Pathophysiology of Heart Failure/Cardiomyopathy

'Chronic Heart Failure' or 'Congestive Heart Failure'?

The word “congestive” means different things to different people and leads to a great deal of confusion. Overall, it is better to discuss “heart failure” with your patients. Different kinds of heart failure include:

• Acute heart failure
• Chronic heart failure
• Systolic heart failure
• Diastolic heart failure
• Left ventricular heart failure
• Cardiomyopathy

How the Normal Heart Functions

The heart is a hollow muscle about the size of a fist. A normally functioning heart is one of the strongest muscles in the human body. It pumps blood through the lungs to deliver oxygen to the remainder of the body.

The heart is divided into four cavities: two atria and two ventricles. The left atrium receives oxygenated blood from the lungs. From there, the blood passes to the left ventricle, which pumps it via the aorta through the arteries to supply the tissues of the body. The right atrium receives the blood after it has passed through the tissues and given up much of its oxygen. The blood then passes to the right ventricle, and then to the lungs, to be oxygenated. The heart tissue itself is nourished by the blood in the coronary arteries.

Definition of Heart Failure

Heart failure (HF) is a state in which the heart is unable to pump blood at a rate that meets the requirements of metabolizing tissues or can do so only from an elevated filling pressure.¹

The incidence of heart failure rises with increasing age, and is three times more likely to occur in men than women. Analysis of numerous published studies indicates that the incidence of heart failure is between 2.3 to 3.7 per thousand per year.²

Usually, HF manifests initially during exertion, however, as the disease progresses the contractile performance of the heart deteriorates and shortness of breath and fatigue result, even when the body is at rest.

Etiology of Heart Failure/Cardiomyopathy

The two main causes of HF are:

1. Myocardial infarction, with loss of heart muscle secondary to coronary artery disease
2. Chronic hypertension

Heart failure can also result from:

• Viral infection of the heart
• Valvular disease
• Alcoholism or other toxins
• Congenital conditions
• Acquired immunodeficiency syndrome

Heart failure can be aggravated by:

• Diabetes
• Anemia
• Thyroid disease³

Table 5.1. Signs and symptoms of heart failure.

Left heart failure (low output/pulmonary congestion)	Right heart failure (systemic venous congestion)
• Dyspnea • Orthopnea • Paroxysmal nocturnal dyspnea • Fatigue • Cough	• Peripheral edema • Weight gain • Anorexia • Abdominal discomfort • Fatigue

These symptoms may be accompanied by:

• Angina
• Cool extremities
• Tachypnea
• Tachycardia
• Elevated jugular venous pressure
• Positive hepato-jugular reflux
• Rales, wheezes
• Added heart sounds
• Pleural effusion
• Detection of enlarged heart on x-ray⁴

References

1. Colucci W, Braunwald E. Pathophysiology of heart failure. In: Braunwald E, ed. Heart disease. 5th Edition. Philadelphia: WB Saunders, 1997;394-420.
2. Cardiology Preeminence Roundtable. CHF in Brief. In: Beyond four walls: research summary for clinical and administrators for CHF management. Washington D.C.: The Advisory Board Company, 1994.
3. Adams KF, Zannad F. Clinical definition and epidemiology of advanced heart failure. Am Heart J 1998;135(Suppl 2, Part 6):S204-S215.
4. Canadian Cardiovascular Society. Report on the 1993 Consensus Conference on the Diagnosis and Treatment of Heart Failure. Guidelines for the management of heart failure. Toronto: Publications Ontario, 1996.

Dietary Considerations

The relationship between proper nutrition and control of heart failure is well understood: low salt intake, reduced alcohol consumption, and a well-balanced diet are the mainstays of helping patients manage HF.¹

When discussing diet and nutrition, it is important to involve the patient’s spouse, family members, and caregivers. In many cases (particularly with men) HF patients are not the primary food preparer in the household and may be unaware of the caloric, salt, and fat content of the foods they’re ingesting. In cases where a patient’s diet must change, involving their family in these changes will promote compliance.

