Nursing Annotated Bibliography for Chronic Heart Failure Management

This annotated bibliography provides evidence-based recommendations for the management of chronic heart failure. The bibliography includes studies on nurse-led heart failure clinics, exercise-based rehabilitation, and diuretics for heart failure. The recommendations include achieving symptom improvement, promoting self-care behavior, and focusing on exercise-based cardiac rehabilitation.

Running head: NURSING ANNOTATED BIBLIOGRAPHY
Nursing annotated bibliography
Name of the student:
Name of the University:
Author’s note

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Part 1: Annotated bibliography
Strömberg, A., Mårtensson, J., Fridlund, B., Levin, L. Å., Karlsson, J. E., & Dahlström, U.
(2003). Nurse-led heart failure clinics improve survival and self-care behaviour in
patients with heart failure: results from a prospective, randomised trial. European heart
journal, 24(11), 1014-1023, Doi: https://doi.org/10.1016/S0195-668X(03)00112-X
A prospective randomized trial was done with hospitalized patient with heart failure to
investigate about the impact of nurse-led heart failure clinic on mortality, morbidity and self-care
behavior of participant. The research was conducted in one university hospital and two county
hospitals in Sweden. It includes one intervention group and one control group and the criteria for
blinding was fulfilled by computer generated list of random numbers and sealed envelopes. The
intervention group at the nurse-led clinic was followed-up by experience cardiac nurse after 2-3
weeks and the activities done by nurses included status evaluation, education on heart failure and
social support to patient. The control group received current clinical practice and follow-up in
primary health care clinic. The data related to demographics and clinical details were collected
from medical chart of patient and data on self-care was collected by means of a questionnaire
tool. The primary outcome variable was all-cause mortality and hospital admission after one year
and secondary variable includes self-care behavior, number of readmissions and number of days
in hospital. The results of the study showed that intervention group had fewer deaths, fewer
admission rates and higher self-score behavior. It was concluded that nurse-led follow after
hospital can improve survival rate and self-care behavior of patients with heart failure.

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Sagar, V. A., Davies, E. J., Briscoe, S., Coats, A. J., Dalal, H. M., Lough, F., ... & Taylor, R. S.
(2015). Exercise-based rehabilitation for heart failure: systematic review and meta-
analysis. Open heart, 2(1), e000163, http://dx.doi.org/10.1136/openhrt-2014-000163
A systematic review and meta-analysis of randomized controlled trial was done to
evaluate the impact of exercise-based cardiac rehabilitation for heart failure. The data sources for
the systematic review included databases like MEDLINE, EMBASE, CINAHL and PsycINFO
and the sample population for the studies needed to include heart failure with preserve ejection
fraction (HFPEF) or heart failure with reduced ejection fraction (HFREF) patient. Another
criteria for study selection was that all participant must have reported about at least 6 months
follow-up and they must all have received exercise training apart from other intervention. The
outcome measure for studies were also considered and the criteria was to have outcome data
related to mortality, hospital admission, health related quality of life and cost and cost-
effectiveness. A total of 33 trials was found to fulfill the research criteria and the systematic
review of these literatures indicated that exercise intervention reduced the risk of heart failure
and overall hospitalization rate. The data were independent of trial duration and dose of exercise.
Overall, the study concluded that exercise based cardiac rehabilitation can lead to improvement
in hospitalization and quality of life in patients with cardiac failure.
Faris, R., Flather, M. D., Purcell, H., Poole-Wilson, P. A., & Coats, A. J. (2006). Diuretics for
heart failure. Cochrane Database Syst Rev, 1. Doi: 10.1002/14651858.CD003838.pub2
A systematic review of randomized controlled trial was done to evaluate the harm and
benefits for chronic heart failure in patients with chronic heart failure. The main rational for this
aim was to evaluate how diuretics can control disease progression and improve survival rate in

