This resource manual has been developed by the CHFN to assist its members in the operation of a heart failure (HF) outpatient clinic. It provides an overview of a management structure for the clinic, identifies the clinic team, and describes the roles and responsibilities of each team member. The manual will be updated periodically by the education subcommittee.
The current edition (Second Edition, August 2010) of the resource manual is divided into seven (7) parts. These parts correspond to the seven (7) sections of the resource manual listed below:
Heart failure (HF) has been a growing clinical problem in Canada and throughout the world resulting in reduced quality of life, recurrent hospitalizations and premature death.
The mission of the Canadian Heart Failure Network (CHFN) is to provide appropriate, comprehensive, high-quality care to limit disability and improve the quality of life of patients with HF through exemplary outpatient management in outpatient HF clinics. Each clinic will be a centre of excellence for the clinical management of HF and will also serve as a resource centre dedicated to improve the quality and quantity of life for HF patients and their families.
This resource manual has been developed to assist health care professionals in the successful operation of a HF outpatient clinic. It provides an overview of a management structure for the clinic, identifies the clinic team, and describes the roles and responsibilities of each team member. A multidisciplinary approach is recommended where Physicians, Nurses, Dieticians, Pharmacists and other health care professionals provide collaborative advice and direction.
Because patient compliance is a key factor in the management of HF, an extensive patient education program is also included in this manual.
Medical management, care protocols and patient monitoring are key elements of the HF clinic and are included as guidelines to assist in the optimization of HF care across Canada.
Data collection using a flexible data-gathering tool is used to guide current and future practice, measure outcomes, determine quality of life (QOL) issues and track patient satisfaction. Periodic analyses of data collected allows practitioners to review and change practice patterns to enhance patient care and QOL. Ongoing data collection will also allow practitioners to demonstrate the cost-benefits derived from treating HF in the clinic setting.
This resource manual will be updated periodically as warranted by new research findings, changes in clinical practice guidelines, and continuing clinical experience.
This website was developed by the Canadian Heart Failure Network (CHFN) as an aid for health care professionals, heart failure patients, and lay persons to better understand heart failure and how it may be prevented and treated. The information and opinions provided are not a substitute for normal medical care provided by Physicians or other health care professionals, and are for general interest only. The advice and information do not constitute recommendation for changes in treatment for any particular individual, and the information may not apply to all patients or clinical situations. Mention of specific products, processes or services does not constitute or imply a recommendation or endorsement by the CHFN.
The CHFN assumes no liability arising from any error or omission in the information available on the website and recommends that you confirm with your Physician if a change in your management is required. Links to other websites are for your information and convenience only and CHFN accepts no responsibility or liability for the content or any advice in those external websites. When you link to an external website, you have left the CHFN website and the CHFN is not responsible for the privacy policies or content located within these external sites.
This program is an independent national network with initial support from SmithKline Beecham Pharma and Hoffmann-La Roche and ongoing support from our corporate partners.
The impetus for the program came from Cardiology Physicians and Nurses from across Canada who envisioned the need for a common and comprehensive approach to the current management of patients with HF.
We welcome any comments and suggestions you may have regarding this important educational program. Kindly send them to:
Malcolm Arnold, MD, FRCPC, FACC
Chair, Working Group
Canadian Heart Failure Network (CHFN)
University Hospital - London Health Sciences Centre
339 Windermere Road
Heart failure (HF) is a major health problem in Canada and throughout the world. Presently, HF affects 5 million to 7 million North Americans and another 20 million individuals in Third World countries.1
In Canada, HF affects more than 1% of the population and is responsible for 9% of all deaths. HF is the most common cause of hospitalization of people over 65 years of age.2
The incidence and prevalence of HF will continue to rise as the population ages. As shown in Figure 1.1, it is estimated that HF prevalence will nearly double due to the aging population by the year 2030.3 In some regions of Canada, the rate of HF is increasing by as much as 4% annually.
