Heart failure self-management

Author:: Larry Alexander Allen, MD, MHS, FACC, FAHA, FHFSA
Section Editor:: Barry A Borlaug, MD
Deputy Editor:: Todd F Dardas, MD, MS

Literature review current through: Apr 2025. | This topic last updated: May 09, 2025.

INTRODUCTION —

Heart failure (HF) is one of the most common causes of reduced health status, hospitalization, and death. Due to the chronic nature of HF and the complexity of care (eg, medication management, changes in symptoms), patient self-management may contribute to improved health outcomes [1,2]. However, many patients lack self-care skills [3,4]. This topic will review the role of self-management in patients with HF.

The medical management of HF and the treatment of acute decompensation are discussed separately. (See "Treatment of acute decompensated heart failure: General considerations".)

Systems-based strategies for avoiding hospitalization are discussed separately. (See "Systems-based strategies to reduce hospitalizations in patients with heart failure".)

OBSERVED RATES OF SELF-CARE —

In general, self-care among patients with HF is low. As examples:

●Medication adherence – The most reliable studies of HF medication adherence used prescription refill data and show that patients have an adequate supply of a given medication at home 60 to 88 percent of the time [5-8]. However, measurement of adherence rates is highly variable due to differences in definitions of adherence and difficulty with objectively capturing adherence data [9].

●Sodium restriction – One study estimated that the rate of adherence to a diet with less than 2 g of sodium per day was less than 25 percent [10].

●Daily weights – Published adherence to daily weight measurement in randomized trials ranges from 20 to 80 percent [11] and may be lower in usual care [12].

●Symptom monitoring – In a study of 202 patients with HF who were recently discharged from the hospital, only 9 percent reported formally monitoring themselves for symptom changes [12].

●Exercise – Published estimates of patients who engage in no physical activity range from 9 to 53 percent [11]. Even in randomized trials, such as HF-ACTION, adherence was difficult to maintain over time. In that trial, the intervention group engaged in a median of 50 minutes per week of exercise in the third year despite a goal of 120 minutes per week [13].

SELECT BARRIERS TO SELF-CARE

Low health literacy — Multiple studies have shown that many patients with HF are unable to describe their medication regimen, do not recognize symptoms of worsening HF, do not know how much sodium they should be ingesting, and have a variety of misconceptions about HF etiology, prognosis, and management [14]. These knowledge deficits impair patients' ability to engage in effective self-care. For instance, while 71 percent of low-literacy patients in one study could read "Take two tablets by mouth twice daily," only 35 percent could correctly describe how many pills to take each day [15].

The effect of health literacy in patients with HF is relatively well-documented. In a population-based study of 2487 patients with HF who completed a health literacy survey, 10.1 percent had low health literacy [16]. After a mean of 15.5 months of follow-up, there were 250 deaths and 1584 hospitalizations. Low health literacy was associated with higher rates of mortality (adjusted hazard ratio [HR] 1.91, 95% CI 1.38-2.65) and hospitalization (adjusted HR 1.30, 95% CI 1.02-1.66) compared with patients who had adequate health literacy. Other observational studies found similar associations [17-20].

Multimorbidity and polypharmacy — The average patient with HF has more than four chronic conditions [21]. The presence of one condition may complicate the treatment of other conditions. For example, antithrombotic therapies for coronary artery disease may exacerbate gastrointestinal bleeding or HF. Patients with multiple chronic illnesses face additional physical, cognitive, and functional challenges to effective self-care. Approximately one-quarter to one-half of patients with HF have cognitive impairment, and geriatric conditions are common [22]. Patients with cognitive impairment [23-25], in particular, may have difficulty conducting self-care activities [26].

In parallel, polypharmacy is increasingly common. The average patient with HF takes more than 10 medications (ie, hyperpolypharmacy) [27]. The increasing challenges of multimorbidity in patients with cardiovascular disease have been well described [28]. Specifically, guideline stacking—when recommendations from each disease are put together—promotes care plans that are impractical for individual patients and clinicians to manage.

Depression and anxiety — Depression and anxiety are highly prevalent among HF patients [29,30]. These comorbidities impair self-care through a variety of means that include effects on cognition, function, social support, motivation, and engagement [31]. Patients with depression and HF have higher rates of medication nonadherence [32], hospitalization, and mortality [33]. Brief screens for depression in the outpatient setting have been validated and can be readily used in the clinic [34]. The role of other interventions is unclear. For example, cognitive behavior therapy in patients with HF reduced the severity of depression but did not improve measures of self-care [35].

