be safe in patients who are able to achieve approximately six metabolic equivalents of exercise (eg can climb two flight 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

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
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