Does Non-pharmacologic Management Prevent the Reoccurrence of Heart Failure - Assignment Example

In elderly patients with congestive heart failure: Does non-pharmacologic management prevent the reoccurrence of heart failure compared to pharmacologic management? Name Institution INTRODUCTION: CONGESTIVE HEART FAILURE (CHF) Congestive Heart Failure (CHF) is a clinical syndrome characterized by ineffective myocardial pumping. It usually presents itself as terminal manifestation of various cardiac diseases, and it affects people in an advanced age. According to statistics available, CHF affects close to 5,000,000 people living in America and leads to more than 286,700 deaths annually. Clinical symptoms of CHF include: breathing problems, fatigue, exercise intolerance and peripheral oedema, and frequent thirst. According to Donner et al. (2012, p. 442), some of the causes of heart failures include high sodium consumption, consumption of foods that are poor in vitamins, mineral and fiber, high intake of saturated fat, cholesterol, and simple carbohydrate. Among adults with over 65 years, CHF is the leading cause of hospitalization. Doris et al. (2007) argue that effective management of heart failure requires pharmacological management combined with non-pharmacological interventions. This position is significant in this literature review because of the need to evaluate the best option between pharmacological and non pharmacological management interventions. It will be vital to evaluate which option will provide the best management that will ensure no reoccurrence of hear failure in elderly patients. In this literature review, three themes stand out in the management of congestive heart failure namely; pharmacological treatment therapies, non pharmacological treatment therapies, and a combination of the two management therapies. PHARMACOLOGICAL MANAGEMENT THERAPIES Pharmacological management therapies involve administration of a drug to alleviate the symptoms of CHF. Diuretics such as furosemide, torsemide, bumetanide and thiazide are important drugs in the management of CHF. Administration of these drugs can either be through intravenous bolus every 12 hours or by continuous intravenous infusion. Debates still exist on the most effective way of administrating these drugs. Some studies have shown that administration by continuous intravenous infusion is more effective in the management of CHF. However, these studies have received a fair share of criticism. Similarly it is not clear as to whether administration of high dose of diuretics is more effective in management of CHF than administration of low doses of diuretics. This means that current guidelines on administration of diuretics are based on expert opinion. This has resulted in variation in the mode of administration and the dosing. There is still some controversy on the administration of pharmacological management therapies. This may have some negative impact on the treatment of CHF among elderly patients. For example, in a study done by Felker et al. (2011), it was observed that among patients with acute decompensated heart failure (HF), there no significant differences in “patients’ global assessment of symptoms” or in the change in renal function on administering diuretic therapy by bolus when compared with continuous infusion or at a high dose as compared with a low dose (p.797). These findings do not agree with findings of previous study, which recommended that continuous intravenous infusion is more effective than intravenous bolus. This leaves the medical doctor at a dilemma and thereby, no agreement on the best way to administer pharmacological treatment to patients. Unless this is done, varying expert opinion will still be used in the administration of diuretics by clinicians, and this poses a danger to the patients because such treatment will be based on try and error. NON PHARMACOLOGICAL CHF MANAGEMENT THERAPIES Non pharmacological CHF management therapies involve the use of non drug approaches to alleviate the symptoms (Kostis, et al., 1994). The occurrence of congestive heart failure is linked to consumption of some foods and therefore, an advice for patients to avoid these foods is significant in the treatment of CHF. Such foods include: high intake of cholesterol, saturated fats and simple sugars, low intake of mineral, fiber, and vitamins (Donner et al., 2012, p. 443). High intake of sodium is closely associated with high incidence of heart failure. In fact, volume overload caused by excessive intake of sodium is the main cause of HF hospitalizations. The non pharmacological treatment therapy in such a case involves reducing or regulation of the amount of sodium intake by the patient with CHF. The major challenge experienced with this therapy is non adherence to low sodium diets (Brook et al., 2009). Non compliance to non pharmacological therapies was noted by Martje et al., (2010). It is important to note that non compliance is not restricted to diet but also on exercise and weight. In this study, the non compliant patients had a higher chance of being readmitted to the hospital. In determining the role of providing nutritional guidelines to patients with CHF on the quality of the patient’s diet, Donner et al. (2012) conducted a study with 46 respondents where the intervention and control groups were randomly selected. The intervention group received additional nutritional guidance about diet. They were informed on the relationship between diet and the CHF disease. At the end of the experiment, it was noted that patient who were trained on better eating habits increased their knowledge about food and nutrition and, therefore, were able to modify their diets accordingly. However, more research is needed to determine whether this intervention has any benefits on the quality