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INTRODUCTION
Chronic heart failure (CHF) is a common condition with a poor prognosis. It generates many debilitating symptoms for the sufferer. Nonpharmacologic treatment modalities play an important role alongside effective modern pharmaceutical, surgical, and device therapies. These treatments include those lifestyle measures that reduce the risk of underlying diseases such as coronary artery disease, diabetes, hypertension, and hyperlipidemia and those lifestyle interventions that benefit either the symptoms or prognosis of established heart failure (HF). The former will have formed a part of the management of the patients prior to the development of HF and should continue. This chapter will review the latter nonpharmacologic treatments that have a role in the management of the patient with HF.
Patient and Care-Giver Education
For patients to get the optimum benefit from their therapy, they and their principal caregivers need to have a good understanding of the nature and causes of CHF. Further information such as awareness of symptoms, diet, salt and fluid restriction, the nature and purpose of their drugs, and how to manage work and other physical activities, lifestyle changes, and measures of self-management of their disease is also important. Nonpharmacologic treatment should include dietary and other
lifestyle advice, advice on appropriate levels of physical exercise, and health-care education. The support engendered by learning these aspects with caregivers and other patients and their families can also be of major benefit. These educational programs should form part of a comprehensive multidisciplinary program organized by the treating physician in conjunction with other health-care workers and primary care doctors, nurses, and, especially, the patients and their families. Other specialists including pharmacists dieticians, physiotherapists, psychologists, nurses, and social workers will play important supporting roles.1
Rest and Exercise
For many years, patients with HF were routinely advised to avoid all strenuous and even mild exertion. From the late 1980s, reports told, however, of the benefits of carefully constructed exercise training regimens for patients with stable mild to moderate CHF. These benefits have now been confirmed for many grades and stages of HF, and beneficial effects have been shown for symptoms, quality of life (QoL), exercise tolerance, and many surrogate measures of HF severity and complications.
In the first randomized controlled trial (RCT) of exercise training in CHF, we showed that training could increase exercise tolerance and improve the symptoms of dyspnea and fatigue.2 In 11 patients with CHF secondary to ischemic heart disease (mean [SEM] age 63 [2.3] years; left ventricular ejection fraction (LVEF) 19 [8]%), 8 weeks of home-based bicycle exercise training and 8 weeks of activity restriction were prescribed in random order in a physician-blind, random-order, crossover trial. Training increased exercise duration from 14.2 (1.1) minutes to 16.8
(1.3) minutes and peak oxygen (VO2) consumption from 14.3 (1.1) mL/min/kg to 16.7 (1.3) mL/min/kg. Heart rates at submaximum workloads and rate-pressure products were significantly reduced by training, and there was also a significant improvement in patient-rated symptom scores. No adverse events occurred during the training phase. This was a home-based physical training program that was shown to be feasible even in severe CHF. Subsequent studies have shown the benefits of exercise training extend to measures of autonomic and neurohormonal balance, muscle structure and function, endothelial and vascular function, ventilatory control, myocardial perfusion, and psychological well-being.
In 1999, Belardinelli and colleagues randomized 99 stable CHF patients (59 ± 14 years of age; 88 men and 11 women) to exercise training at 60% of peak capacity, initially three times a week for 8 weeks, then twice a week for 1 year, or control.3 Ninety-four patients completed the protocol (48 trained and 46 in control). Both QoL and exercise tolerance were improved and mortality was lower after training (n = 9 vs. n = 20 for those with training vs. those without; relative risk (RR) = 0.37; 95% confidence interval [CI], = 0.17–0.84; P = 0.01). Fewer hospital readmissions for HF were seen in the trained group (5 vs. 14; RR = 0.29; 95% CI, 0.11–0.88; P = 0.02). Although showing a significant reduction in mortality and morbidity, this was not a prospective trial powered and designed to evaluate this effect, so we should not consider that this trial alone proved a mortality-reducing benefit of exercise training in CHF. While we wait for definitive evidence from a well-powered major multicenter trial as to whether training has prognostic as well as symptomatic benefit, the next best thing, an individual patient data metaanalysis, has suggested a significant reduction in both the risk of death and in the number of hospitalizations for HF. We coordinated a collaborative meta-analysis with inclusion criteria of all randomized parallel group-controlled trials of exercise training for at least 8 weeks with individual patient data on survival for at least 3 months.4 Nine datasets, totaling 801 patients were identified and analyzed; 395 patients received exercise training and 406 were in controls. During a mean (SD) follow-up of 705 (729) days, there were 88 (22%) deaths in the exercise arm and 105 (26%) in the control arm. Exercise training significantly reduced mortality (hazard ratio [HR] 0.65, 95% CI, 0.46–0.92; log rank chi-square = 5.9; P = 0.015). The secondary end point of death or admission to hospital was also reduced (HR 0.72, 95% CI, 0.56–0.93; log rank chi-square = 6.4; P = 0.011). No statistically significant subgroup-specific treatment effect was observed. We can summarize that training in selected CHF patients is beneficial and safe and can reduce mortality and morbidity. It should therefore be recommended for all stable Class I–III CHF patients.
