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PATIENT EDUCATION TOOLS

The following tools can be used to educate patients on various aspects of heart failure, cardiac rhythm disease, and appropriate management of these conditions. They are provided in a format that can be customized to your practice and workflow needs.

1. What Happens During Normal Heart Function? 2. What Is Heart Failure? 3. Diagnosing Heart Failure 4. What Can I Do to Manage Heart Failure? 5. The Role of Ejection Fraction in Diagnosing and Treating Heart Failure 6. Medicines 7. What Are Arrhythmias? 8. What Is SCA? 9. SCA Patient Fact Sheet 10.SCA Patient Notification Letter 11.Pre-ICD Placement: Frequently Asked Questions 12.Post ICD Placement: Frequently Asked Questions 13.Roadmap to Better Heart Health 14.Healthcare Provider Contact Information 15.Caring for a Person with Heart Failure

SCA Prevention Medical Advisory Team

Gregg C. Fonarow, MD Nancy M. Albert, PhD, RN David Cannom, MDUCLA Cleveland Clinic Good Samaritan HospitalLos Angeles, California Cleveland, Ohio Los Angeles, California

William R. Lewis, MD Julie Shea, MS, RNCS Mary Norine Walsh, MDMetroHealth Medical Center Brigham and Women’s Hospital The Care group, LLCCleveland, Ohio Boston, Massachusetts Indianapolis, Indiana

What Happens during Normal Heart Function

The normal heart is a strong muscle that beats about 120,000 times a day to pump blood through the body. The blood carries oxygen and nutrients to tissues and organs and waste products to the kidneys and liver. The blood travels through a large network of blood vessels known as the circulatory system. This system includes the arteries, veins, and lungs. The heart responds to the body’s needs and adjusts its rate of pumping to meet the body’s requirements.

The heart consists of four chambers that work together: Right and left atria – these are the small upper chambers Right and left ventricles – these are the larger, lower chambers.

The right ventricle pumps blood out of the heart to the lungs, and the left ventricle pumps blood to the rest of the body. The left ventricle is the heart’s main pumping chamber.

Blood FlowDuring each heartbeat, the right side of the heart receives blood from your body and then sends it to the lungs to pick up oxygen (see the blue arrows in the picture on the right).

The left side of the heart receives the blood from the lungs and then sends the blood to the rest of the body to deliver oxygen (see the red arrows).

How the Heart’s Electrical System Works The heart has an electrical system that causes it to beat and pump blood in a smooth and regular way (like a clock or an engine). Special cells in the heart start electrical signals. These signals then travel along pathways through the heart and cause it to beat.

During a normal heartbeat, an electrical signal is first made in a group of cells called the sinus node (SA node). The signal then spreads like a wave through both of the upper chambers of the heart (the atria) and travels to another group of cells called the atrioventricular node (AV node).

©2005 Medtronic, Inc.


The AV node serves as an electrical filter between the upper and lower chambers (ventricles) of the heart. After a pause, the electrical signal spreads through the ventricles.

In a healthy heart, the heart beats once and pumps blood for each electrical signal that starts in the SA node. A normal heart rate is generally between 60 and 100 beats per minute, but will vary based on age and how active a person is.

Adapted by the SCA Prevention Medical Advisory Team from the IMPROVE HF registry toolkit.This material is intended to be educational. It is not intended to replace the information provided to you by your healthcare

providers and may not be directly applicable for your individual clinical circumstance. Please refer to the manufacturers’ prescribing information and/or instructions for use for the indications, contraindications,

warnings, and precautions associated with the medications and devices referenced in these materials.

Sponsored by Medtronic, Inc.May 2007

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What Is Heart Failure?

Heart failure is a serious condition that occurs when the heart’s ability to pump or fill with blood is decreased. It does not mean that your heart has stopped beating or is going to stop beating, but rather that your heart is not pumping blood (systolic heart failure) or filling with blood (diastolic heart failure) as well as it should. Here we will focus on systolic heart failure.

Heart failure can develop after injury to the heart.

Here are some of the things that can cause heart failure: Coronary artery disease • Infection of the heart Heart attack • Heart problems that you were born with Uncontrolled high blood pressure • Long-term alcohol abuse Heart valve problems • Pregnancy, during or after (postpartum)

If you have heart failure, your heart cannot pump enough blood to supply your body’s need for oxygen. Your heart must work harder to keep up and might pump faster for a short time. But the heart eventually gets tired, and its pumping action weakens. That is why you may feel tired much of the time. Also, blood backs up into blood vessels around the heart and fluid seeps into the lungs. That is why you may have shortness of breath or trouble breathing at night. You may also get swollen legs and feet and have weight gain.

As heart failure gets worse, the heart attempts to make up for lost pumping power. This may cause changes in the shape of the heart and result in an uncoordinated heartbeat, which is called an arrhythmia (this means a rhythm that is not normal).

Although heart failure cannot be cured, there are many things that can be done to slow its progress, reduce your symptoms, and help you live an active life. New medicines and treatments – plus self-care activities each day – may help people with heart failure live better lives. There is more hope today for people with heart failure than ever before.

How Common Is Heart Failure?Heart failure is a common problem among older adults in the United States. This year, approximately 550,000 Americans will learn from their doctors that they have heart failure. That is in addition to the nearly 5 million people who already have the condition. Many people with heart failure do not know they have it until they experience symptoms. These symptoms may appear many years after their heart function begins to decline.

Symptoms of Heart FailureHeart failure is sometimes referred to as congestive heart failure. The term “congestive” refers to the fluid that seeps into the lungs. This fluid congestion may also involve other body parts, including the feet, legs, and stomach. Fluid buildup is the cause of many symptoms of heart failure. These signs and symptoms help your doctor classify the severity of your heart failure and monitor the effects of therapies to help you.

Signs and symptoms of heart failure include: Trouble breathing (shortness of breath) • Swollen or tender stomach with loss of appetite Swelling in the feet and legs • Cough with frothy sputum (your spit may be pink Weight gain from water (swelling) due to small amounts of blood) Lack of energy/trouble carrying out • Increased urination at night

physical activities • Confusion and/or memory problems Difficulty sleeping at night due to

breathing problems (you may need morepillows under your head in order to sleepcomfortably)

Classifying Heart FailureDoctors classify heart failure on a scale of 1 to 4 (Roman numerals I to IV) by reviewing your symptoms and your ability to exercise and do activities. The New York Heart Association has developed a system that is commonly used to talk about levels (classes) of heart failure. This system is shown below.

Your heart failure class can get better or worse over time depending on how bad your symptoms are and how you respond to therapies. Some treatments work best at different classes, so you might get a different treatment than other people you know with congestive heart failure.

• No symptoms

• Can perform ordinary activities without any limitations

• Mild symptoms

• Occasional swelling

• Somewhat limited in ability to exercise or do other strenuous activities

• No symptoms at rest

• Noticeable limitations in ability to exercise or

participate in mildly strenuous activities

• Comfortable only at rest

• Unable to do any physical activity without discomfort

• Symptoms at rest

When thinking about your heart failure class, it is important to know that heart failure is a condition that can get worse over time. It is important to find and treat heart failure early. So even though you may be in Class I or Class II and have few symptoms, you still need to see your doctor to be treated for heart failure and follow your doctor’s care plan. What Can Be Done for Heart FailureThe good news is that today doctors and nurses understand more about heart failure and have better ways to manage the condition. New medicines and treatments are some of the reasons that people with heart failure may be able to get back to many of the things they once did and potentially live better lives.





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Diagnosing Heart Failure

Diagnosing heart failure can be a challenge since many of the signs and symptoms may be caused by other diseases or conditions. For example, feeling tired and short of breath can be caused by anemia (low blood count), lung disease, being out of shape, or aging. Also, some people with heart failure may feel fine and have no symptoms. They may have trouble believing their doctor when they are told they have heart failure. Heart failure does not mean that your heart has stopped beating or is going to stop beating. It means your heart is not pumping blood (systolic heart failure) or filling with blood (diastolic heart failure) as well as it should. Once heart failure is diagnosed, there are many effective therapies that can improve your condition.

Symptoms of heart failure include:• Trouble breathing (shortness of breath) • Swollen or tender stomach with loss• Swelling in the feet and legs of appetite• Weight gain from water (swelling) • Cough with frothy sputum (your spit • Lack of energy/trouble carrying out physical activities may be pink due to small amounts • Difficulty sleeping at night due to breathing problems of blood) (you may need more pillows under your head in order • Increased urination at night

to sleep comfortably) • Confusion and/or memory problems

Heart failure is diagnosed by using:• The patient’s medical history• A physical exam• Specific tests

Your doctor will need to know if you have:• A history of high blood pressure• A history of high cholesterol• Blockages in the arteries of your heart, producing chest pain and/or a heart attack• Damaged heart valves• A history of diabetes • A family history of any of these conditions

A complete physical exam can help diagnose heart failure. During a physical exam, your doctor or nurse will check your blood pressure and heart rate; listen to your heart and lungs; and look for swelling in your legs, ankles, and abdomen.

Other testing will provide important information about the cause, the type, and the treatment for heart failure.

One of the most important tests used to diagnose heart failure is to measure the percentage of blood that your heart pumps with each beat. This percentage is called the ejection fraction (EF for short) and indicates how well your heart is pumping. A normal EF is 50-75%. This can be measured by an echocardiogram (or “echo”), which is painless and can often be performed in your doctor’s office. Sound waves are used to make pictures of all of the valves and chambers of the heart.

EF can also be measured by MUGA scan, where a very small amount of radioactive material is injected into the blood to produce images of your heart, by magnetic resonance imaging (MRI), or during a cardiac catheterization.

Other tests commonly used to diagnose heart failure include: Blood and urine tests – these can be used to check your red blood cells and how well your kidney,

liver, and thyroid are working. A B-type natriuretic peptide (BNP) blood test can be used to tell if you have heart failure and helps in making decisions about treatments. Cholesterol and blood sugar levels may be checked as well.

