Heart Failure Lenz Ch. 11

Pharmacy Health and BehaviorSection 301, Group #6November 8, 2011

Artecia BarefieldSabrina FergusonDeatra JohnsonStephen OkonRobert SmithLauren Wood MalphursHeart FailureLenz Ch. 1111Definition of Heart FailureHeart failure is the inability of the heart to adequately deliver oxygen to the body

22Prevalence of Heart Failure (HF)HF has become a significant public health concern in the United States in recent decadesApproximately 550,000 new cases of HF are diagnosed for the first time each yearAn estimated 5 million Americans currently have HFHF accounts for 12 to 15 million physician office visits each year, with an incidence level that is approaching 10 per 1,000 people older than 65 years of ageHF has become the most common Medicare diagnosis33Prevalence of HF (continued)HF is primarily a condition of the elderly, and therefore, as patients get older, they are more likely to have HF.Many patients are diagnosed with HF after they have had a heart attack.Because treatments for heart attacks have improved, more patients are surviving the event, which is most likely the reason for the increased incidence of HF.44Pathophysiology of HFHF is the inability of the heart to adequately deliver oxygen to the appropriate tissues of the body, which is caused by an inability of the ventricles of the heart to fill with or eject blood.The left ventricle is the chamber of the heart primarily responsible pumping blood through the aorta in order to supply the blood and oxygen to all the tissues of body.Failure of the left ventricle usually results in a decrease of cardiac output which is the amount of blood being pumped by the heart per minute. (CO = stroke volume x heart rate stroke volume) Classic signs and symptoms resulting from HF include shortness of breath, fatigue, pulmonary edema, and peripheral edema.

55Four Stages of HF6Stage Apatients are at risk for HF because they possess risk factors for HF such as hypertension, atherosclerotic disease, diabetes, obesity, and metabolic syndrome. Patients do not have structural heart diseaseStage Bpatients have structural heart disease (e.g. post MI) but do not have symptoms of HFStage Cpatients with structural heart disease who have prior or current symptoms of HFStage Dpatients are refractory to HF treatments and require specialized interventionsWe will focus on mainly the prevention of HF (stages A and B) and to a lesser extent, the treatment of HF for patients who are at Stage C.6Environmental Risk Factors for HFCoronary heart diseaseMyocardial infarctionHypertensionPulmonary hypertensionDilated cardiomyopathyGenetic causesValvular heart disease

7The most common causes of HF are coronary artery disease, particularly from myocardial infarction, and hypertension.7Preventing HFThe primary goal in the prevention of HF is to adequately control the causes of myocardial injury. This can then decrease the risks for obtaining HF symptoms. Several diseases and lifestyle habits can lead to myocardial injury. It is important to follow the recommended guidelines of the following diseases as an important first step in HF disease prevention:Atherosclerotic diseaseHyperlipidemiaHypertensionDiabetes mellitusObesityMetabolic SyndomeAdequately controlling blood glucose levels, body weight, as well as blood pressure, and cholesterol levels, are important disease-prevention strategies for HF.

8Adequately controlling blood glucose levels and body weight, as well as blood pressure and cholesterol levels, are important disease-prevention strategies for HF.8Behavior ChangesDiscontinue Use of: CigarettesAlcoholIllicit DrugsLow sodium diet (DASH Eating Plan)Increased consumption of fiber, potassium, magnesium, and calciumDecreased consumption of saturated fat, cholesterol, and sodiumEngage in physical exercise20-40 minutes per day of light to moderate exercise, such as walking or bicycling

9Note: There is no direct evidence that controlling dietary sodium or participation in regular exercise can prevent the development of HF, however, it is well known that specific dietary changes and regular exercise control and decrease the risk for developing many diseases leading to heart disease.Adopting the DASH eating plan may be particularly beneficial for those patients who are stage A or B to prevent HF symptoms as well as those with stage C or D to prevent fluid retention.

Also, Stage C and particularly Stage D HF patients should exercise in a controlled and supervised environment, such as a cardiac rehabilitation center or other setting with appropriately trained personnel. Some Stage B patients should also exercise in a supervised setting depending on the extent of their individual structural heart damage.

