evidence & practice / CPD / cardiology

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1 HEART FAILURE Chroni heart failure part 2: treatment and management NS876 Brake R, Jones ID (2017) Chroni heart failure part 2: treatment and management. Nursing Standard. 31, 20, Date of submission: 19 November 2015; date of aeptane: 20 May doi: /ns.2017.e10762 Rebea Brake Advaned nurse pratitioner in ardiology, Mid Cheshire NHS Foundation Trust, Cheshire, England Ian David Jones Professor of ardiovasular nursing, Shool of Nursing and Allied Health, Liverpool John Moores University, Liverpool, England Abstrat Chroni heart failure is a ommon and omplex linial syndrome that results from impaired ardia relaxation or ontration. There have been onsiderable advanes in the management of hroni heart failure; however, the mortality rate remains high. Patients with hroni heart failure may experiene multiple debilitating symptoms, suh as fatigue, pain, and peripheral oedema. However, breathlessness may be onsidered the most debilitating symptom. The management of hroni heart failure aims to improve the patient s quality of life by reduing symptoms and supporting the patient to manage their ondition. Treatment of patients with hroni heart failure may involve a ombination of pharmaologial therapy, devie implantation and ardia rehabilitation. This is the seond of two artiles on hroni heart failure. Part 1 disussed the pathophysiology of hroni heart failure, its auses, assessment, signs and symptoms. Part 2 outlines the treatment and management of patients with the ondition, inluding pharmaologial strategies, devie implantation, lifestyle modifiation, ardia rehabilitation and palliative are. Keywords breathlessness, ardia resynhronisation therapy, ardiology, hroni heart failure, heart failure, implantable ardioverter defibrillators, left ventriular systoli dysfuntion Conflit of interest None delared Peer review This artile has been subjet to external double-blind peer review and heked for plagiarism using automated software Revalidation Prepare for revalidation: read this CPD artile, answer the questionnaire and write a refletive aount: rni.om/ revalidation Online For related artiles visit the arhive and searh using the keywords Aims and intended learning outomes This artile aims to develop nurses understanding of the treatment and management of patients with hroni heart failure. After reading this artile and ompleting the time out ativities you should be able to: Summarise the treatment options for patients with hroni heart failure resulting from left ventriular systoli dysfuntion. Explain the rationale for different management approahes for patients with hroni heart failure. Disuss with a olleague the lifestyle advie you would offer patients with hroni heart failure to enable them to improve self-management. Introdution This is the seond of two artiles on hroni heart failure, whih provides an overview of the management of this omplex linial syndrome. The first artile addressed the epidemiology, physiology, and pathophysiology of hroni heart failure, its auses, assessment, signs and symptoms (Brake and Jones 2017). The primary aims of the treatment and management of hroni heart failure are: the relief of symptoms, inluding breathlessness and oedema; the prevention of hospital admissions; and improving survival and health-related quality of life (Ponikowski et al 2016). Established evidened-based treatments for hroni heart failure are based on managing a redued ejetion fration. Therefore, this artile fouses on management onsiderations in hroni symptomati heart failure with redued ejetion fration. Treatment an omprise pharmaologial strategies and non-pharmaologial strategies, for example a ardia resynhronisation therapy (CRT) devie or an implantable ardioverter volume 31 number 20 / 11 January 2017 / 53

2 To write a CPD artile Please gwen. larke@rni.om. Guidelines on writing for publiation are available at: journals.rni.om/r/ author-guidelines defibrillator (ICD), as well as lifestyle modifiations. Figure 1 presents an overview of treatment options in hroni symptomati heart failure with left ventriular systoli dysfuntion (Ponikowski et al 2016). TIME OUT 1 A patient presents with hroni heart failure resulting from left ventriular systoli dysfuntion. Make a list of the pharmaologial strategies you would onsider, giving the rationale. Use Figure 1 to develop a treatment algorithm Figure Figure 1. Treatment 1. Treatment options options in in hroni hroni symptomati heart heart failure with left ventriular systoli dysfuntion dysfuntion Patient with symptomati heart failure with redued ejetion fration Diuretis to relieve symptoms and signs of ongestion If left ventriular ejetion fration 35% despite optimal medial therapy or a history of symptomati ventriular tahyardia or ventriular fibrillation, implant implantable ardioverter defibrillator (ICD) Able to tolerate ACE inhibitor or angiotensin reeptor bloker? Angiotensin reeptor neprilysin inhibitor to replae ACE inhibitor Yes Therapy with angiotensin onverting enzyme (ACE) inhibitor and beta bloker (Up-titrate to maximum tolerated evidene-based dose) Still symptomati and left ventriular ejetion fration 35% Yes Add Aldosterone antagonist (Up-titrate to maximum tolerated evidene-based dose) Yes Still symptomati and left ventriular ejetion fration 35% Yes Sinus rhythm, QRS duration 130ms Evaluate need for ardia resynhronisation therapy These above treatments may be ombined if indiated Resistant symptoms No No Sinus rhythm, heart rate 70 beats per minute Ivabradine No Consider digoxin, or hydralazine and isosorbide dinitrate, or left ventriular assist devie, or transplantation No further ation required Consider reduing diureti dose Class 1 (green): is reommended or is indiated. Evidene and/or general agreement that a given treatment or proedure is benefiial, useful, effetive. Class 11a (yellow): should be onsidered. Weight of evidene or opinion is in favour of usefulness or effiay. (Adapted from Ponikowski et al ESC guidelines for the diagnosis and treatment of aute and hroni heart failure, European Heart Journal doi: /eurheartj/ehw12 with permission of Oxford University Press (UK) European Soiety of Cardiology Clinial-Pratie-Guidelines/Aute-and-Chroni-Heart-Failure) 54 / 11 January 2017 / volume 31 number 20