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patient. Relevant research articles were taken from EMBASE databases and the main research
design was meta-analysis of randomized controlled studies. The criteria for study participants in
the selected studies included patient with chronic heart failure and those with symptoms of
breathlessness and fatigue. The intervention for all studies should involve all type of diuretic
drugs. The primary outcome measures include mortality and morbidity and the secondary
measures included effect of diuretic on symptoms, quality of life and worsening of heart failure.
From the review of research studies on the basis of above mentioned criteria, a total of 28 studies
were found relevant to the study objective. Different studies covered different range of outcome
measures. Overall, the review of findings from different studies showed that diuretic is the
conventional treatment for patient with chronic heart failure and it is effective in reducing the
risk of death in patient with heart failure. In comparison to control group, intervention group also
had improved exercise capacity.
Part 2: Justification for the choice of references
The above three evidence has been selected in response to the case scenario of Charlie, a
75 year old overweight who has been diagnosed with chronic heart failure and find out the best
evidence to manage Charlie’s condition. The main symptoms observed in Charlie were
breathlessness, visible peripheral edema and tachycardia. The evidence by Strömberg et al.
(2003) was found suitable for the management of Charlie’s condition because it proved the
effectiveness of follow-up at nurse-led heart failure clinic. This evidence has been chosen
because the study considered challenges in the management of heart failure patent and showed
that poor-follow and low patient education about self-care behavior also leads to poor patient
outcome. Focusing on self-care behavior and follow-up care is necessary because many times
poor awareness about self-care behavior also result in non-compliance to medication and

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increase in hospital readmissions rate. The study by Ruppar et al. (2016) proved poor adherence
to medication results in exacerbation of heart failure symptoms, poor physical function and high
risk of admission in patients with heart failure.
Strömberg et al. (2003) showed that nurse-led heart failure can address management
problem like poor compliance to medication and this is evident from the study outcome. The
study showed that implementation of intervention related to education about heart failure to
patient, psychosocial support and appropriate follow-up with heart failure patient significantly
improved self-care score for patient and reduced the admission rates and length of hospital stay.
The research evidence is also selected for Charlie’s because of the quality and credibility of the
work. The researcher adopted randomized controlled trial method and considered the
requirement for blinding. This eliminated selection biases in studies. The credibility and
generalisability of the work was also enhanced by conducting research in three different setting.
The study gave the clinical implication that improving the process needed for follow-up is
necessary for management of heart failure patient as it is a cost-effective approach to diagnosis
and treatment of the condition. Unverzagt et al. (2016) also confirmed that regular follow-up
visits and self-care programs improves adherence to medication in heart failure patient.
The study by Sagar et al. (2015) has been selected for the management of Charlie’s
condition because the study explained about the effectiveness of exercise-based cardiac
rehabilitation (CR) for reducing overall risk of complication and heart failure specific
hospitalization. As Charlie is an obese patient, he is at higher risk of exacerbation of symptom
related to heart failure (Parto, Lavie and Ventura 2016). The evidence by Sagar et al. (2015) has
been considered because of the positive benefits of exercise-based rehabilitation on health related
quality of life, mortality and hospital admissions rate in patient (Taylor et al., 2014). The study

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proved that exercise CR improves health related quality of life and improves hospitalization rate
in patient with heart failure. The research was done by means of systematic review and meta-
analysis method, however the factor that improves the quality of the evidence is that it includes
only randomized controlled trial (RCT) for analysis. As RCTs come under top level under the
hierarchy of evidence, the results from the study is reliable. This study guides current
practitioners to adapt exercise CR for management of heart failure patient as it gives consistent
results irrespective of the type of CR programme. Haykowsky et al. (2016) also supported the
fact that exercise-based CR improves muscles strength, physical function and quality of life of
patient with heart failure.
The third evidence by Faris et al. (2006) emphasized on the use of diuretic for heart
failure patient. This evidence has been selected for management of Charlie’s condition because
he was suffering from the symptom of breathlessness and diuretic drugs like furosemide are the
first line of treatment for congestive heart failure and relieving symptoms of peripheral oedema
in patient. The study used systematic review method to analyze the effectiveness of diuretic
therapy on improving morbidity and mortality in patient. The quality of the study is high as it
included only double-blinded randomized controlled trial for review and by this means, it
eliminated all biases and confounding factors that influences study outcome. By the review of
relevant research, the researcher proved that diuretic reduces the risk of death in patient. By such
finding, it gave the clinical implication that new diuretic drugs should be considered for
management of patient with heart failure. Buckley et al. (2016) also explained that short course
of IV diuretics is a safe and effective intervention for patient with heart failure.

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Part 3: Recommendations for clinical practice:
Based on the review of research evidence, it can be recommended that important criteria
for management of patient with heart failure is to first achieve symptom improvement in patient
and then focus on promoting self-care behavior and physical movement in patients like Charlie.
This strategy has been proposed because the three interventions focus both on short and long
trem health outcome of patient. As heart failure patients like Charlie experience symptom of
breathlessness, pharmacological therapy by means of diuretic therapy is effective in reducing
pulmonary congestion in patient (Johnson & Oxberry, 2010). Secondly, finding provisions for
adequate follow-up and improving patient-care behavior is also necessary because self-care is
associated with increase in self-confidence of patient to manage risk. It is recommended that to
improve the quality of life of patients with heart failure, clinicians or nurses should educate
patient about self-care behaviors like following diet regiment, having low-salt diet, being
physically active, controlling weight and controlling symptoms of heart failure
(Abotalebidariasari et al., 2016). In addition, clinicians should focus on exercise-based cardiac
rehabilitation as regular exercise is associated with improved quality of life in patients with heart
failure (Rajati et al., 2013).