Canada’s Guide to Healthy Eating offers an excellent template for counselling patients about diet. Encouraging patients to eat foods from the four major food groups will ensure they get their daily requirement of essential nutrients and vitamins.

All heart failure patients should receive written dietary guidelines, reinforced orally by the clinic nurse during regular clinic visits. Those with limited reading ability and certain ethnic groups with unique food preferences should receive specialized counselling.¹

Lowering Sodium Intake

Sodium intake should be limited in patients with HF because it is not efficiently excreted
from their system. In patients taking diuretics, the drug is rendered less effective
when sodium intake is not limited.²

The average person requires less than 500 mg/day of sodium, however, most consume between 5-6 grams/day. The optimum daily salt intake for HF patients is 2 grams/day or less, however, some patients find their diet unpalatable at this level. Therefore, depending on their stability, this level of sodium intake may be increased to 3 grams/day.¹ Patients taking large amounts of diuretics (>80 mg/day of furosemide) need to maintain their sodium intake at 2 grams/day or less. However, for patients with mild to moderate, stable heart failure without fluid retention, 3 grams/day is a reasonable target.¹

In order to increase compliance with a low-sodium diet, patients should be advised to:

• Stop using the salt shaker (remove it from the dinner table)
• Not add salt to food during preparation
• Read food labels carefully
• Stop eating processed and high-sodium foods: the greatest source of sodium (up to 80%) is the salt and other sodium compounds added to food during processing
• Be aware of ‘hidden’ sources of sodium: for example, one slice of bread contains only 150 mg of sodium, however, the quantity of bread eaten during one day could cause total daily sodium intake to be high

Assessing your Patient’s Sodium Intake/Setting Goals for Reduction

Questions that will help assess your patients’ sodium intake are:

• Who prepares your food?
• Is salt added during food preparation?
• Do you add salt to your food at the dinner table?
• How much bread do you eat?
• How often do you eat in restaurants?
• Do you request that your food be prepared without salt or monosodium glutamate?
• How often do you eat processed food (frozen dinners, canned soups, salad dressings, luncheon meats, cheese)?

To ensure compliance with a reduced-salt diet, set small, incremental, achievable goals with your patients (i.e. cut out salt during food preparation, take the salt shaker off the dinner table, stop eating fast food or prepared food). To give patients ‘control’ over their health care, allow them to prioritize the changes they need to make, but help them determine which actions will have the greatest impact on lessening sodium in their diet.

Use this chart to discuss common foods and their sodium content:

Food item Serving size Sodium Breads and cereals     Bagel (plain) 1 (3 1/2” around) 379 mg White bread 2 slices 306 mg Whole wheat bread 2 slices 298 mg Muffin (blueberry) 1 (2 1/2” around) 305 mg Muffin (oat bran) 1 (2 1/2” around) 212 mg Roll (dinner) 1 148 mg Hamburger bun 1 medium 241 mg English muffin (plain) 1 265 mg Puffed rice 1 ounce (2 cups) 0 mg Oatmeal (cooked, no salt added) 3/4 cup 1 mg Shredded wheat 1 large biscuit 0 mg Corn flakes 1 ounce (1 cup) 291 mg Pancake (made with milk & egg) 1 (4” around) 167 mg Waffle (frozen) 1 (4” square) 245 mg Fruits & Vegetables     Any fresh fruit 1 piece 0-5 mg Any canned fruit 1/2 cup 0-5 mg Orange juice (canned) 1 cup 6 mg Prune juice 6 ounces 6 mg Carrots (fresh) 1 25 mg Lettuce (iceberg) 1/4 head 12 mg Mixed vegetables (frozen) 1/2 cup 32 mg Beans (baked, canned) 1/2 cup 554 mg Peas (fresh, boiled, plain) 1/2 cup 2 mg Peas (frozen, boiled, plain) 1/2 cup 70 mg Peas (canned, drained) 1/2 cup 186 mg Potato (baked w/skin) 1 16 mg Potatoes (mashed with whole milk and margarine) 1/2 cup 309 mg Tomato juice (canned) 6 ounces 658 mg

