[Show abstract][Hide abstract] ABSTRACT: One of the challenges in treating patients with heart failure (HF) is achieving clinical stability and reducing the hospital readmission rate. A diuretic dose adjustment algorithm developed in the United States (Diuretic Treatment Algorithm, DTA) and later validated for use in Brazil (as the Algoritmo de Ajuste de Diurético, AAD) has proved feasible and readily applicable, but its effect on clinical outcomes has yet to be assessed. This report aims to describe a randomized clinical trial protocol designed to assess the effectiveness of the AAD and of nonpharmacologic management in improving clinical stability and reducing the readmission rate at 90 days in patients with HF.
A PROBE (prospective randomized open blinded endpoint) parallel-group design will be used. Adult patients with a diagnosis of reduced ejection fraction HF, who are being treated at a specialized HF clinic are being recruited. Those with indications for loop diuretic dose adjustment during routine clinic visits will be randomized to take part in the trial. Participants in the intervention group (IG) shall have their diuretic doses adjusted in accordance with the AAD and receive four telephone calls (one per week) over 30 days to reinforce guidance on nonpharmacological management (fluid and sodium restriction). Participants in the control group (CG) shall have their diuretic doses adjusted by a physician during the first trial visit and shall not receive any telephone calls. Patients in both groups shall return at 1 month for face-to-face reassessment. The study endpoints shall comprise readmission and/or emergency department visits due to HF decompensation within 90 days and clinical instability. All participants shall be required to have a scale at home (or easy access to one), a telephone number, agree to telephone-based follow-up, and be available to return for a 1-month trial visit. Overall, 135 patients are expected to be enrolled in each group.
This trial shall assess the effectiveness of the AAD algorithm and non-pharmacologic management by early identification of clinical deterioration and establishment of a combined intervention to reduce emergency department visits, readmission rate, or a composite endpoint thereof.
ClinicalTrials.gov Identifier, NCT02068937 (23 February 2014).
[Show abstract][Hide abstract] ABSTRACT: Objective
To evaluate whether changes in hydration status (reflecting fluid retention) would be detected by bioelectrical impedance vector analysis (BIVA) and phase angle during hospitalization for acute decompensated heart failure (ADHF) and after clinical stabilization.
Patients admitted to ADHF were evaluated at admission, discharge and after clinical stabilization (3 months after discharge) for dyspnea, weight, brain natriuretic peptide, bioelectrical impedance resistance, reactance, and phase angle. Generalized estimating equations and chi-square detected variations among the three time points of evaluation.
Were included 57 patients: mean age was 61±13 years, 65% were male, LVEF was 25±8%. During hospitalization there were improvements in clinical parameters and increase in resistance/height (from 250±72 to 302±59 Ohms/m, p<0.001), reactance/height (from 24±10 to 31±9 Ohms/m, p<0.001) and phase angle (from 5.3±1.6 to 6±1.6 degrees, p=0.007). From discharge to chronic stability, both clinical and BIVA parameters remained stable. At admission, 61% of patients had significant congestion by BIVA, and they lost more weight and had higher improvement in dyspnea during hospitalization (p<0.05). At discharge, more patients were in the upper half of the graph (characterizing some degree of dehydration), while at chronic stability normal hydration status was more prevalent (p<0.001).
BIVA and phase angle were able to detect significant changes in hydration status during ADHF, which paralleled the clinical course of recompensation, both acutely and chronically. The classification of congestion by BIVA at admission identified patients with more pronounced changes in weight and dyspnea during compensation.