of life and prognosis. In another study by Doris et al. (2007), results indicated that relaxation and exercise in older patients can significantly improve the psychological and various disease-specific quality of life outcomes. This study, however, did not take into account the initial differences in the family support given to the patients. This difference might have had an effect on the final outcome and more is needed to include all the variables in the outcome. Several methods can be used to determine the effect of exercise (non pharmacological treatment therapy) in patients with HF. These include: the maximal, submaximal and endurance exercise protocols. However, there is no agreement on the appropriate exercise testing protocol for CHF patients. For this reason, a study was conducted by Larsen et al., (2001) to determine the most appropriate method to evaluate the effect of exercise in patients with HF. Finding from this study confirmed the positive influence of exercise in managing HF. Further it demonstrated that an endurance test is a more sensitive and appropriate protocol when assessing the efficacy of exercises as an intervention a population. However this study failed to include the different types of exercises that can be done. According to Larsen et al. (2001) there is no consensus on the best method of testing non pharmacological management for CHF patients. Therefore, the limited number of tools that can be used by a clinician to assess the probability of a patient to adherence to a low sodium diet makes it hard for clinician to determine the perception of patients on the low-sodium diet. This creates a need for research to be done to design and evaluate new tools that can be used by clinician to determine the likelihood of a patient to adhere to low sodium diets. Otherwise, compliance is a wanting issue when it comes to non pharmarcological management therapy for elderly patients with CHF. In a study done to evaluate the usefulness of one tool, the DSRQ, in assessing the patient’s attitudes toward adhering to a low sodium diets, it was shown that when this tool is used on white patients with NYHA class II/III HF it could be useful. However, the validity of this tool on other populations with different cultures needs to be evaluated before this tool becomes acceptable (Brook et al., 2009). Unless the validity of this tool is confirmed, clinicians will not be able use this tool to establish the chance of non adherence. PHARMACOLOGICAL AND NON PHARMACOLOGICAL COMBINATION IN THE TREATMENT OF CHF In the combination of pharmacological and non pharmacological treatment among patients with CHF, Control over fluid intake (non pharmacological) during pharmacological management of patient with CHF has been advised by many international guidelines for pharmacological management of CHF. This, in most cases, may result in patient becoming thirsty (one of the symptoms of CHF is that patients often become thirsty). These fluid restrictions have limited scientific justification and recommend fixed levels of fluid intake for all CHF patients. However, in a recent study done by Marie et al., (2008), it was discovered that in clinically stabilized CHF patients on optimal pharmacological treatment, the intake of slightly higher levels of fluid that resulted in reduced levels of thirst did not result in any measurable negative effects on the weight of the patient, symptoms CHF, or the use of diuretic or physical ability. This calls for further research to be done to look into fluid prescriptions to determine whether a more liberal, individualized fluid intake in CHF patients can be achieved. Otherwise, unless enough evidence is found that will warrant the change in guidelines that emphasize on strict fluid control to allow for less strictness in fluid control, clinician will continue to follow the laid down guidelines. Another non pharmacological therapy for the management of CHF involves advising patient to indulge in physical exercise while taking drugs (pharmacological). Symptoms of heart failure are brought about by fluid retention, peripheral vasoconstriction and reduced skeletal muscle perfusion. For a long time, patients with CHF were advised to avoid exercise to prevent decompensation while taking drugs. However, studies have indicated that lack of exercise and deconditioning may be one of the causes of an increase in the pathophysiology of CHF. Using non pharmacological therapy, alongside the medical treatment (pharmacological therapy), could be an alternative for managing CHF. In a research done by Rich et al. (1995) to determine the influence of multidisciplinary intervention in the prevention of readmission of elderly patients with CHF, participants were randomly selected and assigned to the control test treatment. The test treatment consisted of comprehensive education of the patient together with their family; monitoring of their diet, access to social support service, proper medications, and follow-up programs. Results showed that there was a reduction readmission of elderly patients who were receiving the intervention treatment. Rich et al. (1995) argue that combined use of diverse management therapies is significant in improving quality of life and reducing frequent visit to hospital for elderly patients affected by Congestive Heart Failure. However, this study failed to establish whether it was pharmacological therapy or non pharmacological therapy that was the most important in reducing readmission rates and improving the quality of life. Moreover, Doris et al. (2007), contend that when treating CHF, optimal non pharmacological management should be used alongside pharmacological management. According to them, therefore, there should be an imbalanced combination of the two. In another study by Martje et al. (2010), the