Jessica Coviello, MSN, RN

This article provides an overview of the latest in the standard of care and approaches for heart failure treatment. It presents two new American Heart Association Scientific Statements related to heart failure risk. The first addresses the prevention of heart failure with an emphasis on risk reduction. The second statement focuses on efforts to reduce hypertension, a primary risk factor for heart failure, through a self-care regimen that features home blood pressure monitoring. Implications for home care practice are presented.

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eart failure (HF) continues to be the leading cause of hospitalization for Medicare beneficiaries in this country with new cases each year numbering over 550,000 (Rosamond et al., 2007). Global numbers of HF are also growing as a result of three primary factors: 1. the transition from pandemic infection, as a result of effective immunizations, public health initiatives and antibiotic therapy, to

that of cardiovascular disease (Omran, 2001) 2. global aging leading to an increased number of chronic conditions 3. successful treatment programs leading to a decline in mortality with an increased number of survivors (Roger et al., 2004; Lee et al., 2004). This pandemic of HF has lead to the creation of two new American Heart Association Scientific Statements. This article presents a discussion of

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Evolution of Heart Failure

Risk Factors Cellular Pathophysiology Ventricular Remodeling Ventricular Dysfunction

Aging Hypertension Smoking Dyslipidemia Diabetes Obesity Toxins Genes

Hypertrophy Infarction Accelerated Apoptosis Fibrosis

LVH Dilatation Both

Systolic Diastolic Both

Structural Heart Disease Without Symptoms

Symptomatic Heart Failure Stages C and D

Stage A

Stage B AHA/ACC Stages of Heart Failure

Figure 1. Stages of Heart Failure

Data from Hunt, S. A., American College of Cardiology. American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure). (2005). ACC/AHA 2005 guideline update for the diagnosis and management of chronic heart failure in the adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and management of Heart Failure). Journal of the American College of Cardiology, 46(6), e1-82. Used with permission

these statements and their relationship to home healthcare practice.

such as increased left ventricular mass and left ventricular diastolic dysfunction (see Table 1).

Prevention of Heart Failure: A New Scientific Statement

In May of 2008, the American Heart Association Scientific Statement on prevention of HF was published (Schocken et al., 2008). Since 2001, the national healthcare focus has been on the prevention of HF through the reduction of those factors that place an individual at risk (see Figure 1) (Hunt, 2005). Although these risk factors include those long considered standard factors leading to cardiovascular disease (hypertension, diabetes, valvular disease, obesity), several new categories of risk have been added. These include the category of Toxic Risk Precipitants such as chemotherapeutics, cocaine, nonsteroidal anti-inflammatory disease agents (NSAIDS), thiazolidinediones for the treatment of diabetes, alcohol, and doxazosin for the treatment of hypertension and benign prostatic hypertrophy. Two other new categories include Genetic Risk Factors related to specific gene abnormalities and Morphologic Risk Factors

Major Clinical Risk Factors

Hypertension

Hypertension (HTN) is one of the most common risk factors for coronary artery disease (CAD). Hypertension also increases the risk of developing HF by twofold in men and by threefold in women (Levy et al., 1996). HTN promotes hypertrophy, myocardial fibrosis and loss of contractility of the heart muscle. Use of diuretics, beta-blockers, and angiotensin-converting enzyme inhibitors is associated with the prevention of HF in hypertensive individuals (Trumbull, 2003). Blood pressure (BP) lowering also leads to a regression in left ventricular hypertrophy. The benefit of treating HTN to the specified goal of <130/85 or <130/80 for those with diabetes is very clear (Chobanian et al., 2003). According to Healthy People 2010 (2008), the achievement of adequate BP is a major goal for the nation. The new American Heart Association Scientific Statements addressing this goal will be presented.