3 For related CPD artiles visit evideneandpratie. for a patient in your are. You may wish to refer to the 2016 European Soiety of Cardiology (ESC) Guidelines for the Diagnosis and Treatment of Aute and Chroni Heart Failure (Ponikowski et al 2016), available at: eurheartj. oxfordjournals.org/ontent/ehj/37/27/2129.full.pdf. Pharmaologial strategies Pharmaologial strategies form the basis of management in patients with hroni heart failure resulting from left ventriular systoli dysfuntion. Angiotensin-onverting enzyme inhibitors Angiotensin-onverting enzyme (ACE) inhibitors, suh as ramipril, lisinopril and perindopril arginine, are a first-line therapy in the management of left ventriular systoli dysfuntion (National Institute for Health and Care Exellene (NICE) 2010). They improve symptoms of hroni heart failure and redue the risk of mortality by inhibiting the effet of ACE and the prodution of angiotensin II. ACE inhibitors should be ommened at a low dose and the dose gradually titrated upwards to ahieve the maximum tolerated dose (Ponikowski et al 2016), with areful monitoring of the patient s blood pressure, renal funtion and serum potassium beause of the risk of hyperkalaemia (British National Formulary (BNF) 2016). ACE inhibitors an ause a dry ough for some patients, resulting from the breakdown of bradykinin. If this ours and is intolerable, an angiotensin II reeptor bloker liensed for use in heart failure may be used as an alternative. Angiotensin II reeptor antagonists, suh as andesartan ilexetil, inhibit the effet of angiotensin II and are reommended only when ACE inhibitors are not tolerated by the patient (NICE 2010). Angiotensin reeptor neprilysin inhibitor Valsartan with saubitril is an angiotensin reeptor neprilysin inhibitor that has reently been approved for use as a replaement for ACE inhibitors, to further redue the risk of hospitalisation and death in ambulatory patients with heart failure with preserved ejetion fration who remain symptomati despite optimal treatment with an ACE inhibitor, a beta-bloker and an aldersterone antagonist (Ponikowski et al 2016). The ombined effet of saubitril and valsartan bloks the undesirable effets of the reninangiotensin-aldosterone system, and inhibits the breakdown of natureti peptides, whih promote natriuresis and vasodilation (Jhund and MMurray 2016). Trial data have demonstrated the superiority of valsartan with saubitril over ACE inhibitors in reduing symptoms, ardiovasular death and hospitalisation in patients with heart failure (MMurray et al 2014). Bet-adrenoeptor blokers Beta-adrenoeptor blokers (beta blokers) are also onsidered a first-line therapy in left ventriular systoli dysfuntion, together with ACE inhibitors. Beta-blokers liensed for use in heart failure inlude bisoprolol fumarate, arvedilol and nebivolol. These drugs at by bloking the beta ell s ability to take up adrenaline (epinephrine) and therefore redue heart rate. They should be used with a start low, go slow approah; initiating therapy at a low dose and gradually inreasing this to the maximum tolerated dose in aordane with heart rate and blood pressure (BNF 2016). Beta blokers are usually avoided in patients with asthma, but may be presribed under speialist supervision if no alternative is available (BNF 2016). Aldosterone antagonists Aldosterone antagonists, suh as spironolatone and eplerenone are a seondline therapy for patients with left ventriular systoli dysfuntion who are established on an ACE inhibitor and beta bloker, yet remain symptomati, or have had a myoardial infartion in the previous month. They blok the effet of aldosterone, thereby reduing sodium and water re-absorption and fluid retention. Aldosterone antagonists have been shown to improve symptoms of hroni heart failure, as measured by hanges to patient s New York Heart Assoiation (NYHA) lass (Table 1), and redue the risk of mortality (Pitt et al 1999, Pitt et al 2003, Zannad et al 2011). This effet results partly from the ations desribed previously, as well as from their ability to redue unwanted atrophy or hypertrophy beause of ardia remodelling. TIME OUT 2 List the side effets assoiated with the use of diuretis in the treatment of patients with symptomati aute KEY POINT ACE inhibitors an ause a dry ough for some patients, resulting from the breakdown of bradykinin. If this ours and is intolerable, an angiotensin II reeptor bloker liensed for use in heart failure may be used as an alternative. Angiotensin II reeptor antagonists, suh as andesartan ilexetil, inhibit the effet of angiotensin II and are reommended only when ACE inhibitors are not tolerated by the patient (NICE 2010) volume 31 number 20 / 11 January 2017 / 55

4 56 / 11 January 2017 / volume 31 number 20 and hroni heart failure. How might hypokalaemia and hypomagnesaemia affet a patient and how might you manage these onditions? Diuretis Diuretis are entral to the management of symptomati aute and hroni heart failure. They are advoated for use in all forms of heart failure for the relief of ongestive symptoms, inluding breathlessness and fluid retention (NICE 2010). Diuretis are used alongside ACE inhibitors, beta blokers and aldosterone antagonists. However, their effets on mortality have not been tested in a randomised ontrolled trial (Ponikowski et al 2016). The most ommonly used diuretis are loop diuretis, suh as furosemide and bumetanide, and thiazide diuretis, suh as bendroflumethiazide and indapamide. The aim of using diuretis is to ahieve and maintain euvolaemia (a irulating volume equilibrium) with the lowest neessary dose. Changes in symptoms and fluid status require up-titration and down-titration of diuretis over time. Down-titration is partiularly important to avoid dehydration. Other adverse effets of diureti use inlude: deterioration in renal funtion; hypotension, espeially with onomitant use of other vasodilating mediations; and eletrolyte