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HF in developed countries is mainly a disease of the elderly population: the average age of the patients is in fact 75 years [ 1 ]. Continuity of care is one of the basic elements for a correct management of HF, both for its characteristic of chronic disease with more or less frequent exacerbations and for its considerable clinical variability, which manifests itself with different levels of complexity and not uniformly progressive in all stages of its evolution, from the very first symptoms of the terminal stages.

This aspect results in a diagnostic difficulty that swings the estimate of prevalence of the disease from 2 to 6. The diagnosis of HF can be difficult [ 4 ]. Stage A includes patients who are at risk of developing HF but who have no structural heart disease at present. Stage B includes patients with structural heart disease but no symptoms. Stage C includes patients with structural heart disease with current or prior symptomatic heart failure. Stage D includes patients with severe refractory HF. The previous classification of HF, based on the NYHA functional scheme Figure 1 , is used to assess the severity of functional limitations and correlates fairly well with prognosis.

Structural, functional and epidemiologic linkages in CHF for courtesy of Prof. Tang, Assoc. Most patients affected with HF have signs and symptoms of fluid overload and pulmonary congestion, including dyspnea, orthopnea and paroxysmal nocturnal dyspnea. Patients with right ventricular failure have jugular venous distention, peripheral oedema, hepatosplenomegaly and ascites. Others, however, do not have congestive symptoms but have signs and symptoms of low cardiac output, including fatigue, effort intolerance, cachexia and renal hypoperfusion Table 1.

On physical examination, patients with decompensated heart failure may be tachycardic and tachypneic, with bilateral inspiratory rales, jugular venous distention and oedema. Patients with compensated heart failure will likely have clear lungs but a displaced cardiac apex. Patients with decompensated diastolic dysfunction usually have a loud S4 which may be palpable , rales and often systemic hypertension. Diagnostic symptoms and signs for chronic heart failure modified from ESC [ 4 ].

In ambulatory patients suspected of having HF, for an initial working diagnosis and treatment plan, the recommended investigations are [ 4 ] electrocardiogram ECG , echocardiogram and some haematological investigations :. The ECG shows the heart rhythm and electrical conduction, i. The echocardiogram provides immediate information on chamber volumes, ventricular systolic and diastolic function, wall thickness and valve function. Routine biochemical and haematological investigations are also important, partly to determine whether renin—angiotensin—aldosterone blockade can be initiated safely renal function, sodium and potassium and to exclude anaemia which can mimic or aggravate HF.

Most of the evidence supporting interventions in heart failure comes from trials that recruited patients with left ventricular systolic dysfunction LVSD. The necessary criteria for diagnosing heart failure with reduced ejection fraction HF-rEF or preserved ejection fraction HF- pEF or diastolic heart failure are reported in Table 2.

Therapies that improve outcome in people with HFrEF have not been found to help people with HFpEF, further supporting the idea that these two kinds of HF are fundamentally different [ 9 ]. Exercise intolerance is the principal clinical feature in HFpEF. People complain of debilitating symptoms: the elevation of filling pressures during even modest exercise causes significant dyspnea and fatigue [ 7 , 9 ]. NICE guidelines recommend the implementation of exercise training in HFpEF, but the evidence only evaluates surrogate endpoints such as exercise capacity and quality of life [ 10 ].

The treatments for heart failure become progressively more complex, gradually the clinical picture worsens Figure 3 [ 11 ]. General measures, such as the attention to diet and good lifestyle, weight monitoring, patient education and close medical follow-up, should be done on all patients, while medical therapy is based on progressive staging and symptoms classification [ 13 ].

Even if the recommendations for the use of drugs in HF derived principally from studies that recruited patients with left ventricular systolic dysfunction LVSD HFrEF , treatments with same principles are also useful for patients with HFpEF and relevant cardiovascular co-morbidities, such as hypertension and coronary artery disease CAD. Unfortunately, trials using the same medications employed for the treatment of HFrEF have not shown any significant improvements on survival [ 8 , 12 ]. The only indication to the use of diuretics in chronic HFpEF is for symptomatic relief of acute or chronic congestion see Figure 3.