Despite medical management, recent data suggest that the HF mortality rate may be as high as 40% to 50% two years following treatment.4 In addition, the continual cycles of acute crises associated with HF result in high hospital readmission rates and increased health care costs.
This steady increase in the number of deaths, hospitalizations, and medical costs associated with HF continues to occur at a time when morbidity and mortality rates from other common cardiovascular diseases (such as myocardial infarction) are on the decline.
There is an urgent need for aggressive measures to reduce the mortality and morbidity associated with HF, reduce hospital admissions and readmissions, and improve patient management.
In recent years, a number of HF clinics have been established in Canada and the United States in an effort to improve the quality of life of patients with HF and reduce the economic burden associated with the inpatient management of this patient population.
Preliminary findings from the Cardiology Preeminence Roundtable publication suggest that progress in the management of patients with HF depends on avoiding hospitalization in the first place.3
Figure 1.2 shows several approaches that are being successfully used to manage HF patients in the outpatient setting. 3
“As much as 50% of inpatient care for HF ideally should have occurred elsewhere or been avoided altogether.”
Cardiology Preeminence Roundtable3
As shown in Figure 1.3, heart failure
clinics have the potential to reduce length of stay
and hospital admissions.3
“Outpatient intervention not only reduces HF admissions, but when hospitalization is unavoidable, it reduces the average length of stay.”
Cardiology Preeminence Roundtable3
Heart failure (HF) is a state in which the heart is unable to pump blood at a rate to meet the requirements of metabolizing tissues or can only do so from an elevated filling pressure. Many forms of heart disease may lead to heart failure. Other diseases and treatments can precipitate exacerbations of HF.
Ischemia and/or myocardial infarction contribute to the development of heart failure in up to 65% of cases.5 Myocardial infarction can lead to ventricular remodelling with compensatory dilation and hypertrophy and subsequent systolic and diastolic dysfunction progressing to the clinical syndrome called HF. In patients with ischemia, the major cause of heart failure is systolic dysfunction with some degree of diastolic dysfunction.
In a subgroup of patients, the cause of heart failure is diastolic dysfunction. These individuals have signs and symptoms of heart failure but a normal left ventricular ejection fraction. Appropriate management of these patients is to address the underlying etiology. Unfortunately, there are few clinical trials to direct decisions about the best choice of drug therapy.
Some patients have signs of HF such as cardiomegaly on chest x-ray or left ventricular dysfunction, but no symptoms.
The clinical goals of heart failure treatment are to:
Most patients with heart failure have only mild symptoms and often respond well to medical therapy. Unfortunately, because of the progressive nature of HF, these patients remain at risk for worsening disease despite the optimal use of current firstline medications. This is because myocardial damage triggers a series of compensatory mechanisms that progressively compromise cardiac function.
In the early stages of myocardial damage, activation of neurohormonal systems, including the renin-angiotensin-aldosterone (RAA) and sympathetic nervous systems, provides initial support for the failing heart. However, the continued neurohormonal activation becomes deleterious with excessive vasoconstriction, volume expansion, and ventricular remodelling leading to continued deterioration in cardiac function.
Ventricular remodelling can be favourably altered by angiotensin-converting enzyme (ACE) inhibitors, agents that have been shown to reduce morbidity and mortality in patients with HF and asymptomatic left ventricular dysfunction.6
Recent clinical findings suggest that beta-blockers can reduce symptoms, improve left ventricular function, and inhibit disease progression in patients with mild to moderate HF on standard therapy consisting of an ACE inhibitor and diuretics, with or without digoxin.7-10
Emerging data on the beneficial effects on outcome in heart failure patients with beta1-selective blockers further support the importance of this therapy.11,12 However, in a meta-analysis of the clinical effects of beta-adrenergic blockade in heart failure, Lechat and colleagues reported that the reduction in mortality risk was greater for nonselective beta-blockers than for beta1–selective agents.10
Diuretics are very successful in reducing symptoms of HF and they probably reduce readmissions for heart failure. However, their influence on survival has not been adequately tested. Digoxin can improve symptoms and will reduce hospital readmissions for heart failure, but has a neutral effect on survival. Some positive inotropic agents will reduce symptoms and hospital readmissions for heart failure, but may worsen the underlying disease process.
