Heart failure is a condition that’s more common among the elderly population, making it vitally important for long-term care providers, including LTC pharmacy services, to stay up-to-date on the condition and management strategies.
The Long-term Care Providers’ Guide to Heart Failure: Defining the Conditionm
Heart failure is a syndrome that presents with structural abnormalities of the heart and symptoms including fluid retention, shortness of breath, fatigue, or exercise intolerance. It is a progressive state beginning from decreased function of the cardiac muscle, developing into difficulty with circulation of blood and delivery of oxygen to the tissues.Types of Heart Failure
There are two types of heart failure distributed in relatively equal proportions throughout the population. Heart failure with preserved left ventricular ejection fraction (HFpEF) includes residents who have abnormal relaxation of the cardiac muscle, abnormal filling, or stiffness of the ventricle. This results in a heart that can expel most of its blood with each contraction but does not fill to the same maximum capacity as a normal heart would. Heart failure with reduced left ventricular ejection fraction (HFrEF) includes residents who have damage to the cardiac muscle usually due to coronary artery disease. These residents’ hearts cannot contract hard enough to eject a normal amount of blood. Both of these etiologies result in residents with less ability to supply the body with oxygen and keep fluids from accumulating in the periphery and the lungs.Acute Decompensated Heart Failure
Residents who have heart failure with significant volume overload, congestion, and fatigue make up the majority of hospitalized heart failure residents. Progression of these symptoms commonly in conjunction with worsening cardiac function may result in a diagnosis of acute decompensated heart failure, indicating a time when the resident is at especially high risk of death and rehospitalization. Due to poor resident outcomes after progression to this stage of heart failure, the most important goal for long-term care providers is to prevent it. A frequent cause of this occurrence is the failure to adhere to medications or dietary restrictions. Comorbid conditions also play a large role.The Long-term Care Providers’ Guide to Heart Failure: Current Management Recommendations
The type of heart failure is the first variable for long-term care providers to account for in treatment considerations. In heart failure with preserved ejection fraction, comorbidities play a much larger role in therapy considerations. Therapies may also affect these residents in a slightly different way with preserved ejection fraction residents being more sensitive to diuresis. Controlling symptoms is a main goal of therapy for heart failure, which will, in turn, improve quality of life. Functional capacity includes residents’ ability to carry out everyday activities and the amount to which they are limited by heart failure related shortness of breath. A resident presenting with lower functional status may need additional medications and have a lower baseline quality of life. Volume status is an important consideration for optimizing diuretic therapy to reduce edema in the periphery and in the lungs, if present. Comorbidities must also be taken into account when assessing a resident for appropriate therapies. Other disease states may define a resident’s risk for certain adverse effects related to heart failure medications. Comorbidities such as angina, sleep apnea, or syncope may indicate the need for additional treatments that will in turn help to control heart failure.Nonpharmacologic Management
Sodium restriction is recommended in all residents with heart failure to help reduce volume overload and subsequent edema. Goal sodium intake should be 2–3g daily—and further reduced in residents with more severe disease. Fluid restriction should only be considered in residents who are experiencing fluid retention despite high-dose diuretic therapy and adequate sodium restriction. This should be monitored by obtaining weight daily to observe gain or loss of water weight. Smoking cessation is important in the setting of heart failure to improve hemodynamic symptoms. Nicotine’s role as a vasoconstrictor can contribute to these residents’ difficulty with circulation of blood and oxygen. Transdermal nicotine replacement therapy is acceptable for use with appropriate physician monitoring.Heart Failure Medications
The table below details the medication classes commonly used for the treatment of heart failure, when they are used, and potential side effects.
