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Health Information An Expert Opinion: Managing Heart Failure

Doing just what the doctor ordered can keep heart failure in check.

Following the doctor's orders is often easier said than done. In fact, sticking to lifestyle modifications and medication regimens is a major challenge for people with heart failure, a chronic condition in which the heart does not supply enough blood to the rest of the body.

According to a study in the Journal of the American Medical Association, heart failure patients do not take their heart failure medications properly an estimated 30 to 60 percent of the time, and they do not follow lifestyle change recommendations 50 to 80 percent of the time. Medication and lifestyle modifications help treat symptoms of heart failure, such as high blood pressure, shortness of breath and fluid retention. Thus, noncompliance puts patients at  higher risk for stroke, heart attack and faster disease progression. Further, noncompliant heart failure patients are almost twice as likely to be re-hospitalized within a year.

James Calvin, MD, a cardiologist at Rush University Medical Center, is working to improve compliance. Here, he discusses the importance of following medical advice and what he's doing to help heart failure patients stay on track.

Q: Why is compliance such a big problem in managing heart failure?

A. Heart failure is a chronic disease that requires chronic disease management. That can be very complicated for patients. It involves taking multiple drugs — sometimes a dozen or more. Each of these medications has its own set of instructions, rules and side effects, and keeping track of all of them all can be confusing and overwhelming.

This condition also necessitates a change in lifestyle, including changing lifelong dietary habits. You have to think about what you're eating and take your pills every single day. And, if you don't, you get into trouble quickly.

Q: What is the hardest lifestyle change for heart failure patients?

A. Diet. One of the biggest changes is reducing salt intake, which is necessary because heart failure causes the body to hold on to salt, leading to fluid to build up in your body. In addition to swelling of the ankles, feet or stomach, it can also cause congestion in your lungs and make you short of breath. The extra fluid makes your heart work harder.

Reducing salt in your diet is challenging because salt is in everything, and sometimes you don’t even know it’s in there. You have to be mindful of certain foods that have a high amount of salt. You have to learn how to read the labels on the food to determine how much salt is in your food.

It is hard to get people to change their habits. People prefer salt in their food because it tastes better. So we educate our patients about salt substitutes, and we try to help them acquire a broader palate so they can enjoy food without all the salt.

Q: What are you and your colleagues doing to help improve compliance?

A: Our Congestive Heart Failure Adherence Redesign Trial (CHART) centers on both the patients and the physicians. The study focuses on reducing repeated hospitalizations in low-income congestive heart failure patients and improving patients' ability to maintain health-related recommendations.

We are hoping to re-engineer the relationship between the patients and physicians. First, we find out what the doctors are prescribing. Then we talk to the patients and use computerized pill bottles — which record every time they are opened — to find out what the patients are actually taking. When we see discrepancies, we notify the doctors and point out the discrepancy. The doctor can then step in and work with the patient.

Q: Why is the study focusing specifically on low-income patients?

A: Lower-income patients tend to have a higher prevalence of noncompliance, in part because there is an economic barrier. The medications to manage heart failure are expensive. Sometimes patients will actually spread out their medications so they will last longer and ultimately save them money. So if a drug is supposed to be taken twice a day, maybe they only take it once a day. Then, lo and behold, they start to have health issues, such as fluid retention and difficulty breathing.

In a previous trial, we found these patients were more likely to respond to being taught self-management skills. In our CHART study, we are using community health workers to better communicate with these patients, in particular to educate them on how to manage their disease and the importance of taking their medications and eating properly.

Q: What other barriers are there for all patients?

A: We are concerned about the role of depression in people with heart failure. Even mild depression can affect the success of the treatment. People who are depressed and don't feel that there is a reason to live or feel that their fate has been cast may say, "What's the point? I only have a short time to live. I want to enjoy it. I want to eat the foods I like. I don't want to take medicine."

As a doctor, I have to ask myself, "Why isn't this patient taking his medication?" Cardiologists have to realize that you can't treat patients effectively until you deal with their emotional issues. Getting into the heads of heart failure patients takes doctors down a different path; but that path is a big part of treating heart failure now.

Q: What makes some people comply better than others?

A: In my experience, patients who have a strong support system and a positive outlook are more likely to comply. Although the average life expectancy for heart failure is less than five years for patients with symptomatic heart failure, I actually had a patient live for 18 years with heart failure. He had a very supportive family, trusted me and was compliant with his drugs and diet. I have another patient who is in his 90s and doing well. He has a very supportive wife who has done research on the necessary low-salt diet and makes healthy foods that he likes.

Neither of these two patients was depressed. They both had something to live for and a positive outlook on life. They both had a sense of empowerment about managing and controlling their disease. And they had supportive families.

Physicians can help patients face heart failure by presenting a message of empowerment and management in a positive way. Maybe then patients will realize that there is still time left and they can make the most of it.

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Please note: All physicians featured in Discover Rush Online are on the medical faculty of Rush University Medical Center. Some of the physicians featured are in private practice and, as independent practitioners, are not agents or employees of Rush University Medical Center.

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February 2013 


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