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Heart Failure Series: Part 4- Management and Treatment

1.5 Contact Hours
This peer reviewed course is applicable for the following professions:
Advanced Practice Registered Nurse (APRN), Certified Registered Nurse Anesthetist (CRNA), Clinical Nurse Specialist (CNS), Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN), Nursing Student, Registered Nurse (RN)
This course will be updated or discontinued on or before Sunday, June 16, 2024

Nationally Accredited

CEUFast, Inc. is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center's Commission on Accreditation. ANCC Provider number #P0274.


Outcomes

≥ 92% of participants will know how to manage and treat Heart Failure.

Objectives

After completing this continuing education course, the participant will be able to:

  1. Describe the primary goal of the medical management and treatment of Heart Failure.
  2. Categorize common Heart Failure medications and their mechanism of action.
  3. List modalities of invasive and mechanical support of patients with Heart Failure.
  4. Explain the various lifestyle changes that must be made to improve the quality of life of a patient with Heart Failure.
  5. Define the early indications of a change in symptoms for a Heart Failure patient.
  6. Describe end-of-life care for Heart Failure patients.
CEUFast Inc. and the course planners for this educational activity do not have any relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

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To earn of certificate of completion you have one of two options:
  1. Take test and pass with a score of at least 80%
  2. Reflect on practice impact by completing self-reflection, self-assessment and course evaluation.
    (NOTE: Some approval agencies and organizations require you to take a test and self reflection is NOT an option.)
Author:    David Tilton (RN, BSN)

Introduction

The previous course, Heart Failure Series: Part 3- Acute Heart Failure, covered an in-depth explanation of the more acute forms of Heart Failure as well as the diagnostic criteria of Heart Failure. This course, the fourth and final course in the Heart Failure series, will review both non-pharmacologic and pharmacological treatments for Heart Failure, the lifestyle changes associated with Heart Failure, as well as end-of-life care.

Medical Treatment for Heart Failure

Medical treatment aims to restore the largest amount of function to the cardiovascular system with the least expense to other organs and tissues. Consistently, patients experiencing Heart Failure report that the major drawbacks to a decent quality of life are shortness of breath and fatigue (Buddy Balifu, n.d.). We can control these by increasing cardiac output and reducing fluid retention.

Heart Failure is not a simple disease and, therefore, calls for a complex and integrated response using multiple medications to support the positive effects of symptom management. In general, the order of therapy may first call for initiation of loop diuretics to contain and control fluid overload in those individuals showing overt Heart Failure symptoms such as dyspnea or peripheral edema.

Pharmacology of Heart Failure

Diuretics in Heart Failure

Diuretics are almost inevitably prescribed for Heart Failure at some point, often early following diagnosis because they are THE major treatment for fluid congestion (edema).

The goal of diuretics is to reduce filling pressures in the heart by causing the patient to eliminate (urinate) excess fluid.

Diuretics are available in a wide variety allowing individualization to each patient's needs. No one pharmacologic agent has shown significantly greater benefit than the others (Huxel et al., 2021).

Angiotensin-Converting Enzyme Inhibitors in Heart Failure

Whether or not a diuretic is called for as the first line of pharmacologic intervention, the use of angiotensin-converting enzyme (ACE, or ACE-I) inhibitors are sure to be considered early as a first-line treatment for Heart Failure (Shamard, 2022).

The action by which ACE inhibitors work physiologically is by preventing the body from creating angiotensin, a substance in the blood that causes vessels to constrict and raise blood pressure. ACE inhibitor patients in clinical trials have consistently shown improved cardiac function, improved symptoms, and better test results. In a series of large-scale trials, the use of ACE inhibitors in various phases of Heart Failure showed a lower death rate from all causes and a decreased risk of hospitalization (Herman et al., 2021). Please note that ACE inhibitors do not, however, stop disease progression.

Beta-Blockers in Heart Failure

Treatment with beta-blockers is a main strategy for managing patients with known Heart Failure and reduced ejection fraction. These medications have been known to help to improve heart function.

Beta-blockers can reverse some of the neurohumoral effects of the sympathetic nervous system, which has both prognostic and symptomatic benefits. Some specialists feel beta-blockers are underused due to the misconception that hypotension and bradycardia may worsen the hemodynamic status of patients with HFrEF (Masarone et al., 2021).

Large-scale studies suggest that carvedilol, metoprolol, and bisoprolol may prolong Heart Failure survival rates. There is some suggestion that carvedilol might have superior efficacy to metoprolol for improving left ventricular ejection fraction (LVEF), though some patients have shown an increase in edema with carvedilol (Farzam & Jan, 2021).