*Draft changes pending adoption by CHFN
HF clinics offer an effective alternative to the current cycle of acute care management. They offer complete patient evaluations, education, regular monitoring, and immediate response to patients’ clinical needs.
In addition, HF clinics offer long-term benefits to patients, families, and the communities they serve. It is expected that each local HF clinic will be a centre of excellence for the clinical management of HF and a resource centre dedicated to improving the lifestyle of HF patients and their families.
The clinics will be Physician-directed and Nurse-managed. The on-staff Cardiologist will perform all initial assessments and examinations, and then develop a treatment plan that will be implemented and managed by the Clinic Nurses.
The Nurse Manager/Clinic Nurse is experienced in cardiology and may have some experience in the outpatient setting. In many settings, Nurses with advanced training are responsible for patient management and the implementation of delegated medical tasks.
Along with the Nurse(s) and the Cardiologist, the clerical staff are considered primary members of the clinic team. They will perform daily administrative duties and assist in data collection and data entry.
Secondary team members who may be affiliated with the clinic on either a part-time, full-time, or referral-only basis include: Pharmacists, Dietitians, Psychologists, Social Workers, and Exercise Physiologists or Physical Therapists as well as EEP Cardiologists and Cardiac Surgeons.
Pharmacists are important members of the clinic’s multidisciplinary team. They provide both patients and staff with information concerning drug interactions, pharmacokinetics of drug action, side-effects of medications, and dosing adjustments required for comorbid conditions. Counselling by a Clinical Pharmacist has been shown to increase patient compliance with medication regimens, resulting in improvements in peripheral edema and physical capacity.1,6
Referrals to a Registered Dietitian are particularly important for HF patients suffering from comorbid conditions such as diabetes or renal failure. The Dietitian will educate patients about the need for sodium and fluid restriction, assess protein and caloric requirements, and incorporate dietary changes needed to manage comorbid conditions.
Depression, anger, and frustration related to decreased quality of life are common among HF patients, particularly those patients with poor psychosocial adjustment to their situation.2 Therefore, referral to a Clinical Psychologist may be necessary. Counselling by a Psychologist can help patients and their family members adjust emotionally to the difficult lifestyle changes required for HF management.
The primary role of the social worker is to develop an individualized living plan for the HF patient. This plan may include making arrangements for food/meals, transportation, home assistance, and providing access to financial assistance. The Social Worker can also assist patients and their family members in finding support groups that provide open discussions of common issues such as work, sexuality, exercise and leisure activities, and the adjustments that must be made to each.
Although HF patients have traditionally been encouraged to modify physical activity, exercise rehabilitation programs have been used successfully to improve the functional capacity of HF patients.3,4 Therefore, an Exercise Physiologist or Physical Therapist may be affiliated with the clinic to establish an appropriate exercise regimen for the HF patient, provide instruction on exercise limitations, and monitor the exercise program.
In addition to the secondary team members, heart failure clinics may be affiliated with Occupational Therapists, Home-care Providers, Palliative-care Physicians, patient-support groups, transplant teams, members of the clergy, and volunteers. Although not core members of the clinic team, these individuals are highly valued members of a successful clinic program. For example, Home-care Providers are particularly important for the management of older HF patients who may have difficulty performing daily activities such as bathing and sitting in a chair. Also, palliative-care counselling may be required for the emotional well-being of both patients and their family members. Many patients find psychological relief in the ability to talk openly about the mortality associated with heart failure, and preparation for death.5,6,7,8,9
Heart failure clinics are outpatient facilities that offer a comprehensive approach to HF management. All patients with suspected and established heart failure (NYHA Classes I to IV) should be eligible for treatment at these clinics. Referrals to the HF clinic are accepted from any source: community Physicians, hospital-based Physicians, and other clinics. Nurse and patient-facilitated referrals for education may also be accepted.
