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Shukurov Ravshan Tulkinovich, Candidate of Medical Science, Clinical Care Deputy Director of the Republican Specialized Cardiology Center, E-mail: [email protected]
Kurbanov Ravshanbek Davletovich, Member of the Academy of Sciences, Director of the Republican Specialized Cardiology Center, E-mail: [email protected]
Abdullaev Timur Atanazarovich, Doctor of Medicine, Professor, Head of the Non-Coronarogenic Myocardial Diseases and Heart Failure Department, E-mail: [email protected]
SELF-MONITORING TRAINING AND ACTIVE OUTPATIENT OBSERVATION IN PATIENTS WITH CHRONIC HEART FAILURE
Abstract: The influence of group self-monitoring and self-care training of 204 patients with chronic heart failure of II-IV functional class according to NYHA (average age - 58.7 ± 12.9 years) on functional status, quality of life, exercise tolerance, echocardiography indices, rate of adverse events development was studied. The duration of follow-up period was 6 months. Self-monitoring and self-care training of patients with CHF contributed to functional status improvement, quality of life improvement and exercise tolerance. The following results were noted: therapy high compliance maintenance, rate and risk of repeated admissions associated with CHF decompensation reduction, left ventricular ejection fraction increase in group training group.
Keywords: chronic heart failure, outpatient observation, therapeutic training, patient training, self-monitoring, self-care.
To the present day cardiovascular diseases consoli- heart failure treatment regimens, the most important dated their leading position in the structure of mor- part ofwhich is the training ofpatients and their relatives bidity and mortality and in Uzbekistan their share is [4]. Thus, according to meta-analysis of 6 relevant clini-59.3% in the structure of total mortality [1]. Chronic cal trials data, the training in combination with active heart failure (CHF) hardly worsens the quality of life patients' observation didn't affect their mortality com-of patients, 4 times increases the risk of mortality, and pared to control group within 6 months, but it halved mortality rate of patients within 1 year is 15-50%. De- the risk of admission in case of CHF [5]. Analysis of the spite the certain achievements in CHF diagnosis and patients with CHF admission reasons showed that in al-treatment, the prognosis for these patients remains most 70% of cases they are based on behavioral factors unfavorable. The half of all patients dies within 5 years (recommended way of life non-compliance: nutritional after diagnosis establishment [2]. Heart failure (CF) care, exercise regimen, drug therapy) [4]. According remains one of the topical health care problems in many to study results, only one third of the patients after discountries in the world, including Uzbekistan [3]. charge from the hospital continue to take angiotensin-
One of the effective methods for quality of patients converting enzyme inhibitors (ACE inhibitors) and only
with heart failure treatment improvement became the 15% - beta-blockers (BB) and diuretics [5, 6]. In con-
nection with the above, the main problem of HF treatment is that even considering proper diagnosis, timely and adequate therapy, the effectiveness is inadequate, as patients poorly follow recommendations. In addition to correct treatment order, it is also necessary to ensure that the patient will follow all the recommendations.
The aim of this study was to determine the role of training and outpatient observation in treatment optimizing in patients with CHF.
Materials and methods: Patients' selection and their inclusion in study were carried out in the Department of the Republican Specialized Cardiology Center of the Ministry of Health of the Republic of Uzbekistan. The study was screening and included the patients diagnosed with CHF [4]. The study included 204 patients aged from 19 to 82 years (average age 58.7 ± 12.9), where 127 (62.3%) were men and 77 (37.7%) - women. Patient's medical history study allowed finding out that before admission, HF clinical features and symptoms were manifested from several months to 15 years ago.
The main cause of CHF was coronary heart disease (CHD) (58.8%), and in more than half of cases (68.3%) it was combined with arterial hypertension (AH). Non-coronarogenic myocardium diseases included: evoked and congenital heart disorders - 16.2%, cardiomyopathy - 11.3%, myocarditis - 1%, AH without visceral injury - 12.7%. The results of this study part are associated with previous multicenter trials in Europe and Russia, demonstrating the large IHD contribution to CHF development [7, 8]. In 27.5% of cases, diabetes mellitus (DM) of type 2 and 18.6% of Chronic Obstructive Lung Disease (COLD) were detected as a background disease.