Alcohol

Acute ingestion of alcohol depresses myocardial contractility in patients with known cardiac disease. If alcoholism is the suspected cause of a patient’s HF, alcohol intake should be strongly discouraged. For patients with Class I or II HF, ingestion of alcohol should not exceed one drink per day, i.e. 30 mL of liquor, or its equivalent in beer or wine.¹

Smoking

Abstinence is recommended for all patients, especially those with ischemic heart disease (IHD).²

Fluid Restrictions

Unstable HF patients should ingest no more than 1 litre of fluid per day. The recommended daily intake for stable HF patients is 2 litres, which is equivalent to about 6 glasses of water. However, patients must be counselled that not all fluid intake comes from drinking liquids, and that fluid contained in foods such as fruit or soups must be factored into their daily calculation.²

Daily Weigh-in/Weight log

Patients’ weight should be taken and recorded during every clinic visit, to determine whether it has remained stable or if they are experiencing undue water retention. Patients should also be encouraged to weigh themselves daily – particularly if they are taking diuretics – to monitor their weight. Specific instructions to patients include: weigh yourself after emptying your bladder, before breakfast, every morning, wearing the same type of clothing, and using the same weigh scale.

Patients must be counselled to seek medical help immediately should they gain or lose weight quickly. A daily weight log will help monitor weight and encourage control over drug (diuretic) therapy.

Vitamin Supplementation

Vitamin supplementation may be considered for severe HF patients, since vitamin loss may occur with marked diuresis.¹

References

1. Dracup K, Baker D, Dunbar SB, et al. Management of heart failure: counselling, education and lifestyle modification. JAMA 1994;272:1443-1446.
2. Uretsky BF, Pina I, Quigg RJ, et al. Beyond drug therapy: nonpharmacologic care of the patient with advanced heart failure. Am Heart J 1998;135(Suppl 2, Part 6):S264-S284.

Exercise

Until recently, exercise was contraindicated in patients with HF. However, lack of activity may have long-term detrimental effects on physical functioning. Numerous studies have shown that patients with HF can safely engage in suitable physical activity and improve their exercise capacity.¹ In fact, one recent study suggests that higher levels of activity are associated with increased levels of functioning and wellbeing for patients with chronic HF.²

While stressing the seriousness of your patient’s illness and disease progression, you can also encourage an exercise plan that enables them to remain active and enjoy a reasonable quality of life.

Unfortunately, many patients diagnosed with HF were overweight and inactive prior to development of the disease. As a result, it can be a challenge to initiate an appropriate exercise program to which patients will adhere.

The functional classifications of heart failure can serve as a guide to determine the safest level of activity for your patients:

Class I:	No limitation of physical activity. Exercise for 30 minutes or longer.
Class II:	Slight limitation of physical activity. Most physical activity needn’t be restricted, however, ordinary exercise may result in fatigue or dyspnea.
Class III:	Marked limitation of physical activity. Ordinary forms of exercise should be moderately restricted. The patient may only be able to walk 10 minutes per day.
Class IV:	Severe limitation of physical activity. Any strenuous activity can increase discomfort and result in shortness of breath or angina.

Helping your Patients Establish Realistic Exercise Goals

1. Assess your patient’s current level of physical activity by asking the following questions:
   • How many blocks can you walk before getting short of breath or fatigued?
   • Are you breathless with minimal exertion, or when you wake up?
   • Do you have chest discomfort when walking?
   • What type of activity do you enjoy now? In the past?
2. Involve your patients in the management of their diagnosis and empower them to take responsibility for their well-being.
3. Assist your patients in developing a regular, progressive exercise program that will help them to increase their endurance gradually, at their own pace.

Tips for Discussing Exercise with your Patients

Explain the benefits of exercise:

• Improved muscle strength and tone
• Reduced effects of osteoporosis
• Improved functional capacity
• Improved quality of life

Determine Appropriate Exercise Programs for your Patients

• Move from simple to complex: for example, start walking one block per day, assess for symptoms, and then increase distance accordingly
• Increase amount and type of activities according to symptoms: housework, gardening, grocery shopping, or social activities can be initiated and then assessed for symptoms
• Initiate other activities based on patients’ preferences and tolerance, such as swimming, golfing, etc.

