Symptom experience, symptom management in patients with heart failure: A literature review

Available online at www.buuconference.buu.ac.th

2019 - The 7

Burapha University International

“Break the Barriers, Design the Future”

Symptom experience, symptom management in patients with heart failure: A literature review

Warinthorn Damrongratnuwong

, Khemaradee Masingboon

*

a Faculty of Nursing, Burapha University, Muang District, Chonburi, 20131, Thailand.

b Faculty of Nursing, Saint Louis College,Sathon, Bangkok, 10120, Thailand.

Abstract

Heart failure is a condition that causes great suffering to patients and a leading cause of morbidity, mortality, and hospitalization. Patients with heart failure commonly experience numerous symptoms. When a symptom occurs, the patients will seek to manage symptoms. Good symptom management can positively impact quality of life and functional status. The purpose of this paper was to describe symptom experience and symptom management in patients with heart failure.

Electronic databases search included PubMed, CINAHL, SpringerLink, ScienceDirect, and Google Scholar. The keywords included symptom management or symptom control AND heart failure AND symptom experience AND symptom perception. The searching criteria included the original full-text articles were published in English language between 2014 and 2019. Fourteen articles were analyzed. The most common symptoms report by patients with heart failure were dyspnea/shortness of breath, fatigue, pain, depression, sleep disturbances, and swelling/edema. Two symptom clusters were classified, including physical symptom cluster and emotional/cognitive symptom cluster. The strategies used to manage symptoms were various including 1) pharmacological management, especially maintain medications, 2) non- pharmacological management (such as dietary modification, sleep hygiene, cognitive-behavior therapy (including relaxation, meditation, and guided imagery)), and 3) combine both pharmacological and non-pharmacological management.

Future research, nurses should comprehensively assess symptom experiences and they should develop symptom cluster management strategies by using a combination of both methods in order to improve physical status and quality of life.

© 2019 Published by Burapha University.

Keyword: heart failure; symptom experience; symptom management

* Corresponding author. Tel.: +66-081-987-5586; fax: +66-3839-3476.

1. Introduction

Heart failure (HF) is a major public health concern worldwide and a leading cause of morbidity, mortality, and hospitalization. HF affects an estimated 5.7 million people in the US, with more than 915,000 new cases each year. Projections show that the prevalence of HF increases with age and will increase by 46% from 2012 to 2030, with greater than 8 million adult people living with HF (Benjamin et al., 2018). The overall economic cost of HF in 2012 was estimated to be $108 billion per year worldwide, and further aging of the population, the economic burden of HF will continue to rise (Cook, Cole, Asaria, Jabbour, & Francis, 2014). In Thailand, HF is one of the major cardiovascular health problems, economic burdens, and leading causes of death. The Thai Acute Decompensated Heart Failure Registry (Thai ADHERE) demonstrated that Thai patients hospitalized for heart failure were younger and sicker than American and European patients (Laothavorn et al., 2010). There is a high prevalence of heart failure with preserved ejection fraction. The annual cost of HF hospitalization was 3,606 US$ per patient. More than half of patients are readmitted to the hospital many times, and some require care in intensive care units (Laothavorn et al., 2010).

Heart failure is defined as a complex clinical syndrome that is due to the impaired cardiac function that is insufficient to support physical circulation (National Guideline Centre, 2018). Several symptoms and signs characterize the clinical syndrome of HF. Patients with HF usually describe many symptoms such as dyspnea, paroxysmal nocturnal dyspnea (PND), orthopnea, syncope/dizziness, and edema. Signs and symptoms are among the most common reasons that patients seek healthcare. Symptoms are multidimensional, complex, and subjective phenomena that reflect changes in biopsychosocial functioning, sensations, or cognition of an individual (Dodd et al., 2001).

According to Humphreys et al. (2014) stated that a symptom refers to the subjective experience of an individual about changes in biopsychosocial functioning, sensation, or cognition. The symptom experience dimension is composed of perception, evaluation, and response to the symptom (Dodd et al., 2001; Humphreys et al., 2014). Symptoms can have an impact on a variety of outcomes including symptom status, functional status, costs, morbidity and co-morbidity, and quality of life. When symptoms occur, a person will seek to manage those symptoms to maintain physical stability or reduce the severity of symptoms.