Formal exercise training programs have been shown to be effective at decreasing the symptoms associated with HF and improving the capacity of the heart to perform physical work. Improving a patients ability to sustain a low level of physical work can improve independence and quality of life. 9Dietary Recommendations for Patients with HFNutrientsNutrient TargetFat (% of total kcal)27% Saturated6% Monounsaturated13% Polyunsaturated8%Carbohydrates (% of total kcal)55%Protein (% of total kcal)18%Cholesterol150 mg/dayFiber31 g/dayPotassium4,700 mg/dayMagnesium500 mg/dayCalcium1,240 mg/daySodium1,500 mg/day1010Medications Used to Treat HFAngiotensin-converting enzyme (ACE) inhibitorsAngiotensin receptor blockers (ARB)Aldosterone blockersBeta blockersDigoxinDiuretics

11Beyond controlling the risk factors that can lead to HF, current treatment of HF is primarily focused on drug therapy.11Consequences of Uncontrolled HF12Signs and symptoms resulting for HF include:Shortness of breathFatiguePulmonary edemaPeripheral edema

Uncontrolled HF will have a negative impact on quality of life and can eventually lead to death.

12Theory of Planned Behavior1313Theory of Planned Behavior Explores the relationship between behavior and beliefs, attitudes, and intentionsIt is a value-expectancy theoryThe main constructs of the theory are behavioral intention, attitude, subjective norm, and perceived behavioral control. Behavioral intention is the most important determinant of behavior

1414Theory of Planned Behavior15ConceptDefinitionMeasurement ApproachBehavioral IntentionPerceived likelihood of performing behaviorAre you likely or unlikely to perform the behavior?AttitudePersonal evaluation of the behaviorDo you see the behavior as good, neutral, or bad?Subjective NormBeliefs about whether key people approve of disapprove of the behavior; motivation to behave in a way that gains their approvalDo you agree or disagree that most people approve or disapprove of the behavior?Perceived behavioral controlBelief that one has, and can exercise, control over performing the behaviorDo you believe performing the behavior is up to you, or not up to you?Behavioral intention related to HF: Are you likely to improve your diet by reducing sodium and fat intake, etc.? Are you likely to implement exercise into your daily routine?

Attitude related to HF: Do you see the behaviors (e.g. improving diet and exercise) as good, neutral, or bad? Do you think they are important and will help you avoid serious health problems, such as HF?

Subjective Norm: Do your children/spouse/coworkers think this behavior change is good? Are they in support of this change or not?

Perceived behavioral control: Do you believe you can perform this behavior change or do you feel that it is out of your control?15Case StudyA.B. is a 45-year-old female who has been a patron of your pharmacy for 3 months. She has a past medical history of hypertension for 1 year and dyslipidemia for 4 years. She is sedentary with a BMI of 34 kg/m2 (54 tall, 199 lb), follows no specific eating plan, and does not drink alcohol or smoke tobacco. She does admit to eating on the go frequently owing to the busy schedules of her five children and full time job. Her current medications include hydrochlorothiazide 12.5 mg/day, and rosuvastatin 10 mg/day. Her most recent cholesterol panel was taken 6 months ago and revealed total cholesterol 167, LDL 115, HDL 56 and triglycerides 145. Her current blood pressure, which you measured in the pharmacy, averaged 128/82 mm Hg with a resting heart rate of 82 beats per minute.A.B. has been reading some literature displayed in the pharmacy about disease-prevention pharmacy services. She expresses interest in adopting lifestyle modifications such as exercise and weight loss. On average, A.B. consumes a total of 2,687 calories per day, and her diet is extremely high in sodium.1616Questions:17True or False: The primary goal in the prevention of heart failure is to adequately control the causes of myocardial injury.

What are the classic signs and symptoms resulting from heart failure?

True or False: The most common causes of HF include coronary artery disease and hypertension.

TRUEClassic signs and symptoms include shortness of breath, fatigue, pulmonary edema, and peripheral edemaTRUE. The most common causes of HF are coronary artery disease, particularly from myocardial infarction, and hypertension.

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