Karen Harkness

The 2012 Canadian Cardiovascular Society heart failure management guidelines update: focus on acute and chronic heart failure.

The 2012 Canadian Cardiovascular Society Heart Failure (HF) Guidelines Update provides management recommendations for acute and chronic HF. In 2006, the Canadian Cardiovascular Society HF Guidelines committee first published an overview of HF management. Since then, significant additions to and changes in many of these recommendations have become apparent. With this in mind and in response to stakeholder feedback, the Guidelines Committee in 2012 has updated the overview of both acute and chronic heart failure diagnosis and management. The 2012 Update also includes recommendations, values and preferences, and practical tips to assist the medical practitioner manage their patients with HF.

The 2011 Canadian Cardiovascular Society heart failure management guidelines update: focus on sleep apnea, renal dysfunction, mechanical circulatory support, and palliative care.

The 2011 Canadian Cardiovascular Society Heart Failure (HF) Guidelines Focused Update reviews the recently published clinical trials that will potentially impact on management. Also reviewed is the less studied but clinically important area of sleep apnea. Finally, patients with advanced HF represent a group of patients who pose major difficulties to clinicians. Advanced HF therefore is examined from the perspectives of HF complicated by renal failure, the role of palliative care, and the role of mechanical circulatory support (MCS). All of these topics are reviewed from a perspective of practical applications. Important new studies have demonstrated in less symptomatic HF patients that cardiac resynchronization therapy will be of benefit. As well, aldosterone receptor antagonists can be used with benefit in less symptomatic HF patients. The important role of palliative care and the need to address end-of-life issues in advanced HF are emphasized. Physicians need to be aware of the possibility of sleep apnea complicating the course of HF and the role of a sleep study for the proper assessment and management of the conditon. Patients with either acute severe or chronic advanced HF with otherwise good life expectancy should be referred to a cardiac centre capable of providing MCS. Furthermore, patients awaiting heart transplantation who deteriorate or are otherwise not likely to survive until a donor organ is found should be referred for MCS.

Caregivers’ contributions to heart failure self-care: A systematic review:

Aims: The purpose of this study was to conduct a systematic review answering the following questions: (a) what specific activities do caregivers (CGs) contribute to patients’ self-care in heart failure (HF)?; and (b) how mature (or developed) is the science of the CG contribution to self-care? Methods: MEDLINE, EMBASE, Cumulative Index of Nursing and Allied Health Literature (CINAHL), the Cochrane Library and ClinicalTrials.gov were searched using the terms heart failure and caregiv* as well as the keywords ‘careers’, ‘family members’ and ‘lay persons’ for studies published between 1948 and September 2012. Inclusion criteria for studies were: informal CGs of adult HF patients–either as dependent/independent variable in quantitative studies or participant in qualitative studies; English language. Exclusion criteria for studies were: formal CGs; pediatric, adult congenital, or devices or transplant CGs; mixed diagnosis; non-empiric reports or reports publishing duplicate results. Each study was abstracted and confirmed by two authors. After CG activities were identified and theoretically categorized, an analysis across studies was conducted. Results: Forty papers were reviewed from a pool of 283 papers. CGs contribute substantively to HF patients’ self-care characterized from concrete (weighing the patient) to interpersonal (providing understanding). Only two studies attempted to quantify the impact of CGs’ activities on patients’ self-care reporting a positive impact. Our analysis provides evidence for a rapidly developing science that is based largely on observational research. Conclusions and implications of key findings: To our knowledge, this is the first systematic review to examine CGs’ contributions in depth. Informal caregivers play a major role in HF self-care. Longitudinal research is needed to examine the impact of CGs’ contributions on patient self-care outcomes.

