Managing
Altered
Heart Function
Prepared for:________________________
Confidential information in this handout is for your personal reference only. No other copies exist.
Created by:
Susan J. Kerr RN BSc BSN
Coordinator/Case Manager
Heart Function Clinic
Updated February 2010
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TABLE OF CONTENT
Page Number
1. Normal Physiology
2. Function of the Heart
3. Causes of Altered Pump Function
4. What Is Heart Failure?
5. Ejection Fraction
6. Types of Altered Heart Function
7. Symptoms
8. Treatment for Heart Failure
9. Medications
10. Self Management Skills
a. Fluid Restriction
b. Sodium Restriction
c. Daily Weights
11. Signs and Symptoms of Altered Heart Function
12. Exercise
13. Advanced Directive
14. In Conclusion…
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1. Normal Physiology
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2. Function of the Heart
FUNCTION: to move blood ↓ O2 to the lungs and then distribute blood
↑ O2 to the body.
So, our heart is a
PUMP
However, not everyone’s pump is working as well as it used to.
3. Causes of Altered Pump Function
Some of the more common causes of altered pump function are:
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previous heart attack or narrowing in your coronary arteries
high blood pressure
viruses
diabetes
sleep apnea
having a higher than average alcohol intake
problems with heart valves
related to certain medications i.e./ chemotherapy
rapid heart rates
genetic causes
and sometimes we don’t know the causes…
4. What is Heart Failure?
To help explain where the problem lies, let’s look at the actual definition of
the words “heart failure”.
For years and years, doctors and other health professionals have called
altered heart function “heart failure”.
The words “heart failure” are very scary ones to hear!
“Heart failure” is really another medical abbreviation for:
your heart is failing to meet your body’s needs for oxygen.
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Your heart has not stopped nor is it about to stop working, but your heart is
no longer pumping as efficiently as it used to.
Heart failure begins when the heart is damaged or weakened. It looks as if
your pump function may have been altered as a result of:
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Your body tries (unsuccessfully) to adapt to your altered pump function in a
few ways:
1. It hangs on to salt and water in an effort to increase the amount of
fluid in your blood stream.
2. It can also increase your heart rate (your pulse) and the size of your
heart.
Chronic heart failure is progressive, which means it does get worse over
time. Although heart failure usually cannot be cured, various treatments can
control the symptoms, can decrease the chance of hospitalization and can
improve the quality of your life.
5. Ejection Fraction
How do we know that your pump isn’t working as well as it used to?
We do testing such as an Echocardiogram or a nuclear study called a MUGA
to determine a measurement called an:
Ejection Fraction = EF
Ejection fraction tells us how well your heart “squeezes” with each beat.
Normal EF = 60%
(never 100% because when your heart beats, it never forces
all the blood out of it. There is always a residual volume of
blood that remains in the heart.)
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Do you know your ejection fraction? If you do, you can write it in here.
My EF = ________%
Month
Year
If you don’t, ask your doctor what it is and record it in the space above.
Why do an ECHO instead of a nuclear EF or MUGA?
A nuclear EF gives us a more accurate, specific value, for example 27%.
ECHO gives us an estimation of the EF in the form of a range, for example
20-25%.
The ECHO gives us other information that the nuclear study doesn’t. It tells
us:
• how well the walls of the heart are moving
• how well the valves of the heart are working
• the size of the left ventricle
We are very interested in the size of the left ventricle because it does most of
the work of your heart. It works best at a certain size. Once it becomes
enlarged or stretched, the function of your heart becomes less effective.
6. Types of Altered Heart Function
There are two different types of altered heart function
1. If your EF is lower than normal, your heart muscle is not as strong as
is used to be. Because your heart muscle is not as strong as is used to
be, it can’t squeeze as hard as it used to, to move more blood out of
it with each beat.
2. If your EF appears to be in the normal range, your heart muscle is
strong but it is still not functioning as well as it once did. Your heart
is having difficulty relaxing between beats, which makes it difficult
for your heart to fill with blood prior to the next heart beat.
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7. Symptoms
You may be having some symptoms now, or may have had some in the past.
Some common symptoms include:
• Shortness of breath
• Swelling of feet and legs
• Swollen or tender abdomen
• Cough with frothy sputum
• Difficulty sleeping at night due to breathing problems
• Chronic lack of energy
• Confusion +/- impaired memory
We will talk more about this a bit later in this booklet on page 15.