imbalanes (hypokalaemia and hypomagnesaemia) whih ould lead to arrhythmias (Sarraf et al 2009). Careful monitoring of renal funtion and eletrolytes, blood pressure and fluid status is reommended (Albert 2012). Seletive sinus node If inhibitors Ivabradine is a seletive sinus node If inhibitor, and should be used in addition to TABLE 1. The New York Heart Assoiation lassifiation Class Symptoms I No limitation of physial ativity. Ordinary physial ativity does not ause undue breathlessness, fatigue, or palpitations. II Slight limitation of physial ativity. Comfortable at rest, but ordinary physial ativity results in undue breathlessness, fatigue, or palpitations. III Marked limitation of physial ativity. Comfortable at rest, but less than ordinary physial ativity results in undue breathlessness, fatigue, or palpitations. IV Unable to arry on any physial ativity without disomfort. Symptoms at rest an be present. If any physial ativity is undertaken, disomfort is inreased. (The Criteria Committee of the New York Heart Assoiation 1994) first-line therapy for a sub-group of patients in sinus rhythm with a heart rate >75 beats per minute and with an ejetion fration 35%. It inhibits the If hannel in the sinus node, thus slowing sino-atrial ativity. Ivabradine has been found to improve survival in a sub-group of patients with hroni heart failure in sinus rhythm with a heart rate >75 beats per minute and with an ejetion fration 35% (Böhm et al 2013). It is liensed in Europe for this population. Conordane Patient eduation and ongoing support are essential to enable an understanding of the ondition, the importane of onordane with mediation, and the risks assoiated with non-onordane. Non-onordane with mediations in hroni heart failure has been linked to deompensation and preventable hospital admission (Shiff et al 2003, van der Wal et al 2005, Varughese 2007, Fonarow et al 2008, Annema et al 2009). Cardia resynhronisation therapy Chroni heart failure symptoms might ontinue to be suboptimally ontrolled following optimisation of ACE inhibitor, beta bloker and aldosterone antagonist use, partiularly as the ondition worsens. Patients who fulfil the relevant riteria in Table 2 might benefit from a CRT devie, with a CRT paemaker (CRT-P), also known as a biventriular paemaker, or a CRT paemaker with an additional defibrillator funtion (CRT-D). These speialised paemakers aim to restore the synhroniity of left and right ventriular ontration, whih an be lost in patients with hroni heart failure, thereby improving pumping effiieny and ardia output. Patients an experiene improved symptoms and quality of life following the implantation of a CRT devie, as well as improved ardia struture and funtion, redued hospital admissions, and redued mortality rates (Brignole et al 2013). However, not all patients will respond in this way (Rosanio et al 2005). Implantable ardioverter defibrillators ICDs have no diret effet on the improvement of symptoms suh as

5 For related CPD artiles visit evideneandpratie. breathlessness. However, patients with hroni heart failure are at risk of sudden ardia death (NICE 2014). An ICD or CRT-D devie an identify lifethreatening arrhythmias and defibrillate the heart internally to restore normal sinus rhythm, thereby reduing the risk of sudden ardia death. The risks and benefits of an ICD or CRT-D should be disussed with patients who meet the riteria for insertion (Table 2), espeially beause the risks inlude the reeipt of inappropriate shoks and subsequent harm to well-being. When the fous of are shifts to end of life are, the reeipt of shoks an be distressing and the patient s quality of death might be affeted. Deativation of the devie at the end of life should be disussed with the patient. Padeletti et al (2010) advoated inorporating this disussion into the pre-implantation onsent and ounselling proess. TIME OUT 3 Disuss with a olleague how the following omponents ontribute to an effiient heart failure servie and how eah omponent an be ahieved: A system for timely and aurate diagnosis of outpatients. Optimisation of treatment. Identifiation of heart failure in patients. Multidisiplinary team working. Supportive and palliative are. Nurse-led heart failure servies Sine 2002, nurse-led heart failure servies have been reognised as an important aspet of the hroni heart failure pathway (Stewart and Horowitz 2002). Chroni heart failure programmes foused initially on the medial aspets of are (Jaarsma et al 2008) to redue the risk of deompensation and subsequent hospitalisation. They inluded a linial assessment of funtional apaity, fluid status, blood hemistry, ardia rhythm and ognitive and nutritional status, alongside optimising the patient s mediation. Although these aspets are important, they are not suffiient to meet the holisti needs of the patient with hroni heart failure. These needs an only be met by empowering the patient to manage their ondition, by developing their self-effiay and self-are skills (Wilkinson and Whitehead 2009, Ditewig et al 2010). Therefore, it is essential this aspet of patient are is inorporated into heart failure servies. TIME OUT 4 A patient is admitted to your linial area with hroni heart failure. Outline the advie you would give on the reommended physial ativity levels. Lifestyle modifiation The European Soiety of Cardiology (ESC) guidelines (Ponikowski et al 2016) suggest that patients with heart failure should reeive lifestyle advie TABLE 2. Treatment options with an implantable ardioverter defibrillator or ardia resynhronisation therapy devie for people with hroni heart failure who have left ventriular dysfuntion with a left ventriular ejetion fration 35% QRS duration as measured on eletroardiogram (ECG) <120ms New York Heart Assoiation (NYHA) lass I NYHA lass II NYHA lass III Implantable ardioverter defibrillator (ICD) if there is a high risk of sudden ardia death NYHA lass IV ICD and ardia resynhronisation therapy (CRT) devie not linially indiated ms without left bundle branh blok (LBBB) ICD ICD ICD CRT paemaker (CRT-P) ms with LBBB ICD CRT devie ombined with an ICD (CRT-D) CRT-P or CRT-D CRT-P 150ms with or without LBBB CRT-D CRT-D CRT-P or CRT-D CRT-P (National Institute for Health and Care Exellene 2014) volume 31 number 20 / 11 January 2017 / 57

