Revolutionizing Heart Health: Understanding and Treating Heart Failure
Heart Failure: A Background
Heart failure (HF) is a complex and chronic clinical syndrome that affects millions of people worldwide. It occurs when the heart is unable to pump blood effectively to meet the body's demands. Defining the disease in this way may appear straightforward, but its complexity and multiple underlying causes often leave patients struggling to fully comprehend the nature of their illness, its implications, and the significance of self-care and monitoring. In 2020, it was reported that the number of United States citizens with a diagnosis of heart failure was 6.2 million, and heart failure was listed on 13.4% of death certificates as a contributing diagnosis.1 Patients who receive an HF diagnosis, which requires lifelong monitoring and management to stay healthy and avoid hospitalization, have a lot to emotionally process.
HF is always a serious matter that demands ongoing attention and care. The statistic that nearly one-fourth of patients who have been admitted with the diagnosis of heart failure will be readmitted within 30 days with the same diagnosis likely supports the observation that patients may not truly understand the importance of self-maintenance and the chronic nature of their syndrome.2 A 25% readmission rate has not only a negative impact on the lifestyles of the HF population, but also carries adverse effects for healthcare facilities. Hospitals that have higher than expected heart failure 30-day readmission rates face financial penalties under the 2012 Hospital Readmission Reduction Program (HRRP). Avoidable readmissions result in increased staffing costs.3 It is important to assess where hospitals and providers may be lacking in delivering sufficient care for this growing patient cohort.
HF Patient Dynamics
Heart failure patients may struggle to understand their condition due to various reasons. One of these reasons can be the complexity of medical terminology and concepts involved in heart failure. It is easier to explain heart failure with a reduced ejection fraction (HFrEF), which accounts for less than half of heart failure diagnoses, than it is to describe diastolic heart failure or heart failure with a preserved ejection fraction (HFpEF).4 Patients typically have a basic understanding of heart attacks, and ventriculography images are helpful in visualizing HFrEF. However, HfpEF can involve both systolic and diastolic left ventricular dysfunction as well as right ventricular dysfunction,4 which can complicate the patient’s understanding. Other factors such as myocardial ischemia, pulmonary hypertension, abnormal gas exchange, autonomic dysregulation, vascular stiffening, endothelial dysfunction, and renal disease may also contribute to the disease complexity.4
Individuals who suffer from heart failure may experience other health issues that can hinder their ability to concentrate on their condition. Chronic illnesses such as coronary artery disease, diabetes, and hypertension can also lead to the development of heart failure. Patients may also be coping with discomfort, exhaustion, or other symptoms that can make it difficult to grasp and remember information, as well as lack the energy needed for self care. The complexity of this disease dictates an intricate treatment regimen that includes medications, dietary and exercise modifications, implantable devices, and consistent system monitoring. Guideline-driven medical therapy for heart failure includes traditional diuretics to increase sodium and water excretion, as well as beta-blockers, angiotensin-converting enzyme inhibitors, and angiotensin receptor blockers — all of which work to decrease the heart’s demand for oxygen by slowing the heart rate, dilating blood vessels, and decreasing blood pressure. Newer combination drugs, such as angiotensin receptor blockers/neprilysin inhibitors, further potentiate the ability of the body to reduce sodium levels by increasing levels of certain proteins that dilate blood vessels.5 Heart failure patients are usually taking several of these medications, another factor which complicates patient understanding, and these medications can lead to a variety of side effects.
HF Monitoring and Treatment
Self-monitoring for the onset of HF symptoms is key to the prevention of hospital readmission. Daily weight monitoring, regular exercise, and limited intake of sodium are crucial for heart failure patients who aim to manage their condition. It is also important to report any signs of increasing shortness of breath, edema, or chest pain to the physician. These efforts can be burdensome, but they are necessary to keep the clinical condition under control. Often, however, the initial changes in pulmonary artery (PA) pressure that lead to decompensation begin up to 3 weeks prior to when the patient experiences symptoms and/or weight change.6 In some cases, a pulmonary artery sensor may be implanted during a cardiac cath lab procedure that will enable daily monitoring of the PA pressure so the healthcare provider can make decisions for early intervention to prevent readmission.6 Self-monitoring, just like guideline-driven medical therapy, requires a great deal of understanding and commitment to compliance by the patient.
