Conference: 2015 PH Professional Network Symposium
Release Date: 09.17.2015
Presentation Type: Abstracts
The purpose of the study was simply to assess the frequency of counseling to reduce sodium and fluid intake and whether specific targets were provided to pulmonary arterial hypertension (PAH) seen in the pulmonary hypertension (PH) center at Mayo Clinic Florida.
Patients with pulmonary arterial hypertension (PAH) often are afflicted with the consequences of right heart failure including volume overload. Clinical signs and symptoms include worsening dyspnea and peripheral edema. Clinicians often prescribe diuretics to control the fluid retention; however, counseling and education to assist the patient to also restrict the daily intake of sodium and fluid may be underutilized.
The combination of diuretic administration along with fluid and sodium restriction has been shown to reduce hospital admissions in recently compensated left-heart failure (Paterna). Education seems to reinforce the importance of home practice and improve compliance (van der Wal). Little is published regarding the same approach with right-heart failure due to PAH; however, the same benefit of diuretic therapy with sodium and fluid restriction likely exists (Handoko). In addition, such an approach is recommended in published guidelines for management of PAH (1,6).
The study was approved by the Institutional Review Board. Adult patients with PH evaluated in the PH center at Mayo Clinic in Jacksonville Florida (MCF) were eligible. As part of the routine clinical assessment, the patients completed a brief questionnaire to determine if they had received counseling to restrict sodium and fluid from any prior healthcare providers. Consecutive patients from June through November 2013 were then reviewed to confirm and collect the questionnaire responses as well as the following information: World Health Organization (WHO) diagnostic group, functional class, physical examination evidence of fluid retention, brain natriuretic peptide (BNP) in picograms per milliliter (pg/mL), six-minute walk distance (6MWD) in meters (m), and echocardiogram results. Patients were classified according to predetermined groups: group A if the patient had received counseling prior to the current visit to restrict sodium and/or fluid and group B if not.
Subgroups were defined for both group A and B. Group A subgroups were as follows: subgroup A1 if the patient had been previously directed to restrict both sodium and fluid, A2 if the patient had been counseled to restrict only fluid or sodium but not both and then received instruction for both during the current PH Center visit (educational intervention provided) and A3 if the patient had been counseled to restrict only fluid or sodium but not both then did not receive instruction for both during the current PH Center visit (missed educational intervention opportunity). Group B subgroups were as follows: B1 if the patient had not received counseling prior to the current visit to restrict sodium and/or fluid and then received instruction for both during the current PH Center visit (educational intervention provided); B2 if the patient had not been counseled to restrict only fluid and/or sodium and then did not receive instruction for both during the current PH Center visit (missed educational intervention opportunity).
In summary (see table 1), subgroup A1 had previously received appropriate counseling for sodium and fluid restriction; therefore, did not require further education. Subgroups A2 and B1 were patients requiring additional education and it was provided in PH Center visit; however, subgroups A3 and B2 who also required supplemental counseling did not receive it during the PH Center visit and represent an opportunity lost. Descriptive comparisons of the subgroups are provided.
Questionnaires and associated medical records were reviewed in 103 consecutive patients. Three patients had PH excluded as a diagnosis; therefore, were not included in the analysis. Table 2 provides demographic and pulmonary arterial hypertension information for entire cohort (n=100) as well as the subgroups. The entire cohort was mostly women with moderate to severe pulmonary arterial hypertension as assessed by BNP, 6MWD and echocardiogram. The type of PH as defined by WHO diagnostic group was as follows: group 1 pulmonary arterial hypertension (n=59); group 2 pulmonary venous hypertension (n=30); group 3 pulmonary hypertension in association with lung disease (n=5); and group 4 chronic thromboembolic PH (n=6). Nearly 3/4 (74%) were on diuretic therapy.
As outlined in Table 1 and Figure 1, approximately 1/3 had received complete education and counseling with specific amounts of sodium and fluid restriction (subgroup A1). About ½ of the patients (n=47) had received some counseling to restrict either fluid or sodium but no specific goals (subgroups A2 and A3). One-fifth (n=21) had not received any instruction to restrict either fluid or sodium (subgroups B1 and B2).
Of the patients who had only received partial instruction (subgroups A2 and A3) or no instruction (subgroups B1 and B2), 44% (subgroup A2 and B1) received needed education during the PH Center visit and 7% (subgroups A3 and B2) did not.
Sodium and fluid restriction is an important but perhaps underutilized strategy to manage volume overload in patients with congestive heart failure. While challenging for the patient, instructions can be provided by the clinician in a brief period of time particularly if educational materials are used to supplement the education. This process typically occurs in less than 5 minutes in the PH Center at MCF. Nonetheless, clinical experience seemed to indicate that patients did not have prior counseling or had incomplete instructions. This study sought to quantify the frequency of missed opportunity to educate the patients in their prior medical evaluations and also in a current visit to the PH Center. To our knowledge, no prior study has specifically addressed sodium and fluid restriction education in patients with PH. Nonetheless, published guidelines recommend strategies to control volume overload as important general measures in PAH management (1,3,6).
Indeed, only 32% had received complete education in sodium and fluid restriction and 21% of patients had not even had such restriction mentioned to them prior to the PH Clinic visit. Most of the patients (68%) represented an opportunity for improvement in this regard and the majority received such instruction, unfortunately 7% did not (subgroups A3 and B2). Whether the questionnaire on prior sodium and fluid restriction promoted the additional discussion and education that was provided during the PH Clinic visit is unknown but likely.
The patients as a group were not at optimal goals of therapy as recommended by the WHO (McLaughlin JACC 2013, 9) such as functional class II, BNP<180pg/mL, and 6MWD>380m; therefore, additional therapy including dietary restriction of sodium and fluid was warranted. In addition, BNP is a surrogate marker of volume overload and right ventricular failure that correlates with survival in PAH (Nagaya) and can be lowered with sodium and fluid restriction with diuretic therapy. Interestingly, subgroup A3 seemed to be more at goal by BNP and 6MWD than the other subgroups, although the number of patients was small. Perhaps, this partially explains why additional instructions on sodium and fluid restriction were not provided during the PH Clinic visit but this is speculative. Overall, most patients were on diuretic therapy. Data was not collected on the questionnaire as to whether diuretic therapy was added at the PH Clinic visit but the patients not on therapy may represent an additional opportunity for improved treatment.
In summary, guidelines often recommend sodium and fluid restriction as a complimentary strategy to manage right and left heart failure. The percentage with complete education in this regard was only 32% of the consecutive patient cohort seen in the PH Clinic at Mayo Clinic Florida. Our questionnaire approach identified the remainder as an opportunity of improvement and perhaps promoted additional instruction.