Chest X-ray – this shows the size of your heart and whether there is fluid buildup around your heart and lungs

Electrocardiogram (ECG/EKG) – this shows your heart rate and rhythm Angiogram (x-ray of the inside of your heart) – this can be used to see if you have

clogged arteries Magnetic Resonance Image (MRI) – this produces very clear pictures of your heart and arteries.

These pictures can show the size of the chambers in your heart and how thick the walls of your heart are – these are signs of how hard your heart is working.

What can be done for heart failure:The good news is that, these days, doctors and nurses understand more about heart failure and have better ways to manage the condition. New medicines and treatments are some of the reasons that people with heart failure may be able to get back to many of the things they once did and potentially live better lives.





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What Can I Do to Manage Heart Failure?

Although heart failure cannot be cured, it can be managed well. Your treatment plan may include medicines, surgery, implantable medical devices, or a combination of these approaches. There are also a lot of things you can do to help improve your condition. Together with proper medical care and careful monitoring, good self-care can help you feel better, stay out of the hospital, and live a longer life.

To manage your heart failure, it is best if you do the following:

Take your medicines regularly as prescribed by your doctor. When the medicines that your doctor has prescribed are taken regularly and at the correct doses, they can make you feel better, reduce hospitalizations, and help you live longer. Experts in heart failure call many of these medicines “lifesaving.” Since your medication is very important, when traveling, keep your medication in your carry-on luggage and bring it with you on the plane. It is helpful to keep your medicine organized, and remember to refill your prescriptions before you travel so that they do not run out.

Weigh yourself every day and write it down.Daily changes in weight are usually the result of water weight. By weighing yourself every day at the same time, you can help monitor whether your body is retaining fluid due to heart failure. Even though you may feel the same, a gain of just 3 to 4 pounds over a few days is a sign of worsening congestion that must be treated. If treated, your heart and lungs can function more easily and you may feel more comfortable. If left untreated, it may become more serious and require hospitalization.

Follow a low-sodium (low-salt) diet.Heart failure can cause your body to retain sodium and result in fluid buildup. The extra fluid makes your heart work harder and your symptoms get worse.

A low-sodium diet generally means that you eat no more than about 2,000 milligrams (mg) of sodium per day. That amount is less than 1 teaspoon of salt from all sources, including the salt that is already in your food.

To reduce the sodium in your diet, stop adding additional salt to your food. Avoid processed foods –especially canned, boxed, or bagged foods – and eat more fresh vegetables and fruit. Besure to review the nutritional information labels on all packaged foods for sodium content, and decrease the total amount of salt you eat per day. Pay close attention when eating at restaurants. Many restaurants will tell you nutritional information of foods if you ask. They will hold salt when cooking if you ask and will serve salad dressing and sauces/gravies on the side. Also pay attention to certain foods that contain a large amount of water, such as head lettuce or watermelon. Although following a low-sodium diet might be a challenge, by following the diet recommended by your doctor or nurse you will gain better control of your condition.

Get regular physical activity.Heart failure can make you feel tired. One of the ways to feel better is to keep physically active through a regular exercise program. In general, start slowly and increase your exercise gradually. Talk to your doctor about an exercise program that is best for you. Exercise can be a highly valuable plan to improve your condition.

Quit smoking.Quitting smoking is one of the best things you can do for your heart and overall health. Smoking damages your blood vessels, increases your blood pressure, and causes lung disease in addition to other problems. Quitting smoking is strongly recommended for all people with heart disease, including heart failure. Talk to your doctor or nurse about new methods for helping people quit smoking.

Stay connected socially.Your family and friends can help. Don’t keep your condition a secret. Let your family and friends support you and help you stay with your treatment plan. Having an active social life can also help keep your mind off your problems and give you a more positive outlook on life. Participating in activities that you enjoy reminds you of why you want to take good care of yourself and stay healthy. Plan some fun activities that will reduce stress and give you energy.

Monitor your symptoms daily and learn when to call your doctor. You know your heart failure symptoms best. Write down when you notice your symptoms are getting better or worse, or when you developnew symptoms. This information can help alert you as to when you should call your doctor and can also help your doctor make changes to your treatment.

Feel free to ask your doctor and nurse any questions you might have about your treatment plan.





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The Role of Ejection Fraction in Diagnosing and Treating Heart Failure

What is Ejection Fraction?Ejection fraction (“EF” for short) is the percentage of blood that is pumped out of the heart during each beat. For people with normal hearts, this percentage is 50-75% of their blood. Many people with heart failure have an EF that is 40% or less. A below-normal EF means that your heart is not pumping as well as it should.

Why is EF Important?Measuring EF is one of the ways doctors classify the type and severity of heart failure.

If you have a below-normal EF and your heart isn’t pumping well, you have a type of heart failure called systolic heart failure. This type of heart failure involves the large, lower chambers of your heart (the ventricles). Ventricles push blood throughout your body.

If you have a normal EF and your heart is not filling with blood normally, you have a type of heart failure called diastolic heart failure. This type of heart failure often occurs when the ventricles cannot relax properly to fill with blood.

The therapy your doctor uses to treat your heart failure will, in part, be guided by your EF and the type of heart failure you have. If you have the type of heart failure where your heart isn’t pumping well (systolic heart failure), your EF can be used to judge how well your therapies are working or whether your heart failure is getting worse. In recent years, doctors have learned a lot about systolic heart failure and how to treat it. A low EF is also a sign of increased risk for Sudden Cardiac Arrest (“SCA” for short). Sudden Cardiac Arrest is caused by an electrical problem in the heart that triggers a dangerously fast heartbeat, which causes the heart muscle to quiver and not pump blood to the rest of the body and brain. If this happens, your heart must be started again within minutes to prevent death. An implantable defibrillator, a pacemaker-like device, has proven very effective in treating Sudden Cardiac Arrest and saving people’s lives.

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Sometimes people confuse Sudden Cardiac Arrest with a heart attack. Sudden Cardiac Arrest is not the same as a heart attack. A heart attack is caused by blockage in one or more of the arteries supplying blood to the heart. It can be thought of as a problem with the heart’s plumbing system. Sudden Cardiac Arrest is caused by a very fast and irregular heart rhythm that starts in the ventricles (the heart’s lower chambers). It can be thought of as a problem with the heart’s electrical system.

Your EF Can ChangeEF can go up or down depending on the nature of each person’s disease and on the type and effectiveness of therapies that are prescribed. Small changes in your EF are nothing to worry about, but if your EF drops steadily over months, your doctor will change your therapy. Drugs, devices, and surgeries can cause a person’s EF to increase over time. Therefore, your EF on a particular day is less important than the overall trend. Your doctor will let you know how often your EF should be checked.

Measuring EFOne of the most important tests used to diagnose heart failure and measure EF is called an echocardiogram, or “echo” for short. The test, which is painless and can often be performed in your doctor’s office, involves using sound waves to make a picture of your heart. An echocardiogram allows your doctor to study your heart valves and the chambers of your heart to find out whether the heart is pumping normally. There are other ways to measure your EF that your doctor may also decide to use.





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Medicines

Medicines play an important role in treatment for patients who have had a heart attack or who have heart failure. In most cases, people who have had a heart attack or who have heart failure require several types (categories) of medicines.

Research has shown that medicines may help improve your heart function, reduce hospitalizations, and help you live a longer life. Some of the medicines used may also treat other conditions, such as high blood pressure, but we will focus on the dosing that is needed for heart failure. Your doctor may adjust your medicines and the doses from time to time so that you are taking the types and amounts of medicines that work best to treat your condition.

Some of your medicines can cause side effects that may bother you or make you feel worse. If you have side effects, tell your doctor or nurse. Your doctor or nurse will work with you to minimize the side effects or change your medicine. In order to get the full benefit of these medicines, it is important that you take all of your medicines exactly as your doctor or nurse ordered – even if you think your medicines are not making you feel better. Over time, being on the right medicines should make you feel better, all the more reason to keep taking the medicines as prescribed, at the same dose and at the same time every day.

You may have other medical conditions – such as high blood pressure, diabetes, asthma, or arthritis – that need treatment with medicines. You may also be taking over-the-counter drugs (medicine you can buy without a prescription) or herbal therapies that do not require a prescription from a doctor. Sometimes these drugs or therapies may interact with your heart failure medicines and make your heart failure worse or cause risky side effects.

Tell your doctor or nurse about all of your medical conditions and all medicines or over-the-counter drugs you are taking. Your doctor or nurse will then be able to develop the best treatment plan for you. Not everyone responds to treatments in the same way, and your results may be different from other people.

Refer to the manufacturers’ prescribing information or instructions for use before taking any medications.

Medicine Names It is helpful to understand a little about how medicines are named, so you can better understand the types of medicines your doctor has prescribed and feel more comfortable talking with your doctor or nurse about your treatment plan.

Most medicines have two names: Brand name – the name a company uses to market the medicine. This is sometimes followed by a

registered symbol (). Generic name – the name that describes the active chemical in a medicine

Here are some examples of these two types of names:Type of medicine: pain relieverBrand name: TylenolGeneric name: acetaminophen

Type of medicine: angiotensin converting enzyme (ACE) inhibitorBrand name: Vasotec

Generic name: enalapril

Your doctor, nurse, pharmacist, or other healthcare provider may use either the generic or the brand name, but both names refer to the same medicine. In some cases, a generic medicine is sold by more than one company, and each company assigns its own “brand” name.

If the pharmacy changes brand names, you can do two things to make sure you are getting the right medicine: Check the generic name and dosage to make sure it is what you are supposed to take Ask your pharmacist to explain any differences

The major types of medicines used to treat heart failure or to treat a weakened heart muscle after a heart attack are described below by type (or category). You will see important information for each type of medicine. You may want to write down this information for all of the medicines your doctor has prescribed for you.

Angiotensin Converting Enzyme (ACE) Inhibitor This category of medicine may be the first treatment your doctor prescribes ACE inhibitors help reduce the heart’s workload by blocking certain harmful hormones your body

produces that cause the heart to work harder ACE inhibitors are also used to treat patients with high blood pressure or after a heart attack. They

are sometimes used to protect the kidneys in patients with diabetes. Over time (from weeks to months), ACE inhibitors may eliminate your symptoms and prevent

worsening heart failure They have been shown to prolong life in people with heart failure When the heart muscle is weaker than normal, the body produces chemicals to help the heart pump

more strongly. Over time, these chemicals can damage the heart muscle and cause it to get weaker. ACE inhibitors protect the heart muscle from harmful chemicals and may increase heart muscle strength over time.