6 that enables self-management (Table 3). The hange in emphasis from previous guidelines that foused solely on medial management (MMurray et al 2012) is marked, plaing the fous on providing the patient with information to enable them to take ontrol of their life, rather than fostering dependeny. With the exeption of exerise, there is little evidene for the effiay of these interventions on linial outomes. However, the guidelines serve as a framework to support patients through the hroni heart failure pathway. Remote monitoring has been proposed TABLE 3. Eduation for patients with heart failure Eduation topi Definition, aetiology and trajetory of heart failure (inluding prognosis) Symptom monitoring and self-are Pharmaologial treatment Implanted devies and perutaneous or surgial interventions Patient skill Understands the ause of their heart failure, symptoms and disease trajetory. Makes informed deisions, inluding deisions about treatment at the end of life. Is able to monitor and reognise hanges in signs and symptoms, and knows how and when to ontat a healthare professional. Knows how and when to self-manage diureti therapy and fluid intake, in aordane with professional advie. Understands the indiations, dosing and side effets of their mediation. Reognises the benefits of taking mediations. Reognises the ommon side effets of mediations and knows when to notify a healthare professional. Understands the indiations and aims of proedures and implanted devies. Reognises ommon ompliations of implanted devies and knows when to notify a healthare professional. Diet and alohol Eats healthily, avoids exessive salt intake (>6g per day) and maintains a healthy body weight. Monitors body weight to prevent malnutrition. Inreases fluid intake during periods of high heat and humidity, or when experiening episodes of nausea or vomiting. Abstains from alohol or avoids exessive alohol intake, espeially for patients with heart failure resulting from alohol-indued ardiomyopathy. For patients with severe heart failure and as advised, restrits fluid intake to L per day to relieve symptoms and ongestion. Smoking and Understands the benefits of stopping smoking and taking rereational substanes, where appropriate. rereational Knows how to seek professional support, where appropriate. substanes Stops smoking and taking rereational substanes, where appropriate. Exerise Undertakes regular exerise suffiient to promote moderate breathlessness, unless otherwise advised. Immunisation Is aware that annual influenza immunisation and pneumooal vaine are advised for patients with hroni heart failure. Takes an informed deision to be immunised. Sexual ativity Is reassured about engaging in sex, provided sexual ativity does not provoke undue symptoms. Reognises potential problems with sexual ativity, their relationship with heart failure and treatment. Knows how to treat eretile dysfuntion, where appropriate. Sleep and breathing Reognises problems with sleeping and their relationship with heart failure. Knows how to optimise sleep. Psyhosoial aspets Reognises psyhologial problems that may our in the ourse of disease, in relation to hanged lifestyle, pharmaotherapy, implanted devies and other proedures (inluding mehanial support and heart transplantation). Understands that depressive symptoms and ognitive dysfuntion are more frequent in people with heart failure, and that this may affet onordane. Travel and leisure Prepares travel and leisure ativities aording to their physial apaity. Is aware of adverse reations to sun exposure with ertain mediations, for example amiodarone hydrohloride, used in the treatment of arrhythmias where other mediations are ineffetive or ontraindiated. Considers the effet of high altitude on oxygenation. Take mediines in their abin luggage on the aeroplane and have a list of their mediations and the dosage with the generi name. (Adapted from Ponikowski et al ESC guidelines for the diagnosis and treatment of aute and hroni heart failure, European Heart Journal doi: /eurheartj/ehw12 with permission of Oxford University Press (UK) European Soiety of Cardiology 58 / 11 January 2017 / volume 31 number 20

7 For related CPD artiles visit evideneandpratie. as a means of fostering self-management. Improvements in tehnology enable healthare professionals to monitor patients biomedial parameters remotely, negating the requirement to attend timeonsuming follow-up appointments, for some patients. However, there is onfliting evidene to support suh monitoring (Anker et al 2011). Several meta-analyses have found there is merit in remote patient monitoring, but other large prospetive studies have not demonstrated any benefit (Ponikowski et al 2016). Differenes in the methods used for remote monitoring may provide one possible explanation for this. The basis of self-management is the requirement for the patient to develop an understanding of their ondition and prognosis, and to reognise and manage their symptoms (Ponikowski et al 2016). Patients an learn how to monitor their weight daily, reognise the signs of pulmonary or generalised oedema and how to titrate diureti therapy aordingly (Ponikowski et al 2016). However, it is essential that the patient also understands the indiations, dosing and side effets of their mediation. Nurses have an important role in this proess by providing pratial guidane supplemented with written material that is appropriate for the patient s literay level (Ponikowski et al 2016). While patients with hroni heart failure an often gain weight resulting from fluid overload, they an also beome malnourished as a result of liver and gut dysfuntion (Okoshi et al 2013) and experiene weight loss. Cahexia an our in 10-15% of patients and is partiularly assoiated with advaned heart failure (Ponikowski et al 2016). Therefore, it is essential that dietary advie and advie on fluid management is individualised for eah patient. With the inrease in the use of implantable