Treatment & Management Treatment & Management

All patients should be screened for their capacity to manage basic ADL (such as eating, toileting and dressing) and instrumental ADL for living in the community (such as managing money, shopping, telephone use, travel in the community and preparing meals).

An occupational therapy evaluation provides an in-depth understanding of limitations and strengths that can be used to inform management strategies.

Following cardiac intervention

Following surgical interventions involving a sternotomy, a sternal stability assessment should be completed. The diagnosis, complications and procedure may influence the rate of recovery.

Following sternotomy, pressure to the area should be minimised to facilitate healing for approximately 6 weeks. Surgical pain may persist for as long as 6 months post procedure, despite a stable sternum. For these patients, positioning should be modified to reduce discomfort. Methods taught to reduce discomfort as an inpatient, such as splinting the sternum with a rolled up towel or pillow, can be used successfully at home. See sternal stability management.

Following myocardial infarction (MI)

Following an MI, patients should balance activity with rest. Rate of recovery is highly variable and will be dependent on premorbid level of activity, degree of damage to the myocardium, intervention undertaken and medical therapy. As a general guide, activity in the first few weeks of recovery should be at a low to moderate intensity and preferably started within a supervised clinical setting.  See life style physical activity. Advise patients during the recovery period to listen to their body whilst resuming their normal routine. The Exercise program set up and design section provides advice on centre-based group exercise and education programs in terms of staffing ratios, frequency and duration and format for activities.

Patients with CVD will usually have restrictions on private and commercial licences following an MI, arrhythmias, cardiac device implantation or cardiac surgery.

In general, patients with symptomatic HF and those with commercial licences are unable to drive until their condition stabilises or improves.

Licensing laws relating to domestic and commercial drivers can vary considerably between states and countries. For Australian guidelines on driving and related health status see Austroads.

Requirements related to outcomes for people not reporting medical conditions vary and it is recommended that the patient contact their local licensing agency. Clinicians should be familiar with the local driving regulations relevant to each specific cardiovascular condition, and patients should discuss driving restrictions pertinent to their condition with their treating clinicians. Some patients may have a temporary or permanent driving restriction.

If the patient is unable to drive, explore alternatives to assist with independence such as subsidised taxis and home grocery delivery. Occupational therapists can assist with exploring alternatives to driving or testing requirements for restricted driving licences.

Information for patients click here

Note the patient’s usual employment and the physical, cognitive demands, cultural environment and the patient’s attitude towards returning to work.

The timing of returning to work is highly variable and should be individually assessed by an occupational therapist if available. In general, light or sedentary activities can be undertaken 2-3 weeks post infarct, whereas return to more physical work may take 4-6 weeks and require a graded return to work program.

Before returning to work the following should be considered:

  • Patient’s confidence and readiness to work
  • Patient’s role at work and managing physical demands
  • For patients with implantable devices, consider the impact of electromagnetic interference in the work place
  • Supportiveness of employers, co-workers, work partner
  • Impact of cognitive changes
  • Planning a graded return to work. For some, return to work should be incremental by working part time for the first few weeks, and undertaking less demanding duties for a period of time

Balancing returning to work with exercise and healthy eating habits may be difficult. Most patients will need to develop a strategy to balance work demands with the time and energy required for lifestyle modifications to help reduce risk factors.

Information for patients click here

Fatigue is common symptom for people with a cardiac condition and may be compounded by depression, dehydration, low cardiac output state, anaemia, and arrhythmias.  It is characterised by excessive tiredness which can cause confusion, irritability, loss of stamina and endurance, and may not go away with rest or sleep.  The feeling of constant tiredness or weakness and can by physical, mental, or a combination of both. Although physical and mental fatigue are often closely interrelated, these 2 aspects of fatigue correspond to different pathophysiological mechanisms and both need to be managed and supported.  Physical fatigue is related to loss of efficacy of the effector muscle, this is due to multiple causes: mismatch of cardiac output during exercise, muscle and microcirculatory deconditioning, neuroendocrine dysfunction and associated metabolic disorders.

Clients who can learn to manage their fatigue and conserve their energy will be able to better maintain a healthy lifestyle and engagement in meaningful activities.   Energy conservation and work simplification techniques for patients suffering fatigue can greatly improve quality of life. Information and patient handouts can be found on numerous sites such as the ones listed below: 

The following methods may assist your patients in managing their energy levels.  