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Diabetes Mellitus (DM)

DM is associated with a two to fivefold increase in the risk of HF. This risk is more pronounced in women. With every 1% increase in hemoglobin A1C there is as 8% to 16% increase in the risk of hospitalization and death due to HF (Iribarrenet al., 2001).
Valvular Disease

Table 1. Established and Hypothesized Risk Factors for HF

Major Clinical Risk Factors Age, male sex Hypertension, LVH (left ventricular hypertrophy) Myocardial infarction Diabetes mellitus Valvular heart disease Obesity Toxic Risk Precipitants Chemotherapy (anthracyclines, cyclophosphamide, 5-FU, trastuzumab) Cocaine, NSAIDs Thiazolidinediones Doxazosin Alcohol Minor Clinical Risk Factors Smoking Dyslipidemia Sleep-disordered breathing Chronic kidney disease Albuminuria Homocysteine Immune activation, IGF1, TNF IL-6, CRP , Natriuretic peptides Anemia Dietary risk factors Increased HR Sedentary lifestyle Low socioeconomic status Psychological stress Genetic Risk Predictors SNP (eg, 2CDel322-325, 1Arg389) Morphological Risk Predictors Increased LVID, mass Asymptomatic LV dysfunction LV diastolic dysfunction
5-FU indicates 5-fluorouracil; SNP single-nucleotide polymor, phism; LVID, left ventricular internal dimension; LVH, left ventricular hypertrophy; NSAIDs, nonsteroidal anti-inflammatory drugs; IGF insulinlike growth factor; TNF tumor necrosis factor; , , IL, interleukin; CRP C-reactive protein; and HR,heart rate , From Schocken , D. D., Benjamin, E., Fonarow, G. C., Krumholz, H. M., Levy, D., Mensah, G. A.,et al. (2008). Prevention of heart failure: A scientific statement from the American Heart Association Councils on Epidemiology and Prevention, Clinical Cardiology, Cardiovascular Nursing, and High Blood Pressure Research; Quality of Care and Outcomes Research Interdisciplinary Working Group; and Functional Genomics and Translational Biology Interdisciplinary Working Group. Circulation, 117: 2544-2565. Used with permission.

Valvular disease is associated with an increased risk of HF. An increased pressure on the ventricles imposed by valvular disease eventually leads to loss in heart function. Surgical repair of either stenotic or regurgitant valves has been associated with marked improvement in both function and survival (Carabello & Crawford, 2001).
Obesity

Obesity is a major risk factor for CAD and predisposes to HF. This predisposition is related to the fact that weight influences blood sugar, cholesterol and lipid levels, and BP. In addition, obesity increases preload and afterload; pressures that effect cardiac output. Sleep disordered breathing and chronic renal disease are also closely associated to obesity. The effects of weight reduction, once HF has developed, is still in debate and requires further investigation (Kenchaiah et al., 2004a; Kenchaiah et al., 2004b).

Minor Risk Factors for HF

Alcohol

Light and moderate alcohol consumption is actually associated with a reduction in HF. Excessive alcohol, however, may increase the risk of HF by up to 4.5% by increasing BP or by a direct toxic effect on heart cells (Walsh et al., 2002).
Tobacco Use

As with alcohol, excessive cigarette smoking can have a direct toxic effect on heart cells. It can promote insulin resistance, diabetes, coronary artery spasm, and cholesterol levels (Eliasson, 2003).
Renal Dysfunction

Renal dysfunction of any kind effects the development of HF. In addition, complications of renal dysfunction include anemia, HTN, sodium and water retention, and an increase in inflammatory markers and homocysteine levels (Fried et al., 2003).

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Sedentary lifestyle, low socioeconomic status, coffee consumption, an increased resting heart rate, and increased dietary salt intake have been suggested to increase HF. Other Minor Factors
Sleep-disordered breathing may be associated with HF as much as twofold. Sedentary lifestyle, low socioeconomic status, coffee consumption, an increased resting heart rate, and increased dietary salt intake have been suggested to increase HF. Their independent risks remain to be confirmed. Mental stress and depression have been shown to increase symptoms of established HF (Kannel et al., 1999; Abramson et al., 2001; Lloyd-Jones et al., 2002).
Toxic Risk