devies, it is important that nurses ensure patients understand the need for suh devies and the ompliations that an our post-implantation, for example lead frature, undersensing or oversensing, generator failure or infetion (Ezzat et al 2015). The way in whih this information is ommuniated is ruial to ensure the patient is well informed and able to selfare. Smoking and rereational drug use inreases the risk of morbidity and mortality in patients with hroni heart failure (Suskin et al 2001). Cessation of suh ativity is reommended, and referral to smoking and drug-essation servies is advised, as appropriate (Ponikowski et al 2016). Several systemati reviews have demonstrated that exerise an improve health-related quality of life and redue hospitalisation for patients with heart failure (Taylor et al 2014). Therefore, exerise that promotes moderate breathlessness is reommended for the majority of patients with hroni heart failure (Ponikowski et al 2016). However, physial and funtional limitations should be reognised. For some patients who are breathless at rest this is not feasible. Referral to an exerisebased programme is advised; however, the availability of suh programmes is variable (Buttery et al 2013). ESC guidelines reommend that patients reeive annual influenza immunisation and pneumooal vaination management (Ponikowski et al 2016), although there is no diret evidene that they benefit from suh immunisation. Sexual problems are ommon in patients with hroni heart failure (Mandras et al 2007). They may be aused by the symptomology, fear of exertion, ardia mediations or a ombination of these fators (Lainsak et al 2011). It is important to reognise the polypharmay of presribed nitrates and the use of phosphodiesterase inhibitors, whih an be purhased online. Using these drugs in ombination an have serious adverse effets and patients should be aware of the risks of self-mediating. Referral to sexual ounselling servies should be onsidered, where appropriate (Ponikowski et al 2016). Sleep-disordered breathing is also ommon in patients with hroni heart failure, and is assoiated with a higher risk of mortality and morbidity (Kasai and Bradley 2011, MKelvie et al 2011). Therefore, it is important that patients are aware of these risks and are sreened aordingly. High-risk patients should be referred to a sleep laboratory for further investigation. Nurses an help the patient KEY POINT The basis of selfmanagement is the requirement for the patient to develop an understanding of their ondition and prognosis, and to reognise and manage their symptoms (Ponikowski et al 2016). Patients an learn how to monitor their weight daily, reognise the signs of pulmonary or generalised oedema and how to titrate diureti therapy aordingly (Ponikowski et al 2016) However, it is essential that the patient also understands the indiations, dosing and side effets of their mediation volume 31 number 20 / 11 January 2017 / 59

8 KEY POINT Depression affets an estimated one in five patients with hroni heart failure (Lainsak et al 2011). This an affet self-are and onordane with mediation. Therefore, it is important to sreen annually for depression and to initiate treatment plans if the patient is experiening depression. It is essential the patient reognises that psyhologial problems might our during the ourse of the ondition and that they should seek help if they feel their psyhologial health is deteriorating (Ponikowski et al 2016) to identify and address the fators that redue sleep quality, for example the timing of diureti therapy, environmental effets and sleep positioning. Depression affets an estimated one in five patients with hroni heart failure (Lainsak et al 2011). This an affet self-are and onordane with mediation. Therefore, it is important to sreen annually for depression and to initiate treatment plans if the patient is experiening depression. It is essential the patient reognises that psyhologial problems might our during the ourse of the ondition and that they should seek help if they feel their psyhologial health is deteriorating (Ponikowski et al 2016). Family members an be a soure of support and should be involved in are, where appropriate. TIME OUT 5 Do you use a speifi validated tool to sreen for depression in patients with hroni heart failure? Disuss with a olleague if this is the most appropriate tool. What other sreening and assessment tools ould you use? List the benefits and limitations of eah. Patients with hroni heart failure might wish to travel. Although experiening hroni heart failure does not prelude foreign travel, it is important the risks are onsidered in advane and that ontingeny plans are made. This should inlude advising patients of the importane of travel insurane; harities suh as the British Heart Foundation an provide advie and a list of suitable insurane providers. Pratial advie about the journey and subsequent stay should inlude ensuring the patient has a spare supply of mediation. They may wish to arry a opy of a reent eletroardiogram (ECG) and a summary of their medial history with important medial ontat details (MMurray et al 2012). The nurse an disuss with the patient how they should alter gradually the times they take their mediations if they are entering a new time zone. If they are travelling to a hot limate they should onsider the risk of fluid loss and sunburn, and their daily fluid intake should be reviewed. Providing patients with this information in a way that they an omprehend an help support them to manage their ondition. However, many patients may not proess all of the information they are given, so it is important they reeive additional means of support as they aim to manage their ondition. Cardia rehabilitation Cardia rehabilitation was initially introdued to support patients following myoardial infartion and ardia surgery. However, it has been suggested as an additional means of supporting patients with hroni heart failure (NICE 2010). Cardia rehabilitation for patients with hroni heart failure an provide valuable support, eduation and improve levels of physial ability. However, its implementation