Symptom management is a dynamic process that usually requires a change every time (Dodd et al., 2001).

Good symptom management can positively impact quality of life, patient functional status, and ability to live a fairly normal life for persons with heart failure. Poor management leads to worsening symptoms, decreased functional status, anxiety and depression, poor quality of life, and exacerbation leading to more hospital readmission (Rhiantong et al., 2019; Zambroski, Moser, Bhat, & Ziegler, 2005).

Although many studies focused on intervention to manage symptoms, it does not succeed because patients with HF often experience multiple symptoms concurrently. Therefore, a literature review was conducted to describe symptom experience and symptom management in patients with heart failure.

2. Methods

The searched electronic databases were PubMed, CINAHL, SpringerLink, ScienceDirect, and Google Scholar. The keywords used in the review included symptom management or symptom control AND heart failure AND symptom experience AND symptom perception. These search terms had to be identified anywhere in the text in the articles. Both qualitative and quantitative studies were considered in order to capture various aspects of symptom management. The searching criteria were restricted to original research, and the full-text articles were published in English language between 2014 and 2019. Institute (2014) was used to appraise the quality of evidences.

A total of 184 articles were identified in the search process as potentially relevant. An additional 4 articles were identified after hand-searching reference lists. A literature search flow chart of the article search on symptom experience and symptom management in patients with heart failure appears in Figure 1. Of these 188 articles, 14 articles met the inclusion criteria and were included in the review.

Fig. 1. Flow chart of the article search on symptom experience and symptom management in patients with heart failure.

3. The findings

Fourteen articles met inclusion criteria and were used in the review, of which twelve articles were quantitative study (Alkan & Nural, 2017; DeVon et al., 2017; Evans, 2016; Kronkasem, Wattanakitkrileart, Pongthavornkamol, & Kanoksin, 2014; Kwekkeboom & Bratzke, 2016; Lum et al., 2016; Moser et al., 2014;

Norman, Fu, Ekman, Björck, & Falk, 2018; Park, Moser, Griffith, Harring, & Johantgen, 2019; Stewart &

McPherson, 2017; Wirta et al., 2018; Yu, Chan, Leung, Hui, & Sit, 2016) and two articles were qualitative study (Glogowska et al., 2015; Hall et al., 2014). Of the quantitative studies, one article was randomized controlled trials (Norman et al., 2018), one article was systematic review of quasi-experimental (Kwekkeboom

& Bratzke, 2016), and ten articles were descriptive studies (Alkan & Nural, 2017; DeVon et al., 2017; Evans, 2016; Kronkasem et al., 2014; Lum et al., 2016; Moser et al., 2014; Park et al., 2019; Stewart & McPherson, 2017; Wirta et al., 2018; Yu et al., 2016).

Screening

Records after duplicates removed (n= 147)

Identification Records identified through database searching

(n = 184)

Additional records identified through other sources

(n = 4)

Records screened (n = 147)

Records excluded (n = 122)

Eligibility

Full-text articles Assessed for eligibility

(n = 25)

Full-text articles excluded, with reasons

(n = 11)

Studies included in the literature review

(n = 14)

Included

Based on the Joanna Briggs Institute Levels of Evidence and Grades of Recommendation (2014), the study was ranked according to the research findings most likely to provide valid information on the effectiveness of a treatment/care option. Only one of the quantitative study of randomized controlled trials was ranked in level 1(strong evidence) (Norman et al., 2018), one article of systematic review of quasi-experimental was ranked in level 2 (Kwekkeboom & Bratzke, 2016), and twelve articles of descriptive studies were ranked in level 4 (Alkan

& Nural, 2017; DeVon et al., 2017; Evans, 2016; Glogowska et al., 2015; Hall et al., 2014; Kronkasem et al., 2014; Lum et al., 2016; Moser et al., 2014; Park et al., 2019; Stewart & McPherson, 2017; Wirta et al., 2018;

Yu et al., 2016), None of the study was ranked level 5 (weak evidence). All articles were assessed to be of good or adequate quality based on the methodological validity according to JBI. All most studies were presented as full-text articles.

