**4.3 Self-care behaviours of patients with heart failure**

## *4.3.1 Physical activity*

The reduced exercise capacity of patients with advanced stage heart failure is associated with impairments in cardiac and pulmonary reserves, and reduced peripheral and respiratory skeletal muscle perfusion and/or function. Shortness of breath and/or fatigue symptoms in particular cause a decrease in physical activity capacity [25]. In patients with advanced stage heart failure, correct evaluation of the patient's exercise intolerance is an important subject both in the gaining of self-care behaviours and in the determination of medical and device treatment.

Exercise intolerance in advanced stage heart failure is evaluated subjectively in the New York Heart Association [NYHA] functional classification and with health-related quality of life questionnaires. Exercise capacity can be evaluated with objective quantitative methods using the 6-minute walk test [6MWT] and with the cardiopulmonary exercise test [CPX] and graded exercise test with electrocardiography [ECG].

From the subjective methods, the Barthel daily living activities test is a test that can be applied and easily understood by both patients and carers.

Healthcare personnel usually use the 6MWT to evaluate the daily living activity of patients with advanced stage heart failure. The 6MWT is a simple test in which the patient walks at a self-selected speed for 6 minutes along a 30-metre corridor, and the distance covered is measured. The distance walked is useful in providing information about the grade of disease severity and the efficacy of treatment, and in predicting hospitalisations and mortality in heart failure [26, 27].

The CPX is a strong prognostic marker, especially in advanced stage heart failure, and is used to clinically evaluate the risk of unwanted events and candidacy for transplantation. The CPX variables respond positively to pharmacological, lifestyle, and surgical interventions, thereby making serial CPX necessary for the evaluation of therapeutic efficacy [28, 29].

Exercise-based cardiac rehabilitation is a first-class recommendation in the American Heart Association. Medicare and Medicaid Services Centres and most insurance

companies in the USA allow for at least 6 weeks [generally 36 sessions] of exercise-based cardiac rehabilitation service for patients with stable chronic heart failure of LVEF <35% and those who despite this have NYHA functional class II and IV symptoms [30].

#### *4.3.2 Pain control*

In patients with advanced stage heart failure, monitoring of fluctuations in body weight is a very important self-care behaviour as it can be a sign of an increase in retention of body fluids.

#### *4.3.3 Diet*

Cachexia in patients with advanced stage heart failure is associated with a poor prognosis, as it is related to obstruction, inflammation, malabsorption, anorexia, and neurohormonal over-activation. Approximately 5–15% of patients with heart failure experience unwanted weight loss due to reduced skeletal muscle mass, with or without fat tissue depletion [13]. The occurrence of unintended weight loss without oedema of up to >5% within 5–7 months or > 6.12%, or BMI <20 kg/m<sup>2</sup> , is defined as cachexia. Therefore, dietary and nutritional evaluation of patients with advanced stage heart failure is important.

In the evaluation of the nutritional status of patients with advanced stage heart failure by healthcare professionals, structured nutritional evaluation tests such as the Subjective Global Assessment [SGA], the Nutritional Risk Screening [NRS] 2002, or the Mini-Nutritional Evaluation are used in addition to analytical and anthropometric parameters. In recent years, the frequently used NRS has been used as a malnutritionscreening tool based on the self-report of the patient and includes items to evaluate the current nutritional status and disease severity [31].

In advanced heart failure, the body passes from an anabolic to a catabolic status with an increase in the levels and activity of catabolic mediators such as proinflammatory cytokines and glucocorticoids, and a decrease in the levels and activity of anabolic mediators such as insulin and growth hormone. The increase in protein destruction causes muscle loss [32]. Therefore, the daily calorie and protein intake of patients should be regulated.

#### *4.3.4 Oedema follow-up*

Increased activation of the renin-angiotensin-aldosterone system [RAAS] together with increased vasopressin causes a worsening of sodium and fluid retention in patients with advanced heart failure. Pleural effusion and anasarca oedema associated with a volume increase can be seen in patients with advanced heart failure [11].

Oedema becomes evident with an increase of at least 3–5 kg. It is generally bilateral, progresses upwards from the feet as it is mainly determined by gravity, and may form in the trunk, face, and arms. This status can be accompanied by ascites, and pleural and pericardial effusion [33]. Although there is no objective measurement in the classification of oedema, a visual analogue scale and pictures showing the localisation of oedema are generally used in the self-care of patients [34].

Healthcare professionals grade oedema from 1+ to 4+. A grade of 1+ indicates mild oedema in both feet and ankles; 2+ indicates oedema in both feet, legs, and the hands or forearms; 3+ indicates oedema in both lower and upper extremities and in an area of the face region, and 4+ indicates anasarca oedema.