|Cardiologist||• Receives patient referrals
• Performs initial evaluations
• Establishes medical regimen
• Sees patient regularly
• Liaises with Nurse Manager before any major changes in medical intervention
Registered Nurse with cardiology experience
|• Implements treatment plan
• Educates patient
• Adjusts medications (using drug management protocols)
• Schedules patient appointments
• Makes regular follow-up calls
As shown in Figure 2.1, patient education
is key to the success of a HF management
program. Education should involve all members of the multidisciplinary clinic team and
should be ongoing.
Data collection can be used by heart failure clinics for the following purposes:
*Images provided by Microsoft Clip Art
This document provides strategies for the improved diagnosis and management of adults (19 years and older) with heart failure (HF). It is intended for primary care practitioners, allied health professionals and patients with HF. It focuses on approaches needed to provide care to patients with this complex syndrome.
HF is a complex syndrome associated with a high rate of hospitalization and short-term mortality, especially in elderly patients with comorbidities. Early diagnosis and treatment can prevent complications.
HF is under diagnosed in its early stages. Diagnostic accuracy improves when there is a high index of suspicion and a consistent approach to diagnosis.
HF is a clinical syndrome defined by symptoms suggestive of impaired cardiac output and/or volume overload with concurrent cardiac dysfunction. While a normal LVEF is >60%, the threshold of 40% is used for the purposes of diagnostic classification. As such, HF can be classified into systolic heart failure, as defined by the presence of signs and symptoms of HF with an LVEF <40%, and heart failure with preserved systolic function (HF with PSF – previously called diastolic dysfunction) is defined by the presence of signs and symptoms of HF in the absence of systolic dysfunction (LVEF ≥ 40%). Prognosis for systolic HF is significantly worse than HF with PSF. Research evidence for treatment is best established for systolic HF but, in general, the pharmacologic and nonpharmacologic strategies are similar for both.
HF care depends on the patient’s understanding of, and participation in, optimal care. Patients can be important partners in individualized goal setting, salt restriction, weight monitoring, and adherence.
9.1. Goals of Care
9.4. Salt Intake
9.5. Fluid Intake
All HF patients with hyponatremia, or severe fluid retention/congestion that is not easily controlled with diuretics, should limit fluid intake to 6-8 cups of liquid/day (1 cup = 8 ounces = 250 mL), including frozen items and fruit (1 serving = 1/2 cup of liquid).
Not more than one drink per day is recommended. This is equal to a glass of wine (5 oz./150 mL/12% alcohol), beer (12 oz./350 mL/5% alcohol), or one mixed drink (1 1/2 oz./50 mL/40% alcohol). In alcohol related heart failure, alcohol must be totally avoided.
9.7. Exercise Training
All HF patients should be immunized for influenza (annually) and pneumococcal pneumonia (if not received in the last six years) to reduce the risk of respiratory infections.
9.9. Collaboration with complementary health care providers
Aggressive Management of Cardiovascular (CV) Risk Factors (hypertension, diabetes, dyslipidemia, smoking, obesity) and other comorbid conditions is recommended:
13.1. Chronic Kidney Disease
13.2 Anemia (hemoglobin <110 g/L; generally symptomatic if <90 g/L)
Comprehensive HF management is based on setting treatment goals and monitoring the effectiveness of management:
Outcomes in heart failure are highly variable and it is important to provide accurate information to patients about prognosis to enable them to make informed decisions about medications, devices, transplantation and end of life.