In a second overview approach, we searched the Cochrane Controlled Trials Register (The Cochrane Library Issue 2, 2001), MEDLINE (2000 to March 2001), EMBASE (1998 to March 2001), CINAHL (1984 to March 2001) and reference lists of articles, supplemented by direct enquiry of published experts. We selected all RCTs of exercise-based interventions for adults of all ages with CHF. The comparison group was usual medical care, as defined by the study, or placebo. Only those studies with criteria for diagnosis of HF (based on clinical findings or objective indices) were included. Studies were selected, and data were abstracted, independently by two reviewers supplemented by direct enquiry of authors, where possible, to obtain missing information. Twenty-nine studies were found to meet the inclusion criteria, with 1126 patients randomized. The majority of studies included both patients with primary and secondary HF, New York Heart Association (NYHA) Class II or III. None of the studies specifically examined the effect of exercise training on mortality and morbidity as most were of short duration. Exercise training significantly increased VO2 max by (weighted mean difference [WMD] random effects model) 2.16 mL/kg/min (95% CI, 2.82–1.49), exercise duration increased by 2.38 minutes (95% CI, 2.85–1.9), work capacity by 15.1 Watts (95% CI, 17.7–12.6), and distance on the 6-minute walk by 40.9 m (95% CI, 64.7–17.1). Improvements in peak oxygen consumption were greater for training programs of greater intensity and duration. Health-Related Quality of Life (HRQoL) improved in the seven of nine trials that measured this outcome. We concluded that exercise training improves exercise capacity and QoL in patients with mild to moderate HF in the short term.5
Several questions remain unanswered. We do not know the best and safest training regimens. Although the early trials used almost exclusively an aerobic training regimen (approximately 3 days a week for 20–60 minutes per session), more recent trials have also looked at the efficacy and safety of exercise including resistance training. One study evaluated the effects of combined endurance/resistance training on NT-proBNP levels in patients with CHF. In this study, of 27 consecutive patients with stable CHF and LVEF <35% were enrolled in a 4-month nonrandomized combined endurance/resistance training program. After 4 months, exercise training caused a significant reduction in circulating concentrations of NT-proBNP (2124 ± 397 pg/mL before, 1635 ± 304 pg/mL after training; P = 0.046, interaction), whereas no changes were observed in an untrained HF control group. This suggests that combined endurance/resistance training significantly reduced circulating levels of NT-proBNP in patients with CHF, arguing against any increase in adverse remodeling.6 Other recent trials have shown an element of resistance as well as aerobic training to be beneficial, especially for improving muscle strength, bulk, and endurance. Some supervised in-hospital training is necessary, especially at the commencement of a training program, and may well be beneficial for encouraging long-term adherence at regular indefinite intervals. Home-based training can also be recommended in well-evaluated patients to make this a more practical treatment option for larger numbers of patients.
