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> Stress management

Disease Management

Patients at the Heart Failure Treatment Center are treated on an outpatient basis, with emphasis placed on reducing hospital admissions, improving quality of life and increasing activity tolerance and survival.

Heart failure patients are at the center of this program, and are able to benefit from the efforts of an integrated team of physicians, nurses and other clinicians who deliver the most current clinical treatment and research available. The multidisciplinary team approach results in positive outcomes for heart failure patients.

The Primary Care Physician’s role
The heart failure patient’s primary care physician works closely with the team at the Heart Failure Treatment Centers to ensure the best possible outcome for their patient. This program believes in a team approach to treating heart failure, with the primary care physician being at the forefront of the clinical team. Primary care physicians are kept abreast of their patient’s treatment, involved in medical decisions and manage their patients whenever possible.

Medications
Do not allow yourself to run out of medications. It is very important to take medications as instructed. You should never stop or start a medication without talking to your health care provider.

If you have trouble getting your medications, call the office and we will assist you. If you use mail order, be sure to order in enough time, so that you do not run out of medications.

It is important that you bring your medicines or a current list of your medicines with you to every visit.

There are several categories of drugs that are used to treat heart failure. These drugs may:

• help the heart pump better
  
• decrease the progression of heart failure
  
• decrease symptoms and make you feel better
  
• block the effect of harmful substances that are released into the body because of heart failure
  
• slow the heart rate.

Medication Class	Examples	What they do	Common side effects
ACE inhibitors	Lisinopril Captopril Enalapril Fosinopril Quinapril Ramapril	Lowers the pressure in the blood vessels and makes it easier for the heart to pump blood.	Persistent cough Dizziness Altered sense of taste High potassium Kidney problems Swelling of the lips, tongue, or throat
Beta-blockers	Carvedilol (Coreg) Metoprolol XL (Toprol) Bisoprolol (Zebeta)	Blocks body’s response to substances that damage the heart. Helps the heart to not work as hard. Lowers heart rate and blood pressure.	Initially can make you feel more tired. Low heart rate Low blood pressure Can worsen asthma symptoms
Aldosterone Blockers	Aldactone Inspra	Helps prevent further damage to heart from chemicals that are released in response to heart failure.	High potassium Breast enlargement or tenderness (in men)
Cardioglycoside	Digoxin Lanoxin Digitek	Helps the heart have a stronger contraction.	Loss of appetite Bad taste in mouth Low heart beat
Diuretics	Furosemide (lasix) Bumetanide (Bumex) Torsemide (Demadex)	“Water Pill” Gets rid of excess water Helps symptoms	Low potassium Decreased kidney function
Angiotensin II Receptor Blockers (ARB”S)	Candesartan (Atacand) Irbesartan (Avapro) Losartan (Cozaar) Valsartan (Diovan)	Work in similar way to ACE inhibitors Sometimes used when a person cannot take ACE inhibitors	Low blood pressure

Avoid these medications:

• Anti-inflammatory medications: Advil, Aleve, Ibuprofen, Celebrex, Vioxx
  
• Over the counter medications with pseudophedrine (found in cold medications).

DO NOT TAKE ANY OVER THE COUNTER MEDICATIONS WITHOUT TALKING TO YOUR HEALTH CARE PROVIDER.

Ways to remember your medication:

• Take your medicine at the same time you do other daily activities (like brushing your teeth or watching the news).
  
• Set an alarm clock or timer to ring when it’s time for your medicine.
  
• Use a pillbox with sections for different times of the day.

Dehydration
Adjusting medication is a continual process. If you are sick and not eating and drinking normal amounts, and you are taking the same water pill dosage, you may become dehydrated. Sometimes, as the heart function improves, you do not need the same water pill dosage.

Symptoms of dehydration (losing too much fluid) include:

• light-headedness, especially with standing
  
• a drop in the top number of your blood pressure of more than 10 mm of mercury when you stand
  
• a sudden loss of weight.

If you have any of these symptoms and think your medication may need to be adjusted, please call your health care provider.

Self care
You should eat a heart healthy diet that is low in saturated fat (12-17 grams/day) and cholesterol (less than 300 mg./day). Include whole grain foods in your menu. Eat plenty of fruits and vegetables and at least two servings of fish per week. The normal cholesterol values for you are dependent upon the number of risk factors you have for heart disease. Discuss your cholesterol goals with your health care provider.

There are four parts of the cholesterol (lipid) profile:
• Total cholesterol
• HDL cholesterol—your good cholesterol that helps carry bad cholesterol from your body
• LDL cholesterol—your bad cholesterol
• Triglycerides—a different type of fat that also increases your risk of heart disease.

