Managing Heart Failure

People diagnosed with heart failure (HF) usually have medications to increase how much their hearts can pump.  But as with most conditions, many approaches are needed to best manage heart failure.

A daily weight is essential because it is an early indicator of fluid retention from HF.  The best time to weigh yourself is in the morning, after urinating but before breakfast.  A weight gain of around 3 pounds in a day should be reported to the doctor since it indicates fluid may be backing up in various organs.

Generally people with HF are on salt restricted diets.  Salt contributes to water retention, which makes the heart work harder and causes shortness of breath and swelling in the ankles and legs.  Those with severe heart failure may have fluid restrictions.

Mild exercise can improve circulation, as long as it does not overly tax the person.

When we feel anxious or upset, our hearts beat faster and we breathe more heavily.  This can make HF worse.  Reducing stress helps manage HF.

Lying flat may cause shortness of breath. To improve sleep, it may be helpful to raise the head of the bed 45 degrees, or even sleep in a recliner.   And if the person uses oxygen, be sure the tubing is correctly in place and the nasal prongs are in the nostrils.

Avocado Salsa, Low on Sodium but High in Flavor!

Pathways is starting a recipe of the month post on our blog to promote a healthy living lifestyle. Each month will feature an original healthy recipe from our employees. To start us off, I am presenting a recipe titled "Señora's Avocado Salsa".

You will need the following ingredients:

1 package (16 oz) frozen corn, thawed
1 can (15 oz) black beans (look for low sodium)
1 medium sweet red pepper, chopped
1 small onion, chopped
1 bunch cilantro, finely chopped
3 fresh tomatoes, chopped
3 garlic cloves, diced
1/4 cup lime juice
3 tablespoons cider or white vinegar
1 teaspoon dried oregano
1/2 teaspoon or less salt
1/2 teaspoon pepper
4 medium ripe avocados

In a large bowl, combine corn, black beans, red pepper, onion, cilantro and tomatoes. In a small bowl, whisk together the garlic, lime juice, vinegar, oregano, salt and pepper.

Mix well. Pour over corn mixture and toss to coat. Cover and refrigerate overnight.

Just before serving, chop avocados and stir into salsa. Serve with low sodium tortilla chips or as a side dish. Yield about 7 cups. Tip - if you place the avocado pit into the salsa, the avocados won't turn brown.

This is delicious. I was hesitant about a salsa with no spicy peppers in it, but this is really tasty. I tried it in tacos and it's great because you also get all the healthy benefits of the tasty veggies in the salsa. Next time I would add a bit less garlic because it was really strong, but that depends on your preference. I also added green onions because I prefer them in my salsa instead of a regular onion.

By Mandi Cacioppo, Sr. Marketing & Communications Coordinator at Pathways Home Health and Hospice. Recipe credit goes to my cousin Lynn Fors.

Living the Low Salt Life as a Heart Failure Patient

When you have heart failure, it is important to decrease the amount of sodium in your diet. Salt acts like a sponge, making your body hold on to extra water.

Eating too much of it can cause weight gain, increased blood pressure, make legs and feet swell and cause water to go to the lungs.  This makes your heart work harder and worsens heart failure systems. 

Check with your doctor to see how much salt you can have in a day. Most doctors recommend less than 2,000 milligrams (mg) or salt each day.

How much salt in a teaspoon?

• 1 teaspoon of salt = 2000 mg of sodium
• 1 teaspoon of baking soda = 821 mg of sodium
• 1 teaspoon of baking powder = 339 mg of sodium

Read food labels to help figure out how much salt is in the food. A good rule of thumb is to choose foods with less than 250 mg of sodium per serving.

Remember, a serving size is not necessarily an entire container of food. If a can contains 3 servings and you eat the whole can, multiply the sodium per serving by 3.

Read the Label - Serving Sizes

•  A can of soup has 300 mg of sodium per serving
• The can has 2 servings.
• You eat the whole can, or 2 servings.
• So you would have 300 mg x 2 or 600 mg of sodium.

Compare salt (sodium) in foods you eat often, especially processed foods like soup, lunch meat, cheese and frozen meals.  Sort the foods into higher or lower sodium groups.

To lower your sodium intake, stop adding salt to food during cooking. Try taking the salt shaker off the table and add other seasonings to add flavor such as lemon juice, onion or garlic power, or herbs.

Avoid high sodium foods like canned foods, hot dogs, cheese and cheese spreads, deli meats, bacon,  ketchup, soy sauce, salad dressings, barbecue sauce, and frozen meals that are high in sodium.

Replace high sodium foods with fresh fruits and vegetables, lean meats, low fat milk, reduced sodium cheese and cereals low in sodium. When you go out to eat, choose food on the menu marked “healthy choice” or “low sodium”. Ask for sauces and salad dressings “on the side” and ask the waiter for low salt recommendations.

