by Eli Kengerlinski, PharmD Candidate 2019
University of Florida, College of Pharmacy
Congestive Heart Failure (CHF), occurs when your heart muscle doesn’t work as well as it should to pump blood. Some conditions, like narrowed arteries in your heart (coronary artery disease) or high blood pressure, gradually leave your heart too weak or stiff to pump efficiently. Most patients struggling with CHF usually present to the hospital with shortness of breath, the most frequent symptom in patients with deteriorating CHF.1 It is crucial to be able to identify if your CHF is worsening. Early management of CHF can prevent hospitalization and equip you with the proper knowledge to identify trigger factors, improve the signs and symptoms of heart failure, and help you live longer.
Presenting CHF Symptoms
Usually CHF patients present to the hospital with worsening symptoms of:
- Shortness of breath and/or difficulty breathing while lying down
- Weight gain (over 2 kg), usually due to leg or ankle swelling caused by fluid retention.
However, there are major medical conditions reported in literature that can occur simultaneously in a patient with CHF, such as Chronic Obstructive Pulmonary Disease (COPD) and Coronary Heart Disease (CHD).1 Therefore, patients hospitalized with worsening CHF can be admitted for more than one reason such as pneumonia (respiratory infection due to COPD worsening), pulmonary edema (fluid built up in lungs due to CHF), or CHD event (heart attack or stroke).
Patients readmitted following COPD exacerbation have 10-20% readmission rate within 30 days post hospital discharge, especially during May to November compared to January indicating seasonal admissions.4 Accordingly, it is crucial to use your inhalers, as prescribed with proper technique throughout the year, and inform your doctor if your symptoms are getting worse during seasonal changes. Also, management of other conditions like CHF, high blood pressure and cholesterol, can help reduce COPD readmission rates, as one condition can worsen another if not properly managed.
How to Tell if Your Condition is Worsening
|Congestive Heart Failure||Chronic Obstructive Pulmonary Disease|
|Shortness of breath when active or at rest||Shortness of breath, especially when active or during exercise|
|Shortness of breath when lying down or at night||Chronic cough (dry or productive) with clear white, yellow, or greenish mucus|
|Wheezing & coughing||Wheezing|
|Rapid or irregular heartbeat||Chest congestion, tightness, discomfort|
|Swelling in your ankles & feet||Unintended weight loss|
|Frequent urination especially at night||Increased usage of short acting inhalers|
|Weight gain of 2-3 lbs/day or 5 lbs/week||Frequent respiratory infections|
|Feeling fatigued or weak||Feeling fatigued or weak|
Preventing Emergency Room Visits and Hospitalizations
While you may not be able to prevent every return trip to the emergency room or hospital, there are some steps you can take to help minimize the possibility:
- Patient Centered care: Effective communication and rapport between healthcare professionals and patients are crucial in preventing hospitalizations. Patients can have precipitating factors due to their other health conditions therefore reporting on signs and symptoms of worsening conditions are important as it would enable the health care provider to practice preventive medicine and construct appropriate treatment strategy after an effective patient assessment.
- Medication Adherence: Being adherent to your medication therapy will prevent disease progression, hospitalizations, as well as additional health care costs.2 There are multiple tools and resources to help patients overcome barriers such as access to medicine, forgetfulness, improper administration technique, perceived side effects, cost, as well as understanding of their disease state and how to appropriately manage their condition. If you have any issues with adherence, make sure to inform your provider as effective communication will provide you optimal treatment.
- Vaccines: COPD admissions are seasonal as studies show strong association with the flu season, however every patient is unique and can have worsened symptoms during seasonal changes, therefore it is highly recommended to get your flu and pneumonia vaccines to decrease chances of readmission.
- Diet & Lifestyle Modifications:
- CHF: Limit your salt and fluid intake, as increase in salt intake can pull water into your body and cause you to swell up. Therefore, it is crucial to weigh yourself every morning to ensure you do not gain more than 2-3 pounds in a day or 5 pounds in a week. If your medication or limited salt intake is not helping you control your fluids, seek your provider immediately as this is a sign for deteriorating CHF.
- COPD: Current smokers should seek smoking cessation as it is the most effective in minimizing symptoms and risk for respiratory infections. Furthermore, COPD patients should avoid dust as well as indoor and outdoor air pollutants. Make sure to follow up with primary care provider within 7 days after discharge for lab tests and assessment to ensure
- CHD: Controlling your blood pressure as well as your cholesterol will reduce the risk for heart attacks as well as stroke. For patients at a higher risk for heart attacks should have NTG sublingual tablets at hand and report to their provider if they start to experience chest pains more than usual as this can indicate a risk for another heart attack. Obesity is also associated with worsened cholesterol and high blood pressure therefore managing your weight as well as your disease states can put you at a lower risk for heart attacks and stroke.
If you’re having trouble managing your disease states, talk to your doctor for a referral to a dietician and/or lifestyle coach who can aid in minimizing your risk for readmissions.
- Shafazand, Masoud et al. “Patients with Worsening Chronic Heart Failure Who Present to a Hospital Emergency Department Require Hospital Care.” BMC Research Notes5 (2012): 132. PMC. Web. 12 Oct. 2018. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3315737/
- Jimmy, Beena, and Jimmy Jose. “Patient Medication Adherence: Measures in Daily Practice.” Oman Medical Journal3 (2011): 155–159. PMC. Web. 12 Oct. 2018. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3191684/
- Ziaeian, Boback, and Gregg C. Fonarow. “The Prevention of Hospital Readmissions in Heart Failure.” Progress in cardiovascular diseases4 (2016): 379–385. PMC. Web. 12 Oct. 2018. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4783289/
- Simmering JE, Polgreen LA, Comellas AP, Cavanaugh JE, Polgreen PM. Identifying patients with COPD at high risk of readmission. Chronic Obstr Pulm Dis. 2016; 3(4): 729-738. doi: http://doi.org/10.15326/jcopdf.3.4.2016.0136