The results of this study were presented in four parts including sample characteristics, symptoms of heart failure, symptom cluster, and symptom management.

3.1 Sample Characteristics

The results of this study were presented in four parts including sample characteristics, symptoms of heart failure, symptom cluster, and symptom management.

All articles included symptomatic patients with HF [New York Heart Association (NYHA) class I–IV]. The most studies were present NYHA class II-III (Alkan & Nural, 2017; DeVon et al., 2017; Hall et al., 2014;

Kronkasem et al., 2014; Kwekkeboom & Bratzke, 2016; Moser et al., 2014; Norman et al., 2018; Park et al., 2019; Wirta et al., 2018; Yu et al., 2016). The mean age ranged from 56 (DeVon et al., 2017) to more than 89 years (Park et al., 2019). Both men and women were included in all studies, and most articles were male.

Multiple instruments were used to measure symptom. The instrument most commonly used in the HF studies was the Minnesota Living with Heart Failure Questionnaire (MLHFQ). The most studies (four articles) used MLHFQ (DeVon et al., 2017; Kwekkeboom, & Bratzke, 2016; Moser et al., 2014; Park et al., 2019), followed by Memorial Symptom Assessment Scale Heart Failure (MSAS-HF) (Alkan & Nural, 2017; DeVon et al., 2017). In addition, Kansas City Cardiomyopathy Questionnaire Scale (KCCQ) (Lum et al., 2016; Kwekkeboom

& Bratzke, 2016) was reported in two studies, and Edmonton Symptom Assessment Scale was reported in one study (Yu et al., 2016).

3.2 Symptoms of heart failure

The number of symptoms differed widely and ranged from 4-28 symptoms. Most studies evaluated six symptoms (DeVon et al., 2017; Lum et al., 2016; Stewart & McPherson, 2017), followed by two studies that evaluated eight symptoms (Yu et al., 2016; Moser et al., 2014). Collectively, the most common symptoms were dyspnea/shortness of breath (n=9), fatigue (n=8), sleep disturbances (n=5), depression (n=5), pain (n=5), swelling/edema (n=5), anxiety (n=4), and cognitive problem (n=3). The most symptoms are caused by the pathology of disease that causes suffering and negatively impacts physical status and quality of life.

3.3 Symptom cluster

From the review found that the symptoms that occur together and can be grouped should be called symptom clusters. The number of clusters across studies ranged from two to three clusters. Three studies identified two symptom clusters comprises of physical symptom cluster (including edema, shortness of breath, fatigue/increased need to rest, fatigue/low energy, and sleep difficulties), and psychological symptom cluster (including worrying, feeling depressed, and cognitive problems) (DeVon et al., 2017; Moser et al., 2014; Park et al., 2019). Yu et al. (2016) identified three symptom clusters including the distress symptom cluster (including shortness of breath, anxiety, and depression), the decondition symptom cluster (fatigue, drowsiness, reduced appetite, and nausea), and the discomfort symptom cluster (generalized discomfort and pain).

3.4 Symptom Management

Symptom management can be done in many strategies. In the review, five articles were mentioning to symptom management (Hall et al., 2014; Kronkasem et al., 2014; Kwekkeboom, & Bratzke, 2016; Norman et

al., 2018; Stewart & McPherson, 2017). Symptom management was a priority for both patients and their carers.

Symptom management in patients with heart failure depended on an individual perception of symptom, which was pharmacological management, non-pharmacological management, and a combination of pharmacological and non-pharmacological management. One study focused on a combination of pharmacological and non- pharmacological management of the most common symptoms (Stewart, & McPherson, 2017) and four articles used non-pharmacological management (Hall et al., 2014; Kronkasem et al., 2014; Kwekkeboom & Bratzke, 2016; Norman et al., 2018). According to Stewart and McPherson (2017) revealed that the most common symptoms were dyspnea. The management should focus on hemodynamic optimization through maintenance of euvolemia with diuretics and dietary sodium/fluid restriction, afterload reduction, and the use of inotropes if appropriate. Furthermore, opioids had been used to reduce dyspnea. For the fatigue, treatments often focus on behavioral changes to directly target an underlying cause and might include exercise, dietary modification, adjusted diuretic scheduling, upright sleep positioning. Corticosteroids might provide temporary relief of fatigue by increasing energy and inducing a general sense of well-being. Dexamethasone could provide rapid symptomatic improvement. One article reported that the effect of cognitive-behavioral symptom management strategies (relaxation, meditation, and guided imagery) is beneficial to patients with heart failure (Kwekkeboom