8. Treatment for Heart Failure
Regardless of the cause of your heart failure or the kind of heart failure you
have, the treatment is the same. The treatment plan includes:
• Consistent use of medications, as prescribed
• Self-management strategies (things you can do at home)
• Participating in a regular exercise program
• Working toward your ideal weight
• Limiting your alcohol intake
• Smoking cessation
• Some people require further testing such as angiograms to check out
if they have any blockages in their coronary arteries
• Some people are referred to other specialists as necessary for
specialized devices such as implantable defibrillators or for
consideration for transplant
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9. Medications
While heart failure cannot be cured, the progression of it can be slowed
through the use of medications. Medications may also:
• Relieve your symptoms
• Decrease your risk of complications
• Increase your long-term survival
We tend to use two classifications of medications to help improve the
function of your heart:
1.
2.
ACE Inhibitors* (= Angiotensin Converting Enzyme Inhibitors)
β-blockers
*sometimes Angiotensin Receptor Blockers = ARB’s are used instead of
ACE Inhibitors, if an annoying, tickly cough develops
Please refer to information handout in the folder entitled “Medications –
Your heart medication”
It is important to keep an up-to-date list of your medications with you at all
times. This list should include:
• The name of your pharmacy
• The name of the medication you take
• The dosage in milligrams (or micrograms) of the medication you take
• The number of times a day you take the medication
For example, Ramipril 5 mg, twice a day (instead of Ramipril, 2/day because
Ramipril comes in 1.25mg, 2.5 mg, 5 mg, 10mg and 15 mg capsules)
Please inform your healthcare professional if you have made changes to your
medication regime on your own.
PLEASE NOTE: It may take time to determine what combination of
medications works best for you.
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10. Self-Management Skills
There are also some things that you can do at home that can make you feel
better.
a. Fluid restriction
b. Sodium restriction
c. Daily weights
a. Fluid Restriction
If you are regularly taking a water pill, your symptoms of shortness of
breath and tiredness can be improved if you limit the total amount of fluids
you take in a day to:
6 –8 cups
or
Please note:
1 cup = 250 mL
4 cups= 1 L
1½-2L
Limiting fluids is a difficult concept to grasp, especially when the media is
telling us to “drink 8 glasses of water a day”.
When we ingest fluid, it moves from our stomach to our bowels. In our
bowels, the fluid is absorbed and enters our bloodstream.
When your “pump” isn’t working as effectively as it used to, the extra
volume is too much for your heart and it will cause some of the symptoms
that you have been experiencing, such as shortness of breath and swollen
ankles.
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6 –8 cups
or
1½-2L
This number is a combined total of all fluids you ingest in a 24 hour period
and includes:
coffee
tea
juice
milk
pop
water
alcohol
soup
ice cream
Jell-O
yogurt
fruit
etc…
Please refer to (pink) information handout in the folder entitled “Monitoring
Your Fluid Intake”
Included in this pamphlet is the fluid volume of certain common fruits.
Please note that bananas do not contain significant amounts of fluid.
We don’t want you making tea and coffee in a measuring cup, but perhaps
you could measure your fluids for about three days just to get an idea of the
amount of fluids you take in a day.
For those three days, drink what you normally would. Try placing a large
measuring cup or pitcher on the counter. Have your cup of tea or coffee or
juice or bowl of soup, for example. When you have finished it, fill the
glass/cup/bowl to the same level with water and empty it into the jug on the
counter. If you have a piece of fruit during the day, add the appropriate
amount of fluid for that fruit into the jug.
Don’t forget to include the water used to take pills and milk used on cereal.
At the end of the day, see how much your total fluid intake has been by
checking the water level in the large measuring jug. Record this value.
If after a three-day sample, you are finding you are falling into the 6-8 cup
range per day, then you can continue with your regular fluid intake.
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If you find you are above the 6-8 cup range, you need to look at your fluid
intake and determine where you think you would be able to cut back on
some of your fluid.
Remember: try not to ingest all your fluids in the morning, leaving none for
the evening.
You can use the “Heart Function Log Sheet” (white) to monitor your daily
fluid intake.
b. Sodium Restriction
Another way for you to help manage your symptoms is to become aware of
your sodium intake. Even if you are not taking a water pill, following a low
sodium diet can improve how you feel.