Health care team and system factors — A host of system-related factors make self-care education challenging. Clinicians, especially in the outpatient setting, are often ill-equipped to provide self-care education, monitoring, and reinforcement. Ancillary resources, such as nurse educators, pharmacists, informational materials, or registries to identify at-risk patients, may not be available. Commercial payers and Medicare provide limited reimbursement for counseling, follow-up, and monitoring in the fee-for-service setting. Self-care education makes up a tiny fraction of recommended quality metrics. Finally, patients and their clinicians must coordinate with a range of other clinicians.

Social support — Lack of social support and other social determinants of health are strongly correlated with adverse outcomes in patients with HF [36]. Social support may improve self-care behaviors, including medication adherence [37]. Families, peers, and supportive relationships all impact the patient's engagement in self-care. (See "Office-based assessment of the older adult", section on 'Social and environmental assessment'.)

SELF-MANAGEMENT DOMAINS AND APPROACHES

Self-guided medication adjustment — In patients who can reliably adjust their loop diuretics according to changes in body weight (or other measurements), one option for management is to establish criteria for medication changes (eg, a diuretic sliding scale). Some patients are better at safely executing such plans than others. Additionally, when a patient goes from a period of relative stability to a significantly different dose on the sliding scale, this raises concern for important clinical changes that should be investigated. Thus, we prefer that patients call to notify the clinician that they are making significant changes, often prompting more detailed history taking, which may dictate in-person physical examination, vitals, and laboratory testing.

One common approach to self-guided management is with use of a visual tool for tracking weights and edema with thresholds for when to call for help with management or adjust the diuretic dose along with corresponding potassium supplement changes (figure 1 and figure 2 and figure 3). More detailed "HF action plans" are typically divided into green, yellow, orange, and red zones corresponding to a stable state, worsening status, acute exacerbation, and cardiac emergency. The action plan includes an individualized response plan for each state that is developed by the clinician and patient.

Sodium restriction — For stable ambulatory patients with HF, we suggest patients adhere to a moderate restriction of sodium intake (ie, less than 3 g per day) rather than consume an unrestricted amount of sodium or restrict sodium to lower quantities (eg, <2 g per day). In patients in whom the clinician suspects that sodium intake contributes to or causes HF exacerbations, a restriction of sodium intake to less than 2 g per day may be reasonable, but, in our experience, patients are unlikely to adhere to restriction of sodium to less than 2 g per day.

When initiating a sodium restriction, we review the patient's understanding of or educate the patient on the following:

●Relationship between sodium intake, fluid intake, and edema

●Knowledge that sodium and "salt" are the same

●Ability to read a nutrition label

●Ability to calculate total sodium intake in a day

●Recognition of "hidden" sources of salt intake (eg, sauces/seasonings, canned goods, processed meats, dining out)

To achieve the desired sodium restriction most patients will need to engage in actions that include:

●Selection of low-salt foods and avoidance of high-salt foods

●Ordering reduced-salt meals at restaurants

●Reduce the quantity of added salt during home cooking

North American guidelines describe sodium restriction as reasonable for patients with American Heart Association/American College of Cardiology stage C HF but do not suggest a specific sodium restriction [38]. The European Society of Cardiology HF guidelines suggest avoiding excessive sodium intake (>5 g per day) [39].

Trials of sodium restriction provide conflicting evidence on its efficacy:

●In the SODIUM-HF trial, 806 patients with HF randomly assigned to a low-sodium diet (less than 1.5 g/day) or to usual care had similar rates of all-cause death (6 versus 4 percent in the usual care group; hazard ratio [HR] 1.38, 95% CI 0.73-2.60), cardiovascular-related hospitalization (10 versus 12 percent; HR 0.82, 95% CI 0.54-1.24), and cardiovascular-related emergency department visits (5 versus 4 percent) [40]. Compared with the usual care group, the low sodium group had similar weight and caloric consumption, which suggests that sodium restriction did not cause deterioration in nutritional status. These results were likely affected by low adherence to the recommended sodium intake goal in the intervention group and a relatively low sodium intake in the usual care group; the difference in sodium consumption between the two groups was only 0.42 g/day.

