Heart failure presents multiple treatment challenges. Patients require diligent titration of complex drug therapies, detailed education about the disease process and self-management techniques, close attention to volume status, and constant awareness of even subtle changes in symptoms and functional capacity. Enormous amounts of time and effort are required by both patients and the healthcare team to make all of this happen. And this is done just for a patient's heart failure. But how many patients do we have who have just this one diagnosis?
The reality is that the majority of our heart failure patients have multiple coexisting illnesses. A recent study of US Medicare beneficiaries older than 65 noted that nearly 40% of patients with heart failure had 5 or more noncardiac comorbidities.1 The presence of other chronic illnesses greatly increases the complexity of caring for the heart failure patient. Not only does the day-to-day management become more difficult, but patients with multiple comorbid conditions have more frequent hospitalizations and a higher mortality rate as well.1
Questions have arisen over how best to care for these patients. Should heart failure specialists treat only the patients' heart failure and assume (or hope?) that the patients are receiving adequate care for their other illnesses-care that takes into account the impact of their heart failure diagnosis? Or, as Cleland and Clark note, should heart failure specialists be educated in the key aspects of the management of common comorbid medical conditions, resorting to specialist advice where evidence of real benefit exists?2
This supplement to the Journal of Cardiovascular Nursing intends to do just that. Advanced practice nurses routinely care for heart failure patients with multiple chronic illnesses and are in an excellent position to provide and/or coordinate the care for these multiple problems. The articles in this issue cover 8 of the most common chronic conditions experienced by heart failure patients, focusing not only on the impact of the condition itself on the patient with heart failure, but also on how the treatments for the coexisting conditions interact and affect the patient.
The first 2 articles examine the common cardiac comorbidities of atrial fibrillation and ventricular dysrhythmias. Atrial fibrillation occurs in up to a third of heart failure patients, and Offutt presents a concise review of the scant research base available to us to plan our treatment. This article reminds us that there is no "one size fits all" approach for treating atrial fibrillation in the heart failure patient-each patient needs to be considered on an individual basis regarding rate management versus rhythm management until further studies are available to guide our therapy.
Albert reviews one of the hottest topics in heart failure management today-ventricular dysrhythmias and sudden cardiac death. This article includes practical, evidence-based information on both primary and secondary prevention of sudden cardiac death and offers clinicians a great synopsis of the most recent data in a user-friendly table summarizing the pertinent trials. Albert focuses on the powerful role nurses have to improve outcomes for patients in this area.
In the previously mentioned Medicare beneficiary study, chronic obstructive lung disease was one of the most common comorbidities noted in heart failure patients.1 Both of these conditions involve remodeling of organ structures-airway remodeling in obstructive lung disease and ventricular muscle remodeling in heart failure. Lee and Wingate provide critical information about how to differentiate the dyspnea that occurs in both of these conditions and how the medications given to treat each illness impact the coexisting problem.
Diabetes and chronic heart failure result in similar activation of pathologic neurohormonal pathways that may be synergistic when both are present. Type 2 diabetes is present in up to 20% of the heart failure populationand presents tremendous treatment challenges to the clinician. Langford reviews the critical need for vascular disease risk factor modification in this population and provides important evidence, again, about the effects of the pharmacotherapy for each disease process.
The prevalence of depression in heart failure patients ranges from 13% to 77.5% depending on how depression is defined and assessed. Further, few patients are correctly diagnosed and appropriately treated for their depression, which subsequently can lead to additional negative outcomes. Artinian et al give detailed information on appropriate assessment of heart failure patients for depression and also provide an in-depth review of effective pharmacologic and nonpharmacologic therapies.
Anemia is a well-known comorbidity in many chronic conditions, but its role in heart failure has only recently been recognized. Paul and Paul critically review the existing research on anemia and heart failure. Practical information on the evaluation of anemia in the heart failure setting is provided. Most important, the authors present a very helpful algorithm for clinicians to use when considering therapy for anemia in their heart failure patients.
Recent data have shown that 40% to 50% of heart failure patients suffer from some form of sleep-disordered breathing, far exceeding the 2% to 4% rate seen in the general population. Trupp provides an excellent, general primer on sleep and sleep-disordered breathing. The author then reviews practical approaches to diagnosis and treatment strategies for the heart failure patient, with the very helpful addition of actual printout examples of normal and abnormal sleep studies.
Lastly, the concept of pain is reviewed. Acute and chronic pain are common coexisting problems in heart failure patients; however, traditional pain management strategies require adjustment because heart failure patients typically cannot use anti-inflammatory medications and corticosteroids. The authors of this article, Wheeler and Wingate, bring together the fields of palliative care and heart failure management to provide practical information on how to use both pharmacologic and nonpharmacologic interventions for heart failure patients in pain.
The journal editors and I hope that this timely supplement to the Journal of Cardiovascular Nursing will prove useful to you.
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