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New Guidelines for Treating Patients With Heart Failure

By Densie Webb, PhD, RD

Bethany, age 55, began to experience shortness of breath over several months while performing her normal daily activities. She didn’t think much of it, until she started to notice swelling in her feet and ankles, and sometimes dizziness, lightheadedness, and a rapid heart rate. After visiting her primary care doctor, Bethany went to see a cardiologist, who ordered blood tests, an echocardiogram, and CT scan to examine the health of her heart.

Much to her chagrin, Bethany, who still considers herself fairly young with many more years ahead of her, was diagnosed with heart failure—but she’s hardly alone.

The number of people diagnosed with heart failure is increasing and projected to rise by 46% by 2030, resulting in more than 8 million people with heart failure, according to the American Heart Association’s 2017 Heart Disease and Stroke Statistics Update.

More specifically, the number of adults living with heart failure increased from ~5.7 million (2009–2012) to ~6.5 million (2011–2014). Data are based on the National Health and Nutrition Examination Survey, which is taken in stages over spans of years, according to the American Heart Association.

Heart failure occurs when the muscles in the heart wall slowly weaken and enlarge, preventing the heart from pumping enough blood throughout the body. When fluid builds up in the body, it’s referred to as congestive heart failure.

Recently, the Academy of Nutrition and Dietetics’ (the Academy) Evidence Analysis Library® updated its 2008 systematic review of MNT for adults with heart failure, specifically systolic heart failure and advanced heart failure.

The new guidelines focus on individualizing therapy to prevent hospital readmissions and improve management of signs and symptoms. A total of 17 recommendations were developed based on the Academy’s systematic review, the American College of Cardiology/American Heart Association Task Force 2013 and 2016 Guidelines, and the European Society of Cardiology 2016 Guidelines.

For dietitians treating adults with heart failure, here are some of the highlights of the new and updated guidelines compared with earlier recommendations that make the RD an integral part of the treatment plan.

New Recommendations

• A dietitian should implement MNT and coordinate care, including the use of supplements, as part of an interdisciplinary health care team.
• Each patient should have a clear, detailed, and evidence-based plan of care that’s updated regularly and shared with all members of the health care team.
• Assessment of energy and protein intake should be individualized. Energy intake should maintain weight and prevent catabolism. The use of 22 to 24 kcal/kg plus an activity factor (spelled out in the guidelines) is recommended for adults with heart failure, but decrease to 18 kcal/kg plus an activity factor in adults with advanced heart failure.
• Unless medically contraindicated, the dietitian should encourage an individualized physical activity plan.

Updated Recommendations

• Protein intake should be individualized, but provide between 1.1 and 1.4 g protein per kilogram of body weight to prevent the breakdown of muscle tissue.
  (Updated 2008 recommendation: 1.12 g/kg for normally nourished patients.)
• Sodium and fluid intake should be individualized within the ranges of 2,000 to 3,000 mg per day and 1 to 2 L per day. Research shows that sodium intakes within this range improved readmission rates, length of stay in the hospital, mortality rates, and quality of life. Renal function and blood urea nitrogen, creatinine, and serum sodium also were improved. It’s important to note that a sodium intake of less than 2 g may not improve clinical outcomes. (Updated 2006 recommendation: 2,000 mg sodium per day and 1.5 L fluid per day restriction.)
• Although supplements such as omega-3 fatty acids, coenzyme Q10, vitamin D, iron, and thiamin have been suggested in the treatment of heart failure, the review concluded that it’s unclear whether they’re appropriate for patients with heart failure.
  (Updated 2007 recommendation, which stated, “The majority of evidence available indicates that patients with heart failure may benefit from using CoEnzyme Q10.”)

— Densie Webb, PhD, RD, is a freelance writer, editor, and consultant based in Austin, Texas.

* Academy of Nutrition and Dietetics Evidence-Based Nutrition Practice Guidelines are intended to serve as a synthesis of the best evidence available to inform registered dietitians as they individualize nutrition care for their clients. Guidelines are provided with the express understanding that they do not establish or specify particular standards of care, whether legal, medical, or other.