Diet and Nutrition
Obesity is a risk factor for many of the antecedents of HF, including coronary artery disease, diabetes, hypertension, and hyperlipidemia. Adult obesity has been shown to increase the likelihood of later HF. Despite this, in what has been described as the “obesity paradox,” once a patient has HF, a higher body mass index (BMI) is actually protective, and weight loss is an ominous sign of worsening HF and a poor prognosis.7,8 Described as cardiac cachexia, this complication is a dramatic and catastrophic complication of HF in a way that cachexia can complicate other chronic disorders. The challenge of the dietary management of the HF patient is to balance these conflicting needs, aiming for an optimal weight that may mean weight loss early in the natural history and strategies to prevent weight loss later in the clinical course. Data on weight from 7767 patients with stable HF enrolled in the Digitalis Investigation Group (DIG) trial were recently reported. Crude all-cause mortality rates decreased in a near-linear fashion across successively higher BMI groups, from 45% in the underweight group to 28.4% in the obese group (P = 0.001). After multivariable adjustment, overweight and obese patients were at lower risk for death (HR 0.88, 95% CI, 0.80–0.96; and HR 0.81, 95% CI, 0.72–0.92, respectively), compared with patients at a healthy weight. In contrast, underweight patients with stable HF were at increased risk for death (HR 1.21, 95% CI, 0.95–1.53).9
Pasini and colleagues have reported that CHF patients have on average a higher total energy expenditure (1700 ± 53 vs. 1950 ± 43 kcal/day; P <0.01), a negative calorie balance (104 ± 35 vs. −186 ± 40 kcal/day; P <0.01), a negative nitrogen balance (2.2 ± 0.5 vs. −1.7 ± 0.4 g/day; P <0.01), and a hypercatabolic hormonal status (cortisol/ insulin ratio 32 ± 1.7 vs. 65 ± 5.1; P <0.01). This suggests a relatively inadequate calorie intake for daily activities, with consequent important protein breakdown that causes muscular wasting.10 In another study, the effects of nutritional supplementation were assessed. A supervised nutritional intervention was shown to improve clinical status and QoL.11 Sixty-five patients with HF were assigned to one of two groups: the intervention group (IG) (n = 30), received a sodium-restricted diet (2000–2400 mg/day) with restriction of total fluids to 1.5 L/day, and the control group (CG) (n = 35) received traditional medical treatment and general nutritional recommendations. After 6 months, kilocalories, macronutrients, and fluid intakes were significant lower in the IG than in the CG. Urinary excretion of sodium decreased significantly in the IG and increased in the CG (−7.9% vs. 29.4%, P <0.05). IG patients had significantly less-frequent edema (37% vs. 7.4%; P = 0.008) and fatigue (59.3% vs. 25.9%; P = 0.012) at 6 months compared to baseline. Functional class also improved significantly. Physical activity increased 2.5 ± 7.4% in the IG and decreased −3.1 ± 12% in the CG (P <0.05). The IG had a greater increase in total QoL compared with the CG (19.3% vs. 3.2%; P = 0.02).
Kuehneman and colleagues have demonstrated an important role for the dietician in a multidisciplinary HF program. Compared with baseline, QoL scores improved by 6.7 points (P <.003) at 3 months and by 5.9 points (P <.04) at 6 months after dietician intervention, suggesting positive findings in terms of improved nutrition and avoidance of worsening HF due to excessive sodium intake.12
Psychological Support
Depression has been recognized as a common and adverse feature of CHF.13 Gottlieb has shown that in 155 patients with stable NYHA functional Class II, III, and IV HF and an ejection fraction <40%, 48% of the patients could be considered depressed.14 Depressed patients tended to be younger than nondepressed patients. Women were more likely (64%) to be depressed than men (44%). Depressed patients scored significantly worse than nondepressed patients on all components of both the questionnaires measuring QoL. The authors suggested that pharmacologic or nonpharmacologic treatment of depression might have the capacity to improve the QoL of HF patients, although this presently has not been the subject of an adequately powered randomized clinical trial (RCT).14
Sleep Disorders
Many patients with CHF complain of poor sleep. Historically this has been attributed to paroxysmal nocturnal dyspnea, or to depression and anxiety. More recently it has been appreciated that many CHF patients also suffer from sleep-disordered breathing (SDB) due to both obstructive and central sleep apnea with frequent episodes of periodic breathing. One study examined the prevalence of sleep disorders in stable HF patients regardless of ejection fraction. On 3 consecutive days in an HF clinic, all patients were asked to participate in a screening for SDB. This screening involved the placement of an outpatient device (ClearPath, Nexan, Inc., Alpharetta, Georgia), which collects thoracic impedance, oxyhemoglobin saturation, and 2-lead electrocardiogram data. Sixteen patients (42%) had moderate or severe SDB, 22 patients (55%) had mild or no significant SDB. Fourteen of the 16 patients with moderate