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Winning the Game with Heart Failure

HeartFailureCenter.com
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Heart Failure ACC/AHA Staging System for Patients

Karen E. Graham, BS, RN
Heart Failure Clinical Specialist

Heart failure is a clinical syndrome that develops when the heart's muscle becomes weakened after it is injured (eg. heart attack) or as a result of disease which causes it to lose its ability to pump enough blood to supply the body's needs. Common symptoms include shortness of breath, fatigue and leg swelling.

Heart failure usually develops slowly, often over years, as the heart gradually loses its pumping ability and works less efficiently. Some people may not become aware of their condition until symptoms appear years later. Initially the heart tries to compensate in several ways; as the heart muscle works harder, the heart becomes enlarged, heart muscle fibers thicken to attempt more forceful contractions, and the heart rate increases as the heart tries to improve blood flow to the body. If factors causing heart failure are not corrected, compensatory mechanisms eventually fail and signs of heart failure appear.

About five million Americans are living with heart failure, and between 400,000 and 700,000 new cases are diagnosed every year. Heart failure is serious and can be life-threatening. About 250,000 people die annually of heart failure.

Treating heart failure (HF) used to be a simple approach. We thought of the heart as a pump and that when it functioned poorly we could use digitalis, to increase the heart’s contractions, treat the fluid build up, swelling, and other symptoms with diuretics (water pills), restrict salt intake, and encourage bed rest. Patients usually felt better, especially after the removal of excess fluid. However, their 2-year survival was often no better than patients with cancer: 50%.

Today, we have a greater understanding of changes that occur in the heart when it is injured and the cycle of how it tries to compensate in heart failure. With this understanding, the evaluation and treatment of heart failure has become much more complicated.

The American College of Cardiology and the American Heart Association have jointly published clinical guidelines to help doctors and hospitals create good care plans for their patients since 1980. The guidelines are based on scientific research and medical evidence. One set of guidelines written in 2005 is called “Evaluation and Management of Chronic Heart Failure in the Adult.” The guidelines provide a new classification system that assigns the progressive development of HF into 4 major stages. These 4 stages recognize that there are established risk factors as well as patient predisposition for the development of heart failure. This staging process allows clinicians to more accurately classify the patient’s condition and make better treatment decisions with the ultimate goal of preventing further disease progression and improving the patient’s quality of life. These guidelines can be accessed in their entirety on the websites of these organizations. www.acc.org and www.americanheart.org.

As a patient, understanding the basics of the guidelines can help you take a more active role in your treatment. The guidelines suggest specific treatments and actions for each stage. You should ask your healthcare provider what stage of heart failure you are in and check the table below to see if your therapy matches what the American Heart Association and American College of Cardiology recommend.

Stage A includes people at high risk of developing HF with suggested actions that focus on treating risk factors. Example: people with high blood pressure, coronary artery disease, diabetes, history of drug or alcohol abuse, history of rheumatic heart disease, or family history of cardiomyopathy.

Stage B includes patients with a structural disorder of the heart but have never developed symptoms of heart failure. E xample: patients with structural changes to the left ventricle, heart valve disease or who have had a heart attack.

Stage C includes those with past or current symptoms of heart failure associated with underlying structural heart disease. E xample: Patient has shortness of breath or fatigue due to left ventricular systolic dysfunction or is without symptoms and undergoing treatment for prior symptoms of heart failure.

Stage D designates patients with end stage heart failure who might be eligible for specialized advanced treatment including cardiac transplantation or compassionate end-of-life care such as hospice. Example: Patient is frequently hospitalized for heart failure or cannot be safely discharged from the hospital; patient is in the hospital awaiting heart transplant; patient is at home

receiving continuous intravenous support or being supported with a mechanical circulatory assistive device; or patient is in a hospice setting for the management of heart failure.