Salt = Sodium = Na
A diet that is high is salt or sodium causes your body to retain fluid.
As your “pump” is not working as well as it used to, it can’t cope with the
extra fluid in your system.
One small step is to reduce the sodium in your diet by removing the
saltshaker from your table and trying not to add it during cooking.
Another way is to limit processed food. Almost 80% of the sodium in our
diet comes from processed/restaurant foods. As soon as you open a can or a
package of anything, the sodium content of the food increases.
The good news is that most fresh fruits and vegetables, milk, yogurt, whole
grains, pasta, rice, fresh meats, poultry, fish and eggs are naturally low in
sodium.
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Our recommended daily sodium intake is:
Less than 2000 mg of Na per day
which works out to…
approx. 500 mg of Na per meal
Please refer to the (white) information handout in the folder entitled “Why
Is It Important to Reduce My Salt Intake?”
This handout outlines low sodium foods that are excellent choices.
It also suggests foods that are higher in sodium that we would like you to
choose less often.
It gives some alternative seasoning suggestions on page 2. Please do not use
the product called “NoSalt”. It contains no sodium salt, but instead it
contains a potassium salt and if you are taking the medication
spironolactone, your potassium level in your blood could become
dangerously high.
Pages 3 and 4 show some milligram values of sodium in certain foods. If
you have access to the Internet, you can always “Google” the sodium
content of a specific food.
The real reason you have been given a “milligram daily value for sodium” is
because most of the packaged products that we buy now, have a label with
the “Nutrition Facts” on it.
You may already be checking the labels for calories, fats and cholesterol or
grams of sugar. The label also lists how much sodium in milligrams the
food item contains.
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Reading labels can be a bit tricky. The manufactures are hoping they can
fool you!
Let’s go over a few things that might make reading labels a little clearer…
1.
Ignore the “% Daily Value”. It is based on a 2400 mg Na diet but it
can become confusing. It may be easier to think about having 500
mg Na per meal.
2.
Check the serving size that the “Nutrition Facts” box indicates.
Sometimes you are eating a cup of soup, but the information in the
“Nutrition Facts” box is based on a ½ cup serving! If you are eating
twice the “serving size”, remember to multiple the mg of sodium
listed by 2.
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Sodium Reduced Products:
You can buy foods that are labeled sodium reduced, but be careful.
These products have a lower sodium content compared to the same brand
that is not sodium reduced. Sodium reduced products can still be high in
sodium.
For example, if “brand A” has 2000 mg of sodium and “brand A” develops a
second product that has 1800 mg of sodium, they are entitled to label that
product “sodium reduced” because it has less sodium than its first product.
Do check your labels. Sodium content of different products varies quite a
bit. “Brand B” may have only 1200 mg of sodium which is lower than the
sodium reduced product of “brand A” at 1800 mg.
Low Sodium Products:
You can also buy products that are labeled “low sodium”. Only products
labeled “low sodium” are low in sodium. They have to have less than 140
mg per serving to be considered low sodium.
Tips for Eating Out
It is OK to eat meals out. If you know you will be going out for a meal:
1. Try to keep the rest of your day a bit lighter in terms of milligrams
of sodium.
2. You are the consumer. You can ask for your meal to be made
without salt or certain sauces.
3. Look for the “Health Check” symbol at participating restaurants.
These items are lower in fat and may list the number of milligram
of Na per portion.
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c. Daily Weight
One way to monitor your fluid status is by weighing yourself daily.
You can use your daily weight to manage your fluid status because:
1 L of fluid = 1 kg = 2.2 lb
The best time to weigh yourself is:
1. first thing in the morning (before breakfast)
2. after you have emptied your bladder
3. wearing the same clothing
You can use the “Heart Function Log Sheet” (white) to record your daily
weight or you can record your weight on your calendar.
Any rapid changes in weight when you have altered heart function are not
because you ate too much or too little, it is because you are either
retaining or losing fluid.
Rapid changes in weight are defined as:
or of 5 lbs in a week
or
Notify your family doctor
or of 4 lbs in 2 days
Individuals with altered heart function can end up in the Emergency Room if
they become fluid overloaded. A weight gain of 5 lb would be an early sign
of your heart having to work too hard. With your help, you and your family
doctor can intervene early to hopefully decrease your trips to the hospital.