ACE inhibitors are also used to treat patients with high blood pressure, patients who have had a heart attack, and patients with diabetes

How to Take ACE Inhibitors The ACE inhibitor dose will vary depending on which ACE inhibitor is chosen for you and what

condition is being treated You should always take this medicine exactly as it is prescribed by your doctor Your doctor or healthcare team may increase the dose of your ACE inhibitor even if you are feeling

fine or have only mild symptoms. This can be confusing to some patients. Research has shown that higher doses may protect your heart better than lower doses. Your doctor and healthcare team will choose the right dose for you.

You should not take this medicine if you are pregnant. This medicine is known to cause birth defects. If you plan to become pregnant, let your doctor or nurse know right away. If you become pregnant or are concerned you may be pregnant, let your doctor or nurse know immediately.

Possible Side Effects Common side effects include dizziness, an unusual taste in your mouth or loss of taste, low blood

pressure, and dry cough You should report any side effects to your doctor immediately Severe dizziness, fainting, rash, and swelling of the face are rare side effects If you have ever had an allergic reaction to an ACE inhibitor, be sure to tell your doctor Blood will be drawn periodically to check on your kidney functioning and potassium levels

Safety Measures ACE inhibitors may cause you to feel dizzy when you stand up after sitting or when you get up after

lying down. Remember to always stand up slowly. This will make you feel less dizzy and will help you avoid falling. If this dizziness is mild, your doctor may not change the dose or stop this medication.

Do not use salt substitutes without approval from your doctor or nurse Avoid using medicines such as ibuprofen (Advil®) or other NSAIDs (non-steroidal anti-inflammatory

drugs, such as Anaprox® or Naprosyn®) while you are taking an ACE inhibitor

Before you take an over-the-counter drug, you should always ask your doctor or pharmacist if it is OK to take it with your ACE inhibitor

If you are pregnant or plan to become pregnant, you should not take an ACE inhibitor. Be sure to talk to your doctor or nurse.

Talk to your doctor, nurse, or pharmacist for more information about this medication

Angiotensin Receptor Blocker (ARB) ARBs block the same chemicals that ACE inhibitors do, but they work in a different way to reduce

the heart’s workload ARBs can also be used to treat high blood pressure An ARB is often prescribed when a heart failure patient cannot tolerate an ACE inhibitor due to side

effects that cannot be minimized. In some cases, your doctor may want you to take both an ACE inhibitor and an ARB.

Side effects include dizziness and low blood pressure

How to Take ARBs The ARB dose will vary depending on which ARB is chosen for you and what condition

is being treated You should always take this medicine exactly as it is prescribed by your doctor You should take your medicine at the same time each day. This will help you to remember to take it.

If you are taking the ARB more than once each day, you should space out the doses as evenly as possible.

You should not take this medicine if you are pregnant. This medicine is known to cause birth defects. If you plan to become pregnant, let your doctor or nurse know right away. If you become pregnant or are concerned you may be pregnant, let your doctor or nurse know immediately.

Possible Side Effects Dizziness and lightheadedness are some of the common side effects of ARBs If you have ever had an allergic reaction to an ACE inhibitor, be sure to tell your doctor. It is unlikely

that you would also be allergic to an ARB, but your doctor should be aware of your medication history.

Safety Measures ARBs may cause you to feel dizzy when you stand up after sitting or when you get up after lying

down. Remember to always stand up slowly. This will make you feel less dizzy and will help you avoid falling. If this dizziness is mild, your doctor may not change the dose or stop this medication.

Do not use salt substitutes without approval from your doctor or nurse Before you take an over-the-counter drug, you should always ask your doctor or pharmacist if it is

OK to take it with your ARB If you are pregnant or plan to become pregnant, you should not take an ARB. Be sure to talk to your

doctor or nurse. Please talk to your doctor, nurse, or pharmacist for more information about this medication

Beta Blocker A beta blocker is used to treat heart failure and for people who have had a heart attack to prevent

them from having another one When the heart muscle is weaker than normal, the body produces chemicals to help the heart pump

more strongly. Over time, these chemicals can damage the heart muscle and cause it to get weaker. A beta blocker protects the heart muscle from harmful chemicals and may increase heart muscle strength over time.

Beta blockers can also be used to treat other conditions, such as high blood pressure and angina (chest pain), or be given to patients who have abnormal heart rhythms.

How to Take a Beta Blocker The beta blocker dose will vary depending on which beta blocker is chosen for you and what

condition is being treated You will be started on a low dose of medicine at first. The dose will be increased slowly over time. You should take your medicine at the same time each day. This will help you to remember to

take it. Your doctor or healthcare team may increase the dose of your beta blocker even if you are feeling

fine or have only mild symptoms. This can be confusing to some patients. Research has shown that higher doses may protect your heart better than lower doses. Your doctor and healthcare team will choose the right dose for you.

Do not stop this medication without discussing it with your doctor. Doing so can be dangerous. Do not let your medication run out

Possible Side Effects Common side effects include initial fatigue (for 1-4 weeks) and mild dizziness Severe dizziness, fainting, slow heartbeat, and wheezing are also possible side effects, but they are

less common Some people will have a lack of energy and feel tired for the first several weeks after starting a beta

blocker. However, after about 1-2 months, patients generally start to feel much better and have more energy because of the beta blocker.

Erectile dysfunction can occur when taking a beta blocker. If this happens to you, discuss it with your doctor or nurse. There are medicines that can help with this problem that are safe for people with mild to moderate heart failure.

Safety Measures Beta blockers may cause you to feel dizzy when you stand up after sitting or when you get up after

lying down, so remember to always stand up slowly. This will make you feel less dizzy and will help you avoid falling.

You should never suddenly stop taking your daily dose of beta blocker. If your doctor wants you to stop taking a beta blocker, the dose will be decreased slowly (over a few days or weeks).

Do not stop this medication without discussing it with your doctor. Doing so can be dangerous. Do not let your medication run out Please talk to your doctor, nurse, or pharmacist for more information about this medication

Diuretic Sometimes called water pills, diuretics help your body get rid of excess fluid and, in doing so, may

improve problems of swelling and fatigue You should weigh yourself first thing every morning, and keep a record, to watch for fluid gain

or loss Find out your baseline weight, also called your “dry weight.” If your weight increases by 3 pounds

overnight or 5 pounds over 2 days, call your doctor or nurse. Your diuretic dose may be changed based on your changes in weight or specific parameters set by

your doctor or nurse Diuretics can also be used to treat high blood pressure

How to Take Diuretics The diuretic dose will vary depending on which diuretic is chosen for you and your symptoms Take your diuretic at the same time each day, usually first thing in the morning. Plan on staying

close to home for the first several hours after taking it, as it will cause you to urinate frequently. Many times, diuretics are taken twice a day in order to better control symptoms. Take the second

dose in the middle of the afternoon to avoid being up all night going to the bathroom. Some patients are prescribed two diuretics. If you are prescribed metolazone or hydrochlorothiazide

in combination with another diuretic (usually furosemide, bumetanide, or torsemide), the metolazone or hydrochlorothiazide should be taken 30 to 60 minutes before the other diuretic to help the other diuretic work better.

Do not drink excessive fluids when you have heart failure and take diuretics. Take sips of water only when you are thirsty or with your pills. Drink small amounts of fluids with meals. Diuretics remove excess fluid and, by drinking more, you can make them ineffective in improving your symptoms.

Possible Side Effects Leg cramps, dry mouth, and frequent urination are the most common side effects of diuretics Diuretics may cause increased thirst

Safety Measures Diuretics may cause you to feel dizzy when you stand up after sitting or when you get up after lying

down. Remember to always stand up slowly. This will make you feel less dizzy and will help you avoid falling.

Most diuretics can cause you to lose potassium. You will likely be prescribed a potassium supplement.

Before taking an over-the-counter medicine, always ask your doctor, nurse, or pharmacist if it is OK to take with your diuretic

Please talk to your doctor, nurse, or pharmacist for more information about this medication

Aldosterone Antagonist This type of medicine blocks the effects of the hormone aldosterone Aldosterone can cause the heart muscle to get bigger and stiffer. This may decrease how well your

heart pumps. Aldosterone also causes your body to retain sodium (salt) and water, and that may make you bloated and congested.

Aldosterone antagonists help improve heart function and also relieve congestion This category of medicine is also used to treat high blood pressure, but at a different dose Side effects include breast enlargement or tenderness, especially in men, and increased potassium

levels

How to Take Aldosterone Antagonists You should always take this medicine exactly as it is prescribed by your doctor The dose may vary depending on what other medications you are taking You should take your medicine at the same time each day. This will help you to remember

to take it.

Possible Side Effects Common side effects include dizziness, breast tenderness, development of breast tissue in men

(gynecomastia), and high potassium level Your doctor will check your blood on a regular basis when you begin this medicine to monitor

the level of potassium in your blood. It is important to get lab work as prescribed by your doctor or nurse.

Safety Measures These medicines may cause you to feel dizzy when you stand up after sitting or when you get up

after lying down. Remember to always stand up slowly. This will make you feel less dizzy and will help you avoid falling.