Telemonitoring: Catching Heart Failure Problems Early

Fewer Hospitalizations

Telemonitoring puts technology to work improving the lives of Pathways’ heart failure patients.  By catching problems earlier, it reduces hospitalizations.

Home Health nurses don’t visit daily, so telemonitoring gives Pathways a way to assess the patient 7 days a week, from our office.
 
The easy-to-use unit can give us the patient’s:

• Weight
• Blood pressure
• Heart rate
• Oxygen saturation

When a patient touches any button on the small unit, a friendly voice talks them through each step of the health check.  Patients also receive the data, giving feedback.

The information is sent automatically to a nurse via telephone: there is no phone charge to the patient.

Nurses monitor the health information daily, call the patient if necessary, and make home visits when indicated.

Pathways Telemonitoring Program Criteria

• Patient has heart failure
• Patient or caregiver can understand and follow instructions, and are physically able to use the unit 
• Patient or caregiver are open to telemonitoring technology
• Patient does not have an infectious disease (i.e. TB,  MRSA, varicella zoster, herpes zoster)   

This article was originally published in Pathways Physician & Health Professional Bulletin - Issue 26.  To download this issue in PDF format, or past issues, visit our newsletter archives online at www.pathwayshealth.org/publications.

Depression in Heart Patients

Two of every five patients who experience acute coronary syndrome (ACS) will have depression—a very important psychosocial predictor of poor cardiovascular prognosis.

“A growing body of evidence suggests that mental health problems complicate physical health conditions and that this relationship worsens clinical outcomes, increases hospitalization, and adversely affects quality of life,” Joseph A. Ladapo, MD, PhD, of New York University in New York City.

He and colleagues predicted that treatment of depression after ACS would be cost effective and improve patient outcomes.  They conducted a randomized, controlled study comparing enhanced depression care with usual care in patients with ACS and persistent depression 3 months after discharge.  Ladapo and colleagues defined enhanced depression care as problem-solving psychotherapy, antidepressant use or both.

Their conclusion at the close of the 6-month, prospective trial involving 157 patients was that treatment for depression reduced total per-patient healthcare costs by more than 40% and was cost effective for almost all patients.

An assessment of quality of life showed improved health utility in the intervention group.  Interviews 6 months after discharge showed that in the intervention group 51% were using antidepressants or anxiolytics and 75% had visited a mental health specialist at least once for a total cost of $1,083.  In the control group 30% were using antidepressants or anxiolytics and 35% had seen a mental health professional, for an average of $554.

The extra costs for the intervention group were more than offset by the significant reduction in hospitalization for ACS and heart failure (5% vs. 16%), with a mean cost savings of $1,782 for the intervention group and unmeasured improvement in quality of life.

Total healthcare costs averaged $1,857 in the intervention group and $2,797 for the usual-care arm, resulting in an adjusted difference of $1,229, which did not achieve statistical significance (P=0.09). Because the intervention was cost saving, the investigators could not calculate a cost-effectiveness ratio.

The research was reported in Arch Intern Med 2012; DOI: 10.1001/archinternmed.2012.4448, and was supported by the National Heart, Lung, and Blood Institute; the Health Resources and Services Administration; and the American Heart Association.

This article was originally published in Pathways Physician & Health Professional Bulletin - Issue 26.  To download this issue in PDF format, or past issues, visit our newsletter archives online at www.pathwayshealth.org/publications.

Predicting Heart Failure Death in the ER

Ten pieces of information often gathered in the ER may be able to predict the risk of death for people with heart failure within seven days of presentation.

The new tool is called the Emergency Heart Failure Mortality Risk Grade (EHMRG).  To develop the tool lead researcher Douglas Lee, MD, PhD, of the Institute for Clinical Evaluative Sciences in Toronto, and colleagues examined three years’ worth of data from 12,591 heart failure patients in 86 hospitals in Ontario, Canada, from 2004 to 2007.

Within seven days of presentation 2% of the patients had died.  Researchers looked for common links—everything from medications, to lab values and transportation.  After adjustments were made, the 10 factors significantly associated with a greater risk of death in the first week were:

• Older age
• Transportation by emergency medical services
• Lower triage systolic blood pressure
• Higher triage heart rate
• Reduced oxygen saturation
• Higher creatinine
• Potassium level of 4.6 mmol/L or higher
• Elevated serum troponin
• Active cancer
• Use of metolazone at home

The researchers noted limitations of the study, especially the lack of information about left ventricular ejection fractions and brain natriuretic peptide.  The authors also noted that, “Symptomatic improvement, ability of the patient to seek follow-up care, and social circumstances should also be considered, along with quantification of acute prognosis.”  They indicated that the tool is not for use in patients who have chronic, symptomatically stable heart failure.

Lee is applying for a U.S. patent.

For more details or to read the entire study see the June 5 issue of the Annals of Internal Medicine, Prediction of Heart Failure Mortality in Emergent Care. 

This article was originally published in Pathways Physician & Health Professional Bulletin - Issue 25.  To download this issue in PDF format, or past issues, visit our newsletter archives online at www.pathwayshealth.org/publications.