The doses of diuretics should be adjusted continuously, especially when the patient achieves euvolaemia, as further diuresis and dehydration may decrease preload and cardiac output [ 8 ]. The role of the multidisciplinary team in the continuing management of heart failure patients is pivotal and all the principal guidelines on HF management underline that the complexity of both the diagnostic process and the therapeutic options, as well as the continuing difficulties in the diagnosis and management of HFpEF, dictate the recurrent involvement of specialists [ 1 , 4 , 5 , 10 , 14 ].

A rehabilitation program has three main components: education, counselling and exercise [ 10 ]. Education and counselling are usually incorporated into standard care see below , while the role of exercise-based rehabilitation programs in the management of patients with HF is not completely defined. There is some evidence that cardiac rehabilitation can be useful to improve functional capacity, exercise duration, health-related quality of life and mortality [ 1 , 4 ], particularly in patients with HFrEF [ 15 ].

Despite the paucity of direct evidence in HFpEF, recommendations for rehabilitation should relate to all patients with heart failure without contraindications, since symptoms and prognosis of patients with HFpEF do not differ significantly from those with heart failure due to LVSD [ 7 , 10 ]. A psychological and educational component in the program would assure better results of the intervention [ 10 ].

In the absence of specific programs for patients with HF, they can also be enrolled in rehabilitation within other existing cardiac rehabilitation programs i. Healthcare-based rehabilitation programs are likely to be cost-effective in different populations and for different healthcare systems [ 16 ]. The majority of them did not receive a visit from a doctor in the period they stay at home, after discharge. Discharge planning i. Evidence suggests that systems of care for patients with HF improve adherence to published guidelines and clinical outcomes if involve collaborative care with specialists, multidisciplinary teams including primary care , with a focus on transitions of care and chronic disease management [ 19 — 23 ].

All the guidelines on HF management recommend a coordinating care along the continuum of HF and throughout the chain-of-care delivered by the various services, within the healthcare system [ 1 , 4 , 10 , 14 ]. The framework, which is centred in primary care, posits six interrelated elements that are key to high quality chronic disease care: self-management support, redesigning delivery systems, decision support that is system wide, clinical information technology, linkages to community resources and health care system organisation [ 24 ].

Recently, the National Heart Foundation of Australia published guidance on policy and system changes to improve the quality of care for people with chronic heart failure CHF. The recommendations point to reduce emergency presentations, hospitalisations and premature death among patients with CHF [ 14 ].

Among the most critical points to overcome there are:.

Clinician's Corner: Taking a good patient history

To ensure equity of access for everyone in disadvantaged areas, including the most vulnerable people in socio-economic frailty and the cultural minorities. Lack of data and inadequate identification of people with CHF: this leads to ineffectiveness in measuring outcomes and evaluating the CHF care provided. The development of mechanisms to promote data linkage across care transitions is essential. The enhanced community-based management of CHF, across the empowerment of general practitioners to lead care.

Future research activity needs to ensure the translation of valuable knowledge and high-quality evidence into practice. The practical application of these principles is included in the recommendation n. A management program for patients with HF both with reduced and preserved ejection fraction needs particular characteristics and components Figure 5 [ 4 ]. Primary care plays a central role in the early identification of HF, transitions to and from acute care settings, self-care promotion, managing co-morbidities and end-of-life care [ 23 , 25 ].

However, a recent systematic review of 22 studies has pointed out barriers and facilitators of implementing the chronic care model in primary care. The inner setting of the organisation, the process of implementation and characteristics of the individual healthcare providers are the major emerging themes.

The importance of assessing organisational capacity and needs is crucial prior to and during the implementation of the CCM, as well as gaining a better understanding of health care providers and organisational perspective [ 26 ]. Frailty and multiple co-morbidities contribute to non-compliance, leading to higher rate of hospitalisation, rehospitalisation, and ultimately institutionalisation and death [ 27 ].

Co-morbidities are important in patients with HF for four main reasons [ 4 ]:. They may affect the use of some drugs for HF e. Some drugs, useful for co-morbidities symptoms, may decompensate HF e.

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NSAIDs for pain in arthritis ;. After an establishment the deterioration of a status of the heart can be often treated, but as a rule, it is impossible to cancel.