Be sure to tell your doctor about each of your medications, and whether you are taking a potassium supplement or use a salt substitute

Do not use salt substitutes. You may be asked to stop using them. Before you take an over-the-counter medicine, you should always ask your doctor or pharmacist

if it is OK to take it with your aldosterone antagonist Please talk to your doctor, nurse, or pharmacist for more information about this medication

Digoxin This type of medicine can help your heart pump more forcefully and efficiently In patients with abnormal heart rhythms, it can also be used to help the heart beat more slowly and

more regularly Digoxin helps patients with heart failure breathe more easily, decreases their fatigue, and increases

their ability to exercise Side effects include nausea or vomiting, blurry vision, and abnormal heart rhythms

How to Take Digoxin You should always take this medicine exactly as it is prescribed by your doctor You should take your medicine once a day, at the same time each day or as prescribed by your

doctor or nurse

Possible Side Effects Nausea is a possible side effect when taking digoxin Tell your doctor if you notice a change in your vision, especially in your ability to see colors such as

blue, yellow, or green, or if your vision seems more blurry than usual If you have lost your normal appetite or lost a surprising amount of weight, you should

contact your doctor

Safety Measures There are many drugs, including over-the-counter medicines, that affect digoxin Some medicines may cause too much digoxin to stay in your system, and others may reduce

the amount that gets into your system Before you take an over-the-counter medicine, you should always ask your doctor or pharmacist if it

is OK to take it with digoxin Please talk to your doctor, nurse, or pharmacist for more information about this medication

Hydralazine Hydralazine is used to treat heart failure and can also be used to treat high blood pressure It causes the arteries in your body to dilate (get bigger). This lowers your blood pressure and

decreases the heart’s workload.

How to Take Hydralazine You should always take this medicine exactly as it is prescribed by your doctor You should take your medicine at the same time each day. It is important to wait the same amount

of time between each dose of your hydralazine throughout the day. This will help keep the levels of hydralazine constant in your blood.

Possible Side Effects Common side effects include headache, abdominal pain, dizziness, and lightheadedness Contact your doctor or nurse if you notice any new or unusual symptoms of arthritis, joint pain or

swelling, or rashes

Safety Measures Hydralazine may cause you to feel dizzy when you stand up after sitting or when you get up after

lying down. Remember to always stand up slowly. This will make you feel less dizzy and will help you avoid falling.

Before you take an over-the-counter medicine, you should always ask your doctor or pharmacist if it is OK to take it with hydralazine


Nitrate Nitrates can be used to treat angina (chest pain) or high blood pressure, and are also used to help

relieve congestion in patients with heart failure Nitrates allow the blood vessels to get bigger to allow more blood to carry oxygen to the heart. They

also take pressure off of the top part of the heart, so the heart does not have to work as hard.

How to Take Nitrates You should always take this medicine exactly as it is prescribed by your doctor You should take your medicine once a day, at the same time each day. This will help you remember

to take it. If you take this medicine more than once a day, it is important to take it at specific times so that you

have a 10 to 14 hour period when the medicine is out of your system. This will help the nitrate work better and will prevent your body from becoming tolerant to it.

If you have been prescribed isosorbide mononitrate, you should take your dose at 7 am If you have been prescribed isosorbide dinitrate, you should take your last dose by 5 pm If you have been prescribed a nitroglycerin patch, the patch should be off for 10 to 14 hours of

every day (that means you wear it for 10 to 14 hours over a 24-hour period) Your doctor may have other individual instructions regarding the way you take your nitrates. You

should follow your doctor’s instructions.

Possible Side Effects Common side effects include dizziness, abdominal pain, and headache

Safety Measures You should not take any form of nitrates with the medication sildenafil (Viagra®), tadalafil (Cialis®),

vardenafil (Levitra®), or other erectile dysfunction medications similar to these. This combination can cause a fatally low blood pressure.

Nitrates may cause you to feel dizzy when you stand up after sitting or when you get up after lying down. Remember to always stand up slowly. This will make you feel less dizzy and will help you avoid falling.

Before you take an over-the-counter medicine, you should always ask your doctor or pharmacist if it is OK to take it with your nitrate


Note: There is a fixed-dose combination of hydralazine and nitrate called BiDil®

Statin Statins are used to treat high cholesterol Your doctor has prescribed this medicine for you because some, or all of your cholesterol levels are

higher than the range that your doctor has set as your goal

How to Take Statins You should always take this medicine exactly as it is prescribed by your doctor You should take your medicine at the same time each day, day or night, as recommended by your

doctor or nurse

Possible Side Effects The most common side effect of statins is an upset stomach. You can prevent this by taking your

statin with food. This medicine can also affect your liver. Your doctor will check your liver enzymes with a blood test

before you start taking your statin and every 6 months while you are on the medicine. In some cases, statins can cause muscle aches and weakness, like the flu. This is a rare side effect,

but if you feel flu-like symptoms you should call your doctor or nurse.

Safety Measures Some statins can interact with other medications Before you take an over-the-counter medicine, you should always ask your doctor or pharmacist if it

is OK to take it with your statin Please talk to your doctor, nurse, or pharmacist for more information about this medication

Warfarin Warfarin is an anticoagulant, which means that it prevents blood clots from forming or stops a blood

clot from getting bigger Warfarin is used to “thin the blood” in patients with abnormal heart rhythms, patients who have a

history of stroke or clots in the lungs or legs, or patients who have had certain types of heart valves replaced

How to Take Warfarin You should always take this medicine exactly as it is prescribed by your doctor You should take your medicine once a day, at the same time each day. This will help you to

remember to take it. The dose of warfarin will be different for every patient. It depends on your individual response to the

medicine, and also on your body’s absorption and metabolism. Your doctor will determine the correct dose for you by checking a blood test called the INR

(international normalized ratio). The INR test measures how hard it is for your blood to clot. You should know your INR. Discuss this with your doctor. Possible Side Effects Most of the serious side effects of warfarin occur when the medicine level is too much or too little for

a patient (when the INR is too low or too high) Bleeding is the most common side effect. Serious bleeding rarely occurs when the INR is in the

correct range. Some people find that they bruise more easily than usual, or have nosebleeds or

bleeding gums. It is not unusual to make an adjustment in your warfarin dosing after every INR lab test.

Other side effects of warfarin include loss of appetite, nausea or diarrhea, irritated or itchy skin, and hair loss

Safety Measures Many medicines can change the way warfarin works. Some medicines increase warfarin’s effects

and can cause bleeding. Other medicines decrease the actions of warfarin and may prevent your blood from thinning at the right level.

Vitamin K interferes with warfarin and can make it ineffective. Vitamin K is found in certain multivitamins and many foods, especially dark green leafy vegetables, including foods in the list below:

Asparagus – Lettuce Avocado – Liver Broccoli – Mustard greens Brussels sprouts – Parsley Cabbage – Peas (including black-eyed peas, split peas, and chickpeas) Cauliflower – Soybeans and soybean oil Collard greens – Spinach Kale – Turnip greens

The best thing to do is keep your intake of foods with vitamin K constant while you are on warfarin. This means that you shouldn’t eat a lot more or a lot less of foods with vitamin K than you normally do.

You should not drink alcohol when taking warfarin You should not take this medicine if you are pregnant. This medicine is known to cause birth

defects. If you plan to become pregnant, let your doctor know right away. If you become pregnant or are concerned you may be pregnant, please let your doctor or nurse know immediately.

Many medications interact with warfarin. Before you take any new medication, including over-the-counter medicines, you should always ask your doctor, nurse, or pharmacist if it is OK to take it with warfarin. Taking warfarin with amiodarone, coumadin, and antibiotics are common mistakes.


Developed by the SCA Prevention Medical Advisory Team.This material is intended to be educational. It is not intended to replace the information provided to you by your healthcare




UC200705509 EN

What Are Arrhythmias?

Many people have questions about what the word “arrhythmia” means, and arrhythmias can be a difficult subject to understand. The text below should give you a better understanding of what arrhythmias are and the different types of arrhythmias that occur.

Normally the heart beats in a regular way – like a clock. However, many people, especially those with heart failure, have heart rates that are too fast, too slow, or irregular. These abnormal heart rhythms are referred to as arrhythmias. Some arrhythmias are harmless; however, some arrhythmias can be serious and even lead to Sudden Cardiac Arrest and death. Sometimes arrhythmias can cause symptoms such as heart palpitations (a racing heart or a pounding feeling), lightheadedness, or they may occur without any symptoms at all.

Although some arrhythmias do not require specific treatment, there are several ways to decrease, prevent, or treat arrhythmias. Treatments include medication, surgery, and the use of a device such as a pacemaker or an implantable defibrillator.

In a normal EKG, there are regular signals in both the upper and lower heart chambers.

Understanding Why Arrhythmias OccurAn arrhythmia can happen when any part of the heart’s electrical system is not normal. An arrhythmia can be thought of as an electrical problem, or short circuit, in the heart.

In contrast, a heart attack occurs when one or more of the arteries supplying the heart is suddenly clogged or blocked. A heart attack can be thought of as a plumbing problem in the heart.

So, even if a plumbing problem (for example, a blocked coronary artery) has been fixed, an electrical problem or arrhythmia can still develop. Likewise, electrical problems can exist even if there has never been a plumbing problem.

If the heart is enlarged and the muscle has been damaged, the electrical system may become irritated, increasing the risk of developing an arrhythmia.

lower chamberupper chamber

Common ArrhythmiasAtrial FibrillationAtrial fibrillation (atrial = upper heart chambers, fibrillation = quivering heartbeat) is common in patients with high blood pressure and heart disease, but is also found in patients with no heart disease at all. It occurs most commonly in the elderly.

Atrial fibrillation is a very fast and irregular heartbeat in the upper chambers of the heart (the atria). Instead of a single signal creating a normal beat, the atria quiver or fibrillate. If too many signals from the upper chambers travel to the lower chambers (ventricles), the ventricles will beat too quickly. It is important that atrial fibrillation is diagnosed and treated promptly to avoid complications such as stroke, heart attack, and heart failure. Stroke can occur because the atria (upper chambers of the heart) do not beat normally and blood moves slowly. Blood clots can form and travel to the brain, causing a stroke.

During atrial fibrillation, the upper chamber In a normal EKG, there are regular signalssignals are fast and irregular. in both the upper and lower heart chambers.

Some people experience palpitations, or they feel dizzy, lightheaded, short of breath, or fatigued. Other people live with atrial fibrillation but do not have any symptoms.

Treatment options for atrial fibrillation include:Anticoagulants (blood thinners) – anticoagulants (most commonly warfarin) help reduce the chance of blood clots forming and reduce the chance of stroke. When warfarin is used, regular scheduled blood tests are needed to check that the dose is safe. Some people may be treated with aspirin instead of warfarin and some may not need blood-thinning at all.

