Managing heart failure with mHealth
Each year, roughly 550,000 Americans are diagnosed with congestive heart failure (CHF), joining the nearly 5 million Americans living with the disease. Heart failure is the first-listed diagnosis in 875,000 hospitalizations each year. Overall, heart failure is responsible for more hospitalizations than all forms of cancer combined. 287,000 lives are taken each year by heart failure. Half of those diagnosed with heart failure die within five years. CHF is a very serious condition. With the right management, patients can stay healthy and out of the hospital.
What is Heart Failure?
A normal healthy heart pumps enough oxygen-rich blood out of the heart and into the system to nourish all parts of the body. Heart failure happens when the heart cannot pump enough blood to support other organs. While heart failure is a very serious condition, it does not mean that the heart has stopped beating. It means that your heart is not pumping as well as it should. Your body compensates by holding onto salt and water, which increases the amount of blood in your bloodstream. Your heart also beats faster and gets bigger. When your heart can no longer keep up with the increased blood, fluid starts to build up in the body, which makes you feel weak and out of breath. Fluid build up is characterized as congestion. Hence congestive heart failure.
What causes heart failure?
The primary causes of heart failure are high blood pressure, heart attack, coronary artery disease, and diabetes. Let's take at look at how the Mayo Clinic (an Axial partner and investor) describes heart failure causes:
Coronary artery disease and heart attack. Coronary artery disease is the most common form of heart disease and the most common cause of heart failure. Over time, arteries that supply blood to your heart muscle narrow from a buildup of fatty deposits, a process called atherosclerosis. Blood moves slowly through narrowed arteries, leaving some areas of your heart muscle weak and chronically deprived of oxygen-rich blood. In some cases, the blood flow to the muscle is just enough to keep the muscle alive but not functioning well. A heart attack occurs if plaques formed by the fatty deposits in your arteries rupture. This causes a blood clot to block blood flow to an area of the heart muscle, weakening the heart's pumping ability.
High blood pressure (hypertension). Blood pressure is the force of blood pumped by your heart through your arteries. If your blood pressure is high, your heart has to work harder than it should to circulate blood throughout your body. Over time, the heart muscle may become thicker to compensate for the extra work it must perform. Eventually, your heart muscle may become either too stiff or too weak to effectively pump blood.
Faulty heart valves. The valves of your heart keep blood flowing in the proper direction through the heart. A damaged valve, due to a heart defect, coronary artery disease or heart infection, forces your heart to work harder to keep blood flowing as it should. Over time, this extra work can weaken your heart. Faulty heart valves, however, can be fixed if found in time.
Damage to the heart muscle (cardiomyopathy). Some of the many causes of heart muscle damage, also called cardiomyopathy, include infections, alcohol abuse, and the toxic effect of drugs such as cocaine or some drugs used for chemotherapy. In addition, whole-body diseases, such as lupus, or thyroid problems can damage heart muscle.
Myocarditis. Myocarditis is an inflammation of the heart muscle. It's most commonly caused by a virus and can lead to left-sided heart failure.
Heart defects you're born with (congenital heart defects). If your heart and its chambers or valves haven't formed correctly, the healthy parts of your heart have to work harder to pump blood through your heart, which in turn may lead to heart failure.
Abnormal heart rhythms (heart arrhythmias). Abnormal heart rhythms may cause your heart to beat too fast. This creates extra work for your heart. Over time, your heart may weaken, leading to heart failure. A slow heartbeat may prevent your heart from getting enough blood out to the body and may also lead to heart failure.
Other diseases. Chronic diseases such as diabetes, severe anemia, hyperthyroidism, hypothyroidism, emphysema, and lupus and a buildup of iron (hemochromatosis), protein (amyloidosis) or inflammatory cells (sarcoidosis) also may contribute to heart failure. Causes of acute heart failure include viruses that attack the heart muscle, severe infections, allergic reactions, blood clots in the lungs, the use of certain medications or any illness that affects the whole body.
How is Heart Failure Diagnosed?
In addition to checking for risk factors such as diabetes, your doctor will likely listen to your heart with a stethoscope. Abnormal sounds may indicate heart failure. Fluid build up in your abdomen and legs might suggest heart failure. Addtionally, your doctor may order blood tests to check kidney and thyroid function and for a chemical called brain natriuretic peptide (BNP) which may indicate heart failure. A chest x-ray may reveal an enlarged heart and/or fluid build up in the lungs. An ECG helps diagnose heart rythm problems and an echocardiogram helps distinguish systolic heart failure from diastolic heart failure. MRI and CT scans can produce images of the heart. A coronary catheterization (angiogram) can help identify narrowing arteries.