[Show abstract][Hide abstract] ABSTRACT: Significant inter-individual variability on the effect of vitamin K to reverse overanticoagulation has been identified. Genetic polymorphisms of the vitamin K epoxide reductase complex subunit 1 (VKORC1) gene might explain in part this variability. The objective of this study was to evaluate the influence of VKORC1 -1639G>A and 3730G>A polymorphisms on the effect of oral vitamin K supplementation in overanticoagulated patients. We performed an interventional trial of oral vitamin K supplementation in over-anticoagulated outpatients (international normalized ratio [INR] ≥ 4). Subjects received vitamin K (2.5-5.0 mg) according to baseline INR and were genotyped by real time polymerase chain reaction (PCR). INR values were determined at 3, 6, 24 and 72 h after supplementation. We evaluated 33 outpatients, 61 % were males, with a mean age of 62 ± 12 years old. There was a significant decrease in INR values over time for both polymorphisms after oral vitamin K. At 3 h after supplementation, patients carrying the G allele for the -1639G>A polymorphism had a greater decrease in INR values compared to AA patients (p < 0.05 for difference among groups; p < 0.001 for time variation; p = 0.001 for time × group interaction), with differences of -1.01 for GG versus AA (p = 0.003) and -0.84 for GA versus AA (p = 0.024). Mean INR value at 24 h was 1.9 ± 0.6 and at 72 h was 2.1 ± 0.7, with no differences among genotypes. No significant interaction was identified between the 3730G>A polymorphism and vitamin K supplementation. Our study indicated that the VKORC1 -1639G>A polymorphism plays a role in the response to acute vitamin K supplementation in over-anticoagulated patients, with faster decrease of INR value in patients carrying the G allele.
Journal of Thrombosis and Thrombolysis 01/2014; 37:338-344. DOI:10.1007/s11239-013-0947-3 · 2.17 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: IMPORTANCE The benefits of fluid and sodium restriction in patients hospitalized with acute decompensated heart failure (ADHF) are unclear. OBJECTIVE To compare the effects of a fluid-restricted (maximum fluid intake, 800 mL/d) and sodium-restricted (maximum dietary intake, 800 mg/d) diet (intervention group [IG]) vs a diet with no such restrictions (control group [CG]) on weight loss and clinical stability during a 3-day period in patients hospitalized with ADHF. DESIGN Randomized, parallel-group clinical trial with blinded outcome assessments. SETTING Emergency room, wards, and intensive care unit. PARTICIPANTS Adult inpatients with ADHF, systolic dysfunction, and a length of stay of 36 hours or less. INTERVENTION Fluid restriction (maximum fluid intake, 800 mL/d) and additional sodium restriction (maximum dietary intake, 800 mg/d) were carried out until the seventh hospital day or, in patients whose length of stay was less than 7 days, until discharge. The CG received a standard hospital diet, with liberal fluid and sodium intake. MAIN OUTCOMES AND MEASURES Weight loss and clinical stability at 3-day assessment, daily perception of thirst, and readmissions within 30 days. RESULTS Seventy-five patients were enrolled (IG, 38; CG, 37). Most were male; ischemic heart disease was the predominant cause of heart failure (17 patients [23%]), and the mean (SD) left ventricular ejection fraction was 26% (8.7%). The groups were homogeneous in terms of baseline characteristics. Weight loss was similar in both groups (between-group difference in variation of 0.25 kg [95% CI, -1.95 to 2.45]; P = .82) as well as change in clinical congestion score (between-group difference in variation of 0.59 points [95% CI, -2.21 to 1.03]; P = .47) at 3 days. Thirst was significantly worse in the IG (5.1 [2.9]) than the CG (3.44 [2.0]) at the end of the study period (between-group difference, 1.66 points; time × group interaction; P = .01). There were no significant between-group differences in the readmission rate at 30 days (IG, 11 patients [29%]; CG, 7 patients [19%]; P = .41). CONCLUSIONS AND RELEVANCE Aggressive fluid and sodium restriction has no effect on weight loss or clinical stability at 3 days and is associated with a significant increase in perceived thirst. We conclude that sodium and water restriction in patients admitted for ADHF are unnecessary. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01133236.
JAMA Internal Medicine 05/2013; 173(12):1-7. DOI:10.1001/jamainternmed.2013.552 · 13.25 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The aim of this study is to identify the signs and symptoms of patients admitted for decompensated heart failure (HF) in order to infer the priority nursing diagnoses (ND). This is a cross-sectional study undertaken in a university hospital. The data were collected by nurses trained to deal with HF and registered in a file containing identification items, and demographic and clinical variables. We included 303 patients. Most patients were in emergency departments (95.7%) with functional class III (65.7%). The signs and symptoms identified at the time of admission were dyspnea (91.4%), paroxysmal nocturnal dyspnea (87.5%), fatigue (67.3%), edema (63.7%), orthopnea (55.4 %) and jugular vein distention (28.7%). From the signs and symptoms raised, that became the set of relevant clues and consistent as an indicator for ND, we conclude that Decreased Cardiac Output and Fluid Volume Excess diagnoses were the priorities for this population.