or severe SDB subsequently received treatment by confirming SDB and continuous positive airway pressure (CPAP) in a sleep laboratory. Forty-two percent of patients with stable HF presenting to an HF clinic screened positive for SDB, despite receiving optimal standard of care.15 This is now recognized as a common condition and one believed to increase the risk of mortality. Treatment of SDB is considered an important part of the management of CHF.16 Improvements in SDB have shown a positive effect on cardiac output, neurohormonal activity, and QoL. CPAP has been the traditional method used to treat SDB in patients with CHF, but more recent devices such as a mandibular advancement device have also been shown to be effective.17 Nocturnal carbon dioxide inhalation by suppressing chemoreflex drive to ventilation (which is excessive in CHF) has been shown to reduce the frequency of central sleep apnea and improve QoL.18,19 For obstructive sleep apnea, CPAP has been shown to improve cardiac function, sympathetic activity, and QoL.20 For nocturnal Cheyne-Stokes breathing, nocturnal-assist servoventilation has been shown to improve daytime sleepiness compared with the control. A total of 30 subjects (29 male) (with mean apneahypopnea index 19.8 [SD 2.6] and stable symptomatic CHF [NYHA Class II–IV]) were treated with 1 month’s therapeutic (n = 15) or subtherapeutic adaptive servoventilation. Daytime sleepiness Oxford SLEep Resistance test (OSLER test) was measured before and after the trial with change in measured sleepiness the primary endpoint. Active treatment reduced excessive daytime sleepiness; the mean Osler change was +7.9 minutes (SEM 2.9), when compared with the control, the change was −1 minute (SEM 1.7), and the difference was
8.9 minutes (95% CI, 1.9–15.9 minutes; P = 0.014, unpaired t-test). Significant falls also occurred in plasma brain natriuretic peptide and urinary metadrenaline excretion rates suggesting beneficial neurohormonal effects.21 There remains, however, little evidence from RCTs to tell us whether it is cost-effective to screen routinely for SDB in CHF clinics and to treat all cases so detected.
Specialist Heart Failure Clinics and Nurses
In recent years, the value of comprehensive hospital and community-based HF management programs has been accepted, and they have become established as the standard of care in many countries. In the Netherlands, for example, 60% of hospitals support an HF management program. Most of the programs are organized as HF outpatient clinics. In all HF programs, cardiologists and nurses are involved. Other health-care providers involved are, amongst others, general practitioners (29%), dieticians (59%), physical therapists (47%), social workers (30%), and psychologists (17%). All programs offer follow-up after discharge from the hospital and in most of the programs patients have increased access to a health-care provider. Behavioral interventions (68%), psychosocial counseling (64%), patient education (88%), and support of the informal caregivers (59%) are important components. In 90% of the programs, physical examination is the responsibility of the HF nurse and in 65% of the programs nurses are involved in optimizing medical treatment.22
After hospital discharge, follow-up of CHF patients at a nurse-led HF clinic has been shown to be associated with fewer patients with events (death or admission) after 12 months (29 vs. 40, P = 0.03) and fewer deaths after 12 months (7 vs. 20, P = 0.005) in one study. The IG had fewer admissions (33 vs. 56, P = 0.047) and days in hospital (350 vs. 592, P = 0.045) during the first 3 months. After 12 months, the intervention was associated with a 55% decrease in admissions/patient/month (0.18 vs. 0.40, P = 0.06) and fewer days in hospital/patient/month (1.4 vs. 3.9, P = 0.02). The IG had significantly higher self-care scores at 3 and 12 months compared to the CG (P = 0.02 and P = 0.01).23
Intensive home care of middle-aged patients with severe HF has been shown to result in improved QoL and a decrease in hospital readmission rates.24 A telephone-mediated nurse care management program for HF has also been shown to reduce the rate of rehospitalization for HF, although it has been suggested such programs may be less effective for patients at low risk compared to higher risk patients.25,26 Other reports of home health intervention programs have, however, reported less convincing benefits.27 Success has also been reported of incorporating palliative care regimes into the management of end-stage CHF.28
The evidence to suggest that such CHF programs involving individualized multidisciplinary postdischarge health care, with a major focus on specialist nurse management are clinically and economically effective in CHF has recently been reviewed.29 These programs appear to be most effective in “high-risk” patients who typically have recurrent readmissions in high-cost units. Overall, the literature suggests that these programs are able to reduce recurrent hospital stay by 30–50% relative to usual care (even in the presence of optimal treatment) in the short to medium term with comparable cost benefits.
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