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Clinical Decisionmaking

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Problems in self-management of congestive heart failure may contribute to ER visits and poor prognosis

Congestive heart failure (CHF) affects nearly 5 million Americans, and it is the most common reason for emergency room visits and hospitalizations among the elderly. Despite many studies showing the effectiveness of medications in improving survival and quality of life, the prognosis for individuals with CHF is poor; 75 percent of the men and 62 percent of the women die within 5 years of diagnosis. Problems in self-management of the disease may contribute to this poor prognosis, according to a study supported in part by the Agency for Healthcare Research and Quality (HS10402).

CHF is characterized by breathlessness, usually due to fluid buildup in the lungs, and abnormal sodium and water retention, which results in swelling that slows blood flow out of the heart. Unfortunately, many patients don't see CHF symptoms as warning signs that they need treatment. Doctors should advise patients to regularly monitor early markers of fluid retention that signal a deterioration, including increases in weight, swelling (for example, in the legs and ankles), and shortness of breath. Ideally, patients should weigh themselves daily and contact their doctor if their weight changes by more than 3-5 pounds so that their diuretic dose can be adjusted.

Doctors should advise CHF patients to take their prescribed medications and follow a very low sodium diet to avoid fluid retention, suggests lead author Carol R. Horowitz, M.D., M.P.H., of Mount Sinai School of Medicine. Dr. Horowitz and her colleagues conducted interviews with 19 CHF patients at an urban hospital to gauge their understanding of CHF and what underlies their self-care routines.

Most patients did not understand that symptoms such as swelling and shortness of breath were closely related to their salt intake or to an underlying problem with their heart. They also did not recognize that these symptoms worsened over time from their chronic baseline symptoms to an acutely severe state that required urgent care, thus landing them in the emergency room. As a result, they often did not routinely manage symptoms to prevent or minimize exacerbations of their condition.

See "A story of maladies, misconceptions and mishaps: Effective management of heart failure," by Dr. Horowitz, Stephanie B. Rein, M.D., and Howard Leventhal, Ph.D., in Social Science & Medicine 58, pp. 631-643, 2004.

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