May 2018 Issue

Women and Heart Failure
By Judith C. Thalheimer, RD, LDN
Today's Dietitian
Vol. 20, No. 5, P. 24

New guidelines are available to support treatment for this leading cause of hospitalization and death in women.

Heart failure is a chronic, long-term, progressive condition in which the heart muscle becomes too weak to pump oxygenated blood effectively.1 According to 2011 to 2014 National Health and Nutrition Examination Survey data, there are an estimated 6.5 million Americans living with heart failure in the United States.2 This number has been rising and is projected to increase another 46% by 2030.2 An analysis of data by the American Heart Association (AHA) found that women are more likely to be living with, and die from, heart failure.2 It's the leading reason for hospitalization and a major cause of death in women older than 65.3 MNT is a key part of treatment for this condition. To ensure nutrition professionals are up to date on the latest treatment recommendations, the Academy of Nutrition and Dietetics (the Academy) in 2017 released new evidence-based guidance in their Evidence Analysis Library®. "Guidelines like these ensure consistent practice," says Toni Kuehneman, MS, RD, LMNT, chair of the evidence-based nutrition practice guidelines for heart failure in adults in both 2008 and 2017, "and they give us evidence to support our recommendations to the health care team."

Heart Failure's Whole-Body Impact
Heart failure affects the entire body. "Your heart's job is to pump oxygen- and nutrient-rich blood throughout the body," says Sonya Angelone, MS, RDN, CLT, a spokesperson for the Academy, who has extensive experience counseling patients with CVD, including heart failure. "When the heart isn't pumping effectively, the organs aren't getting nourishment and can't function properly." This results in symptoms such as shortness of breath, fatigue, and confusion.

The amount of blood the heart pushes into circulation is called the ejection fraction. In heart failure with reduced ejection fraction (HFrEF), also called systolic failure, the left ventricle loses its ability to contract normally. In a second kind of heart failure, the ventricles contract normally but can't relax and fill fully. This condition is known as heart failure with preserved ejection fraction (HFpEF).4

HFpEF is the most common form of heart failure. It's seen almost exclusively in the older population, primarily in women, and is becoming more prevalent.5 In both these conditions, increased fluid pressure ultimately damages the heart's right side. When the right side loses pumping power, blood backs up in the veins. The resulting congestion in the body's tissues causes swelling (edema), typically in the legs and ankles, and in the abdomen (ascites).4 If fluid collects in the lungs, it causes shortness of breath, especially when the patient is lying down.4

A cascade of events that promotes sodium and water reabsorption by the kidneys exacerbates edema. "When the heart isn't pumping the volume of blood you need, the kidneys think you're hemorrhaging," Kuehneman says. "The kidneys' response to diminished blood flow is vasoconstriction." Peripheral vasoconstriction contributes to feelings of fatigue, as it limits the blood flow to the muscles. As the blood vessels constrict, pressure in the veins increases, which increases edema.6 Once edema begins, the condition is referred to as congestive heart failure.

A form of heart failure unique to women is peripartum (or postpartum) cardiomyopathy (PPCM). This uncommon condition can occur between the last month of pregnancy and five months after giving birth. About 1,000 to 3,000 women develop PPCM in the United States each year.7 PPCM, which begins with fatigue and a cough, may be more likely to be misdiagnosed than other forms of heart failure since the patients don't fit the typical profile. "Heart failure is usually seen in an older population with preexisting risk factors," Angelone says.

Treating Heart Failure
The AHA breaks heart failure into four stages, and nutrition and medication recommendations vary by stage. People at risk of heart failure are said to be in Stage A, or preheart failure. "Coronary artery disease is the number one cause," Kuehneman says, "followed by heart attack, uncontrolled high blood pressure, cardiotoxicity related to cancer treatment, and heart valve disease." Diabetes, metabolic syndrome, a history of alcohol abuse or rheumatic fever, and a family history of heart failure or cardiomyopathy also are risk factors for heart failure.1 Each of these risk factors is treated by the appropriate lifestyle changes (such as dietary changes, regular exercise, and quitting smoking) along with medication as needed. "We approach treating patients with heart failure just like we approach any other condition: We assess, intervene, and monitor," Kuehneman says.