Inotropes in Heart Failure

Inotropes are drugs that change the strength of cardiac muscle contractions. Positive inotropes increase the heart rate and are used to treat Heart Failure. Negative inotropes decrease the strength of muscular contractions, which is useful in the treatment of high blood pressure (Al-Shura, 2020). Common inotropic medications include dopamine, dobutamine, milrinone, and calcium channel blockers (Al-Shura, 2020; Rxlist, 2021).

Inotropics are recommended for use on a short-term basis in Heart Failure to aid during stabilization. Ironically, every inotropic drug that has been studied increases the potential for death (Caramenico, 2022).

Invasive and Mechanical Support of Heart Failure

There are many cases in which a patient suffering with Heart Failure will require additional means of cardiopulmonary support. Invasive interventions include the revascularization of any areas of the heart that are creating physiologic cardiac damage. This occurs by sending out distress electrical pacemaker signals and/or removing areas of tissue that are blocking the rhythmic transfer of electrical impulses.

Often these interventions can be done by cardiac catheterization (thrombus clearing or stent placements) up to coronary artery bypass surgery. A procedure that is increasingly being used to treat Heart Failure patients is a selective ablation or targeted killing of aberrant pacemaker cells that cause dysrhythmias. Locating the source of a dysrhythmia and eliminating that select area of the weakened heart muscle can save much grief and heartache.

One specific type of pacemaker is a significant help in about 1 in 5 Heart Failure patients. This style of pacemaker therapy is called ventricular resynchronization therapy (VRT) or cardiac resynchronization therapy (CRT). This pacemaker paces both ventricles of the heart (biventricular) (John, 2021).

Image 1: Implantable Cardiac Pacemaker

pacemaker and heart graphic

Heart valve surgery is, when needed, a good early prevention for the development of Heart Failure. With the new Universal Definition of Heart Failure, repairing or replacing defective valves during Heart Failure Stages A or B will save lives from early death (Gibson et al., 2021).

End-stage Heart Failure, particularly for those waiting on the best gift of all, a heart transplant, has some invasive options as well. These would include interaortic balloon pump (IABP) circulatory assistance, implantation of a ventricular assist device (VAD), or even the possibility of an artificial heart (Han et al., 2018).

Lifestyle Changes with Heart Failure

Heart Failure afflicts us as individuals, yet it affects entire families. As an individual gradually loses the breath to do even the simplest things, drastic changes must occur. Changes include family and friends' increased effort to help with the house, shopping, errands, and even bathing chores.

Heart Failure is not COVID-19, a cold, or any other type of passing illness. It most often manifests as the gradual, persistent erosion of a person’s entire bodily functions as backpressure and the flow of increasingly congested circulation changes throughout all tissue and organ systems.

One of the most significant changes that any individual with newly diagnosed Heart Failure can make is to get to know their healthcare providers. If a person has been diagnosed with HFrEF Heart Failure or any other variation of Heart Failure, frequent visits to their healthcare providers will be necessary to improve overall quality of life.

Support System in Heart Failure

Each patient will need support. Build a support system into the plan-of-care. If you are the healthcare professional helping in this role, do your best to immediately plug your patient into a Heart Failure support group.

Ask your patient if their families are supportive. Find out what they have in the way of social support networks, and if they do not have ample support, connect them with resources. Heart Failure is a progressive condition that tends to be terminal. That does not mean that you cannot have an excellent quality of life. However, it will take work. That is where the support systems come into play. It is very helpful to Heart Failure patients to have encouraging support.

Nutrition in Heart Failure

One of the greatest challenges in controlling Heart Failure is the dietary lifestyle change that is necessary. A low sodium diet that is commonly prescribed with a Heart Failure diagnosis is tough.

The American College of Cardiology (ACC) and the American Heart Association (AHA) guidelines recommend that individuals with Heart Failure restrict their sodium to less than 3,000 milligrams (mg) per day. Remember that 2,300 mg of sodium is only one teaspoon of salt (Schiller, 2021).

It is beneficial to teach your patients how to read the nutrition labels on food packaging. A daunting task, true. You can do it through; you are a health professional! It is also important to teach your patients to avoid processed foods when possible, selecting mainly fresh fruits and vegetables. At restaurants, asking for low sodium options is one way to simplify the decision-making process and select meals that are healthier for these patients. Even removing the saltshaker from the table is a simple action that can minimize temptation and overall help eliminate the addition of any additional sodium.

Fluid restriction may be called for depending on the type and stage of Heart Failure. If a fluid limit is needed, be sure to coach the patient that this includes coffee, juice, milk, tea, soda, and water. Furthermore, yogurt, pudding, ice cream, and the juice in fruits or smoothies all count as well. For soup, chunkier types that have high-fiber vegetables and less broth is a better choice.

