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II. Counseling, Education, and Lifestyle Modifications

Kathleen Dracup, RN, DNSc; David W. Baker, MD, MPH; Sandra B. Dunbar, RN, DSN; Robert A. Dacey; Neil H. Brooks, MD; Jerry C. Johnson, MD; Carole Oken, MA; Barry M. Massie, MD

JAMA. 1994;272(18):1442-1446.

Abstract
Objective.
—This article reviews the role of counseling, education, dietary modifications, and exercise for patients with heart failure due to left ventricular systolic dysfunction.

Data Sources.
—We reviewed studies published in English between 1966 and 1993 and referenced in MEDLINE or EMBASE. We used the search terms heart failure, congestive; congestive heart failure; heart failure; cardiac failure; and dilated cardiomyopathy in conjunction with terms for the specific areas of interest. Where data were lacking, we relied on opinions of panel members and peer reviewers.

Study Selection and Data Synthesis.
—Studies were reviewed to determine whether patients had heart failure due to systolic dysfunction (left ventricular ejection fraction, <0.35 to 0.40) and whether clinical outcomes were reported. Studies that reported only intermediate outcomes (eg, hemodynamics) were not reviewed.

Conclusion.
—Counseling and education can improve patient outcomes and decrease unnecessary hospitalizations. Patients with mild to moderate heart failure should be restricted to 3 g/d of sodium initially. Those who are unresponsive to this dosage or who have more severe disease should be advised to consume 2 g/d or less. Patients should be strongly advised to drink no more than 30 mL/d of alcohol or, preferably, to abstain completely. Exercise training is safe and can improve exercise duration and symptoms. Adherence to the treatment plan should be stressed and monitored at each visit. Clinicians should inform patients of the seriousness of their disease and their prognosis, but they should emphasize that patients can continue to remain active and enjoy a reasonable quality of life.

(JAMA. 1994;272:1442-1446)

Author Affiliations
From the University of California—Los Angeles, School of Nursing (Dr Dracup); Health Sciences Program, RAND, Santa Monica, Calif (Dr Baker and Ms Oken); Division of General Internal Medicine, Harbor-UCLA Medical Center, Torrance, Calif (Dr Baker); Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Ga (Dr Dunbar); The Mended Hearts Inc and the Clinical Practice Guideline Panel, Boulder, Colo (Mr Dacey); Rockville (Conn) Family Practice (Dr Brooks); Geriatric Medicine Division, University of Pennsylvania, Philadelphia (Dr Johnson); Philadelphia (Pa) VA Medical Center (Dr Johnson); and Department of Medicine, University of California—San Francisco (Dr Massie). Dr Baker is now with the Division of General Medicine, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, Ga.

Footnotes
The views expressed herein are those of the authors and do not reflect the position of the Agency for Health Care Policy and Research, the US Public Health Service, or the US Department of Health and Human Services.

Reprint requests to UCLA School of Nursing, Factor Bldg, 4-238, 10833 Le Conte Ave, Los Angeles, CA 90024-6918 (Dr Dracup).

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