How is Heart Failure Treated?
Heart failure is a chronic disease that requires lifelong management. With treatment, symptoms can improve and, in some cases, the heart can become stronger. According to the Mayo Clinic, the following are heart failure medications and treatments:
Angiotensin-converting enzyme (ACE) inhibitors. These drugs help people with heart failure live longer and feel better. ACE inhibitors are a type of vasodilator, a drug that widens blood vessels to lower blood pressure, improve blood flow and decrease the workload on the heart. Examples include enalapril (Vasotec), lisinopril (Prinivil, Zestril) and captopril (Capoten).
Angiotensin II receptor blockers (ARB). These drugs, which include losartan (Cozaar) and valsartan (Diovan), have many of the same benefits as ACE inhibitors. They may be an alternative for people who can't tolerate ACE inhibitors.
Digoxin (Lanoxin). This drug, also referred to as digitalis, increases the strength of your heart muscle contractions. It also tends to slow the heartbeat. Digoxin reduces heart failure symptoms.
Beta blockers. This class of drugs not only slows your heart rate and reduces blood pressure but also limits or reverses some of the damage to your heart. Examples include carvedilol (Coreg), metoprolol (Lopressor) and bisoprolol (Zebeta). These medicines reduce the risk of some abnormal heart rhythms and lessen your chance of dying unexpectedly. Beta blockers may reduce signs and symptoms of heart failure, improve heart function, and help you live longer.
Diuretics. Often called water pills, diuretics make you urinate more frequently and keep fluid from collecting in your body. Commonly prescribed diuretics for heart failure include bumetanide (Bumex) and furosemide (Lasix). The drugs also decrease fluid in your lungs, so you can breathe more easily. Because diuretics make your body lose potassium and magnesium, your doctor may also prescribe supplements of these minerals. If you're taking a diuretic, your doctor will likely monitor levels of potassium and magnesium in your blood through regular blood tests.
Aldosterone antagonists. These drugs include spironolactone (Aldactone) and eplerenone (Inspra). They are potassium-sparing diuretics but also have additional properties that may reverse scarring of the heart and help people with severe heart failure live longer. Unlike some other diuretics, spironolactone can raise the level of potassium in your blood to dangerous levels, so talk to your doctor if increased potassium is a concern, and learn if you need to modify your intake of food that's high in potassium.
Coronary bypass surgery. If severely blocked arteries are contributing to your heart failure, your doctor may recommend coronary artery bypass surgery. In this procedure, blood vessels from your leg, arm or chest bypass a blocked artery in your heart to allow blood to flow through your heart more freely.
Heart valve repair or replacement. If a faulty heart valve causes your heart failure, your doctor may recommend repairing or replacing the valve. The surgeon can modify the original valve (valvuloplasty) to eliminate backward blood flow. Surgeons also can repair the valve by reconnecting valve leaflets or by removing excess valve tissue so that the leaflets can close tightly. Sometimes repairing the valve includes tightening or replacing the ring around the valve (annuloplasty). Valve replacement is done when valve repair isn't possible. In valve replacement surgery, the damaged valve is replaced by an artificial (prosthetic) valve.
Implantable cardioverter-defibrillators (ICDs). An ICD is a device similar to a pacemaker. It's implanted under the skin in your chest with wires leading through your veins and into your heart. The ICD monitors the heart rhythm. If the heart starts beating at a dangerous rhythm, or if your heart stops, the ICD tries to pace your heart or shock it back into normal rhythm. An ICD can also function as a pacemaker and speed your heart up if it is going too slow.
Cardiac resynchronization therapy (CRT) or biventricular pacing. A biventricular pacemaker sends timed electrical impulses to both of the heart's lower chambers (the left and right ventricles), so that they pump in a more efficient, coordinated manner. Many people with heart failure have problems with their heart's electrical system that cause their already-weak heart muscle to beat in an uncoordinated fashion. This inefficient muscle contraction may cause heart failure to worsen. Often a biventricular pacemaker is combined with an ICD for people with heart failure.
