Nonpharmacologic Management and Health Care Maintenance in Patients With Chronic Heart Failure
Specific Activity and Lifestyle Issues
Recommendation
It is recommended that screening for endogenous or prolonged reactive depression in patients with HF be conducted following diagnosis and at periodic intervals as clinically indicated. For pharmacologic treatment, selective serotonin reuptake inhibitors are preferred over tricyclic antidepressants, because the latter have the potential to cause ventricular arrhythmias, but the potential for drug interactions should be considered. (Strength of Evidence = B)
Background
Depression is common in both elderly and HF populations and has an enormous impact on quality of life and functional capacity.42-44 It is an independent risk factor for coronary heart disease and is associated with increased morbidity and mortality.43,45 In a recent prospective cohort study in outpatients with HF and LVEF <40%, living alone, alcohol abuse, perception of medical care as being a substantial economic burden, and health status were independent predictors of developing depressive symptoms.46 Clinicians should be aware of patients at risk for the development of depression so that they may be targeted for screening and psychosocial intervention, as needed. Several screening questionnaires for depression are available.
Selective serotonin reuptake inhibitors (SSRI) are effective and generally safe in patients with HF. Tricyclic antidepressants have anticholinergic that increase heart rate, promote orthostatic hypotension, and alter ventricular repolarization. A recent study evaluating the association of long-term mortality with antidepressant use versus depression in patients with HF found that depression, but not the use of an SSRI, was associated with a 33% increased mortality risk in 1006 patients followed up over a mean of 972 days (HR 1.33, 95% CI 1.07-1.66).47
Recommendation
Nonpharmacologic techniques for stress reduction may be considered as a useful adjunct for reducing anxiety in patients with HF. (Strength of Evidence = C)
Background
Anxiety is commonly associated with depression, and often manifests as the inability to adjust to stressful situations. Although it is depression that is predictive of a worse prognosis,48 anxiety should be taken seriously and reduced as much as possible. An assessment of intrinsic coping skills may be useful. Relaxation techniques such as meditation and biofeedback may improve patient daily functioning.49 In one small study, researchers found that acupuncture inhibited sympathetic activation during mental stress in patients with advanced HF.50
Effective communication skills can reduce anxiety. The diagnosis of HF and its prognosis are likely to provoke anxiety. Anxiety, in turn, may contribute to a patient's inability to comprehend or follow a treatment plan. In discussing recommendations regarding end-of-life issues, including advance directives, care should be taken to avoid inducing excessive anxiety.
Recommendation
Anxiety is commonly associated with depression, and often manifests as the inability to adjust to stressful situations. Although it is depression that is predictive of a worse prognosis,48 anxiety should be taken seriously and reduced as much as possible. An assessment of intrinsic coping skills may be useful. Relaxation techniques such as meditation and biofeedback may improve patient daily functioning.49 In one small study, researchers found that acupuncture inhibited sympathetic activation during mental stress in patients with advanced HF.50
Effective communication skills can reduce anxiety. The diagnosis of HF and its prognosis are likely to provoke anxiety. Anxiety, in turn, may contribute to a patient's inability to comprehend or follow a treatment plan. In discussing recommendations regarding end-of-life issues, including advance directives, care should be taken to avoid inducing excessive anxiety.
Background
Sexual dysfunction is common in patients with heart disease and should be discussed openly with all patients, male and female. Standard HF therapy may worsen sexual dysfunction in some patients, leading to nonadherence and worsening of HF symptoms.51 Use of phosphodiesterase-5 inhibitors generally is safe when HF symptoms are compensated and there is no concomitant use of nitrate medications. In fact, a number of studies showed a positive impact of sildenafil on cardiac performance, particularly exercise capacity, in patients with HF.52-54
Many other nonpharmacologic aids exist for erectile dysfunction, impotence, and other forms of sexual dysfunction. Patients reluctant to initiate discussion regarding sexuality or who are unaware of treatment options may be intentionally noncompliant with HF medications to determine their influence on sexual dysfunction. A proactive discussion may therefore alleviate some risk of adherence-related clinical instability.