Triglycerides can be elevated from chronically elevated blood sugar and excessive use of alcohol.

Tips for reducing cholesterol: Use low-fat or fat-free milk, yogurt, sour cream or cheese. Select lean beef, poultry, or pork instead high fat meats. Eat nuts and dry beans. Bake, broil or steam foods instead of frying. Substitute liquid oils or trans-fat free margarine for shortening, butter, lard or other solid fats. Top salad with low-fat dressings. Choose vegetable or broth-based soups instead of creamed soups. Read food labels for the amount of saturated fat, trans fat and dietary cholesterol. You should limit your saturated fat to 12-17 grams per day and avoid trans fatty acids. This label, shown below, contains 3 grams of saturated fat and 1.5 grams of trans fat per serving size of one cup

.Tips to increase soluble fiber (which can also reduce cholesterol):

• Eat whole grain cereals.
  
• Eat fresh fruits.
  
• Switch to whole grain breads.
  
• Add more vegetables to sandwiches, pizza, pasta and entrees.
  
• Add beans to dishes such as chili and enchiladas.

Tips to increase soy protein (may reduce cholesterol levels):

• Drink soymilk.
  
02/16/2009
• Use soy nuts as a snack.
  
• Blend tofu into dips and spreads.
  
• Add fresh soybeans to stir-fry.
  
• Talk to your health care provider if you are taking hormone replacement medication.

Because sodium causes you to retain fluid, you should limit your sodium (salt) intake to two to three grams (or 2000 mg – 3000 mg) per day. If you have a problem with fluid retention, you should limit your intake to two grams per day. If you do not retain fluid and do not have high blood pressure you can limit your sodium intake to three grams a day.

Tips to help restrict sodium (salt) in your diet:

• Eliminate processed and prepared foods and beverages high in sodium. High sodium foods contain 500 mg or more of sodium per serving.
  
• Eliminate all salt and high sodium products during food preparation and at the table.
  
• Limit milk and milk products to two cups or 16 ounces per day.
  
• Check labels of canned and instant products for sodium content. The milligrams (mg) of sodium are listed per serving. Be sure to check the serving size.
  
• Watch for the terms “reduced or less sodium” and “light in sodium.” They contain less sodium than the original product. They are not necessarily low sodium foods.
  
• Common medications such as antacids, laxatives, and cough remedies are often high
  in sodium. Check with your pharmacist.
  
• Avoid drinking home or commercially softened water. It has added sodium.
  
• Limit dining at fast food restaurants. When you dine at restaurants, ask that no salt be used in the preparation of your food.
  
• Seasoning blends such as Mrs. Dash or Lawry’s Seasoning 17 may be used to add flavor.
  
• Salt substitutes contain potassium. You may use salt substitutes if you do not have high
  potassium levels.

The label to the left contains 470 mg of sodium per a one cup serving size. Watch for the following terms on food labels: Sodium free—less than 5 mg of sodium per serving Low sodium—less than 140 mg sodium per serving Very low sodium—less than 35 mg per serving.   1 teaspoon of salt = 2000 mg sodium 1 teaspoon baking soda = 821 mg sodium 1 tsp baking powder = 339 mg sodium 1 tsp MSG = 492 mg sodium

Most patients take water pills to decrease the amount of fluid that is pumped through the heart. You should not drink an excess amount of fluid.

Limit your total 24-hour fluid intake to less than two liters (two quarts or 64 ounces). It may be helpful to use a two-liter pop bottle to track your fluid intake. Cut the top of the two-liter bottle off, and use it as a funnel. Each time you drink a fluid, pour the same amount into the empty two-liter. Feeling thirsty is a common complaint. It does not mean that you need more fluids or that you are dehydrated. When you are thirsty:

• use ice chips
  
• freeze juice in ice cube trays
  
• use hard candies (sugar free if you’re a diabetic), chewing gum or lemons.

Limit the intake of caffeine in your diet. Caffeine is a stimulant and can cause an increased heart rate and cause your arteries to constrict.

It is important to weigh yourself daily in the morning before breakfast, with the same amount of clothes, after emptying your bladder. If you gain two pounds, two days in a row, it may be water weight and you should call your health care provider. You may need some additional medication to get rid of the extra fluid.

Avoid colds and flu:

• Get a yearly flu vaccine.
  
• Ask your primary care physician about getting a pneumonia vaccine to guard against the most common form(s) of pneumonia. These should be taken every five years.
  