If your weight has gone up, your family doctor may ask you to increase your
water pill for a few days.
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If your weight has dropped below a certain level, your family doctor may
ask you to reduce your water pill for a certain length of time.
The altering of water pills according to your daily weight is patient specific
and depends on other factors such as medications and your current health
status. What worked for you in the past, may not be appropriate now.
11. Signs & Symptoms of Altered Heart Function
Let’s look at the heart again to see from where some of these signs and
symptoms arise…
We will focus on the LEFT side of the heart first.
Represents normal
flow of blood
Represents “back-up”
of flow of blood
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Because your heart is not pumping as effectively as it used to be, blood can
“back up” in the system.
When it backs up on the left side of the heart, it affects the lungs.
Some of the symptoms you may be noticing are:
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•
•
•
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increased shortness of breath (SOB)
a new or worsening cough (may be moist or may be dry and tickly)
inability to lie flat
need to the number of pillows under your head at night
the ability to sleep for awhile (i.e. 1-4 or more hours), then awaken
suddenly feeling very SOB
• being told by a health care professional that you have “crackles” in
your lungs or that your chest is “wet”
Now let’s look at the RIGHT side of the heart. Again, the flow of blood is
from the atrium through to the ventricle…
Represents “back-up”
of flow of blood
Represents normal
flow of blood
Represents “back-up”
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of flow of blood
When blood is backing up on the right side of your heart, it affects the body.
Some of the signs and symptoms you may be noticing are:
• swelling of your feet/legs
• abdominal bloating. A feeling of “fullness” around your middle
• on examination, being told by a health care professional that you have
an “enlarged liver”
• a loss of appetite. You may not have understood why you were hardly
eating anything, but your weight was going up and your clothing was
getting tighter and it all relates back to:
1 L of fluid = 1 kg = 2.2 lb
and the fact that you were starting to retain fluid.
12. Exercise
Think about your heart as it pumps your blood around your body. It does all
the work…
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…when you walk, the large muscles of the legs squeeze the blood vessels
and help return blood back to your heart. They act like a “booster station” to
take on some of the workload of your heart.
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Walking is a great exercise. You should aim for a walk every day.
Everyone is at different activity levels. Some people may be able to walk
for 30-60 minutes every day. Some people may be able to walk up and
down their hallway ten times, three times a day. You need to start at the
level that is appropriate for you.
Remember:
1. you must listen to your body! If you exercise today and tomorrow
you are exhausted, then you did too much exercise the day before.
2. if you are walking and can carry on a conversation, you are walking
at a good pace for you. If you are too short of breath to talk, then
you are walking too quickly. If you could sing, perhaps you could
pick up the pace!
3. warm-up for 10 minutes before you go for your walk. Some basic
exercises are listed on page 7 and 8 of the blue handout “General
Home Activity and Exercise Guidelines”.
4. it is OK to divide your exercise time up into two or more periods.
Perhaps two sessions of 30 minutes is more tolerated than one of 60
minutes.
5. cool down for 10 minutes after a long exercise session.
Choose an activity that you enjoy, such as stationary cycling, using a
treadmill or swimming. The “Take Heart” cardiac rehabilitation program is
available at RJH and in the community. The exercise sessions are carefully
monitored and supervised in a safe environment. Whether you have
exercised before or not, you will learn how to begin and to progress your
individual exercise program based on your current health requirements. The
program is twice a week for 12 weeks and there is a fee for this program.
10. Advanced Directive
An advanced directive has nothing to do with finances. Instead, it is a
document that directs others about the level of health care you would wish
for yourself.
The Vancouver Island Health Authority (VIHA) has produced the “Advance
Health Care Planning” booklet to help you with this process.
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After you have discussed your decisions with your family, you can give your
family doctor a copy of the completed document.
11. In Conclusion…
HealthLink BC is a toll free health information line where you can speak to
a nurse, a pharmacist or a dietician. You can find them on the web at
HealthLinkBC.ca or you can call toll free at 8-1-1.
In case of an emergency, call 9-1-1.
We have gone over a great deal of information today. Take some time to
review what we talked about today. There is a lot of information in this
folder!
Please write down any questions you have and remember to ask your family
doctor at your next appointment.
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