Poor prognostic factors include:
Predicting time of death in HF is challenging given the cyclical nature of the disease. Helpful clinical prediction tools have been established. Discussions regarding end-of-life care should be initiated with patients who have persistent NYHA Class IV symptomatology or an EF < 25% despite maximal medical therapy (at target doses of study drugs as mentioned above).Prior to initiating end-of-life care ensure that:
*Images provided by Microsoft Clip Art
Dealing with Side-Effects
Beta-Blocker Equivalent Doses
*Target dose used in large CHF trials with clinical endpoints.
Care protocols, like medical and nursing procedures, allow staff to offer a consistent approach to managing clinic patients. Care protocols will allow caregivers to establish routines and govern tasks that are performed in the HF clinic as well as tasks that involve other hospital departments and outside agencies. Protocols ensure that key steps are taken to fill potential gaps in the system of care as the patient moves from clinic to hospital or from hospital to clinic.
The development of the following protocols may assist in enhancing the overall management of clinic patients:
Recent data suggest that, despite medical intervention, HF mortality remains high at a time when morbidity and mortality rates from other common cardiovascular diseases (such as myocardial infarction) are on the decline. Many heart failure patients experience frequent acute medical crises resulting in high hospital readmission rates and increased health care costs.
There is an urgent need to reduce mortality and morbidity associated with HF, reduce hospital admissions and readmissions, and improve patient management. HF clinics have been shown to be an effective alternative to inpatient management of this patient population.
Data collection, using a standard data-gathering tool, will allow practitioners to review and change practice patterns to enhance patient care and improve the quality of life for HF patients and their families.
In general, data collection will allow practitioners to monitor patient issues, measure clinical outcomes, track public health data, document the need for a HF clinic, secure clinic funding, and answer research questions.
A patient care plan, which specifies interventions and teaching done by staff and the anticipated patient outcomes, should be initiated and followed on all patients.
Such a care plan will ensure that patients receive optimum care and understand all facets of their diagnosis and long-term care. Care plans should be customized to meet the individual needs of each patient and should be developed with input from patients and family members.
Moreover, a care plan enhances communication and ensures continuity of care.*Draft changes pending adoption by CHFN
At a minimum, team members starting a multidisciplinary HF clinic should consist of:Executive Sponsor
Physician Leader with expertise in HF Care
The Physician should provide clinical leadership as well as active involvement in preparing the protocols and pathways required for good patient care. The Physician should be committed to providing this leadership.
Nurse(s) with skills in heart failure and patient teaching
Within the multidisciplinary model, the Nurse should have extensive cardiac experience, specifically in HFcare. The Nurse should have skills in education and understand the concepts of chronic disease management.The level of nursing support decided upon may vary from clinic to clinic. Some clinics prefer the Nurse Practitioner role, others an expert Registered Nurse and others a hybrid of both roles. This is a decision that needs to be made with the team from the outset. Nurse Practitioners can provide a wider scope of care, whereas the registered nurse can practice with Physician orders. The scope of practice varies between provinces and we recommend that this is ascertained before starting.
Programs with the following resources should also consider support from the following health care providers:
It is not easy to determine staffing levels. First, it is important to determine how many patients the clinic may expect. To do this, data around local HF demographics should be sought and a clear care pathway be defined to ensure that once the endpoint is reached that the patient is discharged back to their referring source.
A survey to determine patterns of staffing in heart function clinics across Canada was performed in 2004 (presented at Canadian Cardiovascular Congress, 2004 by Kaan A, Clark C and Edmonds M). Fifteen clinics responded and showed that:
There must be a commitment to meet regularly to assess staffing levels based on the patient load and whether or not the patients are appropriate for the clinic.
The database is designed as a local tool like an electronic medical record but also allows download of data without specific patient identifiers to the National Database. The data that is uploaded is secure and password protected, as the upload technology uses the same encryption technology used for online banking. All patients must sign a consent form before their unidentified data can be entered into the database and uploaded to the national database. There is a consent template located in the members section. Once we have approved and received your signed Program Agreement, you will get a username and password for the website.