Antiarrhythmic medicines – these are referred to as rhythm-control medicines. They attempt to maintain or restore normal heart rhythm. As with any medication, there are benefits and risks associated with use. Please discuss this with your doctor so that the complete prescribing information can be provided.

Rate-control medicines – medicines to control heart rate and prevent the heart from beatingtoo fast. Please discuss this with your doctor so that the complete prescribing information can be provided.

Cardioversion – a normal heart rhythm can also be restored electrically through a procedure called cardioversion. A brief electrical shock is delivered to the heart to stop atrial fibrillation and restore a normal rhythm. This procedure is performed using short-term anesthesia. See additional safety information for ICDs.*

Ablation – a procedure called radiofrequency ablation is recommended to treat atrial fibrillation when it cannot be controlled with medicines alone. During this procedure, small thin wires are threaded into the heart and electrical energy is used to remove or ablate the tissues causing heart rhythm problems. There are benefits and risks associated with this procedure. Please ask your doctor to provide you with this information.

Surgery – a surgical procedure that involves making a series of cuts in the atria can be successful in treating atrial fibrillation. This procedure can require open-heart surgery and is most often done if other heart surgery is needed. As with any surgical procedure, there are benefits as well as risks. Talk to your doctor about this type of surgery to determine whether it is right for you and the associated risks.

Ventricular Tachycardia and Ventricular FibrillationVentricular tachycardia (ventricular = lower heart chambers, tachycardia = fast heartbeat) is a rapid heart rhythm that begins in the lower chambers of the heart (ventricles). During ventricular tachycardia, the lower chambers of the heart beat extremely fast. When the ventricles beat too fast, the heart cannot fill with blood or pump effectively. Some people may become dizzyor short of breath, pass out, or experience palpitations.

Sometimes ventricular tachycardia can change into the most dangerous arrhythmia of all, ventricular fibrillation. During ventricular fibrillation, the heart beats very rapidly and abnormally, and no blood is pumped out of the heart. Ventricular fibrillation will lead to Sudden Cardiac Arrest and death within minutes unless a normal heart rhythm is restored. Sending an electrical shock to the heart (which is known as defibrillation) can restore normal heart rhythm. Cardiopulmonary resuscitation (CPR) does not restore a normal heart rhythm, but it can help pump blood to the body until a normal heart rhythm can be restored.

Because they are life-threatening rhythms, ventricular tachycardia and ventricular fibrillation require immediate treatment. Some ventricular tachycardias can be treated with medicines. However, the best way to treat ventricular fibrillation is through the use of a defibrillation shock. Recent clinical studies show that implantable cardioverter defibrillators are better at keeping people who are at high risk of dangerous ventricular arrhythmias alive than treatment only with medicines.

During ventricular tachycardia, there is In a normal EKG, there are regular signalsan extremely fast lower chamber rate. in both the upper and lower heart chambers.

During ventricular fibrillation, there is In a normal EKG, there are regular signalschaotic lower chamber activity. in both the upper and lower heart chambers.

Immediate treatment options for ventricular tachycardia/fibrillation include:Defibrillation – in defibrillation, a device gives the heart an electric shock to restore a normal heartbeat. This treatment is mainly given in two ways: by an automatic external defibrillator (AED), or by an implantable cardioverter defibrillator (ICD). See additional safety information for ICDs.*

Automatic external defibrillator (AED) – AEDs are portable devices that measure the electrical activity of the heart and deliver defibrillation therapy if a fatal heart rhythm is detected. Most Emergency Response Teams carry and use AEDs. Thanks to recent studies showing their lifesaving role, AEDs are being placed in public gathering spots, such as government centers, airports, casinos, malls, stadiums, schools, and office buildings. AEDs do not work by themselves and can only be used by someone properly trained.

Antiarrhythmic medicines – these are referred to as rhythm-control medicines. They attempt to maintain or restore normal heart rhythm and are given through an IV by a physician or nurse. As with any medication, there are benefits and risks associated with use. Please discuss this with your doctor so the complete prescribing information can be provided.

Long-term treatment options for ventricular tachycardia/fibrillation include:Implantable cardioverter defibrillator (ICD) – an ICD is the most effective way to treat ventricular arrhythmias. It is a pacemaker-like device that has been available since the mid-1980s. It is small –about the size of a pager – and is implanted under the skin in the upper chest and connected to the heart by special wires. The battery and computer circuits needed to correct an abnormal or fatal heart rhythm are contained in the device. Once it is implanted, an ICD works by itself and doesn’t require anyone to operate it. The ICD continuously monitors heart rhythm. If the ICD detects a ventricular arrhythmia, it will use small, painless electrical signals or a larger, sometimes painful shock to correct the heart rhythm. Most implantable defibrillators last 5 to 7 years before they need to be replaced.

Antiarrhythmic medicines – these are referred to as rhythm-control medicines. They attempt to maintain or restore normal heart rhythm. As with any medication, there are benefits and risks associated with use. Please discuss this with your doctor so the complete prescribing information can be provided.

Ablation – a procedure called radiofrequency ablation is recommended when heart rhythm cannot be controlled with medicines alone. During this procedure, small thin wires are threaded into your heart and electrical energy is used to remove or ablate the tissues causing heart rhythm problems. There are benefits and risks associated with this procedure. Please ask your doctor to provide you with this information.

Surgery – a surgical procedure has been successful in treating ventricular tachycardia. This procedure can require open-heart surgery and is most often done if other heart surgery is needed. As with any surgical procedure, there are benefits as well as risks. Talk to your doctor about this type of surgery to determine whether it is right for you and the associated risks.

* Safety InformationAdditional Device InformationAn implantable cardioverter defibrillator (ICD) system delivers therapies to treat patients with heart rhythm disorders or who are at significant risk of developing heart rhythm disorders. An ICD is placed inside your body and works automatically.

Risks associated with an ICD system implant include, but are not limited to, infection at the surgical site and/or sensitivity to the device material, failure to deliver therapy when it is needed, or receiving extra therapy when it is not needed. After receiving an ICD system, you will have limitations with magnetic and electromagnetic radiation, electric or gas powered appliances, and tools with which you are allowed to be in contact.

Treatment with an ICD system is prescribed by your physician. This treatment is not for everyone. Please talk to your doctor to see if it is right for you. Your physician should discuss all potential benefits and risks with you. Although many patients benefit from the use of this treatment, results may vary.





UC200705530 EN

What Is Sudden Cardiac Arrest?Normal heart rhythms are usually regular (the heart beats steadily and evenly). Sudden Cardiac Arrest (SCA) occurs when the lower chambers of your heart start beating very fast, weakly, and abnormally, preventing the heart from pumping blood to the body and brain. If SCA is not treated, it can lead to death within minutes.

In most cases, SCA occurs without warning and without symptoms. In some cases, SCA may begin with a decrease in blood flow to the heart or a heart attack. In other cases, SCA may be due to other causes and cardiac conditions. SCA can happen at any time – at home, at work, or when you are out doing your daily activities. People who experience SCA may lose consciousness before they even know what has happened or before they can ask for help.

How Does SCA Differ from a Heart Attack?SCA is not a heart attack. A heart attack, or myocardial infarction (MI), means an area of your heart muscle has been injured and has died. A heart attack occurs when a heart muscle is damaged because it does not get enough blood. Blood vessels, called coronary arteries, supply blood and oxygen to the heart muscle. If one or more of the coronary arteries become fully blocked, the heart muscle cannot get the oxygen it needs, and the heart muscle may be permanently damaged. Think of a heart attack as a plumbing problem in the heart.

In contrast, think of SCA as an electrical problem in the heart. The heart’s pumping mechanism is powered by electrical signals. During SCA, the heart’s electrical system works abnormally, leading to an irregular, abnormal heartbeat. The abnormal heartbeat causes the heart muscle to quiver rather than pump blood, and blood is not pumped to the body and brain.

The good news is that, today, doctors and nurses understand more about SCA and heart attacks, and have better ways to prevent them. There are medicines and treatments available to help avoid these events and potentially help people live normal lives.





UC200705529 EN

Sudden Cardiac Arrest Patient Fact Sheet

This fact sheet is meant to be a guide for you to understand and discuss your risk for Sudden Cardiac Arrest. With the information below, you can be informed and discuss with your doctor or nurse how best to reduce your risk for Sudden Cardiac Arrest. Don’t hesitate to ask your doctor or nurse if you have any questions after reading the information that follows.

If you have had a previous heart attack, heart failure, abnormal heart rhythm, a heart that does not pump well, or a family history of Sudden Cardiac Arrest, you may be at risk.

Sudden Cardiac Arrest means your heart has stopped pumping blood. Sudden Cardiac Arrest is caused by an electrical problem in the heart.

Without defibrillation, Sudden Cardiac Arrest may lead to death in 6 minutes

Sudden Cardiac Arrest and heart attack are not the same thing:o A heart attack is caused by a blood flow or plumbing problem in the heart when one or more

of the arteries delivering blood to the heart muscle becomes clogged or blocked. Oxygen cannot get to the heart and the heart muscle is damaged.o Sudden Cardiac Arrest is caused by an electrical problem in the heart that triggers a

dangerously fast heartbeat causing the heart muscle to quiver and not pump blood to the rest of the body and brain

Even if you had a clogged artery fixed with angioplasty, bypass surgery or other procedure, you can still be at risk for Sudden Cardiac Arrest

People at highest risk for Sudden Cardiac Arrest have: o A heart that pumps poorly, as measured by a low ejection fraction (EF)

EF is a measurement of how much blood is pumped by the heart with each beat A normal EF is 50-75% Many people with heart failure have an EF of 35% or less You should be aware of your EF and ask your doctor when it should be re-checked

AND have had one or more of the following:

o Heart failureo Heart attack

Many people do not realize that Sudden Cardiac Arrest strikes without warning. Often there are no specific symptoms, so even though you feel healthy, you could be at serious risk. The only useful way to treat Sudden Cardiac Arrest is defibrillation, which means an electrical shock is delivered to your heart to return it to a normal heartbeat

Defibrillation within 6 minutes is critical to survive Sudden Cardiac Arrest; however, the average response time to an emergency call is 6 to 12 minutes. Only 5% of people will survive a Sudden Cardiac Arrest.