The 2014 Canadian Cardiovascular Society Heart Failure Management Guidelines Focus Update: Anemia, Biomarkers, and Recent Therapeutic Trial Implications

The 2014 Canadian Cardiovascular Society Heart Failure Management Guidelines Update provides discussion on the management recommendations on 3 focused areas: (1) anemia; (2) biomarkers, especially natriuretic peptides; and (3) clinical trials that might change practice in the management of patients with heart failure. First, all patients with heart failure and anemia should be investigated for reversible causes of anemia. Second, patients with chronic stable heart failure should undergo natriuretic peptide testing. Third, considerations should be given to treat selected patients with heart failure and preserved systolic function with a mineralocorticoid receptor antagonist and to treat patients with heart failure and reduced ejection fraction with an angiotensin receptor/neprilysin inhibitor, when the drug is approved. As with updates in previous years, the topics were chosen in response to stakeholder feedback. The 2014 Update includes recommendations, values and preferences, and practical tips to assist the clinicians and health care workers to best manage patients with heart failure.

Determinants of effective heart failure self-care: a systematic review of patients’ and caregivers’ perceptions

Context Disease management interventions for heart failure (HF) are inconsistent and very seldom incorporate the views and needs of patients and their caregivers into intervention design. Objective and data To improve intervention effectiveness and consistency, a systematic review identified 49 studies which examined the views and needs of patients with HF and their caregivers about the nature and determinants of effective HF self-care. Results The findings identify key drivers of effective self-care, such as the capacity of patients to successfully integrate self-care practices with their preferred normal daily life patterns and recognise and respond to HF symptoms in a timely manner. Conclusions Future interventions for HF self-care must involve family members throughout the intervention and harness patients’ normal daily routines.

The Effect of Early Education on Patient Anxiety While Waiting for Elective Cardiac Catheterization

Background: A supply–demand mismatch with respect to cardiac catheterization (CATH) often results in patients experiencing waiting times that vary from a few weeks to several months. Long delays can impose both physical and psychological distress for patients. Purpose: The purpose of this study was to examine the effect of a psychoeducational nursing intervention at the beginning of the waiting period on patient anxiety during the waiting time for elective CATH. Methods: This was a 2-group randomized controlled trial. Intervention patients received a nurse-delivered, detailed information/education session within 2 weeks of being placed on the waiting list for elective CATH. Control group patients received usual care. Results: The mean waiting time for CATH was 13.4±7.2 weeks, which did not differ between groups (P=0.509). Anxiety increased in both groups over the waiting time (P=0.028). Health-related quality of life deteriorated over the waiting time in both groups (P<0.05). On a visual analogue scale, there was a significant difference (P=0.002) between the intervention (4.0±2.7) and control (5.2±3.0) groups in self-reported anxiety 2 weeks prior to CATH. Conclusions: The waiting period prior to elective CATH has a negative impact on patients’ perceived anxiety and quality of life and a simple intervention, provided at the beginning of the waiting period, may positively affect the experience of waiting.

Predicting cardiac rehabilitation enrollment: the role of automatic physician referral.

Background Despite the established benefits of cardiac rehabilitation, evidence suggests referral to, and subsequent enrollment in, cardiac rehabilitation following a coronary event remains low (10-25%). The aim of this study was to identify predictors of attendance to cardiac rehabilitation intake and subsequent enrollment in rehabilitation after coronary artery bypass graft surgery within the framework of an automatic referral system. Design and methods We conducted a historic prospective study of patients who underwent coronary artery bypass graft surgery between 1 April 1996 and 31 March 2000 and lived within the geographic referral area of a multi-disciplinary cardiac rehabilitation center in central-south Ontario, Canada. Coronary artery bypass graft surgery patients are automatically referred to cardiac rehabilitation at the time of hospital discharge. Consecutive health records of eligible patients were reviewed for medical history, cardiac risk factor profiles, and evidence of cardiac rehabilitation intake attendance and enrolment. Results A total of 3536 patients met eligibility criteria. Patients were predominantly male (79.1%), approximately 64 years of age, living with a spouse or a partner, English-speaking, retired and had multiple cardiac risk factors. Of eligible patients, 2121 (60.0%) attended the cardiac rehabilitation intake appointment. Of patients who attended cardiac rehabilitation intake 1463 (69%) enrolled in at least one cardiac rehabilitation service, based on their risk factor profile. Selected cardiac rehabilitation services were exercise training (n = 1287; 88%), nutrition counseling (n = 571; 39.0%), nursing care (n = 546; 37.3%), and psychological intervention (n = 223; 15.2%). Conclusions An institutionalized, physician-endorsed system of automatic referral to cardiac rehabilitation resulted in higher rates of cardiac rehabilitation intake and enrollment following coronary artery bypass graft surgery than previously reported and should be adopted for all cardiac populations.