Specific Tips for Increasing Physical Activity

• Exercise for short periods throughout the day
• Do not exercise directly after eating
• Make exercise part of a daily routine (i.e. walking each morning to get a newspaper)
• If persistent shortness of breath, chest pressure, or pain occurs, contact the CHF clinic

Tips for Exercise Safety

• Encourage warm-up and cool down exercises
• Encourage a small amount of exercise at frequent intervals, instead of trying to do too much all at once
• Discourage sudden, unexpected changes in physical activity levels

While stressing the importance of physical activity, reinforce the necessity of resting and storing energy as well. Patients should be counselled to:

• Alternate several periods of rest with exercise or other activities during the day
• Use various methods of resting, such as reading, watching television or napping
• Use equipment to save energy, such as bathtub chairs, etc.
• Elevate their legs during rest periods to avoid swelling

Sexual Activity

Fears about physical exertion may contribute to the high prevalence of sexual dysfunction reported in HF patients.¹ While there is frequently reluctance or embarrassment when discussing it, HF patients need to know how to approach sexual relations in light of their diagnosis. Although sexual practices may need to be altered in patients with limited exercise tolerance, there is no reason they need to be curtailed completely. Generally speaking, patients can continue their normal sexual activities, but should be counselled not to have sex if they’re tired, tense, or have just completed a strenuous activity.

Because discussing sex is such a sensitive issue, do not expect your patients to raise it – clinicians must be prepared to introduce the subject in a frank and supportive manner.

References

1. Dracup K, Baker D, Dunbar SB, et al. Management of heart failure: counselling, education and lifestyle modification. JAMA 1994;272:1443-1446.
2. Stewart AL, Hays RD, Wells KB, et al. Long-term functioning and well-being outcomes with physical activity and exercise in patients with chronic conditions in the medical outcomes study. J Clin Epidemiol 1994;47:719-730.

Medications

A variety of medications may be prescribed for HF patients. The following information will help health professionals to fully inform patients of each drug’s mechanism of action and clinical effect.

Patients should be educated that maintaining a relationship with only one pharmacist will help ensure better continuity of care.

Angiotensin Converting Enzyme (ACE) Inhibitors

Patients with HF have enhanced renin-angiotensin-aldosterone system activity, resulting in elevation of angiotensin II, which promotes sodium and water retention. ACE inhibitors work by decreasing the production of angiotensin II, which then results in improved hemodynamic function in HF patients. Numerous clinical trials have indicated that ACE inhibitors have a major impact in all stages of HF.¹

Recent studies have also found that ACE inhibitors have a favourable effect on ventricular remodelling and coronary vascular events. ACE inhibitors have also been shown to reduce hospitalizations and improve survival in HF patients who have had a myocardial infarction and in those with chronic LV dysfunction. In fact, ACE inhibitor therapy has been shown conclusively to reduce mortality and morbidity in HF patients.²

However, concerns about the side effect profile of ACE inhibitors (frequently unjustified if the drug is properly used) render them underused by many practitioners. Common side effects include change in renal function and development of hypotension with dizziness, cough, or both. Other side effects include skin rash, upper abdominal pain, headache, mental confusion, uremia, acute renal failure (in patients with renal artery stenosis), impotence, and, rarely, angioneurotic edema.

Beta-Adrenergic Blockers

Beta-adrenergic blocking agents have been shown to reduce heart rate and improve heart function in HF patients. Recent studies report improved survival, reduced hospitalization, and reduced rates of worsening heart failure rates in stable HF patients introduced to beta-blockers.^3,4

Once patients are started on beta-blockers, careful follow-up is crucial. Alteration in accompanying therapies will also be necessary (increase in diuretic dose, for example). Beta-blockers may be useful in patients with atrial fibrillation and have been shown to produce a rapid ventricular response in patients with a high sympathetic tone that prevents rate control with digoxin alone.¹

However, beta-blockers may lead to worsening heart failure before improvement is seen. LVEF tends to worsen initially in response to beta-blockers, but subsequently improves after 6-12 months of therapy, an improvement in LVEF not seen with other heart failure medications.¹ Low doses must be used initially and then gradually increased over weeks to months.

