Heart failure module 3: pharmacological and non-pharmacological management

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Introduction

The aim of heart failure (HF) management is to improve outcomes for patients with HF by reducing preventable admissions, morbidity, mortality, and in effect improving the overall quality of life.1

4761597-silver-haired-couple-enjoying-walk-in-parkThese can be achieved through optimal non-pharmacological and pharmacological management. Non-pharmacological interventions, such as lifestyle modification, psychosocial support and patient self-management, cannot be overlooked. Ideally a multidisciplinary team that encompasses primary, secondary and tertiary care would ensure a holistic approach to managing HF.

Box 1. Goals of HF treatment(2)
Goals of HF treatment(2)

There are national and international guidelines on the management of HF. The National Institute for Health and Care Excellence (NICE) and the European Society of Cardiology (ESC) have produced guidelines on the management of HF in primary and secondary care.1,2  The Scottish Intercollegiate Guidelines Network have also produced guidelines on the management of chronic heart failure.3

Non-pharmacological management

Box 2. New York Heart Association (NYHA) classification
Goals of HF treatment(2)

Lifestyle

Lifestyle modifications such as improving the level of exercise and nutrition, and advice on smoking cessation, alcohol consumption and weight control should be considered and discussed when commencing treatment for HF (see table 1). These should be reinforced at every available opportunity.

Patients with HF should have individual self-care management plans in place and be encouraged to participate in self-care management programmes.1,2

Useful advice on resumption of sexual activity for patients with cardiovascular disease is available from the British Heart Foundation (BHF). Similarly advice on driving is available from the DVLA and guidance on fitness to fly can be accessed from the British Cardiovascular Society (BCS).4

Table 1. Essential topics that should be covered during patient education, and the skills and self-care behaviours that should be taught in relation to these topics. (click to enlarge)
Table 1. Essential topics that should be covered during patient education, and the skills and self-care behaviours that should be taught in relation to these topics

The role of diet and weight control

It is recommended that patients with HFmonitor their weight on a daily basis to prevent weight gain as a consequence of fluid retention.  This would involve patients increasing the dose of diuretic if there are signs of fluid overload (weight gain >2 kg in three days), and reducing it if there are signs of excessive diuretic use (weight loss >2 kg in three days).5

In obese patients (BMI >30 kg/m2) with HF, weight reduction has been shown to reduce the progression of HF, improving symptoms and well-being.5 Patients should aim to have a healthy diet and a healthy weight while preventing malnutrition. Sodium restriction is sometimes necessary in order to control the signs and symptoms of congestion in patients with symptomatic HF class III and IV.5

Exercise

Most patients with HF have exercise intolerance, fatigue and dyspnoea that make exercise unappealing. In addition, depression and anxiety are commonly encountered in patients with HF resulting in a low motivation to exercise.1,5

Exercise rehabilitation educates and improves exercise tolerance and lifestyle in patients with HF. NICE recommends that a six-minute walking test be performed to assess the physical function of patients with HF, especially the elderly.

NICE Quality Standard 9 recommends that patients with stable chronic HF who do not have a condition or device for which exercise is contraindicated, should be offered a supervised group exercise-based rehabilitation programme.1 The ESC guidelines on HF recommend that patients with HF are reassured about the benefits of exercise and are encouraged to exercise regularly.2