In Stage B of HFrEF, also considered preheart failure, ejection fraction is reduced to 40% or less.1 Patients in this stage still have no symptoms, but additional medications may be necessary.1 Symptoms begin in Stage C.1 "When patients have symptoms, like shortness of breath and fatigue, it becomes essential to restrict sodium and control fluids," Angelone says. "Some cardiologists restrict sodium more than others at this stage." Patients also should keep track of their weight on a daily basis.1 While recommendations vary, the AHA recommends patients notify their health care professional if they gain 3 lbs or more in one day, or 5 lbs or more in one week.8

Since a body in heart failure has trouble ridding itself of sodium and fluid, intake must be restricted. The Academy's 2017 heart failure guidelines, which apply specifically to HFrEF, emphasize the importance of individualizing recommendations based on patient needs, including sodium and fluid restrictions. Ideally, sodium intake should be limited to a range of 2,000 to 3,000 mg per day. This is a change from the 2008 recommendations that stated sodium intake should be less than 2,000 mg per day. Fluid recommendations also have changed in the new guidelines. The guidelines recommend restricting fluid to 1 to 2 L per day, a wider range than the 1.4 to 1.9 L range in the 2008 recommendations, and a change from the 1.5 L recommended in the Academy's 2006 evidence analysis. These changes are based on four different studies showing that sodium and fluid intakes within these ranges improved readmission rates, length of hospital stay, mortality rates, renal function, and clinical laboratory measures such as blood urea nitrogen, creatinine, and serum sodium. Symptom burden (shortness of breath, difficulty breathing when lying flat, edema, lack of energy, and lack of appetite) also was improved by sodium and fluid restriction in these recommended ranges.9

Patients with advanced HFrEF symptoms who don't get better with treatment are in the final stage of heart failure, Stage D, and may need advanced treatment options such as a heart transplant, heart surgery, or palliative or hospice care. HFpEF is more easily managed with medications and lifestyle changes for the long term.1

Recommendations for energy and protein intake also should be individualized. The Academy's 2017 guidelines offer updated energy and protein recommendations designed to maintain weight and prevent catabolism (breakdown of muscle tissue). To estimate total energy needs for adults in the early stages of heart failure (A through C), the guidelines recommend using a minimum of 22 kcal per kilogram of actual body weight (kcal/kg) for normally nourished patients, ranging up to 24 kcal/kg for malnourished patients, multiplied by an activity factor. In cases of advanced heart failure (stage D), this should be decreased to 18 kcal/kg.9 "These patients may look healthy and normal when their condition is under control, but research shows many are in negative nitrogen balance," Kuehneman says. Appropriate protein intake is necessary to prevent catabolism and maintain nitrogen balance. Based on research demonstrating that protein intake between 1.1 and 1.4 g per kilogram of actual body weight (g/kg) resulted in positive nitrogen balance, and 1 to 1.1 g/kg resulted in negative nitrogen balance, the guideline committee recommends a protein goal of at least 1.1 g/kg.9

The new Academy guidelines state that a dietitian, working as part of an interdisciplinary health care team, should implement MNT and coordinate care, including the use of supplements. While a 2007 analysis by the Academy concluded the majority of available evidence indicated that coenzyme Q10 (CoQ10) supplements may be of benefit to patients with heart failure, the new recommendations conclude that it's unclear whether supplements like CoQ10 and omega-3 fatty acids, vitamin D, iron, and thiamin are appropriate in heart failure treatment due to possible interactions between supplements and medications, although evidence is weak.9 "Patients are going to try these supplements," Angelone says, "and health care providers should be knowledgeable enough to advise them. For people wishing to use CoQ10, I recommend the active form ubiquinol, because some people don't have the ability to activate the inactive form. I also recommend fish oil supplements that provide 2 g of omega-3s per day for my heart failure patients. Beet root juice supplements increase nitric oxide production, which can relax stiff, rigid arteries and may be helpful."

Beyond Restrictions
Nutrition professionals are integral to the care of patients with heart failure. "Appropriate MNT can shorten hospital stays, reduce costs, improve quality of life, and prevent readmissions," Kuehneman says. "Medicare won't reimburse for readmission for heart failure within 30 days of discharge, so it's important to help patients remain compliant with diet and medications."

Compliance isn't always an easy thing to achieve. "Patients may not have the skills to do something like lower their sodium intake," Angelone says. "Discuss ideal goals, but choose realistic goals for that patient. The idea is to move them in the direction of the ideal. Too much pressure to be perfect can backfire: Often, when a patient is unable to do what they're told, they won't admit they're not doing it. Do be sure to tell the physician if you know or suspect a patient is noncompliant. They may need more medication."