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References:
Abotalebidariasari, G., Memarian, R., Vanaki, Z., Kazemnejad, A., & Naderi, N. (2016). Self-
Care Motivation Among Patients With Heart Failure: A Qualitative Study Based on
Orem's Theory. Research and theory for nursing practice, 30(4), 320-332,
doi: 10.5681/jcs.2012.029
Buckley, L. F., Carter, D. M., Matta, L., Cheng, J. W., Stevens, C., Belenkiy, R. M., ... &
Stevenson, L. W. (2016). Intravenous diuretic therapy for the management of heart
failure and volume overload in a multidisciplinary outpatient unit. JACC: Heart
Failure, 4(1), 1-8, Doi: https://doi.org/10.1016/j.jchf.2015.06.017
Faris, R., Flather, M. D., Purcell, H., Poole-Wilson, P. A., & Coats, A. J. (2006). Diuretics for
heart failure. Cochrane Database Syst Rev, 1. Doi: 10.1002/14651858.CD003838.pub2
Haykowsky, M.J., Daniel, K.M., Bhella, P.S., Sarma, S. and Kitzman, D.W., 2016. Heart failure:
exercise-based cardiac rehabilitation: who, when, and how intense?. Canadian Journal of
Cardiology, 32(10), pp.S382-S387, doi: 10.1016/j.cjca.2016.06.001
Johnson, M. J., & Oxberry, S. G. (2010). The management of dyspnoea in chronic heart
failure. Current opinion in supportive and palliative care, 4(2), 63-68, doi:
10.1097/SPC.0b013e32833929aa.
Parto, P., Lavie, C.J. and Ventura, H.O., 2016. Reducing Heart Failure Risks in Obese
Patients. Current Cardiovascular Risk Reports, 10(4), p.15, Retrieved from:
https://link.springer.com/article/10.1007/s12170-016-0498-1

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Rajati, F., Mostafavi, F., Sharifirad, G., Sadeghi, M., Tavakol, K., Feizi, A., & Pashaei, T.
(2013). A theory-based exercise intervention in patients with heart failure: A protocol for
randomized, controlled trial. Journal of research in medical sciences: the official journal
of Isfahan University of Medical Sciences, 18(8), 659, Retrieved from:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3872604/
Ruppar, T. M., Cooper, P. S., Mehr, D. R., Delgado, J. M., & Dunbar‐Jacob, J. M. (2016).
Medication adherence interventions improve heart failure mortality and readmission
rates: systematic review and meta‐analysis of controlled trials. Journal of the American
Heart Association, 5(6), e002606, Doi: 10.1161/JAHA.115.002606
Sagar, V. A., Davies, E. J., Briscoe, S., Coats, A. J., Dalal, H. M., Lough, F., ... & Taylor, R. S.
(2015). Exercise-based rehabilitation for heart failure: systematic review and meta-
analysis. Open heart, 2(1), e000163, http://dx.doi.org/10.1136/openhrt-2014-
000163
Strömberg, A., Mårtensson, J., Fridlund, B., Levin, L. Å., Karlsson, J. E., & Dahlström, U.
(2003). Nurse-led heart failure clinics improve survival and self-care behaviour in
patients with heart failure: results from a prospective, randomised trial. European heart
journal, 24(11), 1014-1023, Doi: https://doi.org/10.1016/S0195-668X(03)00112-X
Taylor, R. S., Sagar, V. A., Davies, E. J., Briscoe, S., Coats, A. J., Dalal, H., ... & Singh, S.
(2014). Exercise‐based rehabilitation for heart failure. The Cochrane Library, doi:
10.1002/14651858.CD003331.pub4.
Unverzagt, S., Meyer, G., Mittmann, S., Samos, F.A., Unverzagt, M. and Prondzinsky, R., 2016.
Improving treatment adherence in heart failure: A systematic review and meta-analysis of

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pharmacological and lifestyle interventions. Deutsches Ärzteblatt International, 113(25),
p.423, doi: 10.3238/arztebl.2016.0423