balance a publication of HCR ManorCare | Spring 2014
Cardiac Health
YOURHEART
Getting to the heart of the matter.
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ach day, the heart pumps almost 2,000 gallons of oxygen rich blood to every living cell in the body. In order to supply the tissues with this critical nourishment the average heart needs to beat almost 100,000 beats every 24 hours‌delivering in total almost 65 million gallons of blood in one’s lifetime. When the heart fails to pump blood at a rate sufficient enough to meet the many requirements of the body, the result is heart failure. Before the 1900s, very few people suffered from and even fewer died from heart failure. Since then, however, heart disease has become the number one killer in the United States. Congestive Heart Failure (CHF) has been identified as the most frequent cause of hospitalizations in patients over the age of 65 years and results in a 25% hospital readmission rate within 30 days of hospital discharge. With 670,000 new cases identified each year, CHF has become the fastest growing and clinically most relevant cardiac disease in the United States. For indeed, while the age of technology has made life easier for millions of us, it has also made us more prone to heart disease. Before the Industrial Revolution, most people made their living through some sort of manual labor. Walking was the major means of transportation. Most daily tasks were done by hand. Stairs were climbed, carpets were beat, laundry was scrubbed, and butter was churned. With the arrival of automation, life became less strenuous.
Consulting Cardiologist, like Jason Robin, MD from Chicago, Illinois provide clinical and educational oversight to HCR ManorCare Cardaic Core Programs as well as individual patient consultation. Initiation and management of cardiac medications by HCR ManorCare physicians and nurse practitioners is a mainstay in CHF treatment initiatives which has been proven to improve survivability, decrease disease progression and decrease CHF readmissions.
Most manual labor was either replaced or assisted by machinery. Automobiles, washing machines, elevators, and vacuum cleaners became commonplace. Modern conveniences made physical activity unnecessary. Along with the change in lifestyle came a change in diet. Machines were built to homogenize milk, process cheese, churn butter, and make ice cream. Previously, such high-fat treats had to be made by hand. Fried foods, like potato chips, hamburgers, and French fries, became staples in many diets. The combination of a sedentary lifestyle and a rich diet led to an increase in clogged blood vessels, heart attacks, and strokes. Heart disease became commonplace. In fact, the rate of heart disease increased so sharply between 1940 and 1967 that the World Health Organization called it the world’s most serious epidemic.
The field of cardiology has grown tremendously to meet the demands of the disease.
Dr. Robin HCR ManorCare Cardiac Core Program
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YOURHEART
Today, the causes of heart disease are known and to a certain extent, so are the treatments. The field of cardiology has grown tremendously to meet the demands of the disease. Through the years, tools and techniques for treating heart disease have also evolved to meet the increased need. While many causes of heart disease are not always reversible, the signs and symptoms frequently can be treated with well-established pharmacologic, dietary, and therapeutic modalities.
HCR ManorCare works with patients and their medical team to achieve improved outcomes for patients with cardiovascular disease. The use of medication regimens has been consistently shown in well-designed research protocols to not only improve the symptoms of CHF, but also to reduce hospitalization disease, and death. In addition, life and health modifications such as the monitoring of daily weight, reducing salt intake, increasing functional activity, muscle strengthening, and regular physician follow-ups have also proven effective in decreasing symptoms of and in reducing hospitalizations from decompensated CHF. These strategies which have been implemented in most primary and acute care settings nationwide have been expanded into the post hospital environment allowing for a successful transition from hospital to post hospital rehabilitation to home. HCR ManorCare’s team of physicians, consulting cardiologists, center-based nurse practitioners , nurses, therapists and dietitians strive to ensure proper compliance with established medical regimens, specific evidenced-base care pathways, therapeutic interventions and patient education in an effort to improve the quality of lives of our patients while reducing unnecessary and preventable hospital readmissions, morbidity and mortality.
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YOURHEART
Cardiac patients’ weights are monitored daily during their initial stay as a part of the HCR ManorCare Transition of Care Initiatives. Frequent measurements of body weight are a cornerstone of CHF therapy. A weight gain of 3-5 pounds within a 7 day window may signal the need for a medication change.