Keeping track of fluid amounts can be simple. Keep a pitcher nearby that holds the amount of fluid allowed daily (Schiller, 2021). Each time the patient drinks any fluid, have them empty that same amount from the pitcher. Once the pitcher is empty, they have reached their recommended fluid allotment for the day.

The following table provides additional general guidelines for a diet recommended for patients with Heart Failure (Schiller, 2021):

Table 1: Heart Failure Diet Guidelines (Schiller, 2021)
  • Keep sodium (salt) intake low
  • Keep an eye on fluid intake
  • No alcohol
  • Eat fresh fruits, vegetables, and avoid preprocessed where possible
  • Reduce fat and cholesterol
  • More fish, less fatty meats, choose skinless chicken and poultry

Weight and Heart Failure

Consistency is the key concept with lifestyle changes. Be sure to get across the concept of “weigh yourself daily”. It is especially important to emphasize, too, that weights are done at the same time each day. Daily weights are particularly important in monitoring fluid changes. So, have the patient weigh themselves daily (in the morning is best), after voiding, without clothing, and keep a daily log.

While teaching the patient about this, emphasize the point that if they gain more than 2 to 3 pounds over the course of one night, they are developing edema even if it does not show yet. This increased edema means that extra diuretics may be needed. This would warrant a call to the patient’s physician. Standing written instructions are needed for the Heart Failure patient on whom to call, for what, and when to make the call. Another possibility is that the patient may already have written information on whether to take an “extra” diuretic pill and under exactly what circumstances to do this. Remind them that it is much easier to be in the habit of taking a daily weight and then make any needed correction than it is to get into a fluid overload cycle and end up in the local emergency room.

Exercise and Heart Failure

Exercise is good. It is important to be consistent but not overdo it. If possible, enlist your patient in an official Cardiac Rehabilitation Program during Stage A or B before they have shortness of breath on exertion. If you must initiate a program on your own, walking is the best exercise, but remember that some resistance training is desirable for them to feel and function better. The physician in charge should check the plan of exercise.

Treadmills are good (motorized is best) when used regularly and consistently. Whether the patient takes part in a formal exercise program or not, a person with Heart Failure needs to make time for moderate aerobic exercise, like walking, swimming, or biking. Remind the patient about the importance of always staying within the physician's recommendations and their own comfort zone.

Dental Care and Heart Failure

Remind the patient to inform their dentist of their diagnosis of Heart Failure. Heart medications, especially diuretics, can give a person a persistently dry mouth. The lack of saliva allows germs to stay inside the mouth instead of being naturally rinsed away (Buddy Balifu, n.d.). Lack of saliva can lead to tooth decay, cavities, and infection. Instruct the client to brush after every meal, floss if they can, and talk to their dentist specifically about their heart medications and dry mouth issues. In addition, if they have any “heart valve leakage” at all, their primary cardiologist may want to prescribe an antibiotic to take immediately before any dental work and again immediately afterward as a prophylactic measure. Prevention of infection due to dental issues is best (American Dental Association [ADA], 2022).

Medic Alert Bracelets and Heart Failure

Discuss with your patient how to buy a Medic Alert Bracelet and the importance of always wearing it. Being admitted unconscious to a hospital Emergency Room can be a fatal experience for someone with Heart Failure. The emergency services personnel must know when there is a preexisting heart problem. Have your patient get an appropriate bracelet or necklace, have it engraved with the appropriate warning/condition information, and encourage it always to be worn. It is also a clever idea to issue a wallet card listing all medical problems, all medications, and the physician’s and family's phone numbers. Please use every appointment as an opportunity to ask whether they are wearing and carrying their medic alert information.

Changing Symptoms and Heart Failure

Having Heart Failure requires an active watch by both patient and caregivers to catch early indications of a change in symptoms. If anyone notices something new, or a sudden worsening of a current symptom, it is important that steps be taken immediately. Here is a sample of what to watch for (American Heart Association [AHA], 2017):

  • Sudden weight gain — three or more pounds in one day, five or more pounds in one week, or other amounts the physician designates.
  • Increased shortness of breath while at rest, not related to exercise or exertion.
  • Increased swelling of the lower limbs (legs or ankles).
  • Swelling or pain in the abdomen.
  • Increased trouble sleeping (awakening short of breath, using more pillows).
  • New cough or increased frequency, dry hacking cough.
  • New or increased loss of appetite.
  • New or increased fatigue or feeling tired all the time.