There are two main ways to defibrillate: automated external defibrillators (AEDs) and implantable cardioverter defibrillators (ICDs)

Automated external defibrillators (AEDs) are portable devices that measure the electrical activity of the heart and deliver defibrillation therapy if a fatal heart rhythm is detected. Most Emergency Response Teams carry and use AEDs. Thanks to recent studies1 showing their life-saving role, AEDs are being placed in public gathering spots such as government centers, airports, casinos, malls, stadiums, schools, and office buildings.

AEDs do not work by themselves and need to be operated by someone else. You cannot use the AED on yourself.

Here is a picture of an AED

An implantable cardioverter defibrillator (ICD) is a small, pacemaker-like device placed in your body, under your skin, that can reset your heart’s rate and rhythm and, by doing so, can save your life. Defibrillation is the best way to treat Sudden Cardiac Arrest. An ICD continuously monitors your heart 24 hours a day. If your ICD detects a rhythm problem, it will send out electrical signals to correct it.o Once it is implanted, an ICD will work by itself, but does require follow-up checks

Here is a diagram of an ICD

ICDs can be safe, reliable, and highly effective in treating Sudden Cardiac Arrest and may be a good choice for you

Discuss with your doctor if an ICD is appropriate for your medical needs

There is a lot of information on the web. Ask your doctor for recommended websites.

Reference:1 European Heart Rhythm Association; Heart Rhythm Society; Zipes DP, et al. ACC/AHA/ESC 2006 guidelines for

management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: a report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Develop Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death). J Am Coll Cardiol. September 5, 2006; 48(5):e247-346.





UC200705523 EN

Date:

Dear Mr./Mrs./Ms. ,

We have reviewed your medical records and would like to meet with you to review and discuss your current health. As a valued patient, your health is my primary concern. Based on recent changes to national cardiology guidelines, you may have one or more conditions that may place you at increased risk. The guidelines support use of new therapies to reduce such risk.

I would like to speak with you to explain these therapies and decide if they will be of significant benefit to you.

Please contact my office (information below) to schedule an appointment soon.

Sincerely,

Telephone: Fax: Voice mail: E-mail:





UC200705512 EN

Pre-ICD (Implantable Cardioverter Defibrillator) Placement: Frequently Asked Questions

What is Sudden Cardiac Arrest?Sudden Cardiac Arrest means your heart has stopped pumping blood.

What is the difference between Sudden Cardiac Arrest and a heart attack?A heart attack is caused by a blood flow or plumbing problem in the heart when one or more of the arteries delivering blood to the heart muscle becomes clogged or blocked. Oxygen cannot get to the heart and the heart muscle is damaged. Sudden Cardiac Arrest is caused by an electrical problem in the heart that triggers a dangerously fast heartbeat, causing the heart muscle to quiver and not pump blood to the rest of the body and brain.

Who is at risk for Sudden Cardiac Arrest?In general, most people who are at risk for Sudden Cardiac Arrest have one or more of the following risk factors: Heart failure (heart failure is a condition that reduces the heart’s ability to pump blood)

with a low ejection fraction (EF) A previous heart attack A family member who has experienced Sudden Cardiac Arrest

What is heart failure?Heart failure means that your heart’s ability to pump blood is decreased. It can result from a heart attack, untreated high blood pressure, or another problem. Because of heart failure, the heart cannot pump enough blood to supply the body’s need for oxygen. As a result, fluid may build up in the lungs, legs, and other tissues throughout the body. That is why when you have heart failure you may experience swelling and weight gain and have shortness of breath or trouble breathing at night.

What is ejection fraction?Ejection fraction is the percentage of blood pumped out of the heart during each beat. In a healthy resting heart, 50-75% of the blood is pumped out during each beat. Many people with heart failure pump out less than 35%. A below-normal ejection fraction means that your heart is no longer pumping as it should and may not be able to supply your body and brain with enough blood.

Why is it important to know my ejection fraction?Your ejection fraction is one of the ways your doctor can diagnose heart failure and identify people who are at risk for Sudden Cardiac Arrest. Recent medical research shows that heart attack survivors and people with heart failure who have an ejection fraction of 35% or below are at higher risk for dangerously fast heart rhythms and Sudden Cardiac Arrest.1

How is ejection fraction measured?A simple and painless test called an echocardiogram, or “echo,” is generally used to learn the ejection fraction. The test, which uses ultrasound to measure how well your heart is pumping, can often be performed in your doctor’s office. There are other imaging tests that can be used to measure your ejection fraction.

How is Sudden Cardiac Arrest treated?The only effective way to treat Sudden Cardiac Arrest is defibrillation. Defibrillating means giving the heart an electric shock in a controlled manner to restore a normal heartbeat. This treatment is mainly given in two ways: by an automated external defibrillator (AED), or by an implantable cardioverter defibrillator (ICD).

What is an automated external defibrillator (AED)?AEDs are portable devices that measure the electrical activity of the heart and deliver defibrillation therapy if a fatal heart rhythm is detected. Most Emergency Response Teams carry and use AEDs. Thanks to recent studies2,3 showing their lifesaving role, AEDs are being placed in public gathering spots, such as government centers, airports, casinos, malls, stadiums, schools, and office buildings. AEDs do not work by themselves and need to be operated by someone else. You cannot use the AED on yourself.

Here is a picture of an AED:

TM

What can be done to reduce my risk for Sudden Cardiac Arrest?Defibrillation within 6 minutes is critical to survive Sudden Cardiac Arrest. An ICD is the most effective way to treat Sudden Cardiac Arrest (see next page). It is always there, monitoring your heart rate and administering treatment if needed.

What is an ICD?An ICD is a pacemaker-like device that has been available since the mid-1980s. It is small – about the size of a pager – and is implanted under the skin in your upper chest. The battery and computer circuits needed to correct your heart rhythm are contained in the device. Thin insulated wires, called leads, connect the implantable defibrillator to your heart. If the device detects a problem with your heart rhythm, it will use electrical signals to correct your heart rate. Most implantable defibrillators last 5 to 7 years before they need to be replaced. An implantable defibrillator is the most effective way to treat Sudden Cardiac Arrest. It is programmable and will deliver just the right amount of therapy for your particular heart problem. Once it is implanted, an ICD will work by itself, but does require follow-up checks.

Here is a diagram of an ICD:

How does an implantable defibrillator work?Depending on how it is programmed, an implantable defibrillator can first use small, painless electrical signals to correct your heart rate. If these do not work, a stronger shock is delivered. People describe the shock as surprising and uncomfortable, sometimes even painful, but the feeling passes quickly. Quite often, it is over before you are fully aware of what happened. The good news is that your implantable defibrillator is continuously there monitoring and protecting you, 24 hours a day.

What are the risks and precautions?Generally, use of ICDs is considered safe and highly effective. However, there are potential risks associated with any implantable device system. Risks include, but are not limited to, infection at the surgical site and/or sensitivity to the device material, failure to deliver therapy when it is needed, or receiving extra therapy when it is not needed. After receiving an ICD, you will have limitations with magnetic and electromagnetic radiation and electric or gas powered appliances and tools with which you are allowed to be in contact. Although many patients benefit from the use of these products, results may vary. Please note that there are other important risks and precautions that you will need to review with your physician. Your physician should review all risks and benefits with you.

Will I be able to drive?Most people with an ICD are able to resume driving depending on their doctor’s advice and the laws and insurance regulations of their state.

Will I be able to travel?Most people with an ICD can travel without taking special precautions, but you should discuss this with your doctor. Most patients can travel without problems soon after their ICD implantation.

Will I have a problem with airport security?Airport security systems may detect the metal of your ICD and you may be asked to undergo an additional search. Patients receiving ICDs are given a device identification card, which can be presented at airport security if needed. You can also request a hand search. You should request that any handheld screening devices be kept away from your ICD, since they have the potential to trigger defibrillation therapy.

What happens during the implant procedure?The following is intended as a general overview. The implant procedure is typically quick, low risk, and usually done under local anesthesia. It does not require open-heart surgery, and most people typically

stay overnight. Patients are normally sedated throughout the procedure and should not feel any pain. Your doctor will make a small incision in the upper chest and guide the leads through a vein and into your heart. Your doctor will connect the leads to the ICD and program the device. Then the ICD will be inserted beneath the skin and the incision in your chest will be closed. Your physician will test the ICD to ensure that it is working properly. Your experience may differ, so please talk to your doctor for specifics regarding your implant.

What happens following the procedure?Following surgery, you will stay in the hospital overnight and go home the next day. You will see a bump under your skin where your device is located and the area may be tender. Generally, you should limit arm movement on the side of your ICD for about 2 to 6 weeks. Your doctor will provide you with more specific care instructions, but you can expect to gradually return to your everyday activities shortly after the procedure. If you have any questions, please ask your doctor or nurse.

What about follow-up after the procedure?After the implant, the doctor who implanted your defibrillator will work with the doctor who manages your heart disease. You will still need to take your medication as prescribed and have your ICD checked from time to time. Ask your doctor or nurse about your schedule for follow-up visits with each of your physicians. It is important to keep your appointments with each of your doctors and to follow the recommended daily care instructions to ensure the best possible results. Depending on what type of device you have, you might be able to use a monitoring service that allows you to transfer information from your device to your clinic over a telephone line. This service may reduce the number of clinic visits you need. Your device helps you only when it is functioning properly. It is important to receive regular follow-up care by your electrophysiologist and the doctor or nurse treating your heart failure.

Safety InformationAdditional Device InformationAn implantable cardioverter defibrillator (ICD) system delivers therapies to treat patients with heart rhythm disorders or who are at significant risk of developing heart rhythm disorders. An ICD is placed inside your body and works automatically.

Risks associated with an ICD system implant include, but are not limited to, infection at the surgical site and/or sensitivity to the device material, failure to deliver therapy when it is needed, or receiving

extra therapy when it is not needed. After receiving an ICD system, you will have limitations with magnetic and electromagnetic radiation, electric or gas powered appliances, and tools with which you are allowed to be in contact.


