Letter to the Editor - Treatment Checklist for Advanced Heart Failure

To the Editor:

The review article “Treatment Checklist for Advanced Heart Failure”¹ was a very pleasant read; however, the hallmark to the treatment of congestive heart failure was not even touched. As a matter of fact, on page 24, at the end of paragraph one, is the following quote: "Similarly, restrictions on diet and advice for physical activity may be relaxed." We get people all the time in stage IV heart failure who are gasping for air and are on all of the medications listed in the article. These people are often remedied by just spending a few minutes explaining to them that their bodies need less than 1500 milligrams of sodium a day. Once they figure this out, the edema goes away and the shortness of breath resolves, and they can get along fine with a 20% ejection fraction. In the meantime, if you forget to put a person with heart failure on an ACE inhibitor while he/she is in the hospital, you are termed a “bad doctor.” However, if you feed that patient a regular salt diet and give no education on sodium restriction, nobody cares. There are a lot of good spices out there that can make food taste just fine to a cachexic cardiac cripple. Hiding behind the notion that food is not good without salt has just allowed the drug companies to take over the management of congestive heart failure. Stick to the basics.

Respectfully submitted,
Robert M. Richey, MD Florence, SC

Reference

1. Cooper JK. Treatment checklist for advanced heart failure. Annals of Long-Term Care: Clinical Care and Aging 2007;15(8):21-25.
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Response from Dr. James Cooper:

I welcome the reminder that sodium restriction is important in heart failure (HF). My own pet peeve is the unthinking use of intravenous sodium chloride solution (“normal saline IV”) for daily fluid in HF patients hospitalized for non-HF conditions. Each liter contains over 3500 mg sodium. For my article, I assumed that sodium restriction had been implemented in a very early heart failure stage. I am unaware of studies of the value of very strict sodium restriction in the last days of life. Surely some leniency would be acceptable and probably more humane. It should be discussed with the patient. In earlier stages, there are trade-offs between keeping nutrition appetizing and preventing fluid overload. Some leniency in salt intake may be acceptable if there is careful monitoring and diuretics are still effective. But I agree, we’re probably not talking about hot dogs and chips here.

James K. Cooper, MD, AGSF Division of Geriatrics and Palliative Care George Washington University Medical Center Washington, DC