Diuretics

Diuretic therapy plays a crucial role in both acute and chronic management of HF. The administration of diuretics to patients with HF results in a fall in peripheral vascular resistance and an increase in venous capacitance as well as diuresis. There are three main classes of diuretics: thiazides, loop diuretics and potassium-sparing agents.

Introduced clinically in the 1950s, the major effects of thiazides are to increase sodium chloride and water excretion together with an increase in potassium excretion. Thiazides are rapidly absorbed and diuresis may begin within one hour after oral administration. In patients with decreased renal function, thiazides are relatively ineffective.⁵

Loop diuretics inhibit sodium chloride reabsorption and augment water excretion. In patients with compromised renal function, loop diuretics are preferred. Loop diuretics are quick acting (30-60 minutes after oral administration and 2-5 minutes after IV administration). For patients with recurrent fluid retention, a twice-daily dose of a loop diuretic (furosemide up to 120 mg BID, 5 mg bumetanide BID, or 200 mg ethacrynic acid BID) is indicated. Higher doses can be considered in individual patients.

Potassium-sparing agents inhibit sodium reabsorption and cause moderate natriuresis. Their major action is to cause potassium conservation and retention.⁵ They are usually used in combination with thiazides or loop diuretics in CHF patients. It is important to remember that ACE inhibitors can cause potassium retention. Because of this, patients taking ACE inhibitors and potassium-sparing agents should be monitored carefully.

Spironolactone (25-50 mg OD) has recently been shown to improve survival in NYHA Class III-IV HF patients when used in combination with ACE inhibitors.

The end point of diuretic therapy is relief of symptoms, development of orthostatic changes in blood pressure, or a progressive increase in blood urea nitrogen and creatinine.⁵ The dose of diuretic may be decreased to allow for upward titration of ACE inhibitors.⁶

Digitalis/Digoxin

Digitalis has been used for centuries in the management of HF. It is extracted from the dried leaves and seeds of the foxglove plant. At least 90% of digitalis therapy in North America is carried out with digoxin.⁷ Digoxin is a positive inotrope that also decreases sympathetic activation. In patients with HF and regular sinus rhythm, digoxin improves hemodynamics at rest and during exercise.

Discontinuation of digoxin leads to worsening of HF symptoms and decreased exercise tolerance. This is associated with a reduction in ejection fraction and increase in heart rate.⁷

In the DIG (Digitalis Investigation Group) trial, digoxin had no benefit on survival but reduced symptoms and hospitalizations due to worsening heart failure.⁸

Nitrates and Hydralazine

Nitrates and hydralazine are indicated in patients who cannot tolerate ACE inhibitors or who have a contraindication to their use. Nitrates alone may also be beneficial in HF patients, however, hydralazine alone has not been shown to be beneficial. The combination is used as adjunctive therapy to digitalis or diuretics.

Angiotensin II Receptor Antagonists

This class of drugs holds considerable promise for heart failure patients, but their role is still to be defined. At present, they are indicated if a patient cannot tolerate ACE inhibitors. It should be noted, however, that renal dysfunction is as likely to occur as with ACE inhibitors.

Anticoagulants and Antiplatelets** (Warfarin and Aspirin)

Warfarin is currently the antithrombotic agent of choice in patients with atrial fibrillation, a history of embolic events, and an ejection fraction of <20%. Warfarin is also effective in preventing thrombus formation in patients at high risk of LV mural thrombosis after myocardial infarction.

Aspirin is indicated for all patients with symptomatic atherosclerotic disease.

Amiodarone

Amiodarone is not routinely used in the treatment of heart failure. However, it is prescribed in heart failure to maintain sinus rhythm and prevent symptomatic, sustained ventricular tachycardia.

Inotropic Agents

Several studies have reported that oral positive inotropic agents are associated with increased mortality rates in HF patients. Consequently, no oral inotropic agents except digoxin should be used in patients with advanced HF.² Intravenous inotropic agents are currently used for the short-term management of heart failure patients as a bridge to surgery or to stabilize patients with advanced disease.