All the patients underwent well-defined therapeutic training, including two group sessions for 30-40 minutes. Before discharge from the hospital, each patient received written recommendations that contained a list of drugs including the doses and dosage frequency, directions for salt consumption reduction and daily control of body weight, as well as an instruction sheet for patients with CHF and session materials. In addition, the clinic's telephone numbers for patient calling a doctor for advice are also listed. Throughout the follow-up period, patient's condition and patients' adherence to prescribed treatment were assessed via calls once per month, and treatment recommendations were given. A drug therapy was carried out at hospital in accordance with national
standards for CHF treatment. After discharge from the heart disease department, all patients were recommended to continue taking prescribed drugs. The follow-up period was 52 weeks, during which each patient visited the doctor 3 times: first visit - initiating (week 0), second visit - interim (week 24), third visit - final (week 52).
Over the follow-up period, the dynamics of the following parameters was analyzed: patients' clinical state, 6-minute walk test distance, quality of life (QoL) by use of Minnesota Living with Heart Failure questionnaire (MLHFQ), heart structure and function objective indicators according to echocardiography (ECHO), patients' adherence to treatment, adverse events development -repeated admissions, CHF decompensation, death.
The study results are processed by variance analysis methods (Student's t-test for paired calculations and x2 criterion) using BIOSTAT software package. The data are presented in the form of M ± SD. Statistically significant were the differences atp < 0.05.
Study results and their discussion: Patients regularly took ACE inhibitors/angiotensin-2 receptor antagonists (AIIRA), aldosterone antagonists and indirect oral anticoagulants in 99%, 93.8% and 19.5% of cases, during the first 24 weeks, respectively, where the good tolerability and safety ofthese drugs were observed. By week 24, 91.8% ofpatients continued to take BB, where a heart rate decrease (HR) was observed in 12 patients who took drugs in combination with amiodarone, whereanent they stopped taking BB. At the same time, by week 24 ofthe follow-up a significant decrease to 38.5% in the need for diuretics was observed due to CHF symptoms and signs decrease in patients. By week 52 of the follow-up, 88.8%, 92.9% and 19.4% of patients continued to take BB, aldosterone antagonists and indirect oral anticoagulants on a regular basis, and respectively, the drugs were tolerated well, without side effects. During the second half of the year, 89.4% of patients took ACE/AIIRA, 19 patients stopped taking the drug due to arterial blood pressure decrease. By week 52 of the follow-up, the need for diuretics was noted in 20.6% of patients.
A close correlation between the patients' with CHF health literacy level and their adherence to treatment was revealed. Thus, Noureldin M. et al. [9] found that patients with CHF with an adequate health literacy level are more confined to regular drug intake (69.4%) than the patients with a low health literacy level (54.2%), p = 0.001. The authors believe that patients' health literacy
improvement should be one of the main components in their adherence to therapy increase. The study of L. B. La-zebnik's et al, in which the analysis of reasons for patients with CHF repeated admission and their cost characteristics presented, is especially noteworthy [10]. It turned out that the situation concerning patients with CHF treatment in the Russian Federation both at the hospital and at outpatient levels remains extremely alarming. Outpatients with stage II CHF received ACE inhibitors only in 50% ofcases, and BB took less than 25% of patients. According to CHF severity increase, the treatment of patients becomes more inadequate to existing recommendations. Only 55% of patients with stage II CHF use ACE inhibitors, and BB -14.7%. In patients with stage III CHF, ACE inhibitors usage decreases to 21.9% and BB to 6.2%, while the frequency of cardiac glycosides prescription increases to 71.9%.
Thus, training and dynamic monitoring of doctor's recommendations following by the patients allowed to really maintaining a sufficiently high patients' adherence to therapy. How did this affect the disease state?