References1 European Heart Rhythm Association; Heart Rhythm Society; Zipes DP, et al. ACC/AHA/ESC 2006 guidelines for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: a report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Develop Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death). J Am Coll Cardiol. September 5, 2006;48(5):e247-346.2 Bardy GH, Lee KL, Mark DB, et al; Sudden Cardiac Death in Heart Failure Trial Investigators. Amiodarone or an implantable cardioverter-defibrillator for congestive heart failure. N Engl J Med. January 20, 2005;352(3):225-237.3 Moss AJ, Zareba W, Hall WJ, et al; Multicenter Automatic Defibrillator Implantation Trial II Investigators. Prophylactic implantation of a defibrillator in patients with myocardial infarction and reduced ejection fraction. N Engl J Med. March 21, 2002;346(12):877-883.





UC200705525 EN

Post-ICD (Implantable Cardioverter Defibrillator) Placement: Frequently Asked Questions

You had an ICD placed inside of you because it could reduce your risk of death.

Here is a diagram of an ICD:

What happens following the procedure?Following surgery, you will typically stay in the hospital overnight and go home the next day. You will see a bump under your skin where your device is located and the area may be tender. Generally, you should limit arm movement on the side of your ICD for about 2 to 6 weeks. Your doctor or nurse will provide you with more specific care instructions, but you can expect to gradually return to your everyday activities shortly after the procedure. If you have any questions, please ask your doctor or nurse.

What about follow-up after the procedure?After the implant, the doctor who implanted your defibrillator will work with the doctor who manages your heart disease. You will still need to take your medication as prescribed and have your ICD checked from time to time. Ask your doctor or nurse about your schedule for follow-up visits with each of your physicians. It is important to keep appointments with each of your doctors and to follow the recommended daily care instructions to ensure the best possible results. Depending on what type of device you have, you might be able to use a monitoring service that allows you to transfer information from your device to your clinic over a telephone line. This service may reduce the number of clinic visits you need. Your device helps you only when it is functioning properly. It is important to receive regular follow-up care by your electrophysiologist and the doctor or nurse treating your heart failure.

What happens after a shock? Making a plan.If your ICD detects a problem with your heart rhythm, it may deliver a shock to your heart. People describe the shock as surprising and uncomfortable, and sometimes painful, but it passes quickly. It also means the ICD has done its job and that it may have saved your life. Your doctor or nurse will give you specific directions on what to do immediately after receiving a shock. Work with them to develop a plan that is right for you.

If you do receive a shock: 1. Follow the directions your doctor or nurse gave you about what to do after receiving a shock.2. Stay calm and find a quiet place to sit or lie down.3. Take notice of how you feel and tell others.4. Ask a family member or friend to stay with you until you feel better. Anyone touching you while the

device is delivering a shock might feel the muscles in your chest and upper arms contract. The shock will not harm the person touching you.

5. Instruct the friend or family member to call for an ambulance if you receive a shock and remain unconscious for more than 1 minute.

6. If you do not feel well after the shock, ask someone to call your doctor and help get you to the nearest emergency room.

Put this plan in a handy place so you can get to it easily. Also, make sure to share it with your family and other caregivers, so they can understand how to help you. It is helpful to understand that what you were doing at the time of the shock did not cause the shock. Generally, you will still be able to do the activities you enjoy. Although getting a shock may reduce your confidence for a short time, it is important to return to your everyday activities and focus on enjoying life.

Will I be able to drive?Most people with an ICD are able to resume driving depending on their doctor’s recommendation, and the laws and insurance rules in their state.

Will I be able to travel?Most people with an ICD can travel without taking special precautions, but you should discuss this with your doctor. Most patients can travel without problems soon after their ICD implantation.

Will I have a problem with airport security?Airport security systems may detect the metal of your ICD and you may be asked to undergo an additional search. Patients receiving ICDs are given a device identification card, which can be presented at airport security if needed. You can also request a hand search. You should request that any handheld screening devices be kept away from your ICD, since they have the potential to trigger defibrillation therapy.

Can I walk through anti-theft systems?Yes. Sometimes, however, the systems located in stores, libraries, and other buildings may temporarily interfere with your ICD if you stop or linger near the equipment. Simply walk through the system at a normal pace.

Are physical activities safe?Most physical activities are safe. An ICD can tell when your heart rate increases due to normal physical activities and when it increases because of a problem with your heart. Discuss your activity level with your doctor to determine what is best for you.

What about intimacy?Most patients can resume intimate activity. People who have an ICD may wonder if the device could deliver a shock during sexual activities. This is rare, but possible. The shock will not hurt your partner. Your doctor or nurse can also provide helpful information on the subject of intimacy.

How will I know if my ICD is working properly? What happens if the battery runs out?The doctor who implanted your device will schedule regular follow-up appointments to check your device. If your doctor finds the battery low, he or she will discuss a replacement procedure. Because the battery inside the device cannot be recharged, the entire device must be replaced, usually after 5 to 7 years.

What will I do if I have concerns?

Make a list of any worries you might have about your condition or the ICD. Discuss each concern with your doctor or nurse, your loved ones, or other appropriate sources of information who can help you to develop a plan about how to cope with your concerns.

How do I adjust to having an ICD?Each person adjusts a little differently. Although many patients benefit from the use of these devices, individual results may vary. Your doctor will discuss the benefits and risks with you. The goal is for you to lead a more normal life as soon as possible. Build your confidence by making plans with friends and family. You may want to consider participating in a support group. If you have problems adjusting, there are many other resources to help.

Safety InformationAdditional Device InformationAn implantable cardioverter defibrillator (ICD) system delivers therapies to treat patients with heart rhythm disorders or who are at significant risk of developing heart rhythm disorders. An ICD is placed inside your body and works automatically. Risks associated with an ICD system implant include, but are not limited to, infection at the surgical site and/or sensitivity to the device material, failure to deliver therapy when it is needed, or receiving extra therapy when it is not needed. After receiving an ICD system, you will have limitations with magnetic and electromagnetic radiation, electric or gas powered appliances, and tools with which you are allowed to be in contact.

The Medtronic CareLink® Monitor is a prescription device indicated for use in the transfer of patient data from some Medtronic implantable cardiac devices based on physician instructions and as described in the product manual. This product is not a substitute for appropriate medical attention in the event of an emergency and should only be used as directed by a physician. Medtronic CareLink Service is currently available in the continental United States, Alaska, and Hawaii.

Treatment with an ICD system and/or Medtronic CareLink Service is prescribed by your physician. This treatment or service is not for everyone. Please talk to your doctor to see if it is right for you. Your physician should discuss all potential benefits and risks with you. Although many patients benefit from the use of this treatment, results may vary.

Reference European Heart Rhythm Association; Heart Rhythm Society; Zipes DP, et al. ACC/AHA/ESC 2006 guidelines for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: a report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Develop Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death). J Am Coll Cardiol. September 5, 2006;48(5):e247-346.





UC200705524 EN

Roadmap to Better Heart Health

This pathway shows the steps that you and your doctor or nurse will take over the next few office visits. Keep this reminder in a place where you can refer to it easily, and bring it with you to every office visit to discuss your progress with your doctor or nurse.

Medications Frequently Adjusted to Target Dose

Medication Class Medication Name Starting Dose/Date

Increase Dose/ Target Date

Increase Dose/ Target Date

Angiotensin-converting enzyme (ACE) inhibitor

/ / /

Angiotensin receptor blocker (ARB)

/ / /

Aldosterone antagonist / / /Beta-blocker / / /Other: / / /

Other: / / /

Flu vaccine date: ____________________ (Guideline recommended: yearly)*

Pneumococcal vaccine date: ___________ (Guideline recommended: every 5 years)**Heart Failure Society of America. HFSA 2006 Comprehensive Heart Failure Practice Guideline. J Card Fail. February 2006; 12(1):e1-e122.

Recheck electrocardiogram (EKG)Date: ___________ (after a change in clinical status, or those patients who have experienced or recovered from a clinical

event or received treatment that might have had a significant effect on the EKG)

Reassess left ventricular ejection fraction (LVEF)Date: ___________ (Guideline recommended: 40 days after myocardial infarction (MI), or after a change in clinical status,

or those patients who have experienced or recovered from a clinical event or received treatment that might have had a significant effect on cardiac function)

Date: ___________ (Guideline recommended: 3 to 9 months after onset of dilated cardiomyopathy, or after a change in clinical status, or those patients who have experienced or recovered from a clinical event or received treatment that might have had a significant effect on cardiac function)

Labs

What Is Being Tested Date Result Date ResultSerum potassiumSerum creatinineFasting lipid panelLiver function tests (6 to 8 weeks after statin initiation)INR (at least monthly)Other:Other:

Device InterrogationDate: ___________ (Guideline recommended: every 4 months, or after a change in symptoms/ clinical status beyond

routine, or more frequently if proactive heart failure monitoring capabilities)Safety InformationAdditional Device InformationAn implantable cardioverter defibrillator (ICD) system delivers therapies to treat patients with heart rhythm disorders or who are at significant risk of developing heart rhythm disorders. An ICD is placed inside your body and works automatically.

Risks associated with an ICD system implant include, but are not limited to, infection at the surgical site and/or sensitivity to the device material, failure to deliver therapy when it is needed, or receiving extra therapy when it is not needed. After receiving an ICD system, you will have limitations with magnetic and electromagnetic radiation, electric or gas powered appliances, and tools with which you are allowed to be in contact.






UC200705527 EN

Healthcare Provider Contact Information

If you have questions about taking your medications or need a refill, call: ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________You should have your medicine bottles in front of you when you call.

If you have a question about following a low-salt diet or fluid management expectations (daily weight measurements, checking for worsened swelling in your legs or ankles, or a weight gain of 3 pounds overnight or 5 pounds in 1 week), or if you have worsened shortness of breath, call: ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________

If you experience chest pain, call: ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________Call 911 if you feel a new kind of chest pain, pain that nitroglycerin does not help, or pain that lasts more than 5 minutes, or if you feel suddenly short of breath or lose consciousness.If you have a question about other medical problems not related to your heart, call: ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________

If you have a question about your INR, call: ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________

If you have a question about a lab value checked in between office visits, call: ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________

If you have a question about or receive a shock from your cardiac device, call: ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________You should have your device identification card in front of you when you call.