Setting realistic goals and making sure the patient understands them is a first step, but effective nutrition counseling must go further. "Education doesn't necessarily lead to behavior change, but it may increase compliance," Angelone says. "Take the time to really listen and be supportive."

The pervasiveness of salt in the American food supply, and the biological urge to drink when thirsty, make sodium and fluid restrictions particularly odious. "Fluid and sodium restrictions can be very difficult and unpleasant," Kuehneman says. "It's up to us to help make it livable. That's what dietitians do."

The new guidelines recommend educating patients on self-care, including information on an appropriate eating plan for their stage of heart failure and comorbidities; energy and protein intake; sodium and fluid intake; physical activity; and self-monitoring of weight and symptoms.9 To translate all of this to real life, Angelone offers shopping tips, label reading instruction, cooking guidelines, tips for dining out, and how to use ingredients such as spices and flavored vinegars to add flavor without salt. "I don't recommend salt substitutes because they are too high in potassium," Angelone says, "and I recommend patients limit or avoid alcohol, because the organs are already strained. It's also important to address how to deal with dry mouth and thirst, and how to pace themselves with liquid intake. Emphasize what they can do, not just what they can't do." Tips to track fluid intake may be helpful. "If a patient is restricted to two liters of fluids a day, I recommend getting a two-liter bottle and adding to it whenever they drink. Ice chips, gelatin, and soups count too," Angelone says. "They will be thirsty."

The new guidelines provide the latest information on screening and referral; nutrition assessment; intervention; and monitoring and evaluation.9 They cover the latest evidence on MNT, energy, protein, sodium, fluid, nutrient intake, and supplementation—but Kuehneman stresses that expertise in these areas isn't enough.9 "Dietitians are very good at assessing things like energy and protein needs, but we also need to assess social support," Kuehneman adds. "We must take into account not just what they're eating, but also where they're eating it, and the factors behind their lifestyle choices." In the end, the effort is worthwhile. "Treating patients with heart failure is so rewarding," Kuehneman continues. "The patients improve, and you can see the difference that self-management makes in their lives very quickly."

— Judith C. Thalheimer, RD, LDN, is a nutrition writer, educator, and speaker based outside Philadelphia.

References
1. Heart failure: understanding heart failure: stages. Cleveland Clinic website. https://my.clevelandclinic.org/health/diseases/17069-heart-failure-understanding-heart-failure/stages. Updated October 2016.

2. Benjamin EJ, Blaha MJ, Chiuve SE, et al. Heart disease and stroke statistics–2017 update: a report from the American Heart Association. Circulation. 2017;135(10):e146-e603.

3. Harvard Women's Health Watch: heart failure in women. Harvard Health Publishing website. https://www.health.harvard.edu/newsletter_article/Heart_failure_in_women. Published September 2008.

4. Types of heart failure. American Heart Association website. http://www.heart.org/HEARTORG/Conditions/HeartFailure/AboutHeartFailure/Types-of-Heart-Failure_UCM_306323_Article.jsp#.WqA_DSOZNPM. Updated May 8, 2017.

5. Eggebeen J, Kim-Shapiro DB, Haykowsky M, et al. One week of daily dosing with beetroot juice improves submaximal endurance and blood pressure in older patients with heart failure and preserved ejection fraction. JACC Heart Fail. 2016;4(6):428-437.

6. Klabunde RE. Sympathetic activation in heart failure. Cardiovascular Physiology Concepts website. http://www.cvphysiology.com/Heart%20Failure/HF004. Updated June 30, 2015.

7. Peripartum cardiomyopathy (PPCM). American Heart Association website. http://www.heart.org/HEARTORG/Conditions/More/Cardiomyopathy/Peripartum-Cardiomyopathy-PPCM_UCM_476261_Article.jsp#.WqBDcSOZNPN. Updated December 12, 2017.

8. Lifestyle changes for heart failure. American Heart Association website. http://www.heart.org/HEARTORG/Conditions/HeartFailure/TreatmentOptionsForHeartFailure/Lifestyle-Changes-for-Heart-Failure_UCM_306341_Article.jsp#.Wp_25COZOCQ. Updated September 27, 2017.

9. Heart failure (HF) guidance (2017). Academy of Nutrition and Dietetics Evidence Analysis Library website. https://www.andeal.org/topic.cfm?menu=5289&cat=5227