Revista gaúcha de enfermagem / EENFUFRGS 09/2011; 32(3):590-5. DOI:10.1590/S1983-14472011000300022
[Show abstract][Hide abstract] ABSTRACT: This cross-sectional study aimed to clinically validate the defining characteristics of the Nursing Diagnosis Excess Fluid Volume in patients with decompensated heart failure. The validation model used follows the model of Fehring. The subjects were 32 patients at a university hospital in Rio Grande do Sul. The average age was 60.5 ± 14.3 years old. The defining characteristics with higher reliability index (R): R ≥ 0.80 were: dyspnea, orthopnea, edema, positive hepatojugular reflex, paroxysmal nocturnal dyspnea, pulmonary congestion and elevated central venous pressure, and minor or secondary, R> 0.50 to 0.79: weight gain, hepatomegaly, jugular vein distention, crackles, oliguria, decreased hematocrit and hemoglobin. This study indicates that the defining characteristics with R> 0.50 and 1 were validated for the diagnosis Excess Fluid Volume.
Revista Latino-Americana de Enfermagem 06/2011; 19(3):540-547. DOI:10.1590/S0104-11692011000300013 · 0.54 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To adapt a questionnaire that assesses knowledge about heart failure (HF) and self-care and to analyze its content validity and reproducibility for use in Brazil. The questionnaire was validated through translation, summary, back-translation, expert committee review, pretest and assessment of psychometric properties. The final version (14 questions) was applied at the university hospital to HF outpatients under multidisciplinary team care. Five questions showed total agreement; seven scored Kappa > 0.4; one Kappa = 0.4, and just one presented no agreement. A group of 153 patients within 1-4 years of outpatient follow-up was assessed (age 59±13, 61% male). In the knowledge assessment, right answers varied from 4 to 14 (average 9.9±2.1). Results indicate the validity of the questionnaire for use in Brazil.
Revista Latino-Americana de Enfermagem 04/2011; 19(2):277-84. DOI:10.1590/S0104-11692011000200008 · 0.54 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Nursing approaches to manage patients with heart failure (HF) showed benefits in reducing the morbidity and mortality. However, combining intra-hospital education with telephone contact after hospital discharge has been little explored.
To compare two nursing intervention groups among patients hospitalized due to decompensated HF: the intervention group (IG) received educational nursing intervention during hospitalization followed by telephone monitoring after discharge and the control group (CG) received in-hospital intervention only. Outcomes were levels of HF and self-care knowledge, the frequency of visits to the emergency room, rehospitalizations and deaths in a three-month period.
Randomized clinical trial. We studied adult HF patients with left ventricle ejection fraction (LVEF) < 45% who could be contacted by telephone after discharge. HF awareness was evaluated through a standardized questionnaire that also included questions regarding self-care knowledge, which was answered during the hospitalization period and three months later. For patients in the IG group contacts were made using phone calls and final interviews were conducted in both groups at end of the study.
Forty-eight patients were assigned to the IG and 63 to the CG. Mean age (63 ± 13 years) and L (around 29%) were similar in the two groups. Scores for HF and self-care knowledge were similar at baseline. Three months later, both groups showed significantly improved HF awareness and self-care knowledge scores (P < 0.001). Other outcomes were similar.
An in-hospital educational nursing intervention benefitted all HF patients in understanding their disease, regardless of telephone contact after discharge.
[Show abstract][Hide abstract] ABSTRACT: Cross-sectional study developed to relate the international normalized ratio (INR), used as a parameter to monitor the levels of blood clotting, stability to adherence, age, level of education, socioeconomic level, interaction with other drugs, comorbidities, vitamin K intake, anticoagulation time and drug cost. 156 patients were included, mean age 57 ± 13 years, (53.8%) male, 61 (39.1%) had high adherence, 91 (58.3%) medium and 4 (2.6%) low adherence to treatment, 117 (75%) had INR stability up to 50% and 39 (25%) > 75%, patients with shorter time of anticoagulation presented higher stability, those who spent less on the drug remained more stable and had better adherence. It was concluded that more than 90% of patients had high and medium adherence and that the anticoagulation time and drug cost were the factors related to the anticoagulation stability.