Patient education is one of the most important functions of a heart failure clinic, and is the key to the success of a HF management program. Education should involve all members of the multidisciplinary clinic team and must be ongoing.
Patient education is one of the most important functions of our heart failure clinics. This education comes from all members of the multidisciplinary clinic team responsible for your care and is ongoing.
This section presents a brief overview of state-of-the-art clinical information for health professionals who care for health failure patients. There are six (6) educational sections. You may use this section as a review for yourself prior to patient teaching. In additional, the eight (8) patient information sections allow you to teach directly from the pages.
Members of CHFN may wish to use the information provided as a reference tool and use a flip chart or other medium to share the information with patients and their families. The patient information sheets are also supplied as information pads that are numbered for each section/topic. Members may distribute the sheets following each educational intervention:
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:
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.
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.
The two main causes of HF are:
Heart failure can also result from:
Heart failure can be aggravated by:
|Left heart failure
(low output/pulmonary congestion)
|Right heart failure
(systemic venous congestion)
• Paroxysmal nocturnal dyspnea
|• Peripheral edema
• Weight gain
• Abdominal discomfort
These symptoms may be accompanied by:
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
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:
Questions that will help assess your patients’ sodium intake are:
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:
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
Abstinence is recommended for all patients, especially those with ischemic heart disease (IHD).2
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
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 may be considered for severe HF patients, since vitamin loss may occur with marked diuresis.1
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.|
Explain the benefits of exercise:
While stressing the importance of physical activity, reinforce the necessity of resting and storing energy as well. Patients should be counselled to:
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.
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.
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 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.
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 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 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.
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.
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 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.
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.
* Consult the respective product monographs for appropriate prescribing information.
**Draft changes pending adoption by CHFN
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
During every clinic visit, whether it is acute care or regular follow-up, nurses must offer counselling and education, and monitor patients’ understanding of:
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.
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.
Some institutions retain trained cardiac social workers who can deal with specific needs such as:
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 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.
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:
The two main benefits of telephone management for patients are:1
Patient education is one of the most important functions of our heart failure clinics. This education comes from all members of the multidisciplinary clinic team responsible for your care and is ongoing.
This section presents some basic and easy-to-understand explanations on heart failure for you and your families. A number of handouts and check-sheets are available to help you monitor your medical condition (medications, diet, weight, exercise, hospital admissions, and emergency room visits) and keep health professionals who care for you informed of your progress.
The eight patient information sheets posted below are also supplied as information pads that are numbered for each section/topic. They are available from your clinic team:
The heart is a hollow muscle about the size of your fist. It pumps blood with oxygen and nutrients throughout your body. The heart has four chambers: two at the top, called atria, and two at the bottom, called ventricles. The heart is divided into right and left sides. The right side receives blood from the body and pumps it to the lungs to increase its oxygen content. This blood is then pumped out to the rest of the body by the left side of the heart.
When you have heart failure, your heart is unable to pump enough blood to satisfy your body’s requirements. Blood that should be pumped out of the heart may back up into other organs or tissues, such as your lungs, stomach, liver, intestines or legs.
The heart is divided into left and right sides. The left side of
the heart pumps blood rich in oxygen to your muscles, skin, and organs
by means of vessels called arteries. The left side of the heart is
shown in the picture as (1). At the same time
that blood is providing nutrients and giving oxygen to the cells of
your body, it is removing waste matter from these cells. Oxygen-poor
blood, also containing waste matter, then returns to the right side of
the heart through vessels called veins (2).
From there, the blood is pumped to the lungs (3) where it is oxygenated and cleaned of carbon dioxide. It then returns to the left side of the heart through the pulmonary veins (4) so that it may be repumped throughout the body. Much of the waste matter accumulated from cells is cleared by the liver and kidneys.
There are many reasons why you may have heart failure. It can result from:
Heart failure can be controlled. In most cases, it cannot be cured.
You will probably need to take several different medications, follow a low-salt diet, limit your intake of fluids, and ensure you get plenty of rest, combined with periods of exercise.