  • Prioritise:  Help the patient decide which activities add to quality of life and which ones they would be happy for others to do and how this could be achieved (such as getting in assistance with cleaning).
  • Planning and pacing: Advise patients on strategies to avoid exhaustion (as this is more effective than trying to recover from it). For example, cooking on a different day as food shopping; gathering items to go upstairs to take at one time; and mowing the lawn in sections over a week.  Advise patients to: undertake fatiguing activities during the time of day when they usually have the most energy; pace themselves by having rest periods; alternate between heavy and light activities (such as vacuuming and paperwork); and avoid activities when it’s too hot or too cold or immediately after a meal.
  • Slow and smooth flowing movements:  Smooth even movements aid the heart to meet the physiological demand associated with the activity and cause less fatigue than quick spurts of energy (like the Tortoise and the Hare). This means that patients will need help to adopt a different approach and mindset to a task.  For example, wiping down a surface can be done with short intense jerky movement that provoke fatigue or with gliding large sweeping movement.
  • Avoid heavy carrying:  Advise patients on techniques to avoid heavy carrying, for example, using home shopping and laundry trolleys or a suitcase on wheels to transport items.  Generally pulling and sliding is easier than pushing.
  • Avoid high reaching and low bending.  Help patients to set up their environment to minimise excessive bending and reaching; for example, hanging washing on a clothes horse/drying rack rather than using a clothes line; and placing heavy pots or pans in the kitchen at waist level.
  • Adopt energy efficient positions:  Suggest positions to minimise fatigue, such as sitting on a stool in the kitchen or when showering, or side-lying during sexual activity.
  • Energy efficient mobility: Flat, well supported footwear (such as good quality sneakers which provide arch support and reduce ground impact forces) can reduce fatigue while walking. For deconditioned patients a 4-wheeled walker can be very effective in reducing energy expenditure as well as reducing the risk of falls and a wheelchair may be useful for some outings.
  • Improve fitness: Suggest enrolling in an exercise program to increase exercise capacity and lessen fatigue.

Many patients with cardiovascular disease and heart failure travel nationally and internationally. Travel can be stressful both physically and emotionally but with good planning and risk management most patients will be able to travel.   The following are essential areas to discuss with patients.

Avoiding DVT (blood clot) on long haul flights: Advise patients to limit alcohol to <1-2 standard drinks; to drink plenty of water during the flight to avoid becoming dehydrated (travellers with heart failure may need to drink less); to move their legs and feet for 3-4 minutes per hour while seated and to move around the cabin occasionally. Patients should wear travel socks fitted by a community pharmacist or medical equipment supplier both during the flight and for several hours after arrival at the destination.

Medication Management:  It is recommended that patients take a letter from their doctor to show when boarding the craft.  The Australian Government Department of Home Affairs recommends that for international travel the “letter should itemise any prescription and non-prescription powder, liquid, aerosol or gel medication, prescribed medical devices or equipment, for example, ice or gel packs used to regulate temperatures, or the need for hypodermic needles.”  Detailed medication information is also useful in the event of lost medications or hospitalisation.  If changing time zones, patients should develop a plan (with their doctor or pharmacist) on the timing of taking medications during the flight. To minimise the risk of lost medications, suggest to patients that they pack ½ their medication in their checked in luggage and ½ in their cabin luggage.

High Altitudes and heat: Advise patients to discuss the risk of travel to high altitudes and hot destinations with their doctor. Exposure to altitudes higher than 2,500 metres or 8,000 feet is associated with increased myocardial demand due to decreased partial pressure of oxygen, increased systolic blood pressure and increased heart rate.  Generally, travellers with HF should avoid such destinations. Those with ischemic heart disease and hypertension are more vulnerable at high altitudes.  Advise patients and their travel partners to watch out for shortness of breath or other symptoms that could indicate they are tipping from a stable to an unstable state. When travelling in hot climates it is important to drink more water than usual as a balanced fluid intake is important with cardiac conditions.

Travel Insurance: This is a common area of concern for patients. Most insurance contracts require a declaration of all medical conditions even if the insurance was purchased before the medical condition arose. If a medical condition is not declared then the insurance policy may no longer be valid for any costs incurred because of the condition.  In-person or over-the-phone insurance applications (where additional information can be given) may increase the chance of insurance being approved compared to online travel insurance applications.  While declaring a cardiac condition may increase the cost of the policy, in the event of a claim related to that condition, there should have adequate cover.  Prior to travel patients should read their policy to establish what is covered and what is excluded.

Fatigue: Advise patients to apply ways to manage fatigue (see fatigue)

Many people with CVD and HF experience sexual problems related to their cardiac disease, medications, fatigue, depression and stress. While a change in sexual activity or function may have a major impact on quality of life, it is rarely discussed in a clinical setting as the clinician or the patient may not feel comfortable talking about sexual issues and therefore it may be trivialised or ignored. [#levine-gn-steinke-ee-bakaeen-fg-et-al.-2012] It is therefore important to encourage patients to discuss with a member of the treating team any concerns they may have about their sexual function or libido.

How do I talk about sex with a patient?

Assessment of sexual concerns is of significant importance to individuals with cardiac conditions and is often rated as being poorly considered by clinicians. [#medina-m-walker-c-steinke-e-et-al.-2009]

Sometimes just mentioning the possibility of sexual issues may enable the patient to bring it up with you or another health provider when they are ready. If issues require more than basic information it is advisable to refer the patient to a GP or sexual counsellor.