Revista Latino-Americana de Enfermagem 01/2011; 19(1):18-25. DOI:10.1590/S0104-11692011000100004 · 0.54 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: This cross-sectional study aimed to describe the prescription of non-pharmacological management of patients with heart failure attending the emergency care of a hospital and the effectiveness of the practice. 256 patients aged 63 ± 13 years, 153 (60%) men, participated in the research. The most commonly prescribed non-pharmacological treatment was sodium restriction, 240 (95%), followed by weight control, 135 (53%). Fluid restriction and fluid balance were the least commonly prescribed treatments, 95 (37%) and 72 (28%), respectively. Only 38 (54%) of balances, 89 (67%) of weight controls and 69 (57%) of diuresis controls were performed. Concerning patients' previous knowledge of the treatments, 229 (90%) were advised to restrict salt intake, and 163 (64%) were advised to restrict fluid intake. Weight control was the least commonly known care, 117 (46%). Except for salt control, the other treatments were prescribed in slightly more than half of the samples, and were ineffective.
Revista Latino-Americana de Enfermagem 11/2010; 18(6):1145-51. DOI:10.1590/S0104-11692010000600015 · 0.54 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Clinically validate (using Fehring's model) characteristics of the nursing diagnosis (ND) of decreased cardiac output (DCO) in 29 patients with decompensated heart failure.
Cross-sectional study conducted in a Brazilian university hospital.
According to the reliability rate (R) between the experts, the major characteristics (R ≥ 0.80) were fatigue, dyspnea, edema, orthopnea, paroxysmal nocturnal dyspnea, and elevated central venous pressure, and the secondary characteristics were weight gain, hepatomegaly, jugular vein distension, palpitations, crackles, oliguria, coughing, clammy skin, and skin color changes.
Characteristics with R > 0.50 and ≤1 were valid in the ND of DCO. IMPLICATIONS FOR THE NURSING PRACTICE: Clinical validation studies are necessary to determine the adequacy of this diagnosis and its determining characteristics with Taxonomy II.
International Journal of Nursing Terminologies and Classifications 10/2010; 21(4):156-65. DOI:10.1111/j.1744-618X.2010.01161.x · 0.90 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Adherence to chronic Oral Anticoagulant Therapy (OAT) is directly related to patients' understanding of the therapy. This study verified the knowledge of patients with mechanical valve prostheses concerning OAT. This is a contemporary cross-sectional study, the sample is composed of patients with mechanical valve prostheses (MVP) in outpatient follow-up. A 10-question instrument was used; answers were 'know' (1 point), 'know partially' (half point), or 'do not know' (zero). Patients were grouped according to the result obtained: ≤ 4 points was considered insufficient knowledge; > 4 ≤ 8 equated to moderate knowledge; and > 8 was considered appropriate knowledge. Of the 110 patients, 61.8% presented moderate knowledge, 40.9% were not able to name at least one factor that may alter the INR (International Normalized Ratio) and 37.3% were not able to report their INR target range. The majority of patients presented moderate knowledge concerning the treatment. Strategies to improve knowledge on the topic should be implemented to minimize risks.
Revista Latino-Americana de Enfermagem 08/2010; 18(4):696-702. DOI:10.1590/S0104-11692010000400006 · 0.54 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Non-compliance in heart failure (HF) patients is one of the factors leading to hospital readmissions. Under this perspective, a study was carried out in a university hospital in Rio Grande do Sul, Brazil, to describe the compliance with pharmacological and non-pharmacological treatments of patients admitted with decompensated HF, relating the compliance to the number of hospital admissions and readmissions during a year's period. The pharmacological compliance was measured through Morisky scale and the non-pharmacological compliance was measured through a previously validated questionnaire. The sample was composed of 252 patients, median age 63±13, 151 (60%) male. For the pharmacological compliance, 118 (47%) patients demonstrated high compliance, and 45 (18%) adhered to non-pharmacological treatment. There was no relation found between treatment compliance (pharmacological or non-pharmacological) and readmissions. Patients who had been treated for HF, had knowledge about non-pharmacological care and were able to identify congestion symptoms demonstrated high compliance.