is variable. Buttery et al (2013) identified that 43% of ardia rehabilitation programmes in the UK do not aept patients with hroni heart failure. Therefore, many patients with hroni heart failure might not reeive aess to the eduation that is so vital to their future self-management. With the inreased prevalene of hroni heart failure globally, alternative means of enabling patients to develop self-are skills and self-management should be onsidered. TIME OUT 6 Read the BACPR Standards and Core Components for Cardiovasular Disease Prevention and Rehabilitation 2012 (British Assoiation for Cardiovasular Prevention and Rehabilitation 2012), available at: om/resoures/46c_bacpr_standards_and_core_ Components_2012.pdf. How might you implement these ompetenies in your area of pratie and disseminate this information to olleagues to enable them to support patients with hroni heart failure to develop their selfmanagement skills? Palliative are In ontrast to many other life-limiting onditions, hroni heart failure has an unpreditable disease trajetory, haraterised by frequent hospital admissions resulting from deompensation, followed by episodes of wellness puntuated by further deompensation, with the risk of mortality at any time. 60 / 11 January 2017 / volume 31 number 20

9 For related CPD artiles visit evideneandpratie. The unpreditable nature of the disease makes prognosis diffiult. There are several prognosti tools available that an support end of life disussions (Levy et al 2006, Huynh et al 2008, Pook et al 2013). However, their effiay is likely to require further validation as new treatments beome available. A meta-analysis of 64 prognosti models found only moderate auray in prediting mortality (Ouwerkerk et al 2014). There is evidene that liniians do not always disuss palliative are with patients in the early stages of hroni heart failure (Hupey et al 2009, Hjelmfors et al 2014, Dunlay et al 2015). Many liniians onsider palliative are as synonymous with are in the last few days of life (Hupey et al 2009). Often, they do not disuss patient preferenes until the patient s ondition has deteriorated suffiiently (Dunlay et al 2015). Nurses providing are for patients with heart failure have indiated that a ombination of fators affet their deisions to disuss these issues, with some suggesting that they do not feel that suh disussions are within their remit and that they do not pereive patients lassified as New York Heart Assoiation lass II or III to be nearing the end of life (Hjelmfors et al 2014). Evidene suggests that patients value and welome suh disussions, but are often not provided with suffiient information to plan and to manage their ondition (Howie-Esquival and Draup 2012). This lak of information leads to further anxiety for patients (Howie-Esquival and Draup 2012). Palliative are for patients with hroni heart failure should be onsidered at an early stage of the disease. This is not to suggest that other treatment options should not be used. Instead, if it is aepted that hroni heart failure is not urable and therefore palliative, the holisti philosophy of palliative are that inludes the treatments deemed to prolong life should be adopted. The World Health Organization (2009) defined palliative are as an approah that improves the quality of life of patients and their families faing the problem assoiated with life-threatening illness, through the prevention and relief of suffering by means of early identifiation and impeable assessment and treatment of pain and other problems, physial, psyhosoial and spiritual. If palliative are is onsidered a philosophy of are rather than a means to provide pain-free end of life are, then its priniples an omplement life-prolonging treatments in the early stages of the disease. The authors propose that palliative are an support long-term are and should be inorporated throughout hroni heart failure are. Palliative are is a means of ensuring patients with life-limiting illness are supported adequately during the remainder of their lives. It will be neessary to use a ombination of life-prolonging and palliative strategies to ahieve this goal. This approah requires a hange in ulture and in the onept of palliative are. However, if this is adopted it ould redue the burden of the disease on the patient and their family. Conlusion Chroni heart failure is a omplex hroni ondition with high rates of mortality and morbidity. The prevalene of hroni heart failure is inreasing, and nurses in all healthare settings are likely to enounter patients with aute and hroni heart failure in their pratie. Optimisation of the medial aspets of are and the promotion of self-management are essential to redue mortality, and an also redue the debilitating symptoms of the ondition, thereby improving healthrelated quality of life. It is important that the palliative nature of are of patients with hroni heart failure is reognised and that palliative are disussions are initiated at an early stage. Nurses have a entral role in ahieving these goals by ensuring patients are provided with adequate support and information about their ondition. TIME OUT 7 Now that you have ompleted the artile, you might like to write a refletive aount as part of your revalidation. KEY POINT Chroni heart failure is a omplex hroni ondition with high rates of mortality and morbidity. The prevalene of hroni heart failure is inreasing, and nurses in all healthare settings are likely to enounter patients with aute and hroni heart failure in their pratie. Optimisation of the medial aspets of are and the promotion of selfmanagement are essential to redue mortality, and an also redue the debilitating symptoms of the ondition, thereby improving health-related quality of life volume 31 number 20 / 11 January 2017 / 61