For all stages, the guidelines suggest specific medicines and certain medical tests or procedures. The guidelines also advise providers (doctors and hospitals) to take a “multidisciplinary approach” to your care. This means that, rather than working alone to treat you, your provider teams up with other health care specialists, such as nurses, exercise physiologists and smoking-cessation experts. Your health care team may suggest that you participate in support groups or visit certain specialists to help you make lifestyle changes to manage heart disease. They give providers a range of treatment options. The ultimate decisions rest with the provider and with you. Asking questions about your treatment is smart and responsible. It is important for you to know your health care team’s goals for you —and how clinical guidelines compare to your care plan.

STAGE A STAGE B STAGE C STAGE D

Goals for Treatment:

• Treat hypertension

• Encourage smoking cessation

• Treat lipid disorders

• Encourage regular exercise

• Discourage alcohol intake, illicit drug use

Goals for Treatment:

• Treat hypertension

• Encourage smoking cessation

• Treat lipid disorders

• Encourage regular exercise

• Discourage alcohol intake, illicit drug use

Goals for Treatment:

• Treat hypertension

• Encourage smoking cessation

• Treat lipid disorders

• Encourage regular exercise

• Discourage alcohol intake, illicit drug use

• Dietary salt restriction

Goals for Treatment:

• Treat hypertension

• Encourage smoking cessation

• Treat lipid disorders

• Encourage regular exercise

• Discourage alcohol intake, illicit drug use

• Dietary salt restriction

Medications:

• ACE Inhibitors or ARBs for vascular disease or diabetes in appropriate patients

Medications:

• ACE Inhibitors or ARB’s in appropriate patients

• Beta-blockers in appropriate patients

Medications for routine use:

- Diuretics (water pills)

- ACE inhibitors

- Beta-blockers

Medications for routine use:

- Diuretics (water pills)

- ACE inhibitors

- Beta-blockers

   

Medications for selected patients :

- Aldosterone Antagonist

- ARB’s

- Digitalis

- Hydralazine/Nitrates

Medications for selected patients

- Aldosterone Antagonist

- ARB’s

- Digitalis

- Hydralazine/Nitrates

   

Devices for Selected Patients :

- Biventricular Pacing

- Implantable defibrillators

Devices for Selected Patients

- Biventricular Pacing

- Implantable defibrillators

     

Other Options

• Compassionate end-of-life care/hospice

• Extraordinary treatment considerations

- Heart transplantation

- Chronic inotropes

- Permanent mechanical support

- Experimental surgery or medications

Patients at any stage of HF should be taught about their diagnosis, why it is important for you to take your medications and determine what lifestyle changes you should make to feel better and stay out of the hospital. Your prognosis should be discussed early on, and should be explained when you first start taking medication for heart failure. Some of these medications will not only make you feel better but can improve your lifespan when taken as directed. If you have heart failure symptoms, simple things like dietary salt restriction, daily weights and notifying your healthcare provider if there is an increase or decrease of more than 5 lbs in a week or two can make a difference in how you feel and how your healthcare provider can help you. Additionally, if you engage in behaviors that cause the heart cells to further deteriorate, such as smoking tobacco, marijuana or using cocaine, drinking alcohol or ingesting amphetamines, or taking any weight loss preparations, you should be strongly encouraged to stop.

Nearly any form of heart disease can lead to the development of heart failure. The guidelines stress that early recognition and proper treatment of high blood pressure, diabetes, coronary artery disease and other cardiovascular risk factors can help patients delay or avoid heart failure. 

Heart failure management is a team effort, and you are the key player on the team. Your heart doctor will prescribe your medications and manage other medical problems. Other team members, including nurses, dietitians, pharmacists, exercise specialists and social workers, will help you achieve success. But it is up to you to take your medications, make dietary changes, live a healthy lifestyle, keep your follow-up appointments, and be an active member of the team. With the right care, heart failure will not stop you from doing the things you enjoy. Your prognosis or outlook for the future will depend on how well your heart muscle is functioning, your symptoms, and how well you respond to and follow your treatment plan.