Conclusions

• ACE inhibitors and beta-blockers should be used in appropriate patients to improve heart function and patient outcomes.*
• Diuretics, digoxin, and nitrates should be considered for symptom relief and to improve signs of heart failure.

* Consult the respective product monographs for appropriate prescribing information.

References

1. Gheoghiade M, Cody RJ, Francis GS, et al. Current medical therapy for advanced heart failure. Am Heart J 1998;132:S231-S248.
2. The SOLVD Investigators. Effect of enalapril on mortality and the development of heart failure in asymptomatic patients with reduced left ventricular ejection fractions. N Engl J Med 1992;327:685-691.
3. Colucci WS, Packer M, Bristow MR, Gilbert EM, et al. Carvedilol inhibits clinical progression in patients with mild symptoms of heart failure. Circulation 1996;94:2800-2806.
4. Packer M, Bristow MR, Cohn JN, et al. The effect of carvedilol on morbidity and mortality in patients with chronic heart failure. N Engl J Med 1996;334:1349-1355.
5. Agarwal R, Ram CVS. Diuretics. In: Cardiovascular Pharmacology and Therapeutics. Eds., Singh BN, Dzau VJ, Vanhoutte PM, Woosley RL. Churchill Livingstone Inc. 1994:353-369.
6. Randomized Aldactone Evaluation Study (RALES). Presented at the American Heart Association Meeting [Abstract]. November 1998.
7. Packer M, Gheoghiade M, Young JB, et al. for the RADIANCE Study Group. Withdrawal of digoxin from patients with chronic heart failure treated with angiotensin-converting-enzyme inhibitors. N Engl J Med 1993;329:1-7.
8. The Digitalis Investigation Group (DIG). The effect of digoxin on mortality and morbidity in patients with heart failure. N Engl J Med 1997;336:525-533.

**Draft changes pending adoption by CHFN

Patient Counselling

Treatment Goals

Patients must be taught that the goal of treatment for HF is to control symptoms. Heart failure usually cannot be cured, however, a patient’s physical condition will stabilize or improve with proper medication and diet.

The term ‘heart failure’ strikes terror in patients, so it must be explained with care and compassion. Such discussions should be governed by the level at which a patient is able to understand the clinical information being imparted, by their desire to learn, and their emotional ability to accept the information.¹

The impact of heart failure on a patient’s life is as much related to their psychological outlook as it is to their physical adaptation to the disease. Patients must adjust to the psychological burden of living with new limitations, and the knowledge that their life expectancy may be shortened.²

Factors that Affect Outcomes

During every clinic visit, whether it is acute care or regular follow-up, nurses must offer counselling and education, and monitor patients’ understanding of:

• Medication compliance, and the importance of having all prescriptions filled at the same pharmacy
• Eating a well-balanced diet
• Adhering to a low-sodium diet
• Daily weight-taking
• Getting adequate exercise
• Maintaining a positive outlook on their health

Counselling and Family/Caregiver Support

It is crucial to involve all family members in the care and support of HF patients. By obtaining the involvement of all interested parties, the chances for patient compliance are much greater.

Family-centered intervention is practised in many centres, the goal of which is to empower both patients and their significant others to be part of the health care team. This type of counselling consists of an approach whereby communication patterns within a family are examined and studied, to determine the best way of advising patients to ensure remembrance of and compliance with information that is imparted to them.

It is important also to instill in patients the hope, courage, and inspiration to get through acute episodes and learn to live as normal a life as possible during non-acute periods.

Depression and anxiety are frequent side-effects of HF, in particular, immediately after diagnosis. Nurses must be on the lookout for such behaviours, counsel accordingly when they present, and refer to psychological/psychiatric counsellors when appropriate.

Living Wills/Advance Directives (DNRs)

It is important for the cardiac health care team to understand their patients’ treatment wishes. Since many patients diagnosed with HF are reluctant to discuss advance directives (such as DNRs) or death with family, nurses are in a prime position to initiate discussion and refer them to the necessary resources to assist them. Clergy members and social workers are valuable in helping patients come to terms with their illness and make decisions about how they wish to be treated, as well as helping families participate in this process and support the patient.

