Self-care is the key in the management of chronic heart failure
Heart failure (HF) is a commonly occurring disease affecting numerous patients worldwide. The rates of new HF hospitalization among the Chinese population in Hong Kong between 2005 and 2012 were 0.59 in every 1,000 males and 0.58 in every 1,000 females.1 Prognosis in relation to all-cause mortality in both acute and chronic HF (CHF) is poor in Hong Kong.1 In an interview with Dr. Chan Wai Kwong, Specialist in cardiology, the management strategies of CHF with special focus on self-care were discussed.
CHF- Causes, signs and symptoms
The most common causes for CHF are systemic hypertension, myocardial infarction, valvular lesions or cardiomyopathies. The signs and symptoms of CHF are external dyspnea, systemic edema, cardiomegaly, fatigue and orthopnea.2 CHF occurs when the heart is no longer able to meet the needs of the body.3
Pharmacological therapies in CHF
An angiotensin-converting enzyme inhibitor (ACEI)/Angiotensin receptor blocker (ARB) and a beta-blocker are indicated for HF patients with reduced ejection fraction.4 In CHF, clinical judgement is important to decide which therapy to begin with. ACEI/ARB therapy is usually started at a low dose for CHF and titrated upwards at short intervals (for example, every 2 weeks) until the target or maximum tolerated dose is reached. Once the target or maximum tolerated dose of the ACEI/ARB is reached, treatment should be monitored monthly for 3 months and then once per 6 months, and at any time the person becomes acutely unwell.4 On the other hand, beta-blockers are recommended to start in a 'start low, go slow' manner. It is also mandatory to assess heart rate and clinical status after each titration. Furthermore, blood pressure measurements should be done before and after each dose increment of a beta-blocker.4
In addition to ACEI/ARB and beta-blockers, mineralocorticoid receptor antagonists (MRAs) are also prescribed to CHF patients with continuous symptoms of HF.4 Most importantly, serum sodium and potassium measurements, and renal function assessments should be carried out before and after starting an MRA as well as after each dose increment. Ivabradine can be considered in CHF depending on the severity and should be initiated by a HF specialist with access to a multidisciplinary team (MDT). Dose titration and monitoring should be carried out by a HF specialist, or in primary care by either a GP or a HF specialist nurse.
Sacubitril valsartan is recommended as an option for treating symptomatic CHF with reduced ejection fraction, in patients with New York Heart Association (NYHA) class II to IV symptoms, a left ventricular ejection fraction of 35% or less and who are already taking a stable dose of ACE inhibitor.4 Digoxin is also recommended for worsening or severe CHF with reduced ejection fraction despite first-line treatment.4
Teamwork in the management of HF
The core specialists in the HF MDT should work in collaboration with the primary care team. Additionally, there should be a lead physician with subspecialty training in HF (usually a consultant cardiologist) who is responsible for making the clinical diagnosis, a HF specialist nurse and a healthcare professional with expertise in prescribing for HF.5 The team has to be involved in arriving at CHF diagnosis, giving information to patients whose diagnosis is already made, and are responsible for optimizing treatment and starting new medicines that need specialist supervision. The specialist HF MDT should also directly involve or refer people to other services including rehabilitation, services for the elderly, and palliative care as needed.5
The primary care team should follow up for CHF patients at all times, including when they are receiving specialist care from the MDT. They should also ensure effective communication links between different care settings and clinical services involved in the patient's care and recall the patient at least every 6 months to update clinical records.5
Lifestyle modification advice for CHF patients
It is important to advise on restricting fluids for patients with dilutional hyponatremia, and reducing salt and/or fluid intake for people with high levels of salt and/or fluid consumption. CHF patients should undergo continuous assessment to review any salt and/or fluid intake.5 The monitoring of CHF should include a clinical assessment of functional capacity, fluid status, cardiac rhythm (minimum of examining the pulse), cognitive and nutritional status, a review of medication including need for changes and possible side effects, and an assessment of renal function.5 If the CHF patient has a significant comorbidity or their condition has deteriorated since the previous review, more detailed monitoring is needed. The frequency of monitoring should depend on the clinical status and stability of the patient. The monitoring interval for stable HF patients should be a minimum of every 6 months or shorter (days to 2 weeks) if the clinical condition or medication has changed.5
Self-management approaches in CHF
Most CHF therapy and treatment rely on self-management strategies, and therefore efforts should focus on helping individuals to become more informed about their illness and proactive in their own care to improve long-term CHF outcomes (Figure 1).4 The aim of self-management interventions and support is to assess patients’ ability to self-manage their disease, and provide knowledge, skills and confidence to target their specific goals. Therefore, MDTs play a key role in improving patients’ self-management level through the comprehensive patient assessment, patient-centered goals setting, outcomes evaluation, health promotion encouragement and self-management education. Self-management support and effective strategies should be a part of the routine healthcare.4
Early diagnosis with severity measurement is important in the management of CHF. Optimal measures in clinical care can reduce the rates of hospitalization and prolong survival. Although pharmacological therapies are essential, patient compliance is also important to reach the positive treatment outcomes.
It is necessary to find and examine the best strategies to support CHF patients’ self-management and to develop international strategies to improve their quality of life and clinical outcomes, and fully utilize the healthcare resources. Clinicians, educators and MDTs in HF should work together to promote the effective self-care by ensuring that patients have the appropriate knowledge and skills to engage in healthy behaviors, and thus help transforming the patient–caregiver relationship into a collaborative partnership.
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