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Policymakers should emphasize the need for health professionals in all clinical disciplines to identify patients with diseases that increase the risk of heart failure and prescribe preventive drugs. Ensuring access to preventive drugs should be provided to those who are at greatest risk for developing heart failure, regardless of age, sex, or income. Policymakers should also give priority to the elimination of certain infectious diseases in some parts of the world where they continue to cause heart failure [ 4 , 8 , 10 ].

Risk factors for heart failure vary from lifestyle factors to concomitant diseases, medications, laboratory, and visual characteristics for new biomarkers and genomic markers. The risk of heart failure increases with age, and the male sex is associated with a higher risk.

Heart failure: Educating your patient can help prevent readmission.

Higher physical activity, increased salt intake, and lower socioeconomic status were associated with increased risk. Hypertension, diabetes, obesity, and coronary disease all increase the risk. More than half of patients hospitalized with heart failure, regardless of the ejection fraction, have coronary artery disease. Hypertension and coronary artery disease are the most common and most powerful risk factors, which bring an increased risk of two to three times. Valvular heart disease increases the risk due to hemodynamic changes. Obesity, due to a variety of mechanisms, predisposes to heart failure.

The excessive use of alcohol increases blood pressure and is a direct myocardial toxin; however, light consumption is moderately associated with risk, especially in men. Smoking contributes to several cardiovascular risk factors associated with heart failure. Dyslipidemia and renal dysfunction predispose to heart failure. Other comorbidities that increase the risk include anemia, sleep breathing disorder, increased heart rate, lung dysfunction, and microalbuminuria. The levels of homocysteine and natriuretic peptide are associated with an increased risk.

Serum resistance, lipoproteins associated with phospholipase A2, and myeloperoxidase are also associated with an increased risk [ 9 , 10 , 11 , 12 ]. Most patients are fragile and elderly with concomitant diseases e. Several chemotherapeutic agents, for example, doxorubicin, cyclophosphamide, trastuzumab, and 5-fluorouracil, are associated with heart failure. Inhibitors of cyclooxygenase-2 may increase the risk of myocardial infarction. Thiazolidinediones were associated with edema and heart failure. Several cardiac anatomical and physiological measures are associated with a higher risk, including enlargement of the chamber with an increase in terminal diastolic or terminal systolic dimensions, an increase in left ventricular mass, worsening diastolic filling of the left ventricle, an increase in the left atrium, and asymptomatic systolic dysfunction.

There is growing interest in genomic predictors of heart failure. While patients at high risk benefit greatly from proper and consistent treatment, unfortunately, they often undergo suboptimal management. Their inability to tolerate even minor fluctuations in cardiac and renal function makes them vulnerable to frequent and recurring episodes of acute heart failure. It is now recognized that up to two-thirds of hospitalizations associated with CHF can be prevented.

This is especially important for groups at high risk of developing this condition. Many people have diseases that put them at risk of heart failure. Health-care professionals who treat such patients should adopt a broad approach that includes encouraging positive lifestyle changes that reduce the risk of heart failure and prescribe preventive therapy as needed. Medications that control blood pressure, heart rate, and cholesterol levels are effective in preventing heart failure in a large number of people who have conditions such as high blood pressure, coronary heart disease, kidney disease, and diabetes.

Pacemakers and the replacement of heart valves can also prevent heart failure in a small number of people who have a particular heart rate or valve disorders. The range of diseases that predispose patients to heart failure is extremely wide. Health-care professionals in all clinical disciplines should receive education to identify patients with diseases that increase the risk of heart failure and prescribe preventive medications. This ensures that as many people as possible get access to therapy [ 5 , 7 , 8 ]. Patients receiving long-term preventive therapy should be evaluated regularly at the expense of health-care providers.

In addition, patients with chronic diseases, such as coronary artery disease or Chagas disease, should periodically evaluate and monitor heart changes. Patients with breast cancer are another group that will benefit from such monitoring. Several existing and new methods of treating cancer are toxic to the heart, and it is important for health professionals to be aware of the need to evaluate and manage the risks involved. Bacterial infections that cause heart disease are largely eliminated in economically developed countries due to the use of antibiotics. In other regions, bacteria and tropical parasites cause a significant proportion of heart failure, many of which can be prevented by appropriate treatment methods.