Treatment of heart failure with the implantation of a cardiac resynchronization therapy (CRT) or cardiac contractility modulation (CCM) devices may further reduce mortality for heart failure patients, but these interventions also pose the need for an understanding of additional complicated concepts. CRT devices synchronously pace both ventricles to help the heart pump blood effectively, while CCM devices deliver biphasic high-voltage bipolar impulses to the right ventricular septum, and have been shown to improve exercise tolerance and decrease hospital readmissions.7 Device implants require patient compliance to maintain home monitoring and presence at device clinic appointments.
Driving HF Care Excellence Across the Continuum
Navigating this scientific conundrum as a patient can clearly be quite challenging. To achieve success in patient outcomes and satisfaction, it is imperative that a comprehensive heart failure program place a large emphasis on patient education, both in the inpatient and, more importantly, in the outpatient setting. At the time of diagnosis, a frank conversation between the provider and patient that details the chronic aspects of heart failure is warranted. Patients and their caregivers should be assessed for their ability, resources, and willingness to participate in the level of education and self-management that will be needed to maintain quality of life and reduce the need to return to the hospital. A post-discharge care plan that is customized to the patient is vital to ensure that the necessary aspects of outpatient care will be attained. A patient care agreement that emphasizes patient responsibility and avoidance of failure is also essential. Following hospital discharge, it is crucial for patients with heart failure to have continued contact and support from healthcare professionals who serve as navigators. Patients should feel empowered to ask questions of their healthcare team. Patients who understand their condition are better equipped to manage their symptoms, adhere to treatment, and make informed decisions about their care.
It is also important to consider the existence or development of advance directives during the care continuum of the heart failure patient. Advance directives help to ensure that the patient’s medical care is in line with their wishes and values, and provide the patient with the opportunity to have their voices heard and respected. As a heart failure patient’s condition can evolve over time, open communication about treatment preferences, including decisions about CRT/CCM therapies, ventricular assist devices, cardiac transplantation, or hospice care, will help to ensure that the patient’s wishes continue to be respected should a time come when they cannot actively participate in decision-making.
For heart failure patients, a large portion of the maintenance of care lies directly in the post-hospital period, where knowledge of self-care and monitoring are key to quality of life. The creation and maintenance of a heart failure program that supports the full continuum of care should be a top consideration for healthcare leaders. At Corazon, we work collaboratively with hospitals that seek to create and maintain an accredited comprehensive heart failure program that supports the patient along that continuum. Our experienced consultants and accreditation surveyors work to evaluate existing programs and offer suggestions for enhancements that propel these programs to excellence. We must all work diligently to keep “failure” out of the equation for this critical group of patients.
References
- Virani SS, Alonso A, Benjamin EJ, et al; American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Subcommittee. Heart Disease and Stroke Statistics-2020 Update: A Report From the American Heart Association. Circulation. 2020 Mar 3; 141(9): e139-e596. doi:10.1161/CIR.0000000000000757
- 30-Day Readmission Rates to U.S. Hospitals. Data Infographic. Agency for Healthcare Research & Quality. August 2018. https://www.ahrq.gov/data/infographics/readmission-rates.html
- McIlvennan CK, Eapen ZJ, Allen LA. Hospital readmissions reduction program. Circulation. 2015 May 19; 131(20): 1796-1803. doi:10.1161/CIRCULATIONAHA.114.010270
- Omote K, Verbrugge FH, Borlaug BA. Heart failure with preserved ejection fraction: mechanisms and treatment strategies. Annu Rev Med. 2022 Jan 27; 73: 321-337. doi:10.1146/annurev-med-042220-022745
- Kuchulakanti PK. ARNI in cardiovascular disease: current evidence and future perspectives. Future Cardiol. 2020 Sep; 16(5): 505-515. doi:10.2217/fca-2019-0089
- CardioMEMS HF System - P100045/S056. U.S. Food & Drug Administration. https://www.fda.gov/medical-devices/recently-approved-devices/cardiomems-hf-system-p100045s056
- Tschöpe C, Kherad B, Klein O, et al. Cardiac contractility modulation: mechanisms of action in heart failure with reduced ejection fraction and beyond. Eur J Heart Fail. 2019 Jan; 21(1): 14-22. doi:10.1002/ejhf.1349
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