Nurse Practitioner Patty Jergens, ARNP, works with the Tacoma, Washington team to help improve the quality of life of patients while reducing unnecessary and preventable hospital readmissions, morbidity and mortality. Despite all of the best efforts of their treating physicians and the patients themselves, many patients will remain refractory to interventions and will require more advanced therapy including surgical correction of significant coronary artery disease, repair of valvular lesions, placement of implantable defibrillators and hospital admissions for IV medications. For truly end-stage CHF, consideration for implantation of ventricular assist devices (VAD’s) as either a bridge to transplantation or destination therapy may be considered for appropriate patients. For these patients a strong post-hospital rehabilitation plan like the ones offered at HCR ManorCare will be a critical step in improving their outcomes.
ASK
the doctor.
Heart Failure (also called congestive heart failure or CHF) is a result of heart disease that occurs when the heart is unable to provide sufficient pump action to maintain blood flow to deliver enough oxygen to meet the needs of the body.
CLASS
Here are some recommendations to help you feel better, to monitor yourself more closely and to stay out of the hospital: • Watch your salt intake, A low salt diet is a basic component in the prevention of heart disease.
MILD
I
MILD
II
MODERATE
• Weigh yourself regularly and call your doctor for weight gain greater than 3 pounds in 24 hour, or 5 pounds in 7 days. • Consult your physician if you develop lightheadedness, chest pains, shortness of breath, worsening fatigue, cough or dizziness. • Worsening and/or shortness of breath with exercise is often the earliest symptom of worsening heart problems.
SYMPTOMS
SEVERE
III
IV
No limitation of physical activity. Ordinary physical activity does not cause undue fatigue, rapid/irregular heartbeat (palpitation) or shortness of breath (dyspnea). Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in fatigue, rapid/irregular heartbeat or shortness of breath.
Marked limitation of physical activity. Comfortable at rest, but less than ordinary physical activity results in fatigue, rapid/irregular heartbeat or shortness of breath.
Unable to carry on physical activity without discomfort. Symptoms of fatigue, rapid/irregular heartbeat or shortness of breath are present at rest. If any physical activity is undertaken, discomfort increases.
> New York Heart Association (NYHA) The Stages of Heart Failure.
• The New York Heart Association (NYHA) classification is used to judge the severity of heart disease.
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HEALTHTIP
How many of us are doing the recommended level?
The benefits of
Exercise
Many Americans are not as active as they should be as evidenced by the high rate of obesity in our society. Additionally, as we age, people also become less physically active. According to the Centers for Disease Control, less than half of all adults achieve the physical activity guidelines as described on the next page. How do I get started at home?
There is strong medical evidence that exercise improves health in all age groups including older adults. For those individuals with heart disease, exercise training has been shown to: 1. Reduce cardiovascular risk factors such as high cholesterol, high blood pressure, stress and obesity 2. Improve your aerobic capacity and your tolerance to exercise by allowing you to perform activities with lower heart rates 3. Lower your resting heart rate and blood pressure 4. Reduce anxiety and depression 5. Increase your bone density, joint flexibility, and muscle efficiency
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In addition to outlining these benefits of an exercise program, the American Heart Association and the American Association of Cardiopulmonary Rehabilitation have emphasized that a key fundamental for any cardiac rehabilitation program is a secondary prevention program. HCR ManorCare provides an interdisciplinary but individualized approach to delivering medical and rehabilitation interventions to cardiac patients that allows for restoration of function, accommodation to dysfunction and prevention of coronary disability. Cardiac Rehabilitation for patients who have suffered a cardiac event or who have undergone a cardiac procedure progresses in phases depending on one’s level of recovery: Phase I : The Acute Phase The acute rehabilitation phase, characterized by early mobilization with cardiac monitoring, is initiated in the hospital by trained therapists. Phase 1b: The Functional Phase The subacute rehabilitation phase uses inpatient rehabilitation in an acute or skilled rehabilitation setting to assist with early mobilization, strengthening and functional mobility. Phase 2: The Outpatient Phase The outpatient, training, phase of cardiac rehabilitation, is supervised by trained therapists. Typically, the cardiac training program is 3 sessions weekly for up to 8 weeks. Phase 3: The Maintenance Phase The maintenance phase of cardiac conditioning is essential to the success of the program. This program is lifelong.
Any individual with a chronic health condition such as cardiac disease, diabetes or arthritis should consult their physician before beginning an exercise program. Your medical provider and physical therapist will discuss your exercise program as you prepare to leave the post- acute center. They can assist you in choosing an activity that you enjoy (such as walking) and that you are physically able to perform.
