Death and long term poorer outcomes for patients with ACS and HF can be significantly reduced if symptoms are recognised and treated early. All patients or carers should be provided with written information regarding self-management from reputable sources.

Ensure that patients with IHD or their carers can demonstrate ability to:

• Recognise warning signs of a heart attack. Educate patients to recognise symptoms of myocardial ischaemia and to identify normal or acceptable symptoms for themselves. Advise when to seek help or consult a health care provider
• Follow a heart attack action plan
• Understand the difference between a heart attack and angina, and appropriate management of each

Managing the pain associated with myocardial ischaemia is achieved through correcting the imbalance between myocardial oxygen supply and demand.

Lessen oxygen demand

• Decrease anxiety: Maintain a calm environment and reassure the patient as heightened anxiety can lead to an increase in myocardial oxygen demands secondary to an increase in heart rate
• Rest: Limit patient activity and, where possible, they should recline to minimise the effects of possible hypotension secondary to the medication used to treat chest pain
• Administer glyceryl-trinitrate (GTN): This short-acting nitrate is available as Anginine 600mcg sublingual tablets, or Nitrolingual 400mcg metered dose spray
  
  GTN produces vasodilator effects on both the coronary and peripheral vascular systems which reduces myocardial oxygen demand while enhancing myocardial oxygen delivery.

Oxygen

• Routine use of supplemental oxygen for acute chest pain is not recommended as there is insufficient evidence supporting its use and also some evidence to suggest potential harm. Supplemental oxygen may increase coronary vascular resistance, potentially leading to poorer outcomes compared to utilising room air. [#ogara-pt-kushner-fg-ascheim-dd-et-al.-2013] Oxygen therapy should only be instituted for hypoxaemic patients (SpO2 <93%) and those with evidence of shock, in order to correct tissue hypoxia.
• Oxygen should be used with caution in patients with chronic obstructive pulmonary disease (COPD)and carbon dioxide retention

Short acting nitrate management

People with known CVD should carry a short-acting nitrate at all times unless contraindicated.

Ensure patients can self-manage short acting nitrates as follows:

• Know how to store, discard 3 months after uncapping, and check the expiry date
• Prime with 5 sprays into the air prior to first use
• Avoid taking the short-acting nitrate if syncopal symptoms develop and to call emergency services if symptoms persist
• Know that a prescription is not required in Australia for a short acting nitrate spray

Note and address any barriers to medication adherence.

• The goal of treatment should be to achieve a stable weight (i.e., euvolaemia) using the lowest diuretic dose possible
• Flexibility in the regime may be tailored to suit patients’ needs. At times diuretic doses will need to be adjusted. To support adherence with diuretic therapy flexible timing of doses should be considered to fit patients’ routines and activities
• For patients with difficult to manage fluid balance or chronic renal impairment it is often acceptable for them to exhibit minor oedema, mild shortness of breath with usual exertion, occasional basal crackles and slight elevation of jugular venous pressure (JVP)
• Observe for signs of over treatment causing dehydration, particularly in the summer months, or if patients have diarrhoea or vomiting, or if there is reduced fluid intake for any reason

Signs of dehydration include:

• Dizziness or light headedness
• Fatigue
• Reduced urine output
• Concentrated urine and gout

Consider whether over-diuresis is a contributing factor and whether diuretic dose reduction is appropriate and review fluid management plan

Rapid changes in weight are indicative of fluid overload or dehydration. Patients should weigh themselves daily to promptly identify changes in fluid status and take timely action before experiencing the distressing symptoms of fluid overload or endangering kidney function through dehydration.

Encourage patients to, for example as soon as they wake and after they have emptied their bladder, and to write this in a weight and symptom diary

• Reinforce that weighing is a long term monitoring activity even if weight remains stable
• Clinicians should look at the diary at each consultation to review fluid status and reinforce the importance of daily weighing

Whilst daily weighing is the gold standard for assisting in detecting fluid changes, it is also important to consider fluid overload or dehydration and changes in weight in the context of other signs and symptoms as well as additional information from the patient.

For some patients daily weighing is not possible due to poor vision, instability or poor mobility. At times, such as when travelling, weighing can be inconvenient and patients need to be able to identify other signs and symptoms of fluid changes such as those listed below.

Fluid overload signs may include:

• Shortness of breath
• Feeling bloated
• Swelling of limbs
• Tightness of clothes or belt
• Decreased appetite

Dehydration signs include:

• Feeling generally unwell
• Fatigue
• Dizziness and light headedness particularly on standing
• Reduced urine output

The  Fluid management algorithm will help to guide your intervention.

Advise patients to:

• Consult their doctor or nurse if their weight increases or decreases by more than 2kg within a 48 hour period
• Report more gradual weight gain if associated with increasing dyspnoea or oedema
• Self-adjust diuretic doses according to any changes in body weight by providing a flexible diuretic action plan for those patients who could make changes safely

Fluid intake

It is important that a recommended fluid restriction is individualised for each patient according to the severity of heart failure, renal function, other dietary behaviours and current physical assessment. In general, 1.5 to 2 litres a day is appropriate for most patients and an intake of greater than 2 litres a day should usually be avoided. [#national-heart-foundation-of-australia-and-the-cardiac-society-of-2011]

Educate patients to:

• Manage thirst by using small glasses, sucking ice and spacing fluids over the entire day
• Understand that fluid includes all liquids, as well as solid foods that turns into a fluid at room temperature or in the mouth (e.g., soup, jelly, custard, yoghurt, ice-cream, watermelon, grapes, oranges)
• Familiarise themselves with how much their usual cup, mug or glass holds and to keep a record of fluid intake until they become accustomed to how much they are allowed
• Understand that fluid restrictions may need to be liberalised in warmer weather to account for increased losses through sweat. Increase fluids gently to replace fluid lost from sweat or in extreme heat, ensuring that daily weight is monitored
• Avoid drinking less than their recommended fluid intake to avoid dehydration

Salt/Sodium intake

Excessive intake of dietary sodium contributes to fluid overload and is a major cause of preventable hospitalisation. Generally, sodium intake should be about <2g/day. Reducing intake of dietary sodium may result in beneficial haemodynamic and clinical effects, particularly when combined with a diuretic regimen.

Referral to the Dietitian to optimise sodium restriction is recommended if available.

Educate patients to:

• Understand the relationship between sodium intake and symptom management in HF. Restricting salt intake can help with controlling fluid overload
• Determine current dietary sodium intake and identify options to measure and adhere to recommended daily intake
• Recognise foods low in sodium such as fresh fruit and vegetables, whole grains, lean meats, unsalted beans and nuts, fresh herbs and unprocessed foods
• Recognise foods high in sodium such as processed meats, cheeses, sauces, frozen dinners and packaged mixes, canned soup and canned vegetables
• Gradually reduce salt intake so their palate has a chance to adjust to the change and food does not seem tasteless
• Read food labels and identify lower salt alternatives
• Avoid adding salt to cooking and regular meals  – avoid putting salt on the table to avoid any temptation

See patient education section for factors to consider regarding adult learning and health literacy. Also, explore barriers to adherence discussed in the Supporting behaviour change section.

The table below shows actions to take when patients show signs of worsening of symptoms.

Table 1: HF decompensation signs and severity and action to take