●In another trial of 53 patients who were hospitalized with HF and who were randomized to a sodium (0.8 g/day) and fluid (800 mL/day) restriction or to an unrestricted diet, weight loss was similar in both groups (1.6±2.2 kg versus 1.8±2.1 kg in the unrestricted diet group) as was the reduction in congestion scores (3.4±3.5 versus 3.8±3.4 points) [41]. However, the group assigned to the 0.8 g/day sodium-restricted diet had lower caloric consumption, which suggests possible malnutrition.

●Another trial that included 232 patients with New York Heart Association (NYHA) class II to IV HF who were taking high-dose oral furosemide and spironolactone and less than 1 L of fluid per day found that patients randomly assigned to a sodium restriction of 2 g/day had a higher risk of readmission than patients assigned to a sodium restriction of 3 g/day [42].

●Systemic reviews have not come to any conclusion due to high risk of bias and differential reporting of primary outcomes [43]; two other systematic reviews were retracted [44,45].

Fluid restriction — Patients with stable HF do not require a specific fluid restriction. However, in patients in whom fluid intake is associated with HF exacerbation or significant hyponatremia, it is reasonable to provide an individualized fluid restriction that is achievable by the patient.

The approach to patients with HF and severe hyponatremia (serum sodium <120 mEq/L, symptoms attributable to hyponatremia) is discussed separately. (See "Hyponatremia in patients with heart failure", section on 'Fluid restriction'.)

This approach is similar to North American and European HF guidelines [38,39].

The data on the efficacy of fluid restriction are conflicting, and there is no single fluid restriction known to be effective across broad groups of stable patients:

●In a trial that included 504 patients with NYHA class II or III HF who were assigned to liberal fluid intake (ie, no maximum per day) or restricted fluid intake (ie, <1500 mL per day), there were similar rates of death (0.4 versus 0.8 percent), all-cause hospitalization (1.6 percent in both groups), and intravenous loop diuretic use (2 versus 2.8 percent) at three months [46]. Notably, patients in both groups reported fluid intake of less than two liters per day (1764 and 1480 mL in the fluid restriction group), which may have biased the trial toward a null result.

●A review of four randomized controlled trials involving 678 patients found that fluid restriction of 1.5 to 2 L per day reduced the rate of hospitalizations (risk ratio [RR] 0.58, 95% CI 0.47-0.70) but did not reduce the rate of mortality [47]. Given the large effect size, the efficacy of fluid restriction may be overestimated.

●A registry study reported that fluid restriction of hospitalized patients is the most common intervention, but has little effect on markers of hypervolemia such as hyponatremia [48].

Daily weights and vital signs — Patients should record their weight and vital signs to help guide treatment, with the frequency adjusted to the patient's clinical stability and changes in symptoms.

●Daily weights – Patients at increased risk of HF exacerbation or those in whom the response to diuretics is under evaluation may benefit more from daily weight measurement compared with other groups of patients (eg, stable patients). Since weight is affected by many factors (eg, time of measurement, varying weight of clothing, inconsistencies of scales), clinicians who plan to act on changes in weight should confirm that such changes represent true changes in weight and are not the result of confounding factors.

Weight information is a relatively simple measure for the patient to obtain and report that may help to identify early decompensation and guide diuretic dosing. However, there are no high-quality trials that suggest a benefit of daily weight measurement, which includes trials of remote monitoring. (See 'Remote monitoring' below.)

●Daily vital signs – Measuring daily vital signs can help facilitate management of patients with HF including changes to medications (eg, dose adjustments in vasodilators) and may help explain symptoms (eg, presyncope) [49]. However, there are no high-quality trials that suggest a benefit of daily vital sign monitoring.

Medication adherence — Actions that clinicians and patients can take to increase adherence include:

●Prescribing 90 days of prescription medications

●Prescribing agents with once-daily dosing [9]

●Prescribing medications with the lowest cost to the patient [9,50-53]

●Use of a pill box or personalized blister packs

●Deprescribing and limiting polypharmacy, as appropriate [28]

●Screening for medications with the potential for harm in older patients (eg, Beers criteria) [54]

Daily adherence to the prescribed HF regimen must be as high as possible to maximize the benefit of HF medications. For example, one observational study found that 88 percent adherence or better was necessary for improved event-free survival [55].

There are some data to suggest that increasing adherence generally leads to health benefits in patients with HF [4]. One meta-analysis of medication adherence interventions found a significant reduction in the rate of mortality among 48 trials (RR 0.89, 95% CI 0.81-0.99) and the rate of hospitalizations in 32 trials (RR 0.89, 95% CI 0.81-0.97) [56]. However, the interventions in the component trials were too diverse to suggest an actionable strategy, the absolute effects were not reported, and the results varied significantly among trials.

