Patient Education Questions? Call (206) 598-2625 Your questions are important. Call your doctor or health care provider if you have questions or concerns. Cardiology Diagnostic Center (206) 598-4300 Notes Understanding and improving your symptoms Heart failure is best thought of as a syndrome to be managed rather than a disease to be cured. By understanding how your heart works and the symptoms of heart failure you will be better equipped to help your health care team manage this syndrome. This booklet provides information about heart failure and its treatment. Box 356422 1959 NE Pacific St. Seattle, WA 98195 (206) 598-2625 University of Washington Medical Center 3/2000
Page 2 Page 15 Heart failure is not the same as having a heart attack. What is? Heart failure is not the same as having a heart attack. Heart failure is a syndrome in which the heart is not able to pump forcefully enough to meet all the body s demands. It means your heart s pumping power is weaker than normal. Walking, carrying groceries, or climbing stairs may be difficult, as your heart cannot supply enough blood to your muscles. For most people, heart failure is a chronic condition, meaning it can be treated and managed, but not cured. Causes of Heart failure or heart muscle disease has a number of causes. It occurs most often as a result of either coronary artery disease (heart attacks), disease of the heart valves, viral infections affecting the heart muscle, high blood pressure, or congenital heart abnormalities. Over time, all of these conditions cause great stress or damage to the heart muscle, thus contributing to its decreased pumping ability. Sometimes the exact cause of heart failure is not known. Expected Symptoms The symptoms most commonly associated with heart failure include: Difficulty breathing, especially with exercise or when lying flat in bed. Waking up breathless at night. Dry, hacking cough, especially when lying down. Loss of energy, tiredness, or fatigue. ECG: An electrocardiogram shows the electrical activity of the heart muscle. Each heartbeat is caused by an electrical impulse that begins at the top of the heart and moves down and through the heart muscle, making it contract. An ECG is used to find abnormal heart rhythms and areas of the heart muscle that have been damaged. ECHO: A test that uses high-frequency sound waves (ultrasound) to give a detailed picture of the heart. It shows the size and shape of the heart chambers, movements of the muscular walls, and the opening and closing of the four heart valves. MUGA: This test tags a patient s red blood cells with a radioactive compound. A camera over your chest takes pictures of the tagged blood as it flows in and out of the heart. The change in radioactivity of the heart muscle each time the heart beats allows the doctor to see how well the heart is pumping. Cardiopulmonary Exercise Test: This test measures a patient s cardiovascular (heart and lung) response to exercise. The patient pedals a stationary bicycle and the heart is checked closely during the exercise.
Page 4 Page 13 Fainting or near fainting is an emergency Call 911. Medical Emergencies Of those patients who die from heart failure, onehalf will do so from a cardiac arrest or sudden cardiac death. Sudden cardiac death occurs when the heart muscle suddenly stops pumping blood, causing loss of consciousness. It is therefore vital that you report near fainting or fainting episodes and consider these symptoms medical emergencies and call 911. It is strongly suggested that at least one member of your household is trained in CPR (cardio-pulmonary resuscitation). Your clinic will be able to provide you with a list of community resources that offer this training. Planning Your Treatment Your health care team will want to know: Your symptoms and how long you have had them. If you have ever had a heart attack, murmur, other heart problems and how they were treated. Your general health history and present health. Other health problems you may have had and how they are being treated. Whether your activities have been limited by your heart problems. If family members have had heart problems. Your lifestyle and health habits. If you use tobacco, alcohol or other drugs. Information you share with your health care provider is private. Our ability to evaluate, treat and manage your heart failure depends upon accurate facts you and your family provide. Learn to take your heart rate and blood pressure. Take and record your heart rate and blood pressure daily. We would be glad to teach you how to use a blood pressure cuff. Being able to take your own blood pressure and heart rate and report this information is very useful, particularly when you are not feeling well. Always take all your medicines as prescribed. Carry an up-to-date list of all of your medicines with you all the time (in your wallet or purse). Often during hospitalizations or clinic visits changes will be made in your medicines. Therefore, it is very important that before leaving the hospital, you always review with your health care team any changes made. Be sure to include on your list the over-thecounter medicines you take regularly. Limit your sodium (salt) intake. A reasonable goal is 2000-4000mg of sodium per day. Sodium causes you to hold water, thus increasing the amount of blood. This increases the workload of your failing heart muscle. Therefore, one of the most important things you can do to manage your heart failure is restrict your sodium (salt) intake. Attend our Class/Support Group. This meeting is free of charge and you are welcome to bring friends and family. The goal of this group is to offer you and your family the support and information necessary to participate actively in the management of your heart disease. Please check with your nurse or social worker for the time and location of the next meeting.