If you think your device provided a shock, here is a sample action plan. You should discuss the specific action plan that is best for you with your doctor or nurse:

Event Symptoms Action

Received ICD shock Feeling fine Call heart doctor to discuss the event and arrange appropriate follow-up

Received ICD shock Experiencing chest pain/pressure, shortness of breath, rapid heart action. Feel dizzy, confused, or not well.

Seek medical attention immediately

Received two or more ICD shocks within 24 hours

Feeling fine or ill Seek medical attention immediately

Source: Sears SF Jr, Shea JB, Conti JB. Circulation. 2005;111:e380-e382.

Put this plan in a handy place so you can get to it easily. Also, make sure to share it with your family and other caregivers so they can understand how to help you.

After an ICD shock, if you do not recover consciousness within a minute or do not feel well, a family member or friend may need to call the doctor or 911 for you

Anyone touching you while the device is delivering a shock might feel the muscles in your chest and upper arms contract. The shock will not harm the person touching you.

There is certain information that you should have available at all times: (1) the ICD identification card; (2) a list of medications; and (3) the doctor’s name and phone number (as listed above)

For regular visits to your doctor or nurse, you should bring all of your medications in their bottles, your device identification card, your daily weight measurements, and any questions about your treatment

If you have to go to the hospital, be sure to bring all of your medications in their bottles and your device identification card





UC200705526 EN

Caring for a Person with Heart Failure

Caring for someone with heart problems can be a challenge. There may be a lot of medical information to understand, and you may not know exactly where to start. Here are some simple things that you can do to help improve the health of the person under your care. This is not a complete guide to all issues you will face, so remember to discuss any questions you have with the person’s doctor or nurse, and to use the additional resources listed at the end of this document.

Understanding the Patient’s Medical ConditionIt can be difficult to have a clear understanding of all the heart-related issues the patient faces. Make sure that you ask the doctor or nurse for any educational materials or resources that they find useful; and don’t be afraid to ask questions. It is often useful to bring a written list of questions with you to office visits.

Observing SymptomsIt is important to watch for changes in symptoms. A change may mean that the same symptoms are getting worse or that new symptoms have appeared that you haven’t seen before. Any change in symptoms can be a sign that more urgent care is needed. A person with heart problems may have trouble noticing these changes, so a caregiver can be very helpful in pointing them out. Talk with the patient if you notice changes in his or her symptoms. Encourage the patient to get on the scale and measure weight daily. Changes in weight can be a sign of changes in health.

Below is a table of signs and symptoms seen in those with heart failure:

Common Symptoms Less Common but Important Symptoms• Shortness of breath when active• Trouble breathing when sleeping• Weight gain of more than 3 pounds overnight or 5 pounds in 1 week• Swollen legs and/or ankles• Decreased appetite• Having to urinate during the night• Feeling tired

• Shortness of breath when at rest• Dizziness, lightheadedness, and/or passing out• Irregular heartbeat• Nausea and/or abdominal bleeding• Chest pain• Poor memory

Responding to Symptom ChangesIf you observe symptom changes, immediately contact the doctor or nurse who is treating the patient’s heart problems. Often they have given you detailed instructions on when to call for a change in symptoms. If you are ever in doubt, call and ask for advice.

Dealing with Other IllnessesIf you have questions or concerns about the patient’s health with regard to conditions that are not related to the heart, you should contact the doctor currently treating those conditions or the patient’s primary care doctor.

Helping with Medicine and Treatment OrdersFollow doctor’s orders carefully to gain the most benefit from medical treatment. As a caregiver, you can help by setting a healthcare routine. Make sure that the right medications are always available and that pills are taken exactly as the doctor ordered. By filling up weekly pillboxes, you can help the patient follow his or her medications properly.

Understanding Implantable Devices

Some patients may have an implantable device, such as an implantable cardioverter defibrillator (ICD), placed in his or her heart to correct an abnormal, fast heart rhythm if it occurs. These devices vary in size and work by monitoring the heart’s activity. If the device detects a problem in the heart rhythm, it releases a small amount of electricity – a shock – to the heart in order to reset the rhythm to a normal one. Most patients are aware of a shock when it occurs. It is important to make a plan with the patient and the doctor or nurse so that you know what to do if a shock occurs. Having an action plan will reduce confusion and anxiety for the patient and for you. There is certain information that you should have available at all times: (1) the ICD identification card; (2) a list of medications; and (3) the doctor’s name and phone number.

A sample device action plan is shown below. You should discuss the specific action plan that is best for the patient with their doctor or nurse:

Event Symptoms ActionReceived ICD shock Feeling fine Call heart doctor to discuss

the event and arrange appropriate follow-up

Received ICD shock Experiencing chest pain or pressure, shortness of breath, rapid heart action; feel dizzy, confused, or not well

Seek medical attention immediately

Received two or more ICD shocks within 24 hours

Feeling fine or ill Seek medical attention immediately

Source: Sears SF Jr, Shea JB, Conti JB. Circulation. 2005;111(23):e380-e382.

If the patient receives a shock, comfort them as best you can and stay with them. Help them remain calm and not move around until the shock experience is over. You will not be harmed by the shock if you touch the patient. If the patient passes out, call an ambulance immediately. Even if the patient feels fine after a shock, it is important to call the doctor for further instructions.

Helping with Diet and Exercise/Physical ActivityA proper diet and regular exercise can help someone with heart failure feel better and stay out of the hospital. As a caregiver, you can first help by offering positive encouragement. You can also prepare meals that are low in sodium (salt) and fat, as directed by the doctor or nurse. Read food labels carefully and note the serving size and the amount of sodium, fat, and cholesterol in each serving. An example of a food label is shown here:

Source: National Heart, Lung, and Blood Institute Therapeutic Lifestyle Diet.

Food labels often contain goals of 2,400 grams of sodium per day, but for patients with heart failure this is too high. A low-sodium diet has less than 2,000 mg of sodium (salt) per day and can help prevent or reduce shortness of breath and swelling in the feet and ankles. Since most sodium (salt) is in non-fresh foods, it helps to stay away from foods that are canned, frozen, boxed, or packaged in a bag. Also, do not add salt during cooking, food preparation, or at the table. High levels of sodium are found in salad dressings, cheese, lunchmeats, and other commonly consumed “processed” foods, even when they do not taste salty. That is why it is important to read food labels for sodium content. Be careful when eating at restaurants. Many restaurants will provide you with nutritional information if you ask for it. If you tell them not to add salt when cooking or to give you your salad dressing or sauce on the side, they will do this. Also pay attention to foods that contain a large amount of water, such as head lettuce or watermelon.

Patients with heart failure should remain as physically active as possible, and you can help the patient with whatever activities the doctor or nurse recommends. A healthy way to incorporate exercise into your own routine is to join them in their exercise activities. Participating with them will help to keep both of you motivated to stay active. Walking is the best exercise for patients with heart failure. They should start with 5 minutes of continuous walking and gradually increase to a goal of 45 minutes per day. Remember to warm up and cool down properly by stretching slowly and walking at a slow to moderate pace for about 5 minutes both before and after completing an exercise session.

Driving a CarFollow the doctor or nurse’s instructions about whether or not the patient is able to drive. Rules vary from state to state for persons with an ICD.

Living Arrangements

Talk to the patient and the doctor about the living arrangement that would be best. While some patients with heart-related health issues live and work independently without assistance, some need daily nursing care at home and others need to live in an environment where care is available all day long. There are a lot of issues to take into account when making this decision. Take your time and talk about what would be practical and best for the patient’s health.

Emotional and Social SupportIt is important to discuss the patient’s health in an open and honest way that allows emotions to be expressed. Health issues may cause frustration for the patient, but talking about how they are feeling may help relieve stress. Having the support of family and friends can also make a patient feel better and more positive. You can help the patient socialize with the people they care about, even if illness may make this difficult. Having an active social life can help get a patient’s mind off of health concerns and focus on something more enjoyable.

Communicating with Doctors and NursesGood communication between the patient and their doctor or other health professionals can help them get the best care possible. Write down questions before the next doctor visit. This will help the patient remember to ask about their concerns and get their questions answered. Taking notes about the answers is helpful too. Get in the habit of bringing all medications, both prescribed and over-the-counter substances such as vitamins, herbs, or supplements, to every office visit. Make sure to keep an up-to-date list of all medications, and to keep them refilled. At the office visit, you can also help by listening carefully with the patient to what the doctor says and taking notes.

Advance DirectivesIt is difficult to talk about death and dying with someone close to you, but it is something you may need to do. You can help the patient make plans about where to go and whom to call in an emergency. They may also want to talk about legal issues like making a living will or a healthcare durable power of attorney. Many patients will be relieved that someone close to them is willing to talk honestly about death.

Financial ConcernsGood healthcare can be expensive, but there are ways to make this burden easier. Talk to a social worker at the hospital about government assistance programs. Also, some drug companies offer medicine at a lower cost for those who qualify based on income. Talk to your doctor, nurse, or social worker about these programs.

Taking Care of YourselfAs the caregiver, you must look out for your own health as well. Take advantage of any help offered by friends and family. It is not unusual to feel overwhelmed, anxious, or depressed when taking on responsibilities for another person. Make sure you have someone that you can talk to, obtain regular

physical activity, eat a balanced diet, and get adequate rest. Your health is important too. If you have any questions or concerns, you should ask for help from people around you, including the healthcare professionals in your area. Taking care of someone can be very difficult, but with resources and support from your community, you can still have a healthy and happy life.

Additional ResourcesThere are several resources available to help you in your role as a caregiver. These organizations have more information about heart problems: American Association of Heart Failure Nurses (www.aahfn.org) American Heart Association (www.americanheart.org; 1(800) 242-8721) Heart Failure Society of America (www.hfsa.org; 1 (651) 642-1633) Heart Rhythm Society (www.hrsonline.org; 1 (202) 464-3400)





UC200705503 EN

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