10 Referenes Albert NM (2012) Fluid management strategies in heart failure. Critial Care Nurse. 32, 2, Anker SD, Koehler F, Abraham WT (2011) Telemediine and remote management of patients with heart failure. Lanet. 378, 9792, Annema C, Luttik, ML, Jaarsma T (2009) Reasons for readmission in heart failure: perspetives of patients, aregivers, ardiologists, and heart failure nurses. Heart and Lung. 38, 5, Böhm M, Borer J, Ford I et al (2013) Heart rate at baseline influenes the effet of ivabradine on ardiovasular outomes in hroni heart failure: analysis from the SHIFT study. Clinial Researh in Cardiology. 102, 1, Brake R, Jones ID (2017) Chroni heart failure part 1: pathophysiology, signs and symptoms. Nursing Standard. 31, 19, doi: / ns.2017.e Brignole M, Aurihio A, Baron-Esquivias G et al (2013) 2013 ESC guidelines on ardia paing and ardia resynhronization therapy. European Heart Journal. 34, British Assoiation for Cardiovasular Prevention and Rehabilitation (2012) The BACPR Standards and Core Components for Cardiovasular Disease Prevention and Rehabilitation Seond edition. Standards_and_Core_Components_2012. pdf (Last aessed: 7 Deember 2016.) British National Formulary (2016) British National Formulary No. 72. BMJ Group and the Royal Pharmaeutial Soiety of Great Britain, London. Buttery AK, Carr-White G, Martin FC et al (2013) Limited availability of ardia rehabilitation for heart failure patients in the United Kingdom: findings from a national survey. European Journal of Preventative Cardiology. 21, 8, Ditewig JB, Blok H, Havens J et al (2010) Effetiveness of self-management interventions on mortality, hospital readmission, hroni heart failure hospitalization rate and quality of life in patients with hroni heart failure: a systemati review. Patient Eduation and Counseling. 78, 3, Dunlay SM, Fixen JL, Cole T et al (2015) A survey of liniian attitudes and self-reported praties regarding end-of-life are in heart failure. Palliative Mediine. 29, 3, Ezzat VA, Lee V, Ahsan S et al (2015) A systemati review of ICD ompliations in randomised ontrolled trials versus registries: is our real-world data an underestimation? Open Heart. doi: /openhrt Fonarow GC, Abraham WT, Albert NM et al (2008) Fators identified as preipitating hospital admissions for heart failure and linial outomes: findings from OPTIMIZE-HF. Arhives of Internal Mediine. 168, 8, Hjelmfors L, Strömberg A, Friedrishsen M et al (2014) Communiating prognosis and end-of-life are to heart failure patients: a survey of heart failure nurses perspetives. European Journal of Cardiovasular Nursing. 13, 2, Howie-Esquival J, Draup K (2012) Communiation with hospitalized heart failure patients. European Journal of Cardiovasular Nursing. 11, 2, Hupey JE, Penrod J, Fogg J (2009) Heart failure and palliative are: impliations in pratie. Journal of Palliative Mediine 12, 6, Huynh BC, Rovner A, Rih MW (2008) Identifiation of older patients with heart failure who may be andidates for hospie are: development of a simple four-item risk sore. Journal of the Amerian Geriatris Soiety. 56, 6, Jaarsma T, van der Wal MH, Lesman-Leegte I et al (2008) Effet of moderate or intensive disease management program on outome in patients with heart failure: Coordinating Study Evaluating Outomes of Advising and Counselling in Heart Failure (COACH). Arhives of Internal Mediine. 168, 3, Jhund PS, MMurray JJ (2016) The neprilysin pathway in heart failure: a review and guide on the use of saubitril/valsartan. Heart. 102, 17, Kasai T, Bradley TD (2011) Obstrutive sleep apnea and heart failure: pathophysiologi and therapeuti impliations. Journal of the Amerian College of Cardioliogy. 57, 2, Lainsak M, Blue L, Clark AL et al (2011) Selfare management of heart failure: pratial reommendations from the Patient Care Committee of the Heart Failure Assoiation of the European Soiety of Cardiology. European Journal of Heart Failure 13, 2, Levy WC, Mozaffarian D, Linker DT et al (2006) The Seattle Heart Failure Model: predition of survival in heart failure. Cirulation. 113, 11, Mandras SA, Uber PA, Mehra MR (2007) Sexual ativity and hroni heart failure. Mayo Clinis Proeedings. 82, 10, MKelvie RS, Moe GW, Cheung A et al (2011) The 2011 Canadian Cardiovasular Soiety heart failure management guidelines update: fous on sleep apnea, renal dysfuntion, mehanial irulatory support, and palliative are. Canadian Journal of Cardiology. 27, 3, MMurray JJ, Adamopoulos S, Anker SD et al (2012) ESC Guidelines for the Diagnosis and Treatment of Aute and Chroni Heart Failure 2012: The Task Fore for the Diagnosis and Treatment of Aute and Chroni Heart Failure 2012 of the European Soiety of Cardiology. Developed in ollaboration with the Heart Failure Assoiation (HFA) of the ESC. European Heart Journal. 33, 14, MMurray JJ, Paker M, Desai, AS et al (2014) Angiotensin-neprilysin inhibition versus enalapril in heart failure. New England Journal of Mediine, 371, 11, National Institute for Health and Care Exellene (2010) Chroni Heart Failure in Adults: Management. Clinial guideline No NICE, London. National Institute for Health and Care Exellene (2014) Implantable Cardioverter Defibrillators and Cardia Resynhronisation Therapy for Arrhythmias and Heart Failure. NICE tehnology appraisal guidane No NICE, London. Okoshi MP, Romeiro FG, Paiva SAR et al (2013) Heart failure-indued ahexia. Arquivos Brasileiros de Cardiologia. 100, 5, Ouwerkerk W, Voors AA, Zwinderman AH (2014) Fators influening the preditive power of models for prediting mortality and/or heartfailure hospitalization in patients with heart failure. JACC: Heart Failure. 2, 5, Padeletti L, Arnar DO, Boninelli L et al (2010) EHRA Expert Consensus Statement on the management of ardiovasular implantable eletroni devies in patients nearing end of life or requesting withdrawal of therapy. Europae. 12, 10, Pitt B, Zannad F, Remme WJ et al (1999) The effet of spironolatone on morbidity and mortality in patients with severe heart failure. Randomized Aldatone Evaluation Study Investigators. New England Journal of Mediine. 341, 10, Pitt B, Remme W, Zannad F et al (2003) Eplerenone, a seletive aldosterone bloker, in patients with left ventriular dysfuntion after myoardial infartion. New England Journal of Mediine. 348, 14, Pook S, Ariti C, MMurray JJ et al (2013) Prediting survival in heart failure: a risk sore based on patients from 30 studies. European Heart Journal. 