The tolerance of physical activity significantly improved in patients. According to 6-minute walk test results, a significant tolerance to physical activity increase was noted in 24 and 52 weeks. The distance of 6-minute walk test initially was 196.6 ± 69.2 m. After 24 and 52 weeks of the follow-up and treatment, its increase to 302.5 ± 81.8 and 329.1 ± 82.4 m was observed, respectively, p < 0.05 compared to initial data. Similar data were also obtained in the study of S. Berdnikov [11], where the functional status of patients was significantly improved in the group of outpatient self-monitoring according to 6-minute walk test results. The distance run in 6-minute walk test in the group by month 9 of the study increased on average from 174.5 (108-231.5) m to 248.5 (142-324) m (p = 0.001). By the end of the study, the distance run in 6-minute walk test in outpatient self-monitoring group was significantly greater than in the control group (p < 0.05).
QoL assessment by using Minnesota Living with Heart Failure Questionnaire during the follow-up period revealed a tendency to positive dynamics in comparison with initial data. QoL improvement by week 24 was noted by 14.1% (58.7 ± 11.4 points), and by week 52 - by 28.1% (49.1 ± 9.5 points) compared with initial indices (p < 0.05). There is data that patients' QoL with insufficient medical literacy is lower than in patients who have an adequate medical literacy level (55.4 vs. 63.9 accord-
ing to Heart Failure Symptom Scale, adjusted difference 7.20, p < 0.01) [12]. Based on the study conducted by Lycholip E. et al. [13] results, patients with CHF training improved their quality of life (it was assessed using Minnesota Living with Heart Failure Questionnaire, 37.9 ± 18.78 vs. 49.39 ± 17.86 before training,p < 0.001).
Thus, a significantly better functional state and greater tolerance to physical activity were established in patients with CHF under active care, against the background of therapy conducted.
A sufficient duration of the current study allowed obtaining evidence of cardiac remodeling progression containment possibility during adequate therapy. Central hemodynamics parameters according to ECHO data underwent significant changes. After 24 weeks of the follow-up, end-systolic dimensions (ESD) of left atrium (LA), end-diastolic (ED) and end-systolic volume (ESV) of left ventricle (LV) indices decreased from 4.37 ± 0.89 to 4.23 ± 0.8 cm, from 200.7 ± 67.2 to 192.6 ± 55.4 ml and from 112.9 ± 53.6 to 101.3 ± 45.7 ml (p < 0.05), respectively, and consequently, left ventricle ejection fraction (LVEF) increased from 45.6 ± 8.6 to 49.3 ± 9.4% (p < 0.05). The analysis after 52 weeks of the follow-up showed that the majority of patients had positive dynamics maintenance on the part of ECHO indices, compared with initial indices. Thus, by week 52, a decrease in LA ESD to 4.2 ± 0.76 cm, LV ED to 189.9 ± 55.3 ml, LV ESV to 100.1 ± 44.5 ml (p < 0.05) and an increase in LV EF to 48.9 ± 9.4% (p < 0.05) were observed. All this testifies to active follow-up and adequate therapy positive influence on our patients' basic cardiovascular system indices.
Similar results were obtained in the study of N. A. Ko-shelev et al. [14], where in patients of active surveillance group, by 24th week, a significant improvement of such parameters as LA ESD, LV ESD, compared with the parameters of patients from the standard treatment group was observed. At that, EF in patients of active follow-up group, become more significant than EF in patients of the control group. At further follow-up, the patients of the control group continue to show unfavorable dynamics of echocardiographic parameters changes.
Thus, adherence to recommended medication allows patients to achieve a certain intervention in cardiac remodeling in actual clinical practice. Does active outpatient management of patients with CHF affect their prognosis, adverse events development?