Therefore, the potential benefits of policy initiatives aimed at eliminating infectious diseases extend to preventing heart failure in many parts of the world. In particular, to continue global efforts, it is necessary to eradicate Chagas disease, based on the progress made in Latin America over the past two decades [ 1 , 2 ]. Preventive treatment could be started earlier, identifying people with early signs of abnormal cardiac muscle remodeling.

Unfortunately, large-scale screening programs, such as those that allowed earlier treatment of bowel cancer, cervical cancer, and breast cancer, are unfortunately not possible, because there is no simple diagnostic test for heart failure. Early changes in the structure or function of the heart can be detected using medical imaging technology; however, it is inadvisable to perform these complex procedures in a large number of people with diseases that lead to heart failure and, of course, not for the general population.

In the future, extended genetic tests and statistical modeling of risk groups that take into account the myriad potential causes of heart failure may be available, and this can allow individuals to be identified for in-depth screening. Targeting preventive drugs to people with the highest risk of heart failure can increase profitability, allowing more people to take advantage.

Further research in these areas continues and should continue to be supported by public and private funds. In addition, information programs should be directed at everyone who has medical conditions that predispose to heart failure. They should include education about the symptoms of heart failure and the benefits of positive lifestyle changes. The same messages are important for public information programs [ 3 , 4 , 5 , 6 ].

Preventing heart failure in the elderly is becoming a more urgent health priority, as the age of the population. Elderly patients hospitalized with heart failure mostly are women. Although a number of studies of patients with heart failure have shown that survival rates are better in women than in men, recent studies have shown that long-term prospects for women are not as good as previously thought. Therefore, initiatives aimed at improving the prevention of heart failure should include strategies to reach older people, especially older women [ 14 , 15 , 16 ].

In economically developed countries, heart failure is more common and most likely the cause of death in people with low socioeconomic status than the rest of the population. This is still the case after adjusting for age differences, the use of drugs, and the proportion of people with other cardiac diseases. The view was expressed that the role of housing can be played by housing stability, social support, substance abuse, language skills, and distance to the hospital.

Several studies have reported a reduction in the risk of heart failure with a healthy lifestyle. It has been shown that healthy weight, avoidance of smoking, exercise, and healthy eating reduce the risk factors for heart failure, including ischemic disease, diabetes, and hypertension.

Palliative care in heart failure – Signa Vitae

Recently, researchers in the health research of doctors reported that habits of a healthy lifestyle, that is, normal body weight, rather than smoking, regular exercise, moderate alcohol consumption, consumption of breakfast cereals, and consumption of fruits and vegetables, were associated with a lower risk of heart disease with the most high risk of Although many heart failure risk factors have been described, determining their role in predicting a future event is still difficult.

Despite a strong etiological relationship to the disease, the risk factor may be limited in its prognostic role. Although individual risk factors for heart failure, such as hypertension, are well described, how do we clearly identify individual risk in patients with different combinations of risk factors? For coronary events, schemes for predicting multiple risks have been developed, for example, the Framingham risk score.

However, heart failure syndrome is a spectrum from ischemic to nonischemic etiology and from normal to depressed ejection fraction. Older patients may develop heart failure due to age-related cardiovascular changes in the absence of traditional risk factors. Thus, high-risk subjects cannot be detected using coronary risk regimes [ 15 ]. Several unique problems make the assessment of the risk of heart failure difficult.

First, heart failure is a clinical diagnosis, and this leads to a variety of opinions and diagnostic uncertainties in a number of cases. The most common clinical criteria used to diagnose heart failure are the Framingham criteria, which require at least two basic or one basic and two lower criteria. Researchers from the cardiovascular study have developed alternative criteria that included the use of drugs and imaging techniques. When both sets of criteria were compared, only half of the patients were considered to have heart failure by both criteria, while the other half were labeled either one or the other, but not both.

A similar discrepancy was shown between diagnoses of administrative categories compared to a detailed overview of the diagram [ 2 , 13 , 14 , 15 , 16 ]. Social changes can affect the CVD epidemic in different ways. It may be influenced by globalization, migration, socioeconomic changes, and unemployment. Over the years, differences in the incidence of CVD among countries, regions, and areas have increased; these inequalities can be explained by the components of human behavior, such as diet, exercise, smoking, and work-related functions, as well as overcrowding, unemployment, and other deprivation indicators.

