13 September 2017

Non-pharmacological therapies in heart failure

Cardio Clinical

Heart failure affects about 1% to 2% of the Australian population. It particularly affects the elderly, with as many as 1 in 10 people at age 80 having the condition.1 Heart failure is also a leading cause of admission to hospital.  As many as one in three patients admitted with a diagnosis of acutely decompensated heart failure will be readmitted within a year.2

What’s more, the population with heart failure is increasing, due to increased rates of obesity, diabetes and improvements in treatment of myocardial infarction. Patients are also living longer due to the spectacular gains from heart-failure medications. This means that we will continue to see much more heart failure in the community in the coming decades.

Advances in heart failure therapies, including medications and devices, promise that this will continue to be a dynamic and changing chronic disease. As the prevalence of this condition increases,  The general practitioner will be more often up-titrating heart failure medications, particularly ACE inhibitors and beta-blockers which are the foundations of heart failure therapy.

Failure to titrate to target doses is a missed opportunity to realise the potential of these cheap, readily available and highly effective medications.

In addition, GPs need to ensure heart failure patients are fully vaccinated against infectious diseases as well as managing their other comorbidities.

But perhaps the most important role of the GP is to be the central hub and point of liaison with the cardiac rehabilitation team in order to prevent hospitalisation for patients with heart failure.

Education on self-management of heart failure is essential, and should be reinforced at each review.

Patients can be taught how to monitor their own symptoms, and have a heart failure action plan, including instructions on when to contact health professionals, such as when their weight rises.

they also need to understand the benefits of their medications and devices, and their side effects. For example, diuretics may need to be adjusted in an episode of vomiting or diarrhoea. There is evidence that a comprehensive one-to-one education session with a heart failure nurse is effective in improving outcomes.4 The teach-back method is preferred, and patients aids have been shown to be beneficial, and are available through the Heart Foundation.5

There are lifestyle interventions that are also recommended, although the evidence to support outcomes for these is lacking.6 These include dietary restrictions such as fluid restriction or avoiding excessive fluid intake, and the need to adjust fluid intake in hot weather. Patients should be encouraged to eat a healthy diet, low in salt and maintain a healthy body weight. Alcohol intake should be minimised and stopping smoking encouraged.

Regular aerobic exercise, considered to be sufficient to provoke mild or moderate breathlessness, should be encouraged. Exercise training improves exercise tolerance, quality of life and reduces hospitalisations.7 This can be undertaken through a cardiac rehabilitation service, or through a home-based service.

Transitional support is needed following an acute admission with heart failure.

A transitional care program which performs home visits can reduce readmissions.8 Many Victorian hospitals can facilitate this using a Hospital Admissions Risk Program (HARP). Early outpatient review within seven days after discharge reduces the risk of readmission to hospital.9

Referral to a multi-disciplinary heart failure program should be considered for patients who are symptomatic and are at high risk. These have been shown to reduce hospitalisation and mortality in patients discharged from hospital.10

While such programs vary in their delivery, they all include patient education, optimisation of medications and devices, and psychosocial support.

Regular follow up is an important element of these programs, and this can be through clinics, by telephone or home-based support, depending on the needs of the patient.

Multi-disciplinary heart failure clinics facilitate rapid access to services in the event of deterioration. They also help gain access to other types of specialist care, including dietitians, pharmacists, physiotherapists, psychologists and palliative care.

Depression is a common comorbidity in  heart failure patients, and is associated with poorer prognosis. A high index of suspicion will help in the early recognition and diagnosis of this condition. Cognitive behavioural therapy for major depression in heart failure patients has been shown to improve symptoms and quality of life.

Managing heart failure in patients with cognitive impairment, such as with dementia, represents a major challenge. There are other issues with adherence to medications and a reduced ability to self manage and self monitor. Family and carers can help recognise this, and referral for appropriate specialist care servicesmay be appropriate.

Summary

Comprehensively addressing the non-pharmacological aspects of care, in addition to medications and devices, improves the quality of care for heart failure patients.

Already the GP is the patient’s specialist for life. It follows then that GPs are also the best people to advocate for patients.

The HARP program in Melbourne, and the Health Pathways program in Sydney, are a few programs in place that work on the premise that health outcomes improve when GPs and specialists work together as part of a multi-disciplinary team.

The role of non-pharmacological management in the treatment of heart failure cannot be emphasised enough.

It not only improves the patients, it also ultimately improves their quality of life.

Dr Ingrid Hopper is a heart failure specialist physician at the Alfred Hospital in Melbourne 

References:

1. Sahle BW, Owen AJ, Mutowo MP, et al. Prevalence of heart failure in Australia: a systematic review. BMC cardiovascular disorders 2016;16:32.

2. Chan YK, Gerber T, Tuttle C, et al. Rediscovering Heart Failure: The contemporary burden and profile of heart failure in Australia. Mary MacKillop Institute for Health Research, Melbourne, Australia 2015.

3. Hopper I, Easton K. Chronic heart failure Australian Prescriber 2017;40:128-36.

4. Paul S. Hospital discharge education for patients with heart failure: what really works and what is the evidence? Crit Care Nurse 2008;28(2):66-82.

5. https://www.heartfoundation.org.au/.

6. Ponikowski P, Voors AA, Anker SD, et al. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC)Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur Heart J 2016.

7. Sagar VA, Davies EJ, Briscoe S, et al. Exercise-based rehabilitation for heart failure: systematic review and meta-analysis. Open heart 2015;2(1):e000163.

8. Feltner C, Jones CD, Cene CW, et al. Transitional care interventions to prevent readmissions for persons with heart failure: a systematic review and meta-analysis. Ann Intern Med 2014;160(11):774-84.

9. Hernandez AF, Greiner MA, Fonarow GC, et al. Relationship between early physician follow-up and 30-day readmission among Medicare beneficiaries hospitalized for heart failure. JAMA 2010;303(17):1716-22.

10. McAlister FA, Stewart S, Ferrua S, et al. Multidisciplinary strategies for the management of heart failure patients at high risk for admission: a systematic review of randomized trials. J Am Coll Cardiol 2004;44(4):810-9.

11. Blumenthal JA, Babyak MA, O’Connor C, et al. Effects of exercise training on depressive symptoms in patients with chronic heart failure: the HF-ACTION randomized trial. JAMA 2012;308(5):465-74.

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