researchers agree that non-compliance with non-pharmacological management guidelines have a significant contribution to the clinical outcomes of CHF. This means that non-pharmacological treatment is significant in the treatment of heart failure among elderly patients. In a study by Giuseppe et al., (2005), the use of angiotensin-converting enzyme inhibitors (ACE-inhibitors) appears to be improving cognitive performance in patients with CHF. This study, however, was not able to determine the role of the ACE-inhibitors in improving cognitive performance. This may be attributed to chronic cerebral hypoperfusion resulting from left ventricular systolic dysfunction and systolic arterial hypotension; a reduction in the cognitive performance is commonly noted in patients with CHF. Another study carried by Kostis et al. (1994), it was found that non pharmacological management therapy positively affects functional capacity, body weight and mood status but pharmacological treatment using digoxin partly improved the ejection fraction without changes in the quality of life. Kostis et al. (1994) study concludes that non pharmacological treatment of CHF is better that pharmacological. However, they relied on a single drug and a particular population. It sheds little light on the effectiveness of non pharmacological treatment over pharmacological treatment among the elderly patients. Although these studies mention either pharmacological or non pharmacological treatment therapies in the treatment of HF, not all are dealing with elderly patients and not all are compares exhaustively the effectiveness of either of the management interventions. Most of the studies carried out on the treatment regimen for CHF single out one regimen and compare it with other clinical outcomes. Very minimal research, if any, has come out to compare the effectiveness of either pharmacological or non-pharmacological management with an aim to establish, which regimen can prevent reoccurrence of heart failure among elderly patients of CHF. In my own experience, there has been an interesting result for patients who adhere with the regimen as advised by the doctor. Interestingly, as doctors, I rely on either pharmacological, non pharmacological and mostly a combination of the two depending on the patient I am dealing with. For elderly patients with CHF, there is a challenge in compliance with both, and this makes the rate of reoccurrence high among them. Therefore, it is time research is carried to find out which management therapy will be more effective in preventing reoccurrence of the CHF. CONCEPTUAL FRAMEWORK Conclusion In conclusion, the literature review shows that drugs, non pharmacological therapies (including diet control and use exercise) or a combination of these two therapies can be used to manage CHF. Research gaps that still exist include: determining the most effective mode and dose of administration of diuretic, the appropriate way of examining the effect of non pharmacological treatment therapies in managing CHF and the best management therapy that can reduce CHF recurrence among the aged people. According to this review, much has been done on CHF although controversies still exist on the findings and, therefore, there is need for more research on controversial issues surrounding pharmacologic and non- pharmacologic management and prevention of the reoccurrence of heart failure in patients. In order to determine which management therapy is best for effectively preventing reoccurrence of congestive heart failure among the elderly patients, all these factors will have to be put into consideration. References Brook, B.,Terry, A. L., Biddle, M. S., Misook, I. C. & Debra, K. M. (2009). Demonstration of psychometric soundness of the Dietary Sodium Restriction Questionnaire in patients with heart failure Heart & Lung, 38(2),121-128 Donner, A., Correa, S., Brunetto, S., Schweigert, P. & Biolo, A. (2012). Nutritional orientation, knowledge and quality of diet in heart failure; randomized clinical trial. Nutr Hosp, 27(2), 441-448. Doris, S., Diana T., Lee J., Elsie H. (2007). Non-Pharmacological Interventions in Older People with Heart Failure: Effects of Exercise Training and Relaxation Therapy. Gerontology, 53, 74–81. Felker, et al. (2011). Diuretic Strategies in Patients with Acute Decompensated Heart Failure. The New England journal of medicine, 364, 797-805. Giuseppe, Z., Graziano, O., Emanuele, M., Maria, R., Matteo, C., Alberto, C., Pierugo, C., & Roberto, B. (2005). Use of angiotensin-converting enzyme inhibitors and variations in cognitive performance among patients with heart failure. European Heart Journal, 26, 226–233. Kostis, J. B., Raymond, C. R., Nora, M. C. (1994). Nonpharmacologic Therapy Improves Functional and Emotional Status in Congestive Heart Failure. Chest, 106, 996-1001 Larsen, A., Aarsland, T., Kristiansen, M., Haugland, A., & Dickstein, K. (2001). Assessing the effect of exercise training in men with heart failure: Comparison of maximal, submaximal and endurance exercise protocols. European Heart Journal, 22, 684–692. Marie, H., Anna, S., Maud, L., & Ronnie, W. (2008). Description of self-reported fluid intake and its effects on body weight, symptoms, quality of life and physical capacity in patients with stable chronic heart failure. Journal of Clinical Nursing, 17, 2318–2326. Martje, H. L., Dirk, J., Van, V., Nic, V., Frans, H. R., & Tiny, J. (2010). Compliance with non-pharmacological recommendations and outcome in heart failure patients. Eur Heart J. 31(12), 1486-1493 Rich, M., Michael, W., Valerie, D., Beckham, R. N, Wittenberg, C., Charles, L., Kenneth, E. & Robert, M. (1995). A Multidisciplinary Intervention To Prevent The Readmission Of Elderly Patients With Congestive Heart Failure. The New England Journal of Medicine, 333, 1990-1995. Read More