Exercise — Symptom-limited exercise is generally safe in patients with HF. Exercise in patients with HF is discussed in detail separately. (See "Cardiac rehabilitation in patients with heart failure".)

Smoking cessation and alcohol use — We advise all patients to quit smoking. Current smoking is an independent predictor of mortality in patients with HF [57]. The approach to managing smoking cessation is discussed separately. (See "Overview of smoking cessation management in adults".)

In patients with HF not caused by alcohol use, we suggest no more than one standard drink (figure 4) of alcohol per day. Our approach is based on data that suggest that even small volumes of alcohol are associated with transient cardiac dysfunction (eg, systolic dysfunction, atrial fibrillation) in normal individuals, which is discussed separately. (See "Alcohol-induced cardiomyopathy", section on 'Pathogenesis' and "Epidemiology, risk factors, and prevention of atrial fibrillation", section on 'Alcohol'.)

In addition, studies of alcohol consumption in patients with HF describe conflicting effects (eg, harm, no effect, benefit) and likely contain substantial bias [58-61].

Education on self-care — Patient retention and understanding of factual content can be increased by using a few validated techniques for adult education [62]:

●Utilize teach-back techniques to ensure the patient understands the materials (that is, ask the patient to "teach" the educator the information he/she has just received).

●Ask specific questions to ensure the patient understands the materials; do not just say, "Do you understand?" or "Do you have any questions?"

●Limit teaching points to no more than three or four per session.

●Repeat, reinforce, and review teaching points at regular intervals.

Visual aids may also be of assistance to some patients [63,64]. (See 'Self-guided medication adjustment' above.)

Clinicians and educators can increase patient involvement in and engagement with their care in the following ways:

●Using motivational interviewing techniques [65-67]. (See "Overview of psychotherapies", section on 'Motivational interviewing'.)

●Questioning patients explicitly about their beliefs in disease etiology and efficacy of treatment.

●Questioning patients explicitly about their life goals and tying self-care regimens to the achievement of these goals.

●Engaging patients in developing a plan, and in filling out a notebook or monitoring materials.

●Using brainstorming with patients to help them incorporate self-management into their lives: build on patients' own experience and routines.

●Helping patients identify one concrete action they can do for each aspect of self-care (goal setting) [68].

●Having patients describe their self-management practices and offering feedback to improve them, rather than suggesting or imposing self-management practices.

Formal education on self-care has varying efficacy in patients with HF:

●A randomized trial of a telephone-based coping skills training program involving 180 patients with HF showed improvement in quality-of-life metrics but not hospitalization or death [69].

●The Quality HF-Diabetes randomized controlled trial was designed to improve self-care in patients with both HF and diabetes. This trial demonstrated improved overall quality of life [70] and fewer hospitalization days, and was cost-effective [71]. However, only 134 subjects were enrolled (70 in the intervention arm) out of 741 screened, raising concerns about the generalizability of the intervention to the broader population.

●In one trial, 123 patients who received self-care education appropriately targeted to their health literacy level had a lower rate of HF hospitalization (adjusted incidence rate ratio 0.53, 95% CI 0.32-0.89) [72]. However, this large effect was not replicated in larger trials.

OTHER SELF-CARE INTERVENTIONS

Mobile health — Mobile health (mHealth) applications (apps) are increasingly available to help patients with self-care and health behaviors. Those designed and tested for self-care have not clearly demonstrated superior efficacy to usual care [73-83]. Similar to medication management, symptom monitoring is an area that is seeing substantial growth in mHealth applications intended to support self-care, though again there is little-to-no high-quality evidence that these new technologies are effective [84].

Based on limited data and indirect comparisons to other methods, strategies based on mHealth technology are not clearly more effective than other strategies. A recent trial of text messages triggered by pharmacy fill data did not show significant benefit [85]. In a large meta-analysis of all types of medication adherence interventions (771 trials), interventions delivered via text message (28 trials) had similar effects as those that did not, while computer-based interventions (14 trials) had significantly smaller effect sizes [86]. In one review, interventions conducted face-to-face were the most effective, and, in the five of eight trials that studied patients with HF and in which adherence improved, the successful intervention was not device- or web-based [87].