Heart Failure & Hospice

Patients with congestive heart failure who elect hospice live longer than those who don’t.  These were the findings of a defining 2007 study published in the Journal of Pain and Symptom Management.  Other diagnoses also experience longer prognosis with hospice, but none longer than the 81 day extension of life in heart failure.

Many factors probably contribute to the increased longevity.  Hospice care increases monitoring in the home and gives psychological, emotional and spiritual support from friendly visitors.  This holistic attention may increase the desire to live and reduce the sense of being a burden to one’s family.

Skipping the ER

Heart failure is the diagnosis most commonly associated with hospitalization.  By some estimates, patients with heart failure are readmitted at a rate of nearly 50% within six months.  For some patients, knowing that they have 24-hour access to nursing advice and visits for management of symptoms gives them a welcome alternative to the emergency room. 

Who is Appropriate?

Medicare guidelines include:

• Patient is optimally treated with vasodilators or unable to tolerate them.
• Patients with conditions usually treated with surgery are either ineligible or decline it.
• Patient is Class IV on the New York Heart Association scale: unable to do any physical activity without discomfort and symptoms may be present at rest.
• If ejection fraction is available, 20% or less is appropriate for hospice.
• Co-morbidities play a large role in estimating prognosis.  The following co-morbidities support a prognosis of 6 months or less in conjunction with the conditions listed above:
• Symptomatic arrhythmias resistant to treatment
• History of cardiac arrest, resuscitation or unexplained syncope
• Brain embolism of cardiac origin
• Concomitant HIV disease

The extra time that hospice can give patients may be especially important to patients and families trying to find resolution and peace at the end of life.  

Questions to Ask Patients

• Do you have discomfort when physically active? or Does physical activity give you more discomfort?
• Do you get short of breath when you are lying down?
• Do you ever wake up at night feeling short of breath?
• When you are resting in a chair do you ever feel short of breath, perspire or have chest pain?
• Do you have any swelling?
• Do you need help with activities like dressing, bathing, walking or eating?

Supporting Documentation

• Cyanosis
• Rales
• Dusky nail beds
• Tachycardia or bradycardia
• Hyper- or hypotension
• Jugular venous distension
• Liver enlargement
• Cachexia
• Orthopnea
• Paroxysmal nocturnal dyspnea
• Decreased ejection fraction
• Weight gain due to fluid retention

This article was originally published in Pathways Physician & Health Professional Bulletin - Issue 24.  To download this issue in PDF format, or past issues, visit our newsletter archives online at www.pathwayshealth.org/publications.

Literacy Affects Health

Higher Mortality

Low health literacy is significantly associated with higher mortality in patients with heart failure. This is the conclusion drawn by researchers who designed a retrospective study of patients at Kaiser Permanente in Colorado.

They examined cases of heart failure from 2001 to 2008, surveying patients by mail.  The patients were also followed for a median of 1.2 years.  Health literacy was assessed using well-established screening questions and categorized as either “adequate” or “low”.  Then researchers looked at hospitalization and mortality for all causes.

The survey response rate was 72% (1547 of 2156); 17.5% of responders had low health literacy.  Low health literacy was associated with:

• Increased age
• Lower socioeconomic status
• Less likelihood of having at least a high school education
• Higher rates of co-morbidities 

In multivariable Cox regression, low health literacy was independently associated with higher mortality (unadjusted rate, 17.6% vs 6.3%; adjusted hazard ratio, 1.97 [95% confidence interval, 1.3-2.97]; P = .001), but not hospitalization (unadjusted rate, 30.5% vs 23.2%; adjusted hazard ratio, 1.05 [95% confidence interval, 0.8-1.37]; P = .73).

This study was published in the Journal of the American Medical Association (JAMA.  2011; 305(16):1695-701 (ISSN: 1538-3598).

Care at Home vs. Hospitalization

Home Fares Better for Heart Failure Patients

Hospitalization, the standard venue for short-term medical care, may be hazardous for the elderly according to a study reported in the Archives of Internal Medicine in September, 2009.*  The study evaluated the feasibility and effectiveness of physician-managed home care for selected patients with acute decompensation of chronic heart failure.  The prospective, single-blind, randomized trial followed patients 75 years or older who had been hospitalized.  They were randomly assigned to a Geriatric Home Hospitalization Service or a general medical ward.

Overall Improved Status

Findings demonstrated no significant difference in the number of deaths or subsequent hospitalizations, but the mean time until the first additional admission was longer for the patients cared for in their own homes.  Only the home patients experienced improvements in depression, nutritional status and quality-of-life scores.

The research concluded that home care is a viable alternative to traditional hospital inpatient care for elderly patients with acutely decompensated CHF.
  
*Arch Intern Med. 2009 Sep 28;169(17):1569-75.

For more information about Pathways Home Health services for patients with chronic heart failure, please visit www.pathwayshealth.org/home-health.