Tips for broaching the subject of sexual functioning

  • Bring up the topic of sexual activity within the context of activities of daily living such as driving and working.
  • Normalise and generalise. Make a statement followed by an open ended question. For example:

    “Following a heart attack/ cardiomyopathy/ open heart surgery many men are worried about resuming sexual activity. What worries have you had?”
    or

    “It’s normal after a transplant for men to notice loss of interest in sex or performance problem. What changes have you noticed?" [#king-r.-2014]
     
  • Gain permission. In certain circumstances such as when using an interpreter, or where there are cultural sensitivities, gain the patient's permission by saying "Is sexual activity something that you would like me to talk about?"

Erectile dysfunction

There is potential for patients and clinicians to believe that erectile dysfunction is solely related to medications, however other contributors should be considered such as acute stress, pre-morbid erectile function, age and levels of anxiety or depression. Erectile dysfunction related to, or perceived to be related to, medication may cause the patient to consider stopping the medication.

Male patients who experience erectile dysfunction should be supported and encouraged to discuss this with their doctor as drugs or other aids may improve their erectile function. Phosphodiesterase (PDE) inhibitors (PDE5 selective inhibitors include Viagra® (sildenafil), Cialis® (tadalafil) and Levitra® (vardenafil)), maybe prescribed for patients provided that they are not receiving nitrate therapy and are not experiencing hypotension, arrhythmias or angina.

Libido

Loss of sex drive is a common problem and is usually temporary. Emotional stress, depression, diabetes and many cardiac medications can affect sex drive. Patients with ongoing problems may benefit from specialised sexual counselling.

When to resume sexual activity

The risks for triggering a cardiac event during sexual activity are very low in a person who can exercise expending energy of 3-5 METS (going up 2 flights of stairs) without angina, hypotension, arrhythmia and ischemia. Those who experience symptoms of breathlessness or chest discomfort during or after sexual intercourse should consult their doctor.

The American Heart Association recommends that patients diagnosed with CVD receive a comprehensive evaluation from their healthcare provider before resuming sexual activity. [#levine-gn-steinke-ee-bakaeen-fg-et-al.-2012]

Advice for specific conditions:

  • Sternotomy: Sexual activity can be resumed in line with hospital recommendations or at approximately 6-8 weeks provided the wound is well healed
  • MI: Sexual activity is usually safe 2 or more weeks after a heart attack if there are no symptoms during mild to moderate activity
  • PCI: Sexual activity is permitted after PCI if the vascular access site is without complications
  • Device implantation (e.g. permanent pacemaker, defibrillator): During incision healing avoid supporting weight through arms during sexual activity, while considering the specific instructions about movement of the affected side given by the hospital
  • HF: Usually there are no limitations on sexual activity except in advanced cases
    • There is a correlation with sexual capacity and functional status ( NYHA class or 6 minute walk test) but not with ejection fraction [#levine-gn-steinke-ee-bakaeen-fg-et-al.-2012]
      The American Heart Association recommends that sexual activity is likely to be safe in patients with NYHA class I or II HF
    • For more advanced HF, it is recommended that patients are stabilised and receiving optimal treatment before engaging in sexual activity.
  • Further information on sex and heart failure for patients is available from the www.heartfailurematters website.
  • Women with CVD or HF should be advised about appropriateness of contraception methods and the safety of future pregnancies. Further information is available in the Pregnancy and Cardiomyopathy patient booklet

How to resume sexual activity

The following tips will guide patients on ways to re-introduce sex gently or to conduct ongoing sexual activity where there is advanced cardiac disease such as HF:

  • Choose a time for sex when rested, relaxed and not pressured
  • Avoid having sex immediately after eating a heavy meal or drinking excessive amounts of alcohol
  • Have sex in a comfortable, familiar room that is not too hot or too cold and where you will not be interrupted
  • Use foreplay as a warm-up period to help the body get used to the increased activity level of intercourse
  • Have sex in less strenuous positions such as lying on the bottom or with you and your partner lying side by side
  • Stop and rest if there is discomfort, breathlessness or fatigue during intercourse

Physical training

Regular exercise reduces the risk of a sexual triggered cardiac event and may improve erectile dysfunction and therefore should be considered integral in the program to re-introduce sexual activity. [#levine-gn-steinke-ee-bakaeen-fg-et-al.-2012]

Sexual counselling

Some patients may benefit from a referral to a GP with an interest in sexual counselling.

Steinke et al. [#steinke-ee-jaarsma-t-barnason-sa-et-al.-2013] suggest that sexual counselling for all patients with CVD should include the following:

  • Review of potential effects of medications on sexual function
  • Risks related to sexual activity
  • The role of regular exercise in supporting intimacy
  • Use of a comfortable familiar setting to minimize any stress with sexual activity
  • Use of sexual activities that require less energy expenditure as a bridge to sexual intercourse
  • Reporting of warning signs experienced with sexual activity

Information for patients click here