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.

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

Fatigue is common and may be compounded by depression, dehydration, low cardiac output state, anaemia, and arrhythmias. An exercise program may increase exercise capacity and lessen fatigue, while mobility aids can reduce risk of falls. Teach patients simple techniques to conserve energy by pacing and prioritising their daily activities.

Patients should be aware that there might be an increased risk of travel related conditions such as deep vein thrombosis (DVT) and increased peripheral oedema, particularly on long haul commercial flights.

  • High altitude destinations should be avoided as atmospheric pressure decreases the partial pressure of inspired oxygen and hence the driving pressure for gas exchange in the lungs
  • Modifications to treatment regimens may be needed. For example, travel to hot climates may require relaxation of fluid restriction and DVT prophylaxis may be recommended for long distance travel
  • Prior to a trip it is useful for patients to obtain a medical summary from their doctor in case they need treatment while away. They should also consider insurance, medication management, managing flights, eating out and ways to monitor and manage fluid intake

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 Association1 recommends that patients diagnosed with CVD receive a comprehensive evaluation from their healthcare provider before resuming sexual activity.

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