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November 9, 2010

Integrated Care of the Heart Failure Team

Expertise in Patient Education and Reducing Recidivism: Advanced Practice Nurses, Dieticians, and Pharmacists Dieticians, pharmacists, nurses, clinical nurse specialists, and nurse practitioners all play a key role in educating hospital- ized HF patients and their families on the importance of medication adherence, sodium and fluid restrictions, smoking cessation, and self-care.149–152 Inpatient education begins in the ED,153 where the impact of the “teachable moment” may be


and continues until discharge.152

Although initiated in

the inpatient setting, this education and counseling continues at outpatient follow-up visits as well. The Joint Commission performance measures mandate that, before being discharged home, all HF patients should receive comprehensive written discharge instructions or other educational materials that address activity level, diet, discharge medications, follow-up appoint- ment, weight monitoring, and plans of what to do should symptoms worsen.155 Although obligatory, the delivery of dis- charge information does not necessarily equate with the acqui-

sition of self-care management skills or behaviors156 tal to optimizing patient outcomes.157


Those involved in educating must actively engage patients, their family members, and primary caregivers to identify and address barriers to self-care management such as lack of motivation, complex medication regimens, cognitive impair- ment, low socioeconomic status, low educational level, and inadequate family and social support157,158 to promote self- care and reduce recidivism.152 To this end, advanced practice nurses (APNs), as part of a multidisciplinary team, emphasize evidence-based holistic care that integrates the family, the environment, and human responses to health and illness.159 Strategies enacted by APNs to improve HF self-care manage- ment during hospitalization include visiting the patient daily, assessing patient and family knowledge, collaborating with the healthcare team and family, and assessing learning capabilities and style.160,161 When combined with APN interventions that facilitate discharge planning and home follow-up care, this approach optimizes discharge planning, improves patient- provider communication, and reduces hospital readmission rates, mean costs, and negative outcomes.160,161

Shifting the Paradigm: Focused Areas for Future Investigation

Novel Diagnostics The advent of natriuretic peptides has dramatically altered the diagnostic landscape for AHFS, adding objectivity to what

previously had been a problematic approach.28,31


these biomarkers are not devoid of limitations. Because natriuretic peptides are released in response to cardiac myo- cyte stress regardless of the underlying cause, they lack the specificity necessary to function as absolute indicators of AHFS, even when serum concentrations exceed established thresholds for diagnosis. Detectable quantities are subject to marked variance on the basis of age,162 sex,163 body habitus,164

renal function,39,165

and abruptness of symptom onset,166


ing in the potential for diagnostic errors and, within the context of research, misclassification bias. It has been suggested recently

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that natriuretic peptide utility can be enhanced through consid- eration of respective values as continuous rather than as dichot- omous measures167; however, the incremental benefit of this has yet to be externally validated.168,169

The search for additional tools to improve the diagnostic accuracy for patients with undifferentiated dyspnea and possible AHFS remains a high priority. Much of this effort has centered on the identification of new serum biomarkers that enable assessment of neurohormonal activity, systemic inflammation, extracellular matrix composition, subcellular oxidative and metabolic stress, or acute cardiorenal injury. Unlike the natriuretic peptides, however, few of these bi- omarkers have been rigorously tested in the acute setting and their prospective clinical role, if any, is unclear. Other modalities such as electronic detection of third heart sounds (S3) using

acoustic cardiography,170–172

noninvasive hemodynamic profil-

ing using impedance cardiography,173,174 bedside portable chest ultrasound to evaluate for accumulated interstitial lung fluid,175–177 and quantitative capnometry178 have been investigated as both stand-alone and adjunct diagnostic measures, but appear to provide little benefit over existing approaches. Cardiovas- cular response to the Valsalva maneuver has been proposed as an additional method by which ventricular filling pressures and volume status can be assessed179,180 but its utility in AHFS management has not been well-defined.

Although often overlooked, the quest for novel diagnostics has been hindered by the absence of a uniformly accepted standard for diagnosis of AHFS. In most studies to date, investigators have used retrospectively applied criterion- based standards or blinded cardiology reviews with resolution of disagreement, accounting for approximately 10% of cases, by adjudicated expert consensus. Although practical, such methodology is suboptimal and may contribute to misleading conclusions regarding true test performance. The definitive diagnostic procedure, pulmonary artery catheterization, is simply not feasible in the ED and, given the unfavorable

risk-to-benefit ratio,118,123

unjustifiable for routine manage-

ment or research-specific purposes in AHFS patients. Exist- ing noninvasive alternatives to pulmonary artery catheteriza- tion such as impedance cardiography have not been shown to correlate sufficiently with regard to left ventricular filling pressures174 and produce unreliable measurements in those with severe dyspnea or diaphoresis. Cardiac MRI is an emerging technology that can provide objective diagnostic information on heart anatomy, contractility and perfusion while enabling assessment of potential acute myocardial injury and residual tissue viability.181 These attributes hold promise for the future of cardiac MRI as an objective test in patients with AHFS. However, at present, applicability is limited by high acquisition costs, technical demands, sparse availability, and the difficulty of acutely dyspneic patients lying flat for prolonged periods.

Echocardiography can provide a substantial amount of information regarding cardiac structure and function and is considered a critical component of the workup for patients with suspected AHFS.182,183 Echocardiography also enables categorization of AHFS patients into traditional subgroups based on left ventricular ejection fraction (ie, preserved or reduced) and may provide important information about vol-

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