Pilgrims traveling to the New World called it “dropsy” and named their ship the Mayflower, an age-old herbal remedy to treat it; the Romans recommended bleeding; and the ancient Egyptians treated it with trips to the sauna.
Congestive heart failure has been with us for centuries and remains a leading killer, confounding physicians and case managers alike. The disease occurs when the heart muscle becomes too weak or stiff to pump blood effectively. Certain conditions, such as narrowed arteries in your heart (coronary artery disease) or high blood pressure contribute.
Lisa Smith, Advanced Nurse Practitioner with the Minneapolis Heart Institute, recently shared her insights on heart disease as part of a webinar series from the ROSE® Consulting Group.
It wasn’t until the 1950s that heart disease was linked to diet, exercise, and other physical factors rather than emotional causes. Since then, the science has advanced considerably. How much of a problem is heart failure in the United States?
Heart disease remains a significant problem – and the numbers are going in the wrong direction. Around 6 million Americans in the U.S. over the age of 20 experience heart failure. And by 2030 the prevalence is expected to increase by 25%.The lifetime risk of developing heart failure for both men and women is one in five.
But haven’t we gotten a lot better at detecting heart failure?
Yes. There is a paradox at the heart of heart disease — we have very, very effective ways of preventing and treating it, yet the only diagnosis with a higher mortality rate is pancreatic cancer. That fact might surprise many case managers. Perhaps most importantly, the five-year mortality rate for heart failure is 50%. That's a pretty sobering statistic.
What symptoms should case managers watch for?
Here are some common ones:
- shortness of breath and congestion
- interrupted sleep with breathing difficulties
- inability to lie flat while sleeping
- lower extremity/ankle swelling
- abdominal bloating and rapid weight gain
- fatigue, lightheadedness, or altered mental state
- coolness of extremities and poor appetite
- loss of consciousness
Why is it important to understand the mechanisms behind heart failure?
Case managers can better serve our patients if we understand and can communicate how medical therapies work. I often find that patients are more willing to take medications if they truly understand why they're on them.
We tend to think of heart failure as “pump” failure. The left ventricle is enlarged and the weakened heart muscle can’t squeeze as effectively. But heart failure can also mean stiff ventricles, where the heart can’t fill. The left ventricle can’t relax normally. Because it can’t fill, there’s a backup of blood flow and less blood pumped out with each heartbeat. The result is the same: low cardiac output and/or congestion.
Talk a little about the pathophysiology, or biological mechanisms, of the disease.
The number one cause of cardiomyopathy in the U.S. is coronary artery disease and myocardial infarction. Other causes include hypertension, arrhythmias, chemotherapies and substance abuse. There are also hereditary forms of cardiomyopathy, viral or inflammatory processes, and unfortunately pregnancy-related instances, which we call peripartum cardiomyopathy (PPCM). Also thyroid disease can result in metabolic cardiomyopathy.
Whatever the root cause of an insult to the heart, a cascade of resulting events then further reduce cardiac function.
It’s also important to know pharmacology of heart failure, right?
Absolutely. Multiple trials have shown that ACE inhibitors decrease mortality and prevent progression of heart failure significantly. Angiotensin receptor blockers are effective alternatives when ACE inhibitors cannot be tolerated.
Beta blockers are also important. I've been around long enough to remember when we never gave a patient with heart failure a beta blocker. That has changed dramatically in the last 15 years; blockers result in up to a 44% reduction in mortality in patients with heart failure.
Aldosterone blockers help patients excrete sodium and water and improve survival. Hydralazine and nitrates improve survival significantly in the African-American population with systolic dysfunction. Also it’s worth talking about Digoxin, which does not make your heart beat stronger – a common misconception – and has no mortality benefit. Instead, Digoxin has been shown to improve symptoms related to heart failure and decrease hospitalizations for heart failure.
And then there’s the big gun: Sacubitril/Valsartan is the first new drug we've had approved for heart failure with mortality benefit in many, many years. It’s a very exciting drug for those of us in the field and case managers should recognize it.
How are recent technical and medical innovations being applied to heart disease?
Tech advances are opening new pathways to treatment. For example, a sensor is now on the market that can be inserted into the pulmonary artery of the heart to monitor hemodynamics or pulmonary artery pressures. We can use that pulmonary monitoring to help manage patients remotely from clinics, prevent hospitalizations, and adjust diuretics.
It’s also worth touching on biomarkers, or molecular signs of disease. Our understanding here is increasing significantly. BNP, or Brain Natriuretic Peptide, is released in response to the stretching of the ventricles of the heart. So essentially when the heart muscle is stressed, BNP will be released. BNP is more useful in ruling out heart failure than ruling it in.
What about transplantation?
In the U.S. we perform around 2,200 transplants a year. And that number has gone up a little but not significantly. Hence the need for much more use of mechanical circulatory support. Survival after transplant has improved and is around 10 or 11 years. If you survive the first year, you're more likely to make it closer to 14 years.
So what should case managers know about heart failure treatment protocols?
I would point all case managers to the most recent guidelines for the management of heart failure by the American College of Cardiology Foundation and the American Heart Association, released in 2013. There are more options for treatment in terms of palliative care, transitions of care and quality of care, particularly for stage D, hospitalized patients. As cardiac medicine advances, it is vitally important for case managers to stay up to date on the most recent learnings and breakthroughs.
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