The expected life expectancy is constantly increasing with income. The harmful effect of tobacco, apparently, does not depend on the form of use. An increased risk of cardiovascular disease is reported when tobacco is used by non-smokers. Mechanisms leading to heart failure in smokers include i indirect effects, that is, causing or exacerbating associated diseases associated with heart failure, and ii direct exposure to the myocardium.

Tobacco smoking remains one of the most important preventable causes of premature mortality, and quitting is the most cost-effective strategy for the prevention of cardiovascular disease. Improvements have been made with regard to tobacco smoking, in some countries more than in others, with large differences in accordance with the socioeconomic class. Governmental constraints and rules were successful; high taxes on tobacco products are the most effective policy measure to reduce smoking among young people. However, this needs to be complemented by continuing campaigns in the field of health education, especially those targeting young people and other subgroups of society.

There must be restrictions on advertising, promotion, and sponsorship by the industry [ 12 , 16 ]. All smokers should be advised to quit. Patients should be referred to formal programs to discontinue therapy, and pharmacological therapy should be offered to increase success. Current recommended strategies include the following: a Medicines.

Several drugs are available for tobacco dependence. Seven first-line drugs significantly increase long-term rates of abstinence from smoking, including bupropion SR, nicotinic gum or inhaler or cake or nasal spray, or patch and varenicline. Individual, group, and telephone practical consultations and social support are effective, and their effectiveness increases with the intensity of treatment. However, the combination of counseling and medication is more effective than one, so clinicians should encourage all people who attempt to stop using both counseling and medication.


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Smokers who want to quit smoking should get professional help if needed. Short interventions with recommendations for cessation of smoking, together with pharmacological support and follow-up visits, are effective and safe, but not enough, even for smokers with established ischemic heart disease. In case of relapse, a more intensive approach should be considered, for example, referral of a specialist or center for cessation of smoking. Avoidance of secondhand smoke is another important recommendation for CVD prevention.

If the recommendations, stimulation, and motivation are likely to be insufficient, drug therapy should be considered at an early stage, including nicotine replacement therapy NRT , bupropion, or varenicline. Pharmacotherapy for smoking cessation can double or triple throw rates, and a combination of pharmacotherapy and counseling improves throw rates. The success of cessation of smoking with varenicline is higher than with bupropion; varenicline doubles the chances of stopping smoking compared to placebo. Hypersensitivity is the only contraindication. Nausea is the most common side effect, especially at the beginning of therapy and if taken with food.

In some cases, a dose titration may be required. Electronic cigarettes, or e-cigarettes, can deliver high concentrations of nicotine as a vapor and have been recommended as a measure to help stop smoking conventional cigarettes. The results of studies of the cardiovascular effect of electronic cigarettes are inconsistent, but in some cases, an increased risk is documented.

As for the dietary habits of the population, the changes occurred in different areas. For example, consumption of salt and saturated fats has been reduced in most societies.

The food industry has reduced the presence of trans-fatty acids in different foods. This was promoted by regulatory initiatives in some communities. Nevertheless, the potential for preventing cardiovascular disease through dietary adaptations is still poorly implemented. Compliance with a balanced diet is usually limited. Control of high blood pressure, dyslipidemia, and dysglycemia can be significantly improved due to lifestyle changes. Achieving better adherence to dietary recommendations requires an understanding of the determinants of poor compliance.

At the population level, structural measures, such as product information and user-friendly food labeling, can improve health-friendly options. Energy-intensive products with nutrient deficiencies are usually highly available and inexpensive; marketing of such products may be limited and taxed. There is often a tendency to assume urinary catheterisation for the close monitoring of urine output. The consequences of such an infection are likely to vary, increasing the risk of a prolonged hospital stay and the development of in-hospital confusion, particularly in older adults.

Alongside nursing actions to prevent infection, good practice also includes limiting the use of urinary catheters and, when they are necessary, removal as soon as possible. National and international guidelines suggest best practice in their use. The ongoing monitoring of response to treatment and cardiopulmonary status also necessitates close monitoring of key haemodynamic parameters.