People with chronic heart failure need to maintain a diet low in salt (sodium). Sodium can make your body retain water, which may cause swelling and stress on your heart. You may consume between 2 and 3 grams of sodium per day. It is fairly straightforward to monitor how much salt you eat:
Sodium is found in most processed foods, including canned vegetables and frozen dinners. Other foods and condiments high in sodium are:
Learn to read food labels to determine how much salt different products contain. Ingredients in prepared food are listed in order – if salt is high on the list of ingredients, it means that there is a lot of salt in the product.
HF patients taking diuretics may need to increase the amount of potassium in their diet. Check with your doctor to determine if you need to increase your potassium intake. Potassium is found in:
You need to limit the amount of fluids you drink because the more blood there is in your body, the harder your heart works. This extra work puts a strain on the heart of people with heart failure.
It is important to be aware of the amount of fluid you drink – particularly if you are taking diuretics. You should not drink too much or too little fluid. Ask your doctor or nurse to discuss with you the right amount and kinds of fluids you should be drinking. Most people with heart failure should drink no more than 6 to 8 cups of fluid per day. Remember, even the water you drink to swallow your medication should be counted. If your mouth is dry from drinking less fluid, try chewing gum. You can also take sips of water or suck on hard candies to moisten your mouth.
The following items should be considered liquids when you are calculating your daily fluid intake:
Amount of fluid permitted daily: ____________ounces/____________mLs.
Now that you must start paying attention to what you eat, follow Canada’s Guidelines for Healthy Eating to ensure you get the right amount of vitamins and nutrients to maintain your health.
Physical activity is beneficial for your heart and your general health. A regular program of physical activity will enable you to increase your strength gradually and avoid overtaxing your heart.
Exercise does not have to be strenuous to be valuable. (In fact, strenuous activities should be avoided.) Before you start any exercise program, be sure to:
Side-to-side looks: Look straight ahead, slowly turn your head to one side, hold for 10 seconds, then return to centre. Repeat 3 times on each side.
Shoulder shrugs: Sitting in a chair, slowly lift your shoulders up to your ears by squeezing your shoulder blades together, pause, then lower. Repeat 5 to 10 times.
Shoulder circles: Extend both arms sideways at shoulder height. Rotate arms 10 times in small forward circles. Repeat circling back.
Walking is a simple and effective exercise and is an ideal way to improve your activity level and get more physically fit. Here are guidelines for starting a walking program, but make sure your discuss your plans during a clinic visit before you begin.
|Week 1-2||Walk 5 to 10 minutes|
|Week 3-4||Walk 10 to 15 minutes|
|Week 5-6||Walk 15 to 20 minutes|
|Week 7-8||Walk 20 to 30 minutes|
Your HF diagnosis does not mean you cannot have sex. In general, you may continue your normal sexual activities. But it is recommended that you avoid having sex:
Download and print our daily exercise chart.
The medication your doctor has prescribed is designed to control your symptoms and improve the efficiency of your heart. Here are some tips to help ensure you stick to your schedule:
Angiotensin converting enzyme (ACE) inhibitors
• Widens (dilate) blood vessels.
• Take this medication at the same time
Angiotensin II receptor antagonists*
• Widens (dilate) blood vessels.
• Take this medication at the same time
• Slows heart rate.
• Weakness, tiredness.
• Take this medication at the same time
• Eliminates water and salt (sodium) from
• Frequent urination.
• Take this medication with meals to avoid
• Increases the strength and efficiency of
your heart’s pumping action.
|• Take this medication on an empty stomach.
• Never change brands or take extra pills.
Nitrates/nitroglycerin & vasodilators*
• Expands your blood vessels, making your heart pump more easily.
• Fluid retention.
|• Take this medication with liquid at mealtimes.|
Anticoagulants & antiplatelets*
• Thins your blood to prevent clots from forming.