& Bratzke, 2016). One article used a mindfulness-based intervention to reduce the self-reported impact of fatigue, symptoms of unsteadiness/dizziness, and breathlessness/tiredness related to physical functioning (Norman et al., 2018). Kronkasem et al. (2014) reported that the fatigue management strategy was most commonly used to manage the symptom, and most effective was sleeping. According to Hall et al. (2014) focused on technology for monitoring heart failure symptoms. They found that the participants reported the use of a home monitoring device to measure a vital sign (e.g., blood pressure or weight) and their belief that technology would be useful for managing heart failure symptoms.

4. Discussion

The finding of the review indicated that the symptoms of HF widely and ranged from 4-28 symptoms. The most common symptoms were dyspnea/shortness of breath, fatigue, sleep disturbances, depression, pain, swelling/edema, anxiety, and cognitive problem. These results are similar to Alkan and Nural (2017) found that the most common symptoms in HF patients were waking up breathless at night, shortness of breath, difficulty sleeping, lack of energy, difficulty breathing when lying flat, fatigue, pain, and depression. According to Dodd et al. (2001) stated that a symptom is defined as a subjective experience reflecting changes in the biopsychosocial functioning, sensations, or cognition of an individual. The symptom experience dimension is composed of perception, evaluation, and response to the symptom (Dodd et al., 2001; Dodd, Miaskowski, &

Lee, 2004; Humphreys et al., 2014). However, patients with HF often experience multiple symptoms simultaneously rather than in isolation (Jurgens et al., 2009; Zambroski et al., 2005). Therefore, identifying co- occurring symptoms or symptom clusters might assist health care providers in managing these symptoms more effectively (Moser et al., 2014). Thus, a symptom cluster has been defined as “two or more symptoms that are related to each other and that occur together. In this review, two symptom clusters were classified including physical symptom cluster and emotional/cognitive symptom cluster.

From our review found that the strategies used to manage symptoms were various because of symptoms as an individual perception. Pharmacological management is used in controlling the main symptoms caused by pathology. At the same time, non-pharmacological management will decrease the severity and frequency of symptoms. The two methods decrease heart function, relieve symptoms, increase functional status, and improve quality of life. Significantly, symptom management strategies should focus on symptom cluster management not only one symptom. Management strategies should include a combination of pharmacological and non- pharmacological management. For example, fatigue affects up to 85 % of patients with HF and had many

contributing factors beyond just low cardiac output. Treatments for fatigue often focused on behavioral changes to directly target an underlying cause and may include exercise, scooter use, dietary modification, adjusted diuretic scheduling, upright sleep positioning with a wedge or hospital bed if necessary, or nocturnal supplemental oxygen. If behavioral modifications and good sleep hygiene practices failed to resolve sleep disturbance, medications such as trazodone should be considered (Alpert, Smith, Hummel, & Hummel, 2017).

5. Conclusions and recommendations

The findings of the review indicated that patients with HF experienced multiple co-existing symptoms, which called symptom clusters. Two symptom clusters were classified including physical symptom cluster and emotional/cognitive symptom cluster. The health care professionals and the patient should have the same perception of symptoms in order to effectively manage such symptoms. If patients can self-control their symptoms, the severity and the frequency of such symptoms then decrease, and the quality of life and their functional status are consequently improved.

In addition, nurses should comprehensively assess symptom experiences of patients with heart failure, and then interventions should match and cover co-existing symptoms. The nurse should develop symptom cluster management strategies by using a combination of both methods in order to improve physical status and quality of life.

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