When spider webs unite, they can tie up a lion. - -Ethiopian proverb 1

The effect of heart failure (HF) has been well documented. 2-4 Troubling statistics reveal that approximately 4.6 million Americans are currently living with heart failure and about 400,000 new cases develop annually. Half of these patients will die within 5 years. 5 Heart failure is also now America's most costly health care problem. 6 It is the major reason for hospitalization in people 65 and older. The Health Care Financing Administration (HCFA) reported spending $3.4 billion in 1995 for Medicare patients alone. This figure is sobering, given the aging patient population.

The physical and emotional problems associated with HF challenge patients and their families. Self-care of this chronic and debilitating syndrome requires a consistent and well-informed approach if functional status and quality of life are to be optimized. Patients must manage a complicated medication regimen, assess their signs and symptoms daily, visit their health care providers frequently, and conform routinely to dietary restrictions and exercise programs.

Financial, cognitive, and psychosocial issues may cloud patients' abilities to maintain their health-especially in the older adult. Many elders must balance the need for and financial expense of home care services and equipment, medications, transportation, nutritious food, and health care visits. Cognitive function is often compromised in HF patients, which further complicates these issues. These challenges are particularly difficult for those who lack social support that could assist with finances, cooking, transportation, and regimen management. 7

If outcomes related to HF are to improve, it is imperative that health care providers' actions be comprehensive and woven together in a way that achieves a coordinated, innovative, and scientifically based plan of care. This issue of The Journal of Cardiovascular Nursing (14:4) presents current knowledge concerning heart failure pathophysiology, its treatment, and nursing interventions shown to effectively achieve this goal.

The first article in this issue provides an overview of the pathophysiologic processes responsible for the development of heart failure. Precipitating events such as longstanding hypertension and myocardial infarction are well recognized. It is now understood that changes within the myocardium and neuroendocrine processes are responsible for cardiac remodeling and subsequent heart failure. This knowledge drives new treatment strategies. Piano and colleagues describe processes leading to changes in the myocardium at the cellular level, which lead to an alteration in contractile performance. The reader will gain a thorough understanding of the process of remodeling; the effect of myocyte, fibroblast, and endothelial cell changes; and myocardial cell loss (apoptosis). The role of neurohormones and cytokines perpetuating cellular changes are also discussed. Finally, the authors build on this knowledge base by providing an overview of the pharmacologic therapies that attenuate these processes and limit the extent of heart failure.

When heart failure is discussed, one often assumes systolic dysfunction, although there is a significant subset of patients who have HF because of diastolic dysfunction. Diastolic HF is often the result of longstanding hypertension or myocardial ischemia. These patients are typically older and often female. Beattie's discussion of HF with preserved LV function provides a comprehensive overview of the pathophysiology and diagnostic determinants of this syndrome. Although these patients have a clinical presentation similar to those with systolic dysfunction, Beattie provides important information about potential complications to drug therapy related to an abnormal diastolic pressure-volume relationship. Nursing implications focus on these potential complications to drug therapy and the education necessary for patient self-management.

A frequent and tragic consequence of HF is sudden cardiac death (SCD). A number of factors play a role in the incidence of SCD in the heart failure population including re-entrant conduction dysrhythmias and electrolyte disturbances. The challenge is to find sufficient methods for identifying those patients at risk for SCD and then providing effective treatment for prevention. Tedesco and colleagues review mechanisms responsible for the development of SCD in the heart failure population and current methods available for identifying those patients who may be in jeopardy. Therapeutic interventions for preventing SCD (eg, pharmacologic therapy and prophylactic ICD placement) are discussed in concert with national guidelines grounded in scientific evidence. In addition to diagnostic and therapeutic strategies, the authors discuss myriad psychosocial issues these patients and their families face. They describe how best to help families adapt to lifestyle changes, make difficult treatment decisions, and assist with discussions about advanced directives and other end-of-life concerns.

The identification of effective drug therapies for patients with HF is a continuous scientific process. A well-implemented drug regimen has the potential to control debilitating symptoms and improve functional status. Patients who are well informed about the action, side effects, and benefits of their medications comply better. Milfred-LaForest's article on the pharmacotherapy of heart failure will provide nurses with an update on HF drug therapy and research. Current literature, patient selection, dosing, and nursing implications for therapies advocated in published guidelines is reviewed as well as information on newer agents such as [beta]-blockers, angiotensin II antagonists, endothelin blockers, and the rediscovered spironolactone.

Providing effective interventions for the patient with end-stage heart failure has become a formidable task. The population is aging and cardiac patients are living longer. In addition, the availability of donor organs cannot keep up with the demand for heart transplantation. Health care providers continually strive to develop interventions for the patient with chronic end-stage HF. One intervention frequently implemented in clinics around the country is the short-term infusion of inotropic medications for the management of acute exacerbations of HF and as a bridge to transplantation. This intervention is controversial at best. Levine provides a comprehensive review of the research surrounding this issue. The reader will gain a clear understanding of receptor effects and the short-term benefits of intravenous inotropic medications with a focus on specific outcomes such as functional status, mortality, and cost. A discussion of current indications and the pharmacologic effects of inotropic agents is provided as well.

Imbedded in each patient/family system are barriers to education and compliance with self-care regimens. The identification of these barriers is daunting with shorter stays and limited teaching opportunities in the outpatient setting. Bennett and colleagues discuss the development and initial study of an innovative program based on patient-specific tailored messages provided on the World Wide Web. The Health Belief Model was used as a theoretical foundation to explore patients' perceptions of benefits and barriers to maintaining their heart health. Readers will appreciate the scientific manner in which scales used to assess patient beliefs about medication, diet, and self-monitoring were used to develop and test patient-tailored intervention messages. An evaluation of this computer-based home application is also included.

This is no argument that effective patient teaching and pharmacologic therapy goes a long way in improving outcomes for the patient and family experiencing the debilitating effects of HF. There is an abundance of scientific evidence regarding these interventions and their effects on rehospitalization, mortality, and quality of life. In spite of these interventions, patients experience a variety of psychologic and social problems. Moser and Worster discuss the evidence demonstrating that these factors (eg, social isolation, anxiety, depression) work against interventions by increasing mortality and morbidity and stressing family dynamics.

The challenges of patient self-care in heart failure management are evident within the contents of this issue. Optimizing our interventions to achieve the best possible outcome is of primary concern for all clinicians who provide care for heart failure patients. Deaton's special feature on outcomes research provides a discussion of the concepts related to patient self-management and how it can be measured. Conceptual approaches are discussed that consider the desired behaviors and decision making skills patients and families must accomplish for successful health maintenance.

The approach to HF management is clearly complex and multidimensional. The web of care surrounding these individuals must be crafted to include their physical, emotional, and social health. Together, this carefully crafted web has the best chance of improving outcomes for patients with HF.

It is incumbent on clinicians to make certain that interventions are comprehensive in nature and scientifically valid. In recent years, experts have developed HF treatment guidelines. 7-9 Keeping abreast of these guidelines and current literature, as reviewed in this issue of JCN, will provide the foundation needed to help patients and their families achieve the best possible outcomes.

- Anne Fara-Erny, MSN, RN, CCRN, CS

Issue Editor

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