Social Work Support

Some institutions retain trained cardiac social workers who can deal with specific needs such as:

• Reviewing the patient’s economic status
• Reviewing the patient’s physical surroundings and lifestyle, and counselling them to make changes if/when needed
• Counselling family members in coping with the patient’s illness
• Directing the patient to home care and other support agencies
• Examining government funding issues, and helping patients complete necessary forms to receive financial assistance
• Helping patients make travel arrangements to attend clinics

References

1. Uretsky BF, Pina I, Quigg RJ, et al. Beyond drug therapy: nonpharmacologic care of the patient with advanced heart failure. Am Heart J 1998;135(Suppl 2, Part 6):S264-S284.
2. Dracup K, Baker DW, Dunbar SB, et al. Management of heart failure II: counselling, education and lifestyle modifications. JAMA 1994;272:1442-1446.

Follow-up Care

Stable Patients

Stable HF patients should be seen at the clinic at regular intervals – every three to six months depending on the severity of the illness. Between visits, certain procedures can be scheduled when required, including interim blood work, checking digitalis levels, and INRs (international normalized ratio).

A viable telemanagement system should be put into place, letting patients know the hours they can telephone the clinic and speak to a clinic nurse for advice and support. A 24-hour pager number should also be publicized for their assistance.

It is very important to communicate clearly with the family and the referring physician so that a proper treatment plan can be implemented and reinforced.

Unstable Patients

Unstable patients must be followed daily or weekly. During clinic visits, the following procedures are done: physical assessments, lab assessments, medication adjustment, compliance monitoring, IV diuretics if necessary, and exercise/activity counselling.

The main aim for unstable patients is to minimize hospitalization. Telemanagement for unstable patients is an important factor in achieving this aim. Clinic staff should be prepared to talk with patients as often as needed to ensure that problems are solved before they become exacerbated.

Providing refrigerator magnets or door hangers with the clinic’s telephone and pager numbers will help to ensure patients have the information they need at their fingertips.

Support groups for both stable and unstable patients provide an excellent opportunity for people to learn from experts and network with others. Moreover, support group meetings allow clinic staff to view and assess patients health status during ‘normal’ activity, instead of only in the clinic setting.

Telephone Support

Patient telemanagement helps nurse specialists track and manage large number of patients. Its aim is to identify early warning signs and correct patient problems before hospitalization for an acute event occurs. Nurse specialists who track and manage patients by telephone should be equipped with computer decision algorithms to assist in problem solving and foster proactive patient management.

In the absence of many other proactive outpatient initiatives, clinics are advised to consider telephone management of HF patients. There is indeed evidence that telemanagement alone can reduce the cost of HF by decreasing hospital admissions and inpatient length of stay when hospitalization is necessary.¹

Since many acute HF episodes are linked to noncompliant behaviour or patients’ poor understanding of their symptoms, inadequate patient self-care often goes unnoticed by caregivers who focus on treatment, not health maintenance.¹

By telephoning patients regularly at home, clinic staff identify problems, educate, and provide logistical support for patients. Points to cover during telephone follow-up include:

Problem Identification

• Do you have any physical complaints?
• Can you identify any symptoms of deconditioning?
• Have your symptoms worsened or changed suddenly?

Education

• Discuss dietary restrictions
• Reinforce effects of medical noncompliance
• Strongly discourage alcohol use, reiterate benefits of smoking cessation

Logistical Support

• Schedule visits
• Help arrange transportation to clinic, outpatient hospital services
• Make referrals to home care, social services or physicians as needed

The two main benefits of telephone management for patients are:¹

1. Patients gain access to nurse specialists trained to identify worsening conditions, and to triage appropriate care modality
2. Patients living at a distance from hospital need not travel to receive adequate care

References

1. Cardiology Preeminence Roundtable. Beyond four walls: cost effective management of chronic heart failure. The Advisory Board Company, 1994.