A National Institutes of Health study reported that hospitalizations for heart failure (HF) have increased significantly since 1980; study findings show an increase of 131% between 1980 and 2006.1 Considering that 5 million people in the United States are currently living with HF,2 PAs need to be proactive in caring for this special patient population.
The most common causes for HF include coronary artery disease, hypertension, and diabetes.2 Echocardiography is used to distinguish the type of cardiac dysfunction. Systolic failure is described as poor contraction of the left ventricle and an ejection fraction (EF) below 50%. Alternately, patients may still have symptoms of HF even with normal ventricular pumping. Impaired relaxation of the ventricle is known as diastolic failure.3
After an initial diagnosis of HF, the patient must be monitored and receive counseling in an outpatient setting. Guidelines from the Heart Failure Society of America recommend educating patients and their families about self care within 1 to 2 weeks of hospital discharge.4 Self care includes recognizing an increase in symptoms, initiating appropriate treatment, modifying risk factors, and adhering to dietary/activity guidelines.4
During acute HF, patients are likely to complain of weight gain, dyspnea on exertion, peripheral edema, abdominal distension, orthopnea, paroxysmal nocturnal dyspnea, and fatigue.4 The patient should keep a daily weight and symptom log. A weight gain of more than 2 lb is associated with an increased risk of hospitalization.5 The patient must increase or begin diuretics at home if his or her weight increases by 2 to 4 lb in the short term and/or symptoms of exacerbation appear.4 This should be done only by patients who can reliably follow self care procedures and who have normal renal function.
Strict adherence to BP and weight goals needs to be reinforced during office visits. PAs should consider increasing diuretic doses for patients who have gained weight. Antihypertensives are recommended to maintain a BP below 130/80 mm Hg. In cases of compensated systolic failure with an EF less than 40%, the clinician must verify that the patient is taking the maximum tolerated doses of a beta-blocker and ACE inhibitor or angiotensin receptor blocker (ARB).4 The importance of adherence to medication regimens also needs to be stressed because nonadherence can lead to worsening HF. Risk factor modifications such as smoking cessation should be strongly suggested to those patients who smoke.
An essential subject to discuss with the patient is diet modification. The patient must not consume more than 2,000 mg of sodium per day. Essentially, patients with HF should avoid fast foods, most packaged meals, and canned foods. These patients cannot add salt to their food or use certain salt substitutes.6 Patients with HF may also need to limit their fluid consumption.
Patients who are struggling to adhere to diet and exercise modifications can be referred to a cardiac rehabilitation program. A referral to physical therapy may be needed if the patient has specific physical limitations.
Other treatment options are available for patients who do not appear to be improving and have multiple HF exacerbations. Adding an aldosterone antagonist to the drug regimen might be warranted if the patient is already taking maximum doses of a beta blocker and an ACE-inhibitor or ARB. If the patient is complaining of palpitations, consider ordering a Holter monitor test. Arrhythmias can lead to HF exacerbations that may not be seen during electrocardiography testing in the office. Patients with an EF of 35% or less may need a biventricular pacemaker or an implantable cardioverter defibrillator.4 If the patient already has a pacemaker, an echocardiogramguided pacemaker optimization may be needed. This test is used to adjust pacemaker settings.
BOTTOM LINE
Careful counseling and strong communication are paramount when treating patients with HF. The quality of care for these patients can be improved in many ways, beginning with patient education and continuing with close monitoring at follow-up. PAs can strive to reduce unwanted future hospitalizations by working with the patient and his or her family. JAAPA
Sharon Masinelli has practiced in cardiology for the past 5 years; she was on maternity leave at the time this article was written. She has indicated no relationships to disclose relating to the content of this article.
Mary Hewett, MS, PA-C, department editor
REFERENCES
1. Heart failure hospitalizations up sharply. HealthDay. November 10, 2008. MedlinePlus Web site. http://www.nlm.nih.gov/medlineplus/news/fullstory_71418.html. Accessed February 2, 2009.
2. Heart failure fact sheet. Centers for Disease Control and Prevention Web site. http://www.cdc.gov/dhdsp/library/fs_heart_failure.htm. Accessed February 2, 2009.
3. Learning about heart failure. American Heart Association Web site. http://www.americanheart.org/presenter.jhtml?identifier=337. Updated February 24, 2008. Accessed February 2, 2009.
4. Heart failure in patients with left ventricular systolic dysfunction. Heart Failure Society of America Web site. http://www.heartfailureguidelines.org/index.cfm?id=14. Accessed February 2, 2009.
5. Chaudhry S, et al. Patterns of weight change preceding hospitalization for heart failure. Circulation. 2007;116(14):1549-1554. http://www.circ.ahajournals.org/cgi/content/full/116/14/1549. Accessed February 2, 2009.
6. Cutting down on salt. American Heart Association Web site. http://www.americanheart.org/presenter.jhtml?identifier=336. Updated December 10, 2007. Accessed February 2, 2009.