34, 19, Ponikowski P, Voors AA, Anker SD et al (2016) 2016 ESC guidelines for the diagnosis and treatment of aute and hroni heart failure. European Heart Journal. doi: / eurheartj/ehw128. Rosanio S, Shwarz ER, Ahmad M et al (2005) Benefits, unresolved questions, and tehnial issues of ardia resynhronization therapy for heart failure. Amerian Journal of Cardiology. 96, 5, Sarraf M, Masoumi A, Shrier RW (2009) Cardiorenal syndrome in aute deompensated heart failure. Clinial Journal of the Amerian Soiety of Nephrology. 4, 12, Shiff GD, Fung S, Speroff T et al (2003) Deompensated heart failure: symptoms, patterns of onset and ontributing fators. Amerian Journal of Mediine. 114, 8, Stewart S, Horowitz JD (2002) Home-based intervention in ongestive heart failure: long-term impliations on readmission and survival. Cirulation. 105, 24, Suskin N, Sheth T, Negassa A et al (2001) Relationship of urrent and past smoking to mortality and morbidity in patients with left ventriular dysfuntion. Journal of the Amerian College of Cardiology. 37, 6, Taylor RS, Sagar VA, Davies EJ et al (2014) Exerise-based rehabilitation for heart failure. Cohrane Database of Systemati Reviews. Issue 4, CD The Criteria Committee of the New York Heart Assoiation (1994) Nomenlature and Criteria for Diagnosis of Diseases of the Heart and Great Vessels. Ninth edition. Little, Brown & Co, Boston MA. van der Wal MH, Jaarsma T, van Veldhuisen DJ (2005) Non-ompliane in patients with heart failure; how an we manage it? European Journal of Heart Failure. 7, 1, Varughese S (2007) Management of aute deompensated heart failure. Critial Care Nursing Quarterly. 30, 2, Wilkinson A, Whitehead L (2009) Evolution of the onept of self-are and the impliations for nurses: a literature review. International Journal of Nursing Studies 46, 8, World Health Organization (2009) WHO Definition of Palliative Care. int/aner/palliative/definition/en (Last aessed: 7 Deember 2016.) Zannad F, MMurray JJ, Krum H et al (2011) Eplerenone in patients with systoli heart failure and mild symptoms. New England Journal of Mediine. 364, 1, / 11 January 2017 / volume 31 number 20

11 evidene & pratie / self-assessment questionnaire Chroni heart failure: part 2 TEST YOUR KNOWLEDGE BY COMPLETING SELF-ASSESSMENT QUESTIONNAIRE Management of hroni heart failure with redued ejetion fration inludes? a) Pharmaologial treatments b) Implantable ardioverter defibrillators ) Cardia resynhronisation therapy d) All of the above 2. Whih group of drugs is a first-line therapy in the management of left ventriular systoli dysfuntion? a) Angiotensin II reeptor blokers b) Aldosterone antagonists ) Angiotensin reeptor neprilysin inhibitors d) Angiotensin onverting enzyme (ACE) inhibitors 3. Furosemide is: a) A beta bloker b) An ACE inhibitor ) A loop diureti d) A thiazide diureti 4. Diuretis are: a) Used in the relief of ongestive symptoms in heart failure, inluding breathlessness and fluid retention b) Used instead of ACE inhibitors, beta blokers and aldosterone antagonists ) Reommended only for patients with hroni heart failure with redued ejetion fration d) Reommended only for patients with hroni heart failure with preserved ejetion fration 5. In patients with hroni heart failure, implanting a ardia resynhronisation therapy devie: a) Is effetive for all patients b) May improve symptoms and quality of life ) Aims to restore the synhroniity of left and right atrial ontration d) Aims to restore the synhroniity of left atrial and left ventriular ontration 6. In patients with hroni heart failure, an implantable ardioverter defibrillator: a) Can diretly improve symptoms, suh as breathlessness b) Can identify life-threatening arrhythmias ) May inrease the risk of sudden ardia death d) Is most appropriate when the fous of are is on the end of life 7. Heart failure programmes should: a) Be restrited to interventions that redue the risk of deompensation b) Be restrited to interventions that redue the risk of subsequent hospitalisation ) Empower the patient to manage their ondition d) Be restrited to optimising the patient s mediation 8. For whih lifestyle modifiation is there most evidene to support its benefits for patients with hroni heart failure? a) Introduing exerise that promotes moderate breathlessness b) Restriting salt intake to less than 6g a day ) Inreasing fluid intake d) Sleep optimisation 9. Patients with hroni heart failure should not: a) Monitor their body weight to prevent malnutrition b) Monitor their body weight to detet fluid retention ) Avoid drinking extra fluids during episodes of nausea and vomiting d) Inrease their fluid intake during periods of high heat and humidity 10. In hroni heart failure: a) The patient s ondition has a preditable trajetory b) Palliative are should not be onsidered until the final few days of life ) The ondition is haraterised by frequent periods in hospital, followed by periods of wellness d) Episodes of deompensation orrespond to periods of wellness This self-assessment questionnaire was ompiled by Beth Knight The answers to this questionnaire will be published on 25 January The answers to SAQ 874 on altered body image, whih appeared in the 14 Deember issue, are: b 3. a 4. d a b 9. b 10. How to omplete this assessment This self-assessment questionnaire will help you to test your knowledge. It omprises ten multiple hoie questions that are broadly linked to the artile starting on page 53. There is one orret answer to eah question. You an test your subjet knowledge by attempting the questions before reading the artile, and then go bak over them to see if you would answer any differently. You might like to read the artile before trying the questions. The orret answers will be published in Nursing Standard on 25 January. Subsribers making use of their RCNi Portfolio an omplete this and other questionnaires online and save the result automatially. Alternatively, you an ut out this page and add it to your professional portfolio. Don t forget to reord the amount of time taken to omplete it. You may want to write a refletive aount based on what you have learned. Visit journals.rni.om/r/ refletive-aount volume 31 number 20 / 11 January 2017 / 63