The American Heart Association Guidelines for Physical Activity
[1]
Regular physical activity can relieve tension, anxiety, depression and anger. You may not only notice a “feel good sensation” immediately following your physical activity, but most people also note an improvement in general well-being over time during the weeks and months as physical activity becomes a part of your routine.
150 minutes per week of moderate exercise or 75 minutes of vigorous exercise weekly
30 minutes a day 5 days a week is a good way to achieve 150 minutes per week
It’s helpful to exercise with someone else to keep each other motivated and compliant with the exercise commitment. Remember that exercise is a habit so stick with it and you will benefit! You may also want to look into community resources such as programs offered at the YMCA or senior community center. What resources are available to help? There are many great resources for starting an exercise program. Remember to discuss any activity with your provider before undertaking! Some Internet websites have on-line logs to track your progress or “apps” to find and measure walking paths. A few suggested resources are:
American Heart Association Start Walking Now program www.StartWalkingNow.org National Institutes for Health/ National Institute on Aging Go 4 Life program http://go4life.nia.nih.gov
Activity may be performed in 10-15 minute segments throughout the day to accomplish the 30 minutes
Muscle strengthening exercises should be done at least 2 days per week Flexibility and stretching should be included
Order exercise and physical activity publications for free at: http://newcart.niapublications.org/ shopdisplayproducts.aspx?id=5&cat= Exercise+And+Physical+Activity
1 Centers for Disease Control, http://www.cdc.gov/physicalactivity/data/facts.html, accessed Feb 21, 2013.
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NUTRITION
Nutrition and Cardiac Health
Eat fatty fish such as salmon, tuna, mackerel and sardines for heart healthy omega 3 fatty acids
Eat at least
What is Sodium? Sodium is a mineral found naturally in many foods. The most significant source of sodium in the diet is table salt, which is about 40% sodium. Processed, convenience, and preserved foods also contain a large amount of sodium. The body needs very little sodium to function well. Why Limit Sodium?
Suggestions • Eat at least 3 servings of vegetables every day • Avoid foods containing high amounts of saturated fats (examples: meat, butter, lard and full fat dairy products) • Read food labels and do not eat foods containing trans fatty acids (examples: stick margarine, shortening, high fat pre-packaged baked goods) • Buy whole wheat bread products, brown rice and whole grain cereals to add fiber and antioxidants to your diet • Eat fatty fish such as salmon, tuna, mackerel and sardines for heart healthy omega 3 fatty acids • Eliminate processed and convenience foods • Limit sodium intake by not adding salt during cooking or at the table
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A build-up of sodium in the body can cause thirst, increased blood pressure, shortness of breath, and water retention. Decreasing sodium in the diet can reduce fluid retention and the risk of heart attack or stroke associated with high blood pressure. Keep in mind that there are many other factors involved in these health problems. Heredity, obesity, lack of exercise, cigarette smoking, stress, and what you eat all play a role. Eating Out Generally, foods served in restaurants are often seasoned with salt and/or MSG. Request to have an item prepared without these seasonings. Good choices are broiled or roasted meats, fish, or poultry without sauces or gravies. Baked potato and salad should be ordered with allowed dressings on the side. Fruits and sherbet or ice cream are lower in sodium than rich pastries and desserts (such as pie). “Fast foods” are generally high in sodium. Careful selection is required. For example, choose a hamburger, roast beef, or sliced chicken sandwich without added condiments (like “secret sauces”). Lettuce, tomato, and mayonnaise are okay.
>
Being overweight, not exercising and having high cholesterol levels have been associated with an increased risk of developing heart disease. Good eating habits and lifestyle changes can help lower the risk. Eating foods high in dietary cholesterol, trans fatty acids and saturated fat raises cholesterol in the blood. A diet rich in whole grains, fruit, vegetables, and omega 3 fatty acids may help with weight loss, lower cholesterol and decrease your risk of heart disease.
servings of fruit every day.
HCR ManorCare skilled nursing centers have teamed up with Sodexo to provide patients with healthy , nutritious meals made from scratch in the center’s kitchen. Our clinical dietitians consult with the patient and family as well as the care team to develop customized nutrition plans to help ensure patients receive the best possible nutritional care to meet their individual goals. Our wellness program’s nutrition criteria meet the dietary guidelines of most health organizations.