The Canadian Cardiovascular Society Heart Failure Companion: Bridging Guidelines to Your Practice

The Canadian Cardiovascular Society Heart Failure (HF) Guidelines Program has generated annual HF updates, including formal recommendations and supporting Practical Tips since 2006. Many clinicians indicate they routinely use the Canadian Cardiovascular Society HF Guidelines in their daily practice. However, many questions surrounding the actual implementation of the Guidelines into their daily practice remain. A consensus-based approach was used, including feedback from the Primary and Secondary HF Panels. This companion is intended to answer several key questions brought forth by HF practitioners such as appropriate timelines for initial assessments and subsequent reassessments of patients, the order in which medications should be added, how newer medications should be included in treatment algorithms, and when left ventricular function should be reassessed. A new treatment algorithm for HF with reduced ejection fraction is included. Several other practical issues are addressed such as an approach to management of hyperkalemia/hypokalemia, treatment of gout, when medications can be stopped, and whether a target blood pressure or heart rate is suggested. Finally, elements and teaching of self-care are described. This tool will hopefully function to allow better integration of the HF Guidelines into clinical practice.

Cognitive function and self-care management in older patients with heart failure

Aims: People with heart failure have difficulty with self-care management. We do not know if patients with heart failure have difficulty with self-care management due to underlying, mild cognitive impairment (MCI). The purpose of this study was to determine whether MCI, as identified on a simple screening tool, is significantly associated with self-care management in a sample of community dwelling older patients with heart failure. Methods and results: Using a cross-sectional design, heart failure patients (n=100, mean age 72 SD 10 years) attending an outpatient heart failure clinic completed the Montreal Cognitive Assessment tool (MoCA), Self-Care in Heart Failure Index (SCHFI) and Geriatric Depression Scale. The presence of MCI, as defined by a MoCA score <26, was present in 73% patients; 21% had an adequate self-care management SCHFI score; and 12% reported symptoms of depression. Participants with a MoCA score <26 vs. ≥ 26 scored significantly lower on the self-care management subscale of the SCHFI (48.1 SD 24 vs. 59.3 SD 22 respectively, p=0.035). Using backward regression, the final model was fitted to self-care management while controlling for age and sex and was significant, with (F= 7.04 df (3, 96), and p<0.001), accounting for 18% of the total variance in self-care management (R2 = 18.03%). The MoCA score was the only variable which remained in the model significantly with p= 0.001. Conclusion: Findings from this study highlight the difficulty older heart failure patients have with self-care management and the need to include formal screening for MCI when exploring variables contributing to self-care management in heart failure patients.

The 2013 Canadian Cardiovascular Society Heart Failure Management Guidelines Update: Focus on Rehabilitation and Exercise and Surgical Coronary Revascularization

The 2013 Canadian Cardiovascular Society Heart Failure Management Guidelines Update provides focused discussions on the management recommendations on 2 topics: (1) exercise and rehabilitation; and (2) surgical coronary revascularization in patients with heart failure. First, all patients with stable New York Heart Association class I-III symptoms should be considered for enrollment in a tailored exercise training program, to improve exercise tolerance and quality of life. Second, selected patients with suitable coronary anatomy should be considered for bypass graft surgery. As in previous updates, the topics were chosen in response to stakeholder feedback. The 2013 Update also includes recommendations, values and preferences, and practical tips to assist the clinicians and health care workers manage their patients with heart failure.