Heart failure (HF) has become a significant public health problem, with a rapidly rising incidence and prevalence that is predicted to continue to rise far into the 21st century.1 Overall, 1-2% of the adult population in developed countries worldwide suffers from HF but prevalence increases 10-fold in those over 75 years of age.2 Because the incidence of HF rises with age its prevalence will markedly increase as our population ages, placing a significant economic burden on society, consuming about 1-2% of the healthcare budget. Approximately 70% of this is spent on hospitalisations.1-3
The burden of HF affects the individual, their direct environment (such as family and friends), and society overall. HF is associated with a poor prognosis, with symptoms affecting daily functioning, and a treatment regimen that can have a major impact on the daily life of patients and their families.4 Despite some recent evidence of improving morbidity and mortality rates,4,5 pharmacological treatment does not impressively improve the high morbidity and mortality rates associated with chronic HF. There is still a lot to gain from non-pharmacological treatment and appropriate follow-up in terms of improving patient stability, functional capacity, mortality, and quality of life.
Improving Outcomes in HF
In general, healthcare providers aim their treatment at improving the survival and quality of life of patients. However, it is known that HF patients are often readmitted due to worsening symptoms.6 There are many preventable and often interrelated factors contributing to readmission, such as:6,7
- inadequate or inappropriate medical treatment;
- discharge in unstable condition;
- inadequate knowledge of chronic HF and prescribed treatment;
- non-compliance with prescribed treatment;
- inadequate follow-up;
- problems with caregivers or extended care facilities;
- early clinical deterioration; and
- co-prescribed drugs (see Table 1).
It has been stated that 40-59% of readmissions would be avoided if there were better assessments, if non-pharmacological treatment was addressed, if rehabilitation was more adequate, if discharge was more carefully planned, if potential non-compliance problems with diet and medication were identified and if patients were instructed to seek medical attention when symptoms first occurred.6,7 In the updated European guidelines for the diagnosis and treatment of chronic HF, non-pharmacological treatment and adequate follow-up are recommended.4
Non-pharmacological Treatment and Patient Education
In the guidelines on HF treatment from the European Society of Cardiology (ESC),4 several educational topics are listed as important to include in patient education for patients with chronic HF and their close relatives (see Table 2). The following major areas in non-pharmacological management and patient education in HF patients can be identified:
Diet and Nutrition
Controlling the amount of salt in the diet (<2,000mg) is relevant in patients with advanced HF4,8 and a fluid restriction of 1,500-2,000ml should be advised to advanced HF patients.
It should also be advised that salt substitutes must be used with caution, as they may contain potassium. In large quantities, in combination with an angiotensin-converting enzyme (ACE) inhibitor, they may lead to hyperkalaemia.10
Alcohol consumption must be prohibited in suspected cases of alcoholic cardiomyopathy, but otherwise moderate alcohol intake is permitted.4 Other nutritional advice includes weight reduction in the overweight or obese (body mass index (BMI) >25) and prevention of malnutrition and cardiac cachexia.4,8
Rest and Exercise
Traditionally, patients with HF have been instructed not to exercise in order to avoid deterioration. More recently, physical rest is only advised in acute HF or destabilisation of chronic HF.4 If in a stable condition, the patient should be encouraged to, and advised how to, carry out daily physical and leisure-time activities that do not induce symptoms, in order to prevent muscle de-conditioning. In earlier days HF was described as a contraindication for exercise training.
However, several studies have demonstrated that training programmes in selected HF patients are feasible and safe and that physical training can induce favourable clinical effects.4 Exercise training programmes are encouraged in stable patients in New York Heart Association (NYHA) class II-III.4
Improve Symptom Recognition and Related Self-care Behaviour
In order to make patients recognise deterioration and take relevant action in case of exacerbation, patients and partners need information on HF symptoms.4,8,10 Patients are advised to weigh on a regular basis (once a day to twice a week) and, in case of a sudden unexpected weight gain of more than 2kg in three days, to take appropriate action. Patients are also encouraged to monitor other HF symptoms or note unexpected changes in the health status. They need to be aware how serious these symptoms can be and what appropriate actions are.
More recently, a flexible diuretic regimen has been suggested as an option in relation to increasing HF symptoms. Based on changes in symptoms, daily weight and fluid balance, patients are advised to increase or decrease their diuretics within pre-specified and individualised limits.4
Other Lifestyle Changes and Other Therapies4,8,10
- Smoking should always be discouraged.
- Pneumococcal and influenza immunisation may reduce the incidence of respiratory infections that may worsen HF.
- Continuous positive airway pressure (CPAP) to improve daily functional capacity and quality of life may be used in patients with HF and obstructive sleep apnea.
- Non-pharmacologic techniques for stress reduction may be considered as a useful adjunct for reducing anxiety in patients with HF.
On average, HF patients are prescribed 7.5 different drugs, with various advice, such as at what time of day to take them. In addition to this complex regimen, patients sometimes suffer from side effects of HF medication. To optimise compliance, patient education is vital. Topics to address are:
- reason for prescription and the relationship of the drug with HF;
- nature of each drug, dosing, desired effects and side effects of all drugs;
- need for refills of the prescribed medication;
- in some drugs, improvement may be gradual and only complete after several weeks, and with some drugs months, of treatment;
- Some medications (ACE inhibitors and beta-blocking drugs) will be gradually up-titrated to desired dosage levels, which will not directly improve the patient's symptoms.
- how to cope with a complicated regimen (e.g. using medication organisers);
- what to do in case of skipped doses;
- what to do if dehydration occurs;
- how to act if symptomatic hypotension occurs; and
- which drugs to avoid (e.g. non-steroidal anti-inflammatory drugs (NSAIDS) (see Table 1).
Improve Compliance with Medication and Other Lifestyle Changes
Compliance with the long-term medical regimen of patients with HF is poor, with overall non-compliance rates ranging from 42% to 64%.11 In a study of elderly patients with HF, only 55% of the patients could correctly name which medication had been prescribed, 50% were unable to state the prescribed doses and 64% could not account for the medication that was to be taken, i.e. at what time of day and when in relation to meals the medication was to be taken.12 Noncompliance extends to other aspects of the treatment regimen like daily weighing, keeping a salt-restricted diet, restricting fluid and alcohol intake, and exercise.13
Adequate Disease Management and Follow-up
Recently, several meta-analyses described that comprehensive discharge planning plus post-discharge support for older patients with HF significantly reduce readmission rates and may improve health outcomes such as survival and quality of life without increasing costs. Various models have been tested (HF clinics, nurse-led home visits and/or telephone follow-up, multidisciplinary care, extended home care services) but it is not clear which model is superior.
Most of the successful disease management programmes are multi-faceted and consist of an in-hospital phase of care, patient education, self-care supportive strategy, optimisation of medical regimen, and on-going surveillance and management of clinical deterioration.14
Depending on the local healthcare system, it seems important to determine which healthcare provider is the most appropriate to participate in various components. Nurses and other healthcare providers can play an important role in these innovative forms of care. Both researchers and healthcare providers are challenged to determine in the near future the optimal approach for the education and follow-up of patients with chronic HF.