Heart pumps (left ventricular assist devices, or LVADs). These mechanical devices are implanted into the abdomen or chest and attached to a weakened heart to help it pump. Doctors first used heart pumps to help keep heart transplant candidates alive while they waited for a donor heart. LVADs are now sometimes used as an alternative to transplantation. Implanted heart pumps can significantly extend and improve the lives of some people with severe heart failure who aren't eligible for or able to undergo heart transplantation or are waiting for a new heart.
Heart transplant. Some people have such severe heart failure that surgery or medications don't help. They may need to have their diseased heart replaced with a healthy donor heart. Heart transplants can dramatically improve the survival and quality of life of some people with severe heart failure. However, candidates for transplantation often have to wait months or years before a suitable donor heart is found. Some transplant candidates improve during this waiting period through drug treatment or device therapy and can be removed from the transplant waiting list.
Stop smoking. Smoking damages your blood vessels, raises blood pressure, reduces the amount of oxygen in your blood and makes your heart beat faster. If you smoke, ask your doctor to recommend a program to help you quit. You can't be considered for a heart transplant if you continue to smoke.
Weigh yourself daily. Do this each morning after you've urinated, but before you've had breakfast. Notify your doctor if you have a weight gain of 3 pounds (1.4 kilograms) or more in a day. It may mean that you're retaining fluids and need a change in your treatment plan. Record your weight every morning and bring the record with you to your doctor's visits.
Restrict salt in your diet. Too much sodium contributes to water retention, which makes your heart work harder and causes shortness of breath and swollen legs, ankles and feet. For people with heart failure, the daily recommended amount of dietary sodium is no more than 2,000 milligrams (mg) a day — check with your doctor for the restriction recommended for you. If you have high blood pressure, are 51 or older or are African-American, you should aim for no more than 1,500 mg of sodium a day in your diet. Keep in mind that most of this salt is already added to prepared foods, and be careful when using salt substitutes.
Maintain a healthy weight. If you're overweight, your dietitian will help you work toward your ideal weight. Even losing five to ten pounds (2.3 to 4.5 kilograms) can help.
Limit alcohol and fluids. Your doctor likely will recommend that you don't drink alcohol if you have heart failure, since it can interact with your medication, weaken your heart muscle and increase your risk of abnormal heart rhythms. If you have severe heart failure, your doctor may also suggest you limit the amount of fluids you drink.
Be active. Moderate aerobic activity helps keep the rest of your body healthy and conditioned, reducing the demands on your heart muscle. Before you start exercising though, talk to your doctor about an exercise program that's right for you. Your doctor may suggest a walking program. Check with your local hospital to see if it offers a cardiac rehabilitation program; if it does, talk to your doctor about enrolling in the program.
Reduce stress. When you're anxious or upset, your heart beats faster, you breathe more heavily and your blood pressure often goes up. This can make heart failure worse, since your heart is already having trouble meeting the body's demands. Find ways to reduce stress in your life. To give your heart a rest, try napping or putting your feet up when possible.
Sleep easy. If you're having shortness of breath, especially at night, sleep with your head propped up at a 45-degree angle using a pillow or a wedge. If you snore or have had other sleep problems, make sure you get tested for sleep apnea. To improve your sleep at night, prop up your head with pillows and avoid big meals right before bedtime. Also, discuss with your doctor changing the time for taking medications, especially diuretics. Taking diuretics earlier in the day may keep you from having to urinate as often during the night.
Here's how one health system characterices heart failure status from the perspective of a patient:
How mHealth can Help with Health Literacy
The first step in patient engagement is patient education. With all of the medical misinformation available online, patients should have a trusted resource at their fingertips. Below is an sample of the Mayo Clinic's health library optimized for a smart phone:
How mHealth can Help with Health Management
Patient engagement goes beyond education. Education should lead to active health management. Until the last few years, personal health management meant endless manual journaling -- a process that few maintained. The good news is that mHealth offers a solution that is at once less labor intensive and more effective than manual tracking.
The Bottom Line
Heart failure is a serious condition with serious costs. According to the CDC, heart failure is responsible for over $34 billion in annual direct and indirect costs. With patient engagement, health outcomes and the corresponding financial burden can improve. Health systems that provide patients with a platform for engagement will be positioned for success with pay-for-outcome arrangements with CMS and private insurers.
Interested in mHealth for your health system? See:
mHealth and the Closing Window for Patient Engagement
mHealth ROI Part 1: Readmissions
mHealth ROI Part 2: HCAHPS / Value-Based Purchasing
mHealth ROI Part 3: Patient Loyalty