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Authors: Rachael Broscious, PharmD, and Kristin Watson, PharmD, BCPS-AQ Cardiology

Patient interview remains one of the most important tools in the management of heart failure (HF). The data obtained from patient interview coupled with the physical examination are critical in accurately assessing and managing patients with HF. Clinicians, regardless of their area of practice, will frequently encounter patients with HF, as the disease currently affects over 6.5 million adults in the United States – a number that is expected to increase to over 8 million by 2030. Heart failure remains one of the leading causes of hospitalizations annually and continues to generate high healthcare costs.1In an effort to combat issues related to readmission rates and healthcare expenditures, a growing focus has been placed on care coordination and outpatient HF management.Outpatient clinicians, regardless of their area of practice, play an important role in triaging the management of patients with HF. This two-part series will provide an overview of the fundamentals of conducting a successful patient interview. You may wish to develop a collection tool to help with the structure of the interview; a sample is provided here.

In general, open-ended questions are preferred as they encourage patients to expand upon their answers. However, it may be necessary to consolidate into yes/no or similarly direct questions if more information is required to facilitate a thorough evaluation. For example, when discussing medication adherence, patients will often state they never miss their medications. However, when questioned further (e.g., “How many times in a month do you miss your medications?”), they may provide more useful information regarding their adherence.

Getting Started
For new patients, we like to begin the interview by getting to know them and their understanding of HF. This will likely add a few extra minutes to the interview but we believe it is well worth it! By doing so, you gain an idea of the patient’s insight into their disease process. We have found that patients are often not educated about what it means to have HF, allowing you an opportunity to provide education, fill in gaps in their understanding, or answer questions they may have about their condition. Keep in mind that, depending on how recent the patient was diagnosed, this may be the first time a health care professional has explained the disease process to them.

Functional Classification
It is imperative to inquire about the patient’s symptoms and functional capacity. Assessment of these symptoms will allow you to determine the patient’s New York Heart Association (NHYA) Functional Class (Table 1), which is an important step to triaging the patient’s care and determining treatment.2,3Evaluation of functional status can be accomplished by asking a few pointed questions referenced in our sample intake tool.

Table. New York Heart Association Functional Classification

Class Definition
Class I Asymptomatic left ventricular dysfunction, no limitations with ordinary physical activity
Class II Dyspnea with maximal exertion, comfortable at rest
Class III Dyspnea with minimal exertion, limitations in activity due to symptoms
Class IV Dyspnea at rest

The Criteria Committee of the NY Heart Assoc. Nomenclature and Criteria for Diagnosis of Diseases of the Heart and Great Vessels. 9thed. Boston, MA. Little, Brown and Co. 1994

Symptom evaluation in patients with physical limitations due to other chronic conditions can be difficult, especially for exertional symptoms. Careful attention must be paid to patient history. When conducting the patient interview, further questioning should be used to help discern the source of the limitation. For instance, a patient may report that he can only walk a block at a time. One might assume this limitation is due to HF whereas further questioning may reveal that the patient is actually limited by claudication symptoms and requires evaluation for peripheral arterial disease.

A large spectrum of disorders can impede physical activity, from osteoarthritis and other common sources of pain to chronic lung disease, where the origin of shortness of breath can be difficult to discern. While these comorbidities may confound your assessment of symptoms, appropriate supplemental questioning and physical examination findings can assist in determining the etiology.

Be sure to determine how much activity a patient does on a daily basis. A patient may report that she can walk 5-6 blocks without difficulty but upon further questioning you may discover that she has not attempted to do so in the past year. Ask patients to compare their level of activity to a previous visit or time point (e.g., since the last hospitalization/clinic visit or pre-heart failure diagnosis) to evaluate if symptoms have improved or worsened.

Finally, never underestimate the usefulness of walking a patient back from the waiting room, taking the patient on a walk around the clinic, or even accompanying them up the stairs. We have found that these observations can really help in the assessment of HF symptoms.

Sample questions to help determine the NYHA class:

How far can you walk before becoming short of breath? How often do you walk this distance?

Do you have stairs in your home? If so, how many do you climb before you become short of breath?

Do you become short of breath with getting dressed or with showering?

Do you do any cooking or cleaning in your home? If so, how long can you do this before becoming short of breath? Are there any household chores that you cannot complete because of shortness of breath?

Do you become short of breath at rest? For example, while watching TV or reading the newspaper?

 

Once you’ve gained a general sense of the patient’s functional status, the interview turns to specific signs and symptoms of HF. Stay tuned for our next post, in which we’ll discuss some of the finer details of assessing these signs and symptoms as well as adherence to medications and dietary recommendations.

 
Kristin Watson, PharmD, BCPS-AQ Cardiology

Kristin Watson is an associate professor in the Department of Pharmacy Practice and Science at the University of Maryland School of Pharmacy, and practices as a clinical pharmacy specialist in the ambulatory heart failure clinic at the Veterans Affairs Medical Center in Baltimore, MD. Follow her on Twitter @cards_pharm_gal

Rachael Broscious, PharmD

At the time of this writing, Dr. Broscious was a postgraduate year 2 (PGY2) cardiology pharmacy resident at the University of Maryland in Baltimore, MD.

 

References

  1. Benjamin EJ, Virani SS, Callaway CW, et al. Heart Disease and Stroke Statistics—2018 Update: A Report From the American Heart Association. Circulation 2018.
  2. Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2013;62:e147-239.
  3. Yancy CW, Jessup M, Bozkurt B, et al. 2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. J Card Fail 2017;23:628-51.

 

Getting to the Heart of the Patient Interview: A Focus on Heart Failure (Part I)

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