Certain cancer chemotherapeutic medications as well as NSAIDS, cocaine, and doxazosin have been associated with cardiac damage that results in left ventricular dysfunction. The U.S. Food and Drug Administration has mandated specific warnings in regard to both pioglitazone and rosiglitazone. Both of these drugs are in the category of thiazolidinediones. Troglitazone has been withdrawn from the market because of safety issues regarding precipitation of HF (Masoudi et al., 2005; Schocken et al., 2008).
Genetic Risk

wide. Our most common chronic conditions are merely extensions of our most common cardiovascular risk factors. DM, obesity, lung disease secondary to tobacco abuse all effect not only the incidence of myocardial infarction but also of HF. Chronic conditions represent the bulk of home healthcare visits (VNAA.org). With an ever-growing population of Medicare patients at high risk for developing HF due to longstanding HTN, DM, tobacco abuse and/or obesity, the importance of all healthcare professionals doing their part to reduce risk is apparent. Home healthcare professionals are in a unique position not only to help increase public awareness but also to directly intervene upon the risk factors of their patient population. The importance of treating hypertension and diabetes in order to achieve glucose and BP goals are part of the routine self-care measures instituted into a home healthcare plan. Similarly, it is now recommended that the use of home BP monitors can be effective in helping a patient reach target goals. For patient monitoring and education tools as well as an update on the standard guidelines for BP, DM, and HF, see www.chronic conditions.org.

Reducing the Risk of Hypertension in the Home Healthcare Setting

Recently, a joint scientific statement from the American Heart Association, the American Society of Hypertension and the Preventive Cardiovascular Nurses Association states that the use of home BP monitoring (HBPM) predicts risk better than a providers office BPs. BPs taken at home are often lower than readings taken in the office and are closer to the average BP recorded by 24 hour ambulatory BP monitors (Pickering et al., 2008). HBPM information has been shown to be reliable and reproducible (Stergiou et al., 2002). Reliability of patient reporting the HBP readings, however, has been variable and is dependent upon both self-care education and compliance. In one study, 20% of the readings were reported with an error of >10 mm Hg. and the error rate was high in patients with less well-controlled hypertension (Johnson et al., 1999). In another study, there was a tendency for high readings to be underreported (Megden et al., 1998). It is for this reason that monitors with memory are to be encouraged.

Most patients with HF do not have a rare genetic mutation underlying their disease. Those with HF due to idiopathic dilated cardiomyopathy likely have a complex disorder that does relate to both genetic and environmental exposures. Continued research will eventually reveal the genetic links related to HF and the effects of environmental factors on these (Schocken et al., 2008).

Implications for Self-care: More Important Than Ever

This new standard of care lists the importance of aggressive lifestyle change, risk reduction and public awareness of HF as it relates to those risk factors. It also speaks to the need of an increased awareness to the increasing burden of HF world-

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There are some patients in whom HBPM is contraindicated. Patients in atrial fibrillation or in those with frequent arrhythmias may not have reliable BPs at home due to their rhythm irregularity. Before a HBPM plan is instituted, the nurse should compare the HBPM with a cuff pressure in order to verify that the BPs are comparable. The other patient in whom HBPM may be contraindicated is the anxious patient who maybe/is obsessed with the BP readings. The inherent variability of BP readings may exacerbate anxiety in some individuals. This may lead to higher BPs, which then leads to more anxiety. In these patients, frequent BP checks should be discouraged. A strict plan of the number of BPs taken, the time and location should be set as part of the plan. In extreme cases, HBPM may need to be abandoned for a 24-hour BP monitor.

Taking an Accurate BP: A Review

Home healthcare clinicians can provide the critical education to patients in the proper use of HBP monitors. Automated oscillometric devices (digital BP devices) are much easier to use than the standard cuff/aneroid combination but still require some training. Patients should be advised to only purchase monitors that have been validated according to standard protocols. This is information is usually indicated in the instruction pamphlet accompanying the device. In addition, the local pharmacist can be very helpful when trying to make a decision on what device is best suited to the patients need. Monitors should be readable and have a memory that stores the BP readings. The upper arm circumference should be measured so that they can be advised if they need a large cuff. Patients should be taught that readings should be taken when they are sitting quietly and after resting for 5 minutes, with the arm supported on a flat surface, such that the upper arm is supported at the level of the heart. The patients back should also be supported, and both feet should be flat on the floor. The cuff should be positioned so that the midportion lies over the brachial artery. Most patients find it easiest to measure BP in the nondominant arm. This should be encouraged unless there is a marked difference between the 2 arms, which is relatively rare in the absence of obstructive arterial disease. More than a 15 mm Hg difference between the two arms should be reported to the primary care provider and