Page 6 Page 11 Set up a system to take your medications as prescribed, especially if you take several each day. Medicines commonly prescribed for treating heart failure include: Vasodilators work by opening wider the blood vessels entering and exiting the heart. Diuretics or water pills help to remove excess fluid and salt from the body. Digoxin slows and strengthens each heartbeat. Beta Blockers attempt to protect the heart muscle from further damage. Vasodilators ACE inhibitors are a type of vasodilator and have been shown to help heart failure patients live longer and feel better. They relax blood vessels and make it easier for the heart to pump. However, it may take weeks before you feel better after beginning this medication. ACE inhibitors may be the first medicine prescribed for you. Based on your symptoms, a diuretic and digoxin may be prescribed with the ACE inhibitor or added later. Although most patients take an ACE inhibitor without problems, some have side effects. They include cough, dizziness, skin rash, or swelling of the neck and tongue. Tell you doctor if any of these occur. ACE inhibitors may also cause high potassium levels in your blood and affect kidney function. You will have blood tests to watch for these effects. General recommendations include: Don t push yourself to the point of lightheadedness, palpitation, or chest pain. These are serious warning signs that vital organs (brain and heart) are not getting enough nutrient-rich blood. If these symptoms occur stop immediately! You should always be able to carry on a conversation or be able to talk while exercising. If you are breathing so heavily that you cannot complete a sentence you should slow down! The key is slow, moderate, consistent exercise. You may ask to see a cardiac rehabilitation specialist to help plan and monitor an exercise program. The clinic can provide you with a list of local cardiac rehabilitation programs with special expertise in patients who have heart failure. Many insurance plans pay for these programs. Lifestyle and Health Habits Heart failure may require you to change your lifestyle and health habits. The following changes can reduce the symptoms of heart failure and improve the quality of your life: Do not smoke or chew tobacco. Eliminate or reduce alcohol intake. Do not use illegal drugs. Lose weight, if you are overweight. There are many other health habits and lifestyle changes that will improve your quality of life: Avoid extreme exercise that causes you to experience lightheadedness or palpitations. Get a flu shot annually and pneumonia shot every 5 to 10 years.