• Hemorrhaging (bleeding), which may result in feelings such as headache, chest, abdomen or joint pain, dizziness, shortness of breath, difficulty breathing or swallowing, swelling, or weakness.
|• Take your dose as soon as possible on the same day if you’ve forgotten, but don’t take a double dose the next day to make up for missed doses.|
• Helps your heart pump more effectively.
• Nausea, vomiting.
|• Inotropic agents are administered intravenously while you are in hospital.|
Calcium channel blockers*†
• Used to treat the high blood pressure often associated with heart failure.
• headaches, facial flushing and dizziness, ankle swelling.
• These medications are not used often to
treat heart failure.
• Since most diuretics remove potassium from the body, heart failure patients who use them are at risk of losing too much potassium. Some patients need to take potassium supplements or pills to compensate for the amount they're losing.
• ACE inhibitors can actually cause the body to retain potassium, so this needs to be taken into account as well. Patients should check with their doctors to determine their potassium needs.
• Instead of potassium, sometimes all is
needed to do is eat foods high in potassium, such as bananas.
*Draft changes pending adoption by CHFN
†Adopted from Medications Commonly Used to Treat Heart Failure, American Heart Association
Please use this sheet to record important changes in your medical condition that you should report during your HF clinic visits. This information will help your doctors and nurses to better manage your care.
If your heart failure has been determined to be stable, you should be visiting the heart failure clinic every three to six months, or you may be asked to see your family doctor. Your doctor or nurse will tell you how often you should visit the clinic. During these visits certain procedures will be done, including:
If your heart failure has been determined to be unstable, you should be visiting the heart failure clinic daily or weekly. Your doctor or nurse will tell you how often is appropriate. During these visits certain procedures will be done, including:
The clinic’s main aim in seeing you frequently during this time is to ensure you don’t have to be admitted to hospital, and to help you function better at home.
Telemanagement means that should you need to call your clinic with any questions or concerns, feel free to do so at any time. A clinic nurse will be available to assist you.
Your clinic’s telephone support hotline number is: ____________________
Should you need to call after hours, the pager number is: ________________
Your HF clinic has started a support group to help you meet other patients and to learn more about your disease from health care experts.
The next support group meeting will be held: _______________________
The speaker will be: ______________________________________
She/he will be speaking about: ________________________________
We look forward to seeing you there!
Controlling the anxiety you may be feeling after being diagnosed with CHF is very important to your overall well-being. There are many ways to control anxiety. Here are some suggestions:
Managing Congestive Heart Failure* (free)
Published by: The Heart and Stroke Foundation of Canada
Heart and Stroke Foundation of Canada
477 Mount Pleasant Road, 4th Floor
Toronto, Ontario M4S 2L9
Living with congestive heart failure: (free)
a guide for people taking Coreg™*
Edited by Peter Liu, MD and Shanas Mohamed, RN
Published by: SmithKline Beecham Pharma
Phone: 1 800 567-1550
SmithKline Beecham Pharma
Medical Information Department
2030 Bristol Circle Place
Oakville, Ontario L6H 5V2
A stronger pump: A guide for people with heart failure (cost:
U.S. $6.50 per copy)
Published by: Pritchett & Hull Associates
Phone: 1 800 241-4925
Pritchett & Hull Associates
3440 Oakcliffe Road, Suite 110
Atlanta, Georgia 30340-3079
Dietary fats and your heart: action plan for a healthy heart*
Published by: The Becel Heart Health Information Bureau
Phone: 1 800 563-5574
Becel Heart Information Bureau
160 Bloor Street, Suite 1500
Toronto, Ontario M4W 3R2
An owner’s manual for patients with congestive heart failure
(cost: $2.00 per copy)
Contact: Rosa Gutierrez, RN MScN
Walter McKenzie Centre
8440 – 112 Street
Edmonton, Alberta T6G 2B7
Phone: 403 492-8157
Fax: 403 492-6452
* available in English and French