In the immediate period of stabilisation, overly aggressive management with diuretics and vasodilators may lead to hypotension. Equally, patients may be undertreated or their underlying condition may deteriorate. Early warning scores allocate and weight points to vital signs outside pre-agreed ranges. These points are then summed to provide a single composite score. An increase in score will identify those patients who will benefit from escalation of monitoring or treatment. For example, they may benefit from an increased frequency of observationor ugent medical review.

chapter and author info

To provide standardisation and limit misunderstanding the UK has adopted the National Early Warning Score NEWS 9 see Figure 1 for use in routine recording of clinical data, replacing traditional observation charts. Such tools have been reported to improve the ability of ward staff both nursing and medical to identify and respond to indicators of clinical change. Close monitoring requires a care environment where nurses have the time and expertise to identify and respond appropriately to changes in physiological data.

The association between the competence of nurses and quality of care has long been recognised and more recently the association between nurse staffing, nurse expertise and patient outcome has been confirmed. A study of more than , patients in acute hospitals in nine European countries reported an association between an increase in the number of nurses and the risk of death.

Within the context of heart failure the UK National Heart Failure audit revealed that in-hospital mortality is lower when patient care is managed in specialist cardiology wards rather than general medical wards 7.


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  • Countries will need to decide locally how to interpret and implement these findings but they point to an association between the quality of nursing care and patient outcome. It is not always possible for every patient to receive in-patient care on a specialist cardiology ward and some will be best cared for on general medical or care-of-the-elderly wards where nursing staff have specific expertise in managing the care needs of the frail, older adult. The heart failure management of the older adult is complicated by concomitant comorbid conditions, altered pharmacokinetics, frailty and cognitive impairment.

    Consequently their hospital length of stay is likely to be longer and also influenced by the availability of post-discharge social support. The UK National Audit data reports an increased length of stay LOS in heart failure patients not cared for on cardiology wards and this relates to the majority of those patients aged above 74 years mean LOS The in-patient hospital stay allows review of all medication, as well as combinations that may increase the risk of side effects.

    The in-patient admission also provides time for the safe introduction of new heart failure medication and this is likely to be slower in the older patient. For example, nurses can remind patients to stand up slowly to reduce their risk of dizziness and falls, teach them to modify the timing of diuretics to enable activities outside the home and facilitate the supply of continence aids when necessary.

    Where in-patient care is not provided on a cardiology ward this can be facilitated by regular outreach by the heart failure team and the heart failure specialist nurse has a central role in this, providing advice, education and liaison between the health-care teams directly involved in providing care and the heart failure specialist team. Regardless of the place care is delivered, ideally patients with heart failure should be identified and followed up during their hospital stay by a specialist heart failure team.

    Using medical admission records the heart failure specialist nurse can identify patients with suspected heart failure, act as a point of contact for advice and ensure appropriate discharge planning and follow up. Once stabilised patients should be started or restarted on evidence medicines. Various models for such outreach exist but the exact model will depend on the local organisation of care. In-patient management extends beyond haemodynamic monitoring and initiation of medication to planning for discharge and the smooth transition to a community heart failure disease management programme.

    It is now well recognised that patients are at high risk of hospital re-admission during the first few months following discharge. This has led to recommendations for follow up early in the postdischarge period and ideally within the first one to two weeks. Preparing for discharge requires assessment of social environment into which the patient will be discharged as well as their capacity to self-care. Patients admitted to hospital with heart failure are frequently elderly with multiple comorbidities. They have reduced physiological reserve to adapt to change and stress and may require a period of rehabilitation and supportive community resources in the initial post-discharge phase.

    In such situations the heart failure nurse co-ordinates discussions to develop a collaborative discharge plan. They report a mean of 6. Regardless of age, discharge from hospital is frequently cited as a period of high anxiety for both patients and their families. A coordinated care plan that estimates time to euvolamia and commencement of heart failure medication can be communicated and discussed at an early stage and so help prepare both the patient and their family for discharge.

    The in-hospital period is also an ideal time to provide education about heart failure, its monitoring and management. It is possible that some hospital admissions are preventable if worsening heart failure is recognised early; some patients and family wish to be involved in self-care e.