Yes, it does. Even over such a relatively short period, positive changes in patients' treatment results were noted. The total number of adverse events during the year was 34 cases (16.7%). At that, repeated admissions at an early stage (first 3 months after discharge from the hospital) were not required. The frequency of repeated admissions within one year after discharge was 33 (16.2%) cases, 16 (48.5%) of which were men. The main reason for repeated admissions was CHF decompensation - 24 (72.7%) cases. Other reasons for admissions were observed in 9 cases: 7 (21.2%) of patients were admitted due to atrial fibrillation seizure development, an acute cerebrovas-cular disease was diagnosticated in 1 patient, in another case, the cause of admission was COLD recrudescence. Causative factors and comorbidity analysis showed that comorbid conditions most frequently were observed in repeatedly admitted patients (myocardial infarction in anamnesis - 54.5% vs. 49.4% (x2 = 0.001, p = 0.98), permanent form ofatrial fibrillation - 33.3% vs. 16.5% (x2 = 4.04, p = 0.046), type 2 diabetes mellitus 42.4% vs. 24.7% (X2 = 4.31, p = 0.038), COLD30.3% vs. 12.4% (X = 5.56, p = 0.018) compared with the group of not repeatedly admitted patients. A distinctive feature ofmodern therapeutic and diagnostic process is the comorbidity availability in patient [15]. In general, the comorbidity prevalence rate is 20-30% among population at large, 55-98% among elderly and senile patients [16]. According to the data of some authors, among the majority of elder patients CHF almost never runs independently: in 12% it is combined with COLD [17], a combination with type 2 diabetes mellitus is observed from 12 to 22% of cases and reaches 30% in patients with CHF of ischemic genesis [29]. When comparing the indices ofsystolic and diastolic blood pressure, heart rate differences are not also revealed (p > 0.05). According to ECHO, LV EF values in repeatedly admitted patients and the number of patients with systolic dysfunction didn't vary definitely (p > 0.05) in comparison with singly admitted patients. Also, the age-related aspect of re-admitted patients, which showed an increase of the mean age (70.4 ± 6.8 years) and the number of patients older than 65 years (75.8%) was analyzed. The patient's age is an important predictor in medicine. Young CHF patients have some features of relatively elderly patients, who have a lot of concomitant diseases, higher risk of side effects after drug therapy. Elderly patients are treated less intensively than young patients, as evidenced by the re-
sults obtained. According to E. V. Efremov et al. [18] the patients with CHF with a high comorbidity were older than the patients with a low comorbidity: 67.6 ± 8.2 and 55.2 ± 7.0 years, respectively, p < 0.01. The total number ofnosologies in patients with CHF also increases with age (p < 0.01).
No fatal outcomes among the patients examined were detected during the first six months of the follow-up. During the period from 24th to 52nd week of the follow-up, 1 patient (0.5%) died at the age of 43 years. This patient died at home and the post mortem examination wasn't carried out. According to relatives, the patient's death occurred suddenly. Two years ago the patient was diagnosed with dilated cardiomyopathy, frequent, complicated ventricular arrhythmia types, as well as runs of ventricular tachycardia were noted. The risk factors were smoking, abuse of alcohol; the patient sometimes violated the diet and salt-water regimen. Against the background of complex standard therapy, the patient regularly took a maintenance amiodarone dose - 200 mg per day. Perhaps, a ventricular tachycardia with transition to ventricular fibrillation was developed in patient, in connection with which a sudden death occurred. Based on the results of retrospective cohort study conducted by Peterson P. N. et al. [19] it is established that low medical literacy level in patients with CHF is independently associated with high rates of their mortality - 17.6% vs. 6.3% in patients with CHF with an adequate medical literacy level (RR1.97, 95% CI 1.3-2.97, p = 0.001).
The need for "Schools for patients with CHF" ubiquitous organization, which would allow to timely identifying the patients who lose the capacity to conduct adequate self-monitoring and increase their adherence to treatment by training is obvious. The strategy of active outpatient monitoring and self-care among the patients with CHF, on-call consulting of them allowed not only to improve the culture of outpatient self-monitoring, adherence to treatment and functional status of patients, but also to reduce the number of repeated admissions. At the same time, the need for repeated admissions reduction realizes a significant economic effect of this form of patients' outpatient management. The directions for further research are seen in studying online training opportunities for patients, the role of nurses in patients' outpatient self-monitoring organization and multidisciplinary approach and tele-medical technologies introduction.
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