The New York Heart Association Classification is commonly used to identify the stage and severity of HF. In stage I, there are no symptoms of HF with ordinary activity. In stage II, there are mild symptoms with ordinary activity, and in stage III, there are symptoms with minimal exertion. Stage IV is severe HF marked by symptoms at rest (American Heart Association, 2018).
Pharmacologic treatment of systolic HF is mainly based on diuretics to relieve symptoms associated with congestion. Diuretics, both loop and thiazide, reduce blood volume and increase excretion of water in the urine. Pulmonary congestion is significantly reduced with use of diuretics and patients' breathing is eased (Chavey et al., 2017).
ACE Inhibitors and Angiotensin Receptor Blockers
ACE inhibitors are the cornerstone of HF treatment. They block the transformation of angiotensin I to angiotensin II. Angiotensin receptor blockers perform similarly. By blocking angiotensin II receptors, angiotensin II cannot bind to the receptor and in turn cannot stimulate arterial vasoconstriction or trigger adrenal release of aldosterone (Pfeffer et al., 2003).
Beta1-adrenergic blockers are also indicated as these drugs counteract the sympathetic nervous system effects in HF. These agents lower heart rate and decrease peripheral arterial vasoconstriction. Beta-blockers are effective at reducing mortality in patients with symptomatic HF when combined with ACE inhibitors (Chavey et al., 2017).
Aldosterone antagonists, such as Spironolactone and Eplerenone, block the action of aldosterone that reduces sodium and water reabsorption at the kidney. These drugs are recommended in combination with ACE inhibitors and beta1-blockers (Zannad et al., 2011).
When beta-blockers are not effective in reducing heart rate, Ivabradine is recommended. Ivabradine decreases heart rate by directly inhibiting the sinoatrial node, and is indicated in patients with an ejection fraction of 35% or less and persistent symptoms despite maximally tolerated doses of a beta1-blocker (Chavey et al., 2017).
Digoxin should be considered for those who remain symptomatic despite therapy with other agents. It works as a positive inotrope but can also stimulate dysrhythmias. In a large controlled trial of digoxin in patients with HF, digoxin had no impact on mortality but decreased hospitalization rates (Ambrosy et al., 2014). Further analysis of digoxin has revealed increased morbidity and mortality with digoxin levels greater than 0.8 ng/mL, particularly in women, older adults, and those with compromised renal function (Rathore et al., 2003).
Implications for Home Healthcare Clinicians
Patients with HF are commonly hospitalized due to episodes of acute decompensation. Among Medicare patients hospitalized for HF between 2008 and 2010, 67% experienced readmission at some time during their disorder (Dharmarajan et al., 2015). Preventing hospital readmission for HF patients is a high priority for clinicians and insurers. Predicting acute decompensation of HF is significant as it can save lives and dollars. Home healthcare clinicians play a major role in the prevention of HF decompensation and exacerbation among their patients by closely monitoring signs and symptoms of HF.
A multidisciplinary healthcare team is needed as patients often have comorbidities such as diabetes, arthritis, osteoporosis, or chronic lung disease. Depression and anxiety are very common in patients with HF, which can lead to social isolation, apathy, and diminished cognition. Patients are often homebound and lack social support (van der Wal et al., 2017). Closely monitor the patient's condition, assist in coordinating multidisciplinary care, evaluate the home for safety and the mobility needs of the patient, assist patients with lifestyle changes, and provide emotional support. Astute assessment at every visit can prevent patient relapse and rehospitalization. Close contact with the patient's primary provider is essential. Involvement of the family in the care of the patient is also vital (Rogers & Bush, 2015a).
Provide educational materials, assess the patient's knowledge through teach-back, and reiterate the goals at every visit. Each medication's usage and purpose should be explained and kept in a timed, pillbox. Alternatively, a smartphone can be set to alert the patient to take medications. The necessary laboratory testing schedule should be recorded on a calendar for the patient. Transportation issues should be discussed and arranged. The patient should keep a list of all their medications and bring it to every healthcare appointment. Those who live alone may need an emergency alert system (Waters & Giblin, 2019).
Patients should weigh themselves daily to detect water retention. A gain or loss of 2 lb from 1 day to the next is usually due to water weight and should be reported to the primary care provider. A low-sodium (<1,500 mg) diet needs to be fully explained. Excessive sodium in the diet is a common cause of fluid congestion in HF (Waters & Giblin, 2019). Foods with high sodium content need to be clearly listed. Patients should understand how to read nutrition labels in order to choose low-sodium foods, and they should understand how to choose low-sodium meal options on a restaurant menu. If permitted, look in the refrigerator and cabinets to get an idea of the patient's diet; nonrecommended foods should be pointed out. Use teach-back to verify the patient's understanding of recommended food choices. Weight control is also important as obesity increases the work of the heart.
Why Are Patients Commonly Rehospitalized?
Many patients with HF who are rehospitalized cite escalating shortness of breath, physical activity intolerance, and increasing fatigue as reasons for seeking healthcare (Gheorghiade et al., 2013). Commonly, patients who are readmitted for HF demonstrate signs of fluid overload such as weight gain, pulmonary crackles, jugular venous distension, and increased peripheral edema. Therefore, physical assessment to rule out fluid congestion is extremely important in patients with HF. There are a number of history inquiries and physical assessments that should be made at every home healthcare visit (Table 3).
Some healthcare organizations using remote monitoring systems referred to as telemedicine. Telemedicine uses technology that can assess relevant biologic parameters to evaluate the patient's risk of decompensation in HF. Remote monitoring of the patient's vital signs, weight, cardiogram, and physical activity can be done through body sensors in some telemedicine systems. The goal of remote monitoring systems is to gather data that can be used to optimize treatment and prevent decompensation. At this time, these types of remote support systems are not available in many parts of the country.
Palliative care is an approach that focuses on alleviation of suffering and improving quality of life for those living with serious illness, regardless of prognosis. During the course of HF, patients can experience debilitating physical and emotional symptoms that severely degrade quality of life. Physical symptoms in advanced HF, such as dyspnea and pain are highly distressing for patients and caregivers (Goebel et al., 2009). Patients and their caregivers often face decisions about high-risk and complex treatments (e.g., cardiac devices, transplantation) without adequate education about prognosis, decision support, or advance care planning. Currently, a palliative care approach for HF is not widely used; however, multiple clinical trials are currently underway examining various forms of palliative care delivery for HF (Kavalieratos et al., 2017).
Instructions for Taking the CE Test Online
Systolic Heart Failure: An Update for Home Healthcare Clinicians
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