Beyond Drugs: New Recommendations for the Everyday Management of HF

Nonpharmacologic management strategies represent an important contribution to heart failure (HF) therapy, and may significantly impact patient stability, functional capacity, mortality, and quality of life. Recently, the HFSA released updated guidelines for clinicians who treat this patient population; topics covered include dietary instruction, activity and lifestyle issues, and health maintenance.

Recommendations:

• Specific dietary instruction regarding sodium intake is recommended in all patients with HF.
• Dietary sodium restriction (2-3 g daily) is recommended for patients with the clinical syndrome of HF and preserved or depressed left ventricular ejection fraction (LVEF). Further restriction (<2 g daily) may be considered in moderate to severe HF.
• Restriction of daily fluid intake to <2 L is recommended in patients with severe hyponatremia, and should be considered for all patients demonstrating fluid retention that is difficult to control despite high doses of diuretic and sodium restriction.
• Specific attention should be paid to nutritional management of patients with advanced HF and unintentional weight loss or muscle wasting (cardiac cachexia). Measurement of nitrogen balance, caloric intake, and prealbumin may be useful in determining appropriate nutritional supplementation. Caloric supplementation is recommended; however, anabolic steroids are not recommended for cachexic patients.
• Patients with HF, especially those on diuretic therapy and restricted diets, should be considered for daily multivitamin-mineral supplementation to ensure adequate intake of the recommended daily value of essential nutrients.
• Documentation of the type and dose of naturoceutical products used by patients with HF is recommended.
• Naturoceutical use is not recommended for relief of symptomatic HF or for the secondary prevention of cardiovascular events. Patients should be instructed to avoid using natural or synthetic products containing ephedra (ma huang), ephedrine, or its metabolites because of an increased risk of mortality and morbidity. Products should be avoided that may have significant drug interactions with digoxin, vasodilators, beta blockers, antiarrhythmic drugs, and anticoagulants.

Other Therapies

• Continuous positive airway pressure to improve daily functional capacity and quality of life is recommended in patients with HF and obstructive sleep apnea documented by approved methods of polysomnography.
• Supplemental oxygen, either at night or during exertion, is not recommended for patients with HF in the absence of an indication of underlying pulmonary disease. Patients with resting hypoxemia or oxygen desaturation during exercise should be evaluated for residual fluid overload or concomitant pulmonary disease.
• The identification of treatable conditions, such as sleep-disordered breathing, urologic abnormalities, restless leg syndrome, and depression should be considered in patients with HF and chronic insomnia. Pharmacologic aids to sleep induction may be necessary. Agents that do not risk physical dependence are preferred.

Specific Activity and Lifestyle Issues

• It is recommended that screening for endogenous or prolonged reactive depression in patients with HF be conducted following diagnosis and at periodic intervals as clinically indicated. For pharmacologic treatment, selective serotonin reuptake inhibitors are preferred over tricyclic antidepressants, because the latter have the potential to cause ventricular arrhythmias, but the potential for drug interactions should be considered.
• Nonpharmacologic techniques for stress reduction may be considered as a useful adjunct for reducing anxiety in patients with HF.
• Anxiety is commonly associated with depression, and often manifests as the inability to adjust to stressful situations. Although it is depression that is predictive of a worse prognosis, anxiety should be taken seriously and reduced as much as possible. An assessment of intrinsic coping skills may be useful. Relaxation techniques such as meditation and biofeedback may improve patient daily functioning. In one small study, researchers found that acupuncture inhibited sympathetic activation during mental stress in patients with advanced HF.
• Effective communication skills can reduce anxiety. The diagnosis of HF and its prognosis are likely to provoke anxiety. Anxiety, in turn, may contribute to a patient's inability to comprehend or follow a treatment plan. In discussing recommendations regarding end-of-life issues, including advance directives, care should be taken to avoid inducing excessive anxiety.

Health Care Maintenance Issues

• It is recommended that patients with HF be advised to stop smoking and to limit alcohol consumption to ≤2 standard drinks per day in men or ≤1 standard drink per day in women. Patients suspected of having an alcohol-induced cardiomyopathy should be advised to abstain from alcohol consumption. Patients suspected of using illicit drugs should be counseled to discontinue such use.
• Pneumococcal vaccine and annual influenza vaccination are recommended in all patients with HF in the absence of known contraindications.
• Endocarditis prophylaxis is not recommended based on the diagnosis of HF alone. Consistent with the AHA recommendation, 'prophylaxis should be given for only specific cardiac conditions, associated with the highest risk of adverse outcome from endocarditis.' These conditions include: 'prosthetic cardiac valves; previous infective endocarditis; congenital heart disease (CHD)' such as: unrepaired cyanotic CHD, including palliative shunts and conduits; completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first six months after the procedure; repaired CHD with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device (which inhibit endothelialization) cardiac transplantation recipients who develop cardiac valvulopathy.
• Nonsteroidal anti-inflammatory drugs, including cyclooxygenase-2 inhibitors, are not recommended in patients with chronic HF. The risk of renal failure and fluid retention is markedly increased in the setting of reduced renal function or ACE-inhibitor therapy.
• It is recommended that patients with new- or recent-onset HF be assessed for employability following a reasonable period of clinical stabilization. An objective assessment of functional exercise capacity is useful in this determination.
• It is recommended that patients with chronic HF who are employed and whose job description is compatible with their prescribed activity level be encouraged to remain employed, even if a temporary reduction in hours worked or task performed is required. Retraining should be considered and supported for patients with a job demanding a level of physical exertion exceeding recommended levels.

For a full listing of the 2010 Heart Failure Society of America Comprehensive Heart Failure Practice Guideline, visit www.heartfailureguideline.org.