[Show abstract][Hide abstract] ABSTRACT: Non-compliance in heart failure (HF) patients is one of the factors leading to hospital readmissions. Under this perspective, a study was carried out in a university hospital in Rio Grande do Sul, Brazil to describe the compliance with pharmacological and non-pharmacological treatments of patients admitted with decompensated HF, relating the compliance to the number of hospital admissions and readmissions during a years period. The pharmacological compliance was measured through Morisky scale and the non-pharmacological compliance was measured through a previously validated questionnaire. The sample was composed of 252 patients, median age 63 +/- 13, 151 (60%) male. For the pharmacological compliance, 118 (47%) patients demonstrated high compliance, and 45 (18%) adhered to non-pharmacological treatment. There was no relation found between treatment compliance (pharmacological or non-pharmacological) and readmissions. Patients who had been treated for HF, had knowledge about non-pharmacological care and were able to identify congestion symptoms demonstrated high compliance.
Revista gaúcha de enfermagem / EENFUFRGS 06/2010; 31(2):225-31.
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND: Currently, bed rest time after diagnostic cardiac catheterization does not follow a consensus. Reducing it, within safety thresholds, would optimize the use of the existing resources in face of the increasing demand of these exams and would also improve patient comfort. The objective of this study was to evaluate the safety of reducing bed rest time from six to three hours after diagnostic cardiac catheterization with a 6 F arterial sheath. METHOD: Randomized clinical trial carried out at an Interventional Cardiology laboratory in Santa Maria, Rio Grande do Sul, Brazil, from August 2007 to November 2008. Male and female patients undergoing diagnostic catheterization aged > 18 years were included and patients on oral anticoagulants, with morbid obesity, history of bleeding, aortic diseases or non-controlled severe hypertension were excluded. Patients were divided into an intervention group (IG), with ambulation three hours after sheath removal, and a control group (CG), with ambulation after six hours of bed rest. They were all monitored hourly by the nursing team and 24, 48 and 72 hours after discharge by telephone contact. RESULTS: Overall, 406 patients were included (200 in the IG and 206 in the CG), mean age was 64 ± 9.4 years, 47.3% were women and 17% were diabetic. There was 1 case of bleeding (0.5%) in the IG and 4 (1.9%) in the CG; there were 3 (1.5%) cases of hematoma in the IG and 4 (1.9%) in the CG; 4 (2%) patients presented a vasovagal reaction in the IG and 7 (3.4%) in the CG. There were no statistical differences between the two groups for any of the comparisons. Conclusions: The reduction of bed rest to three hours did not increase complications in patients undergoing diagnostic cardiac catheterization with a 6 F arterial sheath, and proved to be safe when compared to the six-hour rest period.
[Show abstract][Hide abstract] ABSTRACT: to identify the prevalent nursing diagnoses (ND) in the hospitalized elder care; to compare the prevalent ND with the duration of hospital stay and with the prescribed cares for their respective diagnoses.
Transversal historical study carried through in Porto Alegre, RS, by analyzing patient records age e60 years old, interned in clinical unities of a university hospital.
1665 records were analyzed; the four prevalent NANDA nursing diagnoses--within 62 identified ones--were: Self-Care Deficit--Bathing/Hygiene, Imbalanced Nutrition--Less than Body Requirements, Risk for Infection and Ineffective Breathing Patterns, varying from 14 to 17 days of hospital stay. THE MAIN CARES WERE: aiding bed bath, communicating diet acceptance, implementing routines of care in venous puncture and checking respiratory pattern.
four prevalent ND were identified with the appropriate prescribed care. However, other care could have been established as a priority.
Revista Latino-Americana de Enfermagem 09/2008; 16(4):707-11. DOI:10.1590/S0104-11692008000400009 · 0.54 Impact Factor