• Avoid people that have colds, flu, or viruses. Try to avoid crowds during the flu season and wash your hands often.
  
• If you get a cold, it is caused by a virus and antibiotics will not kill viruses. However, a viral illness may become bacterial. If you have a cold that is not getting better after 10 days and you are feeling worse and not better, call your health care provider.
  
• When you have a cold, you can treat the symptoms with benedryl, robitussin DM and Tylenol.

Stress Management
Stress and anxiety stimulate your body to release chemicals that cause the heart to work harder:

• Learn to accept the things you cannot change.
• Don’t feel obligated. Learn your limitations and learn to say no.
• Join a support group.
• Find someone to talk to: friend, mental health professional or clergy.
• Don’t use smoking, drinking, eating or drugs to help you cope. They only make your health condition worse.
• Meditation and relaxation may also help.

Exercise
Many heart failure patients are afraid to exercise, because they are afraid they may cause more damage to their heart. You may feel more tired and may get tired more quickly when you exercise, but you will not make your heart failure worse.

Walking is a very good exercise to start increasing your activity. Most people are able to walk and it does not cost any money.

Rule of thumb:

• If you are too short of breath to talk while exercising then you are probably exercising
  too hard.
  
• If you have to take a nap or lie down after exercising you are probably exercising too
  hard.
• Exercise helps many heart failure patients feel better and allows patients to do their daily
  tasks and chores.

Regular exercise has many benefits:

• strengthens the heart
  
• lowers blood pressure and helps you lose weight
  
• improves the blood flow through your body
  
• builds energy levels so that you can do more activities without becoming tired or short of breath
  
• improves muscle tone and strength which helps muscles use less oxygen to work
  
• improves balance and movement of joints
  
• strengthens bones
  
• helps reduce stress, tension, anxiety and depression
  
• improves sleep
  
• helps you see yourself in a more positive way.

You should talk to your health care provider before starting any exercise program.

Smoking
Smoking increases the heart rate and blood pressure, which makes it more difficult for medication to work well. It causes high levels of carbon monoxide in the lungs and blood stream resulting in less oxygen available to your body. Smoking also lowers your resistance to colds and pneumonia, due to the damage smoking does to your lungs.

Talk to your health care provider about a plan to quit smoking. Nicotine replacement therapy is available as: a nicotine patch, nicotine gum, nicotine nasal spray, and nicotine inhaler. Only take these medications as directed. Alternative therapies include: Zyban (Wellbutrin), acupuncture, and hypnosis. The Ohio Tobacco Quit Line, 1-800-QUIT-NOW, is a free telephone service that helps Ohioans quit smoking and using tobacco. The Quit Line information:

• Monday – Thursday: 9 a.m. – 11 p.m.
  
• Friday: 9 a.m. – 9 p.m.
  
• Saturday and Sunday: 10 a.m. – 6:30 p.m.
  
• 24-hour voice mail
  
• www.Standohio.org for more information.

Those who do not reside in Ohio and would like more information may contact: American Cancer Society or American Heart Association

Sleep Apnea
Sleep Apnea is a common disorder found in heart failure patients. It is found in more than 50 percent of patients with heart failure and in more than 90 percent of patients with resistant high blood pressure.

If you snore, wake up gasping for air or coughing, and do not feel rested when you wake up, you may have sleep apnea. Discuss these symptoms with your health care provider.

Diagnosis of sleep apnea requires a polysomography. This is a test where you sleep in a lab overnight and your breathing and oxygen levels are monitored. Treatment of sleep apnea is very important in the treatment of your heart failure.

Depression
It is common for people with chronic diseases, such as heart failure, to experience depression. There are emotional, physical, psychological and social symptoms of depression.

Emotional symptoms include:

• feeling sad
  
• no pleasure or interest in activities that you normally enjoyed, including work, hobbies
  and sex
  
• feeling tired
• feeling hopeless
  
• having trouble concentrating or making decisions
  
• thinking about dying

Physical symptoms include:

• not being able to sleep or wanting to sleep all the time
  
• having no appetite or wanting to eat all the time
  
• hurting all over
  
• chest pain and shortness of breath
  
• headaches
  
• digestive problems such as heartburn, nausea or constipation

Psychological symptoms include:

• feeling anxious or irritable
  
• problems with memory
  
• crying
  
• injuring yourself

Social symptoms include:

• anger
  
• withdrawing from friends or family
  
• problems with work
  
• using drugs or alcohol

If you think you might be depressed, talk with your health care provider about treatment. Depression rarely gets better without treatment. Our social worker may be able to assist you, and is available by calling the office.