Remote monitoring — The strategy of obtaining data provided by the patient to detect changes in health and respond in a manner that maintains or improves health is compelling. However, interventions that use this approach show conflicting and generally low efficacy. A National Institutes of Health-funded trial of telemonitoring in patients with HF found similar rates of readmission (49.3 versus 47.4 percent in the control group; difference 1.9 percent, 95% CI -3 to 6.7) and death (11.1 versus 11.4 percent) in the telemonitoring and control groups [88].

Remote monitoring with an implantable hemodynamic monitor is discussed separately. (See "Treatment and prognosis of heart failure with preserved ejection fraction", section on 'Device-based therapies'.)

SOCIETY GUIDELINE LINKS —

Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Heart failure in adults".)

INFORMATION FOR PATIENTS —

UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topics (see "Patient education: Heart failure (The Basics)" and "Patient education: Medicines for heart failure with reduced ejection fraction (The Basics)" and "Patient education: Coping with high drug prices (The Basics)")

●Beyond the Basics topic (see "Patient education: Heart failure (Beyond the Basics)" and "Patient education: Coping with high prescription drug prices in the United States (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

●Observed rates and barriers to self-care – In general, self-care among patients with heart failure (HF) is suboptimal, and barriers to self-care include low health literacy, multimorbidity, polypharmacy, depression, anxiety, complexity of the health care system, and lack of social support. (See 'Observed rates of self-care' above and 'Select barriers to self-care' above.)

●Self-management domains and approaches

•Self-guided medication adjustment – In patients who can reliably adjust their loop diuretics according to changes in body weight (or other measurements), one option for management is to establish individualized criteria for medication changes (eg, a diuretic sliding scale). (See 'Self-guided medication adjustment' above.)

•Sodium restriction – For stable ambulatory patients with HF, we suggest patients adhere to a moderate restriction of sodium intake (eg, less than 3 g per day) rather than consume an unrestricted amount of sodium or restrict sodium to lower quantities (eg, <2 g per day) (Grade 2C). In patients in whom the clinician suspects that sodium intake contributes to or causes HF exacerbations, a restriction of sodium intake to less than 2 g per day may be reasonable. In our experience, most patients cannot adhere to a sodium restriction of less than 2 g per day. (See 'Sodium restriction' above.)

•Fluid restriction – Patients with stable HF do not require a specific fluid restriction. In patients in whom fluid intake is associated with congestion or significant hyponatremia, it is reasonable to provide an individualized fluid restriction that is achievable by the patient. (See 'Fluid restriction' above.)

•Daily weights and vital signs – Patients should record their weight and vital signs to help guide treatment, with the frequency adjusted to the patient's clinical stability and changes in symptoms. (See 'Daily weights and vital signs' above.)

•Medication adherence – Actions that clinicians and patients can take to increase medication adherence include:

-Prescribing 90 days of prescription medications

-Prescribing agents with once-daily dosing

-Prescribing medications with the lowest cost to the patient

-Use of a pill box or personalized blister packs

-Deprescribing and limiting polypharmacy, as appropriate

-Screening for medications with the potential for harm in older patients (eg, Beers criteria)

•Exercise – Symptom-limited exercise is generally safe in patients with HF. Exercise is discussed in detail separately. (See "Cardiac rehabilitation in patients with heart failure".)

•Smoking cessation and alcohol use – We advise all patients to quit smoking. The approach to managing smoking cessation is discussed separately. (See "Overview of smoking cessation management in adults".)

We counsel patients with HF to limit alcohol consumption to ≤1 standard drink (figure 4) per day, ideally abstaining from alcohol. (See "Alcohol-induced cardiomyopathy" and "Cardiovascular benefits and risks of moderate alcohol consumption", section on 'Heart failure'.)

•Education on self-care – Formal education on self-care has unclear efficacy. (See 'Education on self-care' above.)

●Other self-care interventions

•Mobile health – Mobile health (mHealth) applications (apps) are increasingly available, but those designed and tested for self-care in patients with HF have not clearly demonstrated superior efficacy to usual care. (See 'Mobile health' above.)

•Remote monitoring – The strategy of obtaining data provided by the patient to detect changes in health and respond in a manner that maintains or improves health is compelling. However, interventions that use this approach show conflicting and generally low efficacy. (See 'Remote monitoring' above.)

ACKNOWLEDGMENTS —

The UpToDate editorial staff acknowledges Leora Horwitz, MD, MHS, and Harlan Krumholz, MD, who contributed to earlier versions of this topic review.

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Topic 13607 Version 33.0

خرید پکیج

Heart failure self-management

References