Additional Information: Refer to the following websites for additional information on nutrition and cardiac health: American Heart Association www.heart.org Dietary Guidelines for Americans health.gov/dietaryguidelines/ USDA MyPlate Choosemyplate.gov Consult with your physician or registered dietitian if you have questions.
Adapted from Sodexo Senior Living, Resident and Nutrition Services, Heart Healthy Living; Sodexo, Feed your body of knowledge, When your nutrition prescription is two gram sodium, 9/2012; Sodexo, Feed your body of knowledge, Nutrition guidelines for heart health, 9/2012
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THEPHARMACY
Just what the
Dr. Ordered
T
he foxglove plant is a biennial plant grown in ornamental gardens because of its many bright colored flowers. It like many plants and herbs found in nature has a prominent place in pharmacologic “hall of fame.” Foxglove, known as Digitalis purpurea, has been used as early as the year 1250 in herbal prescriptions to make patients with heart conditions feel better but it wasn’t until 1998 that this lifesaving cardiac medication was approved for heart failure by the Food and Drug Administration. The delay in approval by the FDA was as much about ensuring efficacy as it was about proving safety. Whether by prescription or over the counter, one of the primary fundamentals in taking medication for heart disease is making sure that the medication is safe and effective. It is important that you always talk to your doctor or pharmacist before using any over-the-counter (OTC) medications or herbal preparations if you have heart disease. While there are an almost infinite number of medications that will impact heart function, we have listed a few medications that you may want to discuss with your medical care providers. ACE-INHIBITORS This class of cardiac medications includes Vasotec, Capoten, and Lisinopril. ACE—Is are considered a mainstay of therapy for patient’s with heart failure. Medical evidence has shown that these medications improve survivability, decrease disease progression and reduce readmissions. Cardiologists will often recommend that ACE-Is be titrated slowly on a week-to-week basis while diuretics are being weaned in order to enhance and maintain cardiac function. DIURETICS Cardiologists will often recommend a diuretic like Lasix for patients with New York Heart Association Class II, III or IV (see page 2).
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Daily diuretics may not be necessary in patients who are on a strict low-sodium diet and have no signs or symptoms of congestion. Spirinolactone, also known as Aldactone is a diuretic that has been shown to lower mortality and decrease hospitalization rates in patients. BETA BLOCKERS While beta blockers have an important place in the treatment of heart disease; historically, they have been avoided in patients with heart failure. NONSTEROIDAL ANTI-INFLAMMATORY DRUGS Nonsteroidal anti-inflammatory drugs (NSAIDs) like high dose aspirin, Ibuprofen (Advil and Motrin) and Naproxen (Naprosyn and Aleve) can block the effects of diuretics and ACE inhibitors, causing some patients to become refractory to treatment. Additionally, at least one study cited a twofold increase in hospitalizations for heart failure in elderly patients taking diuretics and NSAIDS. CALCIUM CHANNEL BLOCKERS Calcium channel blockers, with the exception of amlodipine (Norvasc), should be used cautiously in patients with heart failure. DECONGESTANTS Decongestants are commonly noted in cold, cough, flu, or sinus medications. They may make your blood pressure and heart rate rise. Higher blood pressure puts an extra burden on your heart. Common Decongestants include Oxymetazoline (Afrin, Dristan, and Vicks Sinex), Phenylephrine (Sudafed PE, Suphedrin PE) and Pseudoephedrine (Silfedrine, Sudafed, and Suphedrin) and herbal remedies such as ma huang and Herbalife. Many medicines combine an antihistamine and decongestant, like Allegra-D, Benadryl Allergy Plus Sinus, Claritin-D, and Zyrtec-D. DIABETIC MEDICATIONS Diabetes medications should be discussed with your doctor as some patients may want to avoid such products as Metformin (Glucophage), Rosinglitazone (Avandia) and Pioglitazone (Actos) because they can worsen heart failure.
For more information on your heart and medication or to learn about HCR ManorCare’s cardiac core programs, please visit our website at www.heartland-manorcare.com.
balance a publication of HCR ManorCare Spring 2014
www.hcr-manorcare.com HCRMC-0029A ŠCopyright 2013