Rest and Relaxation in Heart Failure

If a person has Heart Failure, they need to schedule time every day for rest and relaxation. Rest times are essential because it gives the heart a chance to pump more easily and effectively. Encourage your patient to try napping after lunch, putting their feet up for a few minutes every couple of hours, or sitting down while doing certain household tasks, such as preparing food or ironing (Judeo Christian, n.d.). Daytime rest can help keep them from "overdoing it," which might bring repercussions much worse than a difficult day or two.

It also makes it easier to cope with feelings of tiredness caused by nighttime sleep interruptions (Judeo Christian, n.d.). Heart Failure sufferers sometimes find themselves awakened by symptoms such as shortness of breath and coughing. Their sleep may also be interrupted due to the need to urinate more often. Frequent urination is usually a result of the prescribed diuretics to help rid the body of extra fluid. If getting a good night's sleep is hard, resting during the day is even more essential (Judeo Christian, n.d.).

To improve nighttime sleep, you can recommend the use of pillows to prop up the head. Avoiding naps or big meals immediately before bedtime is helpful as well. Sometimes diuretics can be timed to be less likely to cause nighttime urination (Judeo Christian, n.d.). Ideally, it is best to take diuretics in the morning, and it is a good subject for patient negotiation with their physician.

End of Life Care in Heart Failure

Heart Failure is typically a fatal condition. Unless a patient passes from another cause first, the syndrome known as Heart Failure will continue towards its inevitable, terminal conclusion.

Education of both patient and family about the expected or predicted course of this illness is necessary. Final treatment options, advanced care directives, and all necessary planning for this outcome must be discussed and completed before the individual becomes too ill to take part in the decision-making process.

Recently hospice services expanded to include those who are dying of Heart Failure. Initially, hospice care focused on those in the final stages of terminal cancer, but now care has expanded to include the relief of symptoms other than pain. Expanding care was a wise and caring decision, and hospice workers must be commended for the challenging task they accept. Family members of Heart Failure patients agree that it is not the pain that is the symptom most burdensome to the end-stage Heart Failure sufferer, but instead, the breathlessness. Therefore, compassionate care may require the frequent administration of intravenous diuretics, the use of supplemental oxygen, and in certain instances, the infusion of positive inotropic agents to supply symptom respite rather than the use of potent analgesics.

The time of diagnosis is when to begin the ongoing process of advanced care planning, including end-of-life care. Heart Failure is a dynamic, often swiftly changing process. Interactions with environmental influences (unseasonal heatwaves, a harsh allergy season, stress brought on by regional weather disasters, etc.) and routine public health patterns (e.g., flu season, grandkids bringing colds from school, norovirus at the senior center, etc.) can crash a hard-stabilized patient metabolism, bringing the possibility of circulatory or respiratory failure. Thinking early about what care decisions and life priorities are most important is essential for those living with Heart Failure. Remember, care goals can always be revisited, rethought, and rewritten as necessary and as desired. The most important piece is that there be goals for the end of treatment, and by this, we mean end-of-life care.

Goals of care are not simply a euphemism for “code status.” Goals of care include making decisions about specific treatment preferences, the depth or intensity of care provided during each stage of the disease process, as well as future care planning, e.g., what advanced care choices are preferred. Not all care goals are medically oriented. For example, how everyone wants to live their life and what they prioritize as wishing to do in their remaining span is overwhelmingly important. Are there people they want to see, relationships they want to mend, tasks they are driven to complete, events or special occasions significant to them? Making the determination of how your patient regards length of life versus quality of life lived and getting that down in the care plan is important for everyone involved.

Conclusion

As mortality records show, it is often in the first five years post-diagnosis that death comes using the conventional diagnosis of Heart Failure. Please commit to discussing and utilizing the new 2020 Universal Definition of Heart Failure, as most thoroughly explained in the first course in this series, Heart Failure Series: Part 1- Definitions and Classifications, so that early syndrome recognition will allow treatment to begin quicker and bypass the seventeen-year waiting period that it traditionally takes the healthcare profession to recognize and accept new findings, definitions, and ways of providing care (Niven, 2017).

Both science and medicine are easing the burdens carried by wounded hearts. From heart transplants to total artificial hearts, repairing parts of the existing failing heart, and finding ways to mechanically help the heart in failure to function better are all real goals. New drugs, new surgeries, new hope for a better quality of life and a longer, fuller life are the focus of today’s medical therapies. Together with all-encompassing, at times drastic, lifestyle changes, a person with Heart Failure has more to look forward to than wasting away and waiting for death. Even when all treatments fail, helping to ease patients into a loving goodbye is our duty. So, remember and take pride, for it is all our jobs in the healthcare field to be participants in the fight against Heart Failure by early recognition and management of this difficult condition. Together, using all our skills, we can be effective in the effort to control one of the biggest killers of our time, the heart in failure.

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References

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