may indicate the presence of thoracic arterial disease. The patient should not have indulged within the 30 minutes preceding the measurement in activities such as smoking, drinking coffee, or exercising, which are likely to affect BP. It is recommended that at least two and preferably three readings be taken at one time and the value for each reading written down, unless the device has the preferred memory that stores the readings automatically. The interval between readings can be as little as 1 minute. Readings should routinely be taken first thing in the morning (preferably before the patient takes medications) and at night before the they go to bed. The frequency of readings can be determined by the provider. Patients should be encouraged not to take readings at other times. Patients can routinely keep diaries if the effectiveness of treatment is being tested. The diaries can also be used to record if they missed taking their medications or if experiencing side effects from a new medication. Patients should be advised that the variability of readings is high and that individual high or low readings have little significance. Once a monitor has been purchased, it is recommended that the clinician and the patient verify both the patients technique and the accuracy of the device. This procedure should be repeated annually. Unlike aneroid and mercury devices, however, it has been found that the accuracy of the measurement of the cuff pressure does not deteriorate over time with oscillometric monitors (Coleman et al., 2005). This scientific statement recommends that: HBPM should become a routine component of BP measurement in the majority of the patients with known or suspected hypertension. Patients should be advised to purchase oscillometric monitors that measure BP on the upper arm with an appropriate sized cuff and that have been shown to be accurate according to standard international protocols. Patients should be shown how to use the cuff correctly by a healthcare provider. A total of 12 readings over 7 days are recommended for making clinical decisions. If the average value is >135/85 mm Hg, there is a high probability (85%) that the ambulatory BP will also be high, and a decision to start treatment can be made. If the HBP is <125/76 mm Hg the

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As a discipline, we are not only in a unique position to help increase public awareness but also to directly intervene upon the risk factors of this patient population. The importance of treating BPs to goal remains a significant part of the national healthcare agenda.
probability of missing a diagnosis of true hypertension is low (Mansoor & White 2004). HBPM is indicated in patients with newly diagnosed or suspected hypertension, in whom it may be distinguished between white-coat and sustained hypertension. In patients with prehypertension, HBPM may be useful for detecting masked hypertension. HBPM is recommended for evaluating antihypertensive treatment and may improve compliance. The target goals for treatment are <135/85 mm Hg or <130/80 mm Hg in Hg risk patients such as those with diabetes. HBPM is useful in the elderly in whom both BP variability and the white-coat effect are increased. HBPM is of value in patients with diabetes in whom tight BP control is of paramount importance. Other populations where HBPM may be beneficial include pregnant women, children, and patients with kidney disease. HBPM has the potential to improve the quality of care while reducing costs. With a diagnosis of hypertension and a prescription from the provider for a HBP device, many insurance companies will provide coverage. Once a device has been purchased, it should be brought into the office to validate accuracy against a cuff pressure. This procedure should be performed annually.

practice of the home healthcare clinician as the management of chronic illness, particularly HF, increasingly moves into the community. It is incumbent upon us to find the most efficient means of home healthcare delivery. As a discipline, we are not only in a unique position to help increase public awareness but also to directly intervene upon the risk factors of this patient population. The importance of treating BPs to goal remains a significant part of the national healthcare agenda. Self-care monitoring, as a key component, increasingly shifts the emphasis out of the primary care provider's office and into the home care domain where the goal has always been that of patient independence. Through our home healthcare practice, well informed and well adapted patients will become more adept at self-care management. It is through these efforts that an impact on the incidence and the management of chronic disease may be realized. Jessica Shank Coviello, MSN, RN, Assistant Professor. Adult Advanced Practice Nursing Specialty, Yale University School of Nursing, New Haven, CT. jms255@comcast.net The author of this article has disclosed that she has no financial relationships related to this article.

REFERENCES

Monitors with memory that are able to store measurements are preferred.

Implications for Homecare Practice

New standards in the prevention of HF and a new scientific statement support the use of HBPM. These recent events have potential impact on the

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