Although previous studies have examined medication adherence among heart failure patients, limited information is available on these patients' adherence to the complex nonpharmacologic regimen of sodium restriction, fluid restriction and daily weighing.

We examined the effect of education and counseling by heart failure nurses on adherence to nonpharmacologic treatments because these are so important to the patients' survival, said Martje H.L. van der Wal, R.N., Ph.D., study lead author and a cardiology nurse researcher at the department of cardiology of the University Medical Center Groningen, University of Groningen, in The Netherlands.

Researchers referred to the Coordinating Study Evaluating Outcomes of Advising and Counseling in Heart Failure (COACH) study, representing data from 17 Dutch hospitals and 1,023 heart failure patients (average age 71).

Patients were assigned to three groups: The first group (the controls) received usual care, which included regular visits to their cardiologist during the 18-month trial. The second group (basic support) received basic education and counseling from a specialized heart failure nurse. Patients in this group visited the heart failure nurse every three months at the heart failure clinic and could call the nurse with questions or if their heart failure worsened. The third group (intensive support) received intensive education and counseling from a heart failure nurse and had at least monthly contact with the nurse, including one or more home visits. Patients in this group also received advice from a dietician, physiotherapist and social worker.

On five occasions during the study, all patients completed questionnaires addressing adherence, knowledge of heart failure and depressive symptoms.

The study found that heart failure nurses make a positive impact on these patients' adherence to nonpharmacologic treatment. While basic support improved compliance in all three areas, intensive support led to more significant improvement in daily weighing, which is vital for monitoring the condition, van der Wal said.

During the 18 months of the study: 90 percent of patients in the support groups adhered to their fluid restriction, compared to 67 percent at the study's start, while there was no improvement in the control group; 90 percent of both support group patients adhered to heart failure diet restrictions versus 75 percent before the study; 79 percent in the basic support group and 89 percent in the intensive support group weighed themselves regularly versus 56 percent of patients in the control group.

More patients in the support groups were aware of important symptoms of worsening heart failure and when to call health care providers.

Support from a heart failure nurse can help patients to cope with the difficult and complex regimen they have for their heart failure and to incorporate the regimen into their daily lives, van der Wal said.

Future studies should explore other ways to educate and communicate with heart failure patients, including using the Internet. Researchers also should look at how to optimally increase adherence in heart failure patients with depressive symptoms or cognitive decline, she said.

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The researchers recruited 43 lean, healthy volunteers from the community who each had a body mass index -- a statistical measure of the relationship of height to weight -- of between 18.5 and 24.9 kilograms of weight/meter2 of height. The average age was 29, and 42 percent were women. None took medications or smoked. After a weight maintenance period supervised by an experienced dietitian, volunteers randomly were assigned to either gain weight (4 kilograms [kg], or about 9 pounds) or maintain weight. The fat-gainers consisted of 35 people. The weight-maintainer group totaled eight.

Researchers used ultrasound to measure endothelial function of the large vessel in the upper arm called the brachial artery, under several flow conditions, always at the same time in the early morning. Low flow indicated vessel dysfunction. For the fat-gainers, endothelial function was measured at the start of the study, after fat gain at eight weeks and after weight loss at 16 weeks. For the weight maintainers, endothelial function was measured at the start of the study and at follow-up eight weeks later. To measure body fat percent, the researchers used advanced body composition analysis techniques, including abdominal CT scans.

Results

At the conclusion of the study: The fat-gainer group put on an average of 4 kg of fat and significantly increased their visceral and subcutaneous fat. In the weight-maintainer group, the two kinds of flow measurements taken in the brachial artery of the upper arm to assess endothelial dysfunction remained unchanged. In fat-gainers, brachial artery flow measurements decreased with the addition of weight. But once subjects shed the gained weight their flow levels improved, and returned to levels measured at the beginning of the study. Visceral fat gain -- but not subcutaneous fat gain -- was significantly correlated with the decreased flow conditions in the brachial artery.

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