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Authors: Rachael Broscious, PharmD, and Kristin Watson, PharmD, BCPS-AQ Cardiology
In our previous post, we reviewed the importance of assessment in patients with heart failure (HF) and outlined strategies for determining functional status. In this post, we’ll pick up where we left off by discussing signs and symptoms of HF as well as the assessment of medication and dietary adherence. If you missed it in our first post, don’t forget to check out our sample data collection tool.
Orthopnea and paroxysmal nocturnal dyspnea
Orthopnea is the term for dyspnea occurring in the recumbent position. Orthopnea is quantified by the number of pillows that the patient requires to sleep or rest comfortably. Patients with more advanced HF may need to sleep propped up in a chair. There are numerous reasons why patients use pillows to sleep; do not assume that a patient has two-pillow orthopnea just because he reports using two pillows to sleep at night! These pillows may be used to relieve back pain or may simply represent what the patient finds most comfortable. To discern the need for pillows, ask patients if they get short of breath when sleeping flat or when using fewer pillows.
Paroxysmal nocturnal dyspnea is defined as sudden episodes of dyspnea that occur after the patient has been asleep for a few hours. Be sure to assess if other symptoms accompany these awakenings. For instance, a patient with nightmares may be awakened by shortness of breath but may also report sweating and tachycardia. The number of episodes per night and per week should be documented and it should be determined if the frequency has changed with time.
Worsening orthopnea and/or paroxysmal nocturnal dyspnea are signs of worsening HF and may require titration of diuretic therapy.
We love that this now has an official term! Bendopnea is when a patient develops dyspnea within 30 seconds of bending at the waist.1Patients may report that they get short of breath when bending over to tie their shoes. Be sure to ask about this if the patient does not offer this information voluntarily. You can also directly observe this as part of your examination.
Additional information should be ascertained to determine if patients are hypervolemic, euvolemic, or volume depleted. While much of this is garnered from the physical examination (e.g., jugular venous pressure, edema), patients can also provide important data, including changes in their weight. If they are not already checking their weight at the same time each day, this is a perfect time to educate them on the importance of doing so. Patients should be counseled to record their weights and when they should notify their provider about changes in weight. Patients should also be asked about changes in their abdominal circumference, which can be assessed by asking about changes in the waist size of their pants or if they’ve needed to loosen or tighten their belt.
Patients should be questioned about the presence and height of lower extremity edema (e.g., to the knee, thigh) and how this has changed over time. Men with thigh edema should be questioned on the presence of scrotal edema. Patients with pulmonary edema may report a productive cough.
Patients who are volume depleted may report unintentional weight loss, dizziness or lightheadedness, and/or increased thirst.
Patients should be questioned about the presence of chest pain, especially in those with known coronary disease. Patients should also be questioned regarding dizziness or lightheadedness. When a positive response is obtained, the interviewer should then ask further questions and obtain objective data to ascertain the etiology (e.g., volume depletion, orthostatic hypotension).
Finally, patients should be asked if they have had a syncopal event. The circumstances (e.g., prodrome; relationship of the event to meals, activity) surrounding the event must also be collected, as should any injuries that may have occurred as a result of syncope. This information will assist you in determining a differential for the cause of the event and to develop a plan to determine the etiology.
Past Medical History
The interview should also include obtaining the patient’s medical history to help identify the etiology of their disease, if unknown. This includes obtaining information regarding prior testing such as cardiac catheterization, stress testing, or cardiac magnetic resonance imaging.
Diet and Social History
Other important aspects of the patient interview include an assessment of diet and lifestyle. This is an opportune time to evaluate dietary patterns, reiterate the importance of a low sodium diet, and suggest dietary alternatives. Physical activity is generally evaluated during symptom evaluation, but it may be important to reiterate the importance of safe physical activity, such as walking, with the potential to refer motivated patients to a cardiac rehabilitation program. Quantification of alcohol, tobacco and illicit substance use must also be determined.
Medication Reconciliation and Adherence
A thorough medication reconciliation should be completed at each visit. Encourage patients to bring their prescription bottles with them or create a medication list to carry with them. Ask patients if they have seen other providers or have been hospitalized since their last visit. Determine if any medication changes were made and the rationale for doing so. It is important to ask about each medication individually.
One of the most important reasons for performing medication reconciliation is that it prevents the adjustment of medications based on erroneous or outdated information. For example, a patient with stable HF symptoms and a heart rate of 105 bpm who is taking metoprolol succinate 100 mg once daily would be eligible for a dose increase. However, by asking the patient about their adherence, you may learn that it has not been refilled in several months, in which case up-titration could result in a HF exacerbation.
In addition to evaluating adherence, understanding when chronic HF medications (beta blockers, angiotensin-converting enzyme inhibitors, and/or hydralazine/isosorbide dinitrate) were initiated or last titrated can aid decision-making regarding when to perform additional adjustments.
When performing a medication history, pointed questions may be especially useful. Examples include:
How many times a week do you miss your medications?
Are there any medications that you decide to skip? Why?
Do you ever miss a dose of your water pill (give the medication name too)? Do you ever take extra doses of this medication? If so, what prompts you to do this?
What time(s) a day do you take your medications?
For thrice daily medications – how many days a week do you take all three doses? What time of day are you taking each dose? We find that the mid-day dose is commonly missed so we will follow-up with– Do you find that taking the mid-day dose is hard to do? How many times of week do you miss that dose?
As you review each medication, ask about potential side effects unique to that therapy. For example, men who are receiving spironolactone should be asked if they have breast tenderness or swelling.
Triggers for Worsening Heart Failure
Lastly, evaluation of potential triggers for worsening HF may overlap with some of the above categories. However, it is imperative to ask about nonprescription medications such as non-steroidal anti-inflammatory drugs, illicit substances, and alcohol – all of which can exacerbate HF and lead to poor outcomes. Discussing triggers for HF can be another opportunity to use motivational interviewing to promote healthy alternatives and an overall healthy lifestyle.
The more time you spend conversing with patients and conducting patient interviews, the easier they will become. It is important to individualize your interview style but to always remember the fundamentals of conducting a patient interview. Readers wanting to learn more about coupling the patient interview with the physical examination in patients with HF are referred to a recent piece by Thibodeau and Draznerin the Journal of the American College of Cardiology: Heart Failure.
Key points for a successful patient interview include:
Utilizing open ended questions
Conducting a thorough symptom evaluation
Assessing medication adherence
Applying motivational interviewing when appropriate.
Employing these techniques will allow you to complete a thorough patient interview and facilitate in providing your patient’s the best care possible.
Kristin Watson, PharmD, BCPS-AQ Cardiology
Rachael Broscious, PharmD
- Thibodeau JT, Turer AT, Gualano SK, et al. Characterization of a novel symptom of advanced heart failure: bendopnea. JACC Heart Fail 2014;2:24-31.
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