Page 8 Page 9 One of the most important things you can do to reduce your symptoms is to eliminate table salt and reduce processed foods. Name of medicines. When each is taken. Doses of the medicines. Reason for taking the medicines. Diet In addition to taking medicines, changing your diet can dramatically affect your symptoms. Sodium (or salt) causes your body to hold onto water, thus increasing the amount of fluid/blood in your body. This increases the workload of your heart. Sodium is most commonly found in table salt. One teaspoon of table salt contains almost 2400mg of sodium. One of the most important things you can do to reduce your symptoms is to eliminate table salt and reduce processed foods (which contain high amounts of salt). If not, your feet, ankles, legs, lungs and abdomen may swell, and you may find it hard to breathe. If severe, these symptoms may require hospital treatment. Changing your diet can be complicated and confusing. The goal is to reduce sodium in your food but still enjoy the pleasure of eating. A dietitian is available in the hospital and through the clinic to work with you and your family to help reduce your sodium intake. You can learn new ways to prepare food and alter old recipes. For example, lemon juice, spices, and herbs can add flavor to unsalted foods. You will also learn to identify foods with hidden salt such as frozen or canned foods, processed cheeses, meats and olives. Finally, you will learn to read and to check nutrition labels for sodium content. If you drink alcohol, you may be asked to stop. Alcohol depresses both the function of your central nervous system and other organs of your body. Therefore, alcohol can further reduce the pumping capacity of your heart and cause worsening symptoms of heart failure. Daily Activities There are many things you can do at home to keep yourself feeling well and diminish your chance of being hospitalized for heart failure. The most common reason a patient with heart failure is admitted into the hospital is for fluid retention causing shortness of breath, difficulty catching your breath, and abdominal swelling. By weighing yourself every day and calling the clinic with changes in your weight you will detect fluid retention prior to developing severe symptoms. Weigh yourself every day! Weigh and record your weight each morning. This way you can monitor your fluid (water) status at home. Call the clinic if your weight changes by more than 4 to 5 pounds. A 5-pound weight gain is equal to about a half gallon of extra fluid. Mild heart failure may have little effect on work or recreation. Severe heart failure may restrict activities that used to be quite easy for you. Talk to your health care team about: Work: Can you still work? Full-time or parttime? Recreation: Can you go hiking, play golf, swim, and attend sporting events? Leisure: Can you travel, work in the garden, and do volunteer work? Sex: Can you have sexual intercourse?
Page 10 Page 7 The key is slow, moderate, consistent exercise. Talk with your family members about activities. They need to know how to support and help you. This is especially true when what you can do changes from day to day. Some activities, such as work or recreation, may become more difficult, while others do not change. As you learn to live with heart failure, you may discover new satisfactions and pleasures. Changes in daily life can be positive and rewarding. Cutting back on work may lead to interesting and enjoyable leisure activities. Recreation may become a valuable part of your daily life. Sexual relations can be very enjoyable as you and your partner discover less demanding ways to express and share affection. Exercise Many people with heart failure say they feel better when they exercise regularly. Recent studies in people with heart failure have shown that if done properly it is safe and improves the quality of your life. Usually you can exercise safely at home or in a supervised setting such as a hospital s cardiac rehabilitation program, health club, YMCA or YWCA. Exercising can include walking, cycling, or swimming. Your health care team can advise you about the right kind and amount of exercise. Talk to them before starting. In general, if you are short of breath or have difficulty catching your breath at rest, you should not exercise. Diuretics The most commonly used diuretics are furosemide, torsemide, and spironolactone. By making you urinate more often, diuretics keep fluid from collecting in your feet, ankles, legs, lungs, and abdomen. Skipping doses can cause swelling of these parts of your body and shortness of breath when lying down or during exercise. Diuretics may lead to potassium loss and other imbalances, therefore blood tests are needed regularly to check these chemical levels. Digoxin Prescribed as digoxin or lanoxin, this medication is taken daily by many patients. Digoxin helps the heart pump more effectively and may improve your ability to exercise. If too much digoxin is in your body, you may have nausea or loss of appetite, confusion or yellow-colored vision. Tell your doctor right away if you have these side effects. Beta Blockers As your heart begins to fail, your body produces large amounts of certain stress hormones, such as adrenaline. In the early stages of heart failure, these hormones help your heart s ability to pump, but over time these same stress hormones may further weaken your heart muscle. Beta blockers are thought to block these stress hormones, thus protecting your heart muscle from further damage. Keeping Track of Your Medicines Setting up a system to assure that you take your medications as prescribed, especially if you take several each day is very important. Also, make a list of your medicines and carry it with you all the time. In an emergency, this information can direct medical workers and your family in helping you. This list should include:
Page 12 Page 5 Let family and friends know how they can help. You may want to make other changes too, such as learning how to reduce stress. Work with your health care team to decide the choices best for you. Family and Social Support Your family and friends can be a great source of support and encouragement. As much as possible, include family and friends in decisions about your lifestyle and your ability to work and earn a living. Support by family and friends can be especially helpful in adjusting to lifestyle changes and in facing emotional difficulties. Let family and friends know how they can help. Some possible ways they can help include: Keeping track of medicines. Preparing special low-salt meals. Exercising with you. Joining a support group. What You Can Do Your early recognition and reporting of changes in your symptoms of heart failure and overall health status is the key to successful management. Reporting your symptoms early can greatly reduce your risk of being hospitalized for severe symptoms of heart failure. The following are key steps to living well with your heart disease. Weigh yourself every day. This allows you to watch for fluid (water) buildup. Call the UW clinic if your weight changes by more than 5 pounds. This allows your health care team to adjust your diuretic (water pill) dose to keep your fluid level stable. A health history, physical exam, chest X-ray and an echocardiogram (ECHO) help diagnose heart failure. Based upon your symptoms, further tests may be needed. An Echocardiogram (ECHO) is a widely used test that uses high frequency sound waves (ultrasound) to produce a picture of the heart. It shows the size and shape of the heart chambers, movement of the muscular walls, and the opening and closing of the four heart valves. The last section of this booklet describes other tests that may be used to evaluate your heart muscle s pumping capacity. Medications to Treat Taking medicines every day is vital to treating heart failure. Remember that heart failure is not frequently cured but the symptoms can be greatly reduced and your life expectancy significantly lengthened with medications. Depending on your symptoms, your doctor may start treatment by prescribing one medicine and adding others later. Sometimes treatment will begin with two or more medicines. It may take days or weeks to find the right doses of medicines. Be patient as your health care team works with you to find the right medicines, the right amount of each, and the best time and day to take each medicine. The benefits of these medicines will be lost or reduced if you do not take them as prescribed. Skipping doses or not refilling a prescription can cause serious problems. Be sure to tell your health care team about other conditions you have and other medicines you take, including nonprescription medicine such as aspirin, antacids, and cold remedies. Any medicine can have unplanned results. If you have any side effects, tell your health care team right away as they can work with you to lessen these effects.
Page 14 Page 3 You are the most important member of your health care team. Goal of Treatment The goal of your treatment is to maximize your remaining heart muscle function and prevent any further damage. The symptoms listed below may reflect changes in your heart function. If you have any of the symptoms listed below, call your health care provider or clinic: Increased shortness of breath. Waking up breathless at night. Weight increase of 5 pounds. Increasing dizziness of light-headedness. Chest pain or heaviness. Heart flutterings (palpitations). You are the most important member of your health care team. Taking your medicine, attending scheduled clinic visits, recognizing and reporting symptoms of worsening heart failure are directly linked to how well you will live. Tests to Evaluate Your Heart Chest X-ray: This is a simple way to get a picture of the heart. It shows the size, shape, and position of the heart. A chest X-ray can confirm the heart is not able to keep up with its workload by showing a build-up of fluid in the lungs. Dizziness, light-headedness, or fainting. Swollen ankles, feet or legs. Nausea, loss of appetite, belly bloating, swelling or pain. Other medical problems can cause these same symptoms. A complete physical exam, health history, and certain tests are needed to diagnose heart failure. Explanation of Symptoms A healthy heart can adjust the amount of oxygenrich blood it pumps to the organs and muscles based upon what is needed. When your heart pumps with less strength, at times it cannot meet all of the body s demands. As a result of your heart failure, you may have less energy. Fluid may collect or pool in your lungs, causing breathing problems when you lie flat. Fluid can also collect in other parts of your body, causing swelling of the feet, ankles, legs or belly. These symptoms can often be treated with adjustments in your medications. It is very important that you report to your health care team dizzy spells or the feeling that you may faint or pass out. These symptoms may be a warning sign of very serious, even life threatening problems, and need to be addressed immediately. If you have an increase or change in any of your symptoms, call your clinic or health care team.