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Living with failure Resources to help you manage your How to use this resource This book contains collection of fact sheets on the most important things for you to know to help manage your heart failure. Share it with your care partners, family and friends as it can help understand heart failure and how they can support you living with heart failure.

The table of contents will give you an overview of what resources (fact sheets) are in the booklet and how it is organized. Read the fact sheets that are important to you. There is space to help you keep track of important information such as symptoms and .

When you and the people around you better understand heart failure, you can manage it with more confidence and support.

Do you want to keep up to date on new heart failure information? We invite you to join our Community of Survivors, to share, learn and connect with others who are living with heart failure, heart or ? Sign up at heartandstroke.ca/connect

Acknowledgements Heart & Stroke gratefully acknowledges Cardiac Services BC and the experts at British Columbia Heart Failure Network as the original creators of the fact sheets included in this resource. Heart Failure Overview Managing Heart Failure Activity More Information 1 7 9 8 11 71 41 15 21 31 13 19 27 52 45 54 35 59 62 56 43 29 33 64 48 69 38 66 50

Evaluation Tips for Travelling When You Have Heart Failure Have You When Travelling for Tips Yourself of Care Taking with Heart Someone Failure: Caring for with Heart Failure Live to Learning Plan Action Personal Heart Failure Advanced More Information More Depression Stress (Coumadin) Warfarin or Toloxin) (Lanoxin Supplements Herbs and Herbal List Medication Receptor – Inhibitor (ARNI) Inhibitor – Neprilysin Receptor Angiotensin (Lancora) and a Nitrate of Combination The ACE Inhibitors ACE (ARBs) Blockers II Receptor Angiotensin Blockers Beta (MRA) Antagonist Receptor Mineralocorticoid Activity “Active” Should Keep with Heart Failure People Why Should with Heart Failure People Why Medication Daily Weight Information Weight Daily Heart Failure Have When You () Limiting Heart Failure Have Limiting Fluid When You High in Foods Understanding Heart Failure – The basics – The Heart Failure Understanding Managing Heart Failure Zones Heart Failure Sheet Self- Heart Failure Overview Heart Failure

Table of Contents of Table Living with Heart Failure Heart with Living Failure You don’t have to face this If you have experienced heart disease, or are caring for someone who has, connecting with other people who know what you are going through can help the recovery journey. Our Community of Survivors and Care Supporters’ Community are two separate members-only Facebook groups: one for survivors of heart disease or stroke, and one for those who provide support or care to them. Community members can find social and emotional support in a safe, inclusive and respectful environment. Both are free, both are bilingual. Our Facebook communities are places you can be reassured that you are not alone. There are others who are living similar experiences, and who understand and can offer practical advice. You may also wish to share your experience and wisdom, extending a caring word to others. Members care, share and help pay it forward.

Join a Community and learn more at heartandstroke.ca/connect

What are members saying?

The "magic" of this group happens if we tell about our experiences, our journey, so we all can learn from each other and get inspired, empowered to keep going and growing. Those who can fully understand our journey are the ones who are on the same road. We have different stories and ““circumstances, but we do know the struggle, we do understand when we read other survivor's experiences.” — Community of Survivors members

I have learned a lot from this group. I don’t feel so alone anymore. It helps to know that other patients worry about the same things that I do” ““— Community of Survivors members Hello to all of you, I am a natural caregiver to my elderly mother for several years. I had to retire to be more present with her. She suffered a stroke in 2015, and she recovered well enough. Thank you for accepting me in your group! It'll be good to talk to people who know what it's like to be a natural ““carer” —Care Supporters’ Community members

Heart & Stroke – Living with Heart Failure Heart FailureHeart Overview

Heart Failure Overview

Heart & Stroke – Living with Heart Failure Heart Failure Overview Heart Failure

The power of Community Have you experienced heart failure or stroke, or are you caring for someone who has? Our members-only Facebook groups are safe, welcoming and helpful online communities. Ask questions, give and receive support and get practical advice. You’re among friends here.

Community of Survivors Care Supporters’ Community – for people living with heart – share, support and lean on others who, disease or stroke. like you, are caring for others.

Join a Community and learn more at heartandstroke.ca/connect

Heart & Stroke – Living with Heart Failure Heart FailureHeart Overview Understanding Heart Failure – The Basics

How does the heart work? What is heart failure? Your heart is a muscle about Heart failure is when your heart is not pumping the size of your fist. It works like as strongly as it should. Your body does not get a pump, pumping and the right amount of blood, , and it nutrients around your body. needs to work properly.

The heart is actually a 2-sided Heart failure usually gets worse over time. While pump. The right side of the heart heart failure cannot be cured, people do learn to pumps ‘used’ blood from the live active, healthy lives by managing their heart body to the . In the lungs, failure with medication, changes in their , your blood is loaded up with weighing daily and physical activity. oxygen. The left side of the heart pumps ‘fresh’ blood full of oxygen from the lungs to the rest of There are two main types of heart failure: the body. The left side of the heart is usually larger • A weak pump: When the heart muscle is weak, than the right. That is because it has to pump hard it gets larger and ‘floppy’. to get the blood out to all parts of your body. • A stiff pump: When the heart muscle cannot Each side of the heart has 2 chambers. Valves link relax between beats because the muscle has the chambers and keep blood pumping in the right become stiff. The heart cannot properly fill with direction. These valves open and close with each blood between beats. heartbeat.

Both types of heart failure reduce the blood flow and oxygen to your body.

Heart & Stroke – Living with Heart Failure 1 What causes heart failure? • You cannot walk as far you normally can. Heart failure has many causes including: • You are tired all the time and have no energy to • Heart attack do daily activities. • High • You feel lightheaded or dizzy, especially when you stand up or increase your activity and this is • problems new for you. Heart Failure Overview Heart Failure • Heart defects at birth • You cannot eat as much as you normally would. • conditions • You are not hungry and do not feel like eating. • Excessive use of alcohol or drugs • You feel bloated or your clothes feel tighter than Other possible causes of heart failure include: normal. • • You have swelling in your feet, ankles, legs, or even up into the belly (abdomen). • Sleep • Sudden increase in body weight where you gain • affecting the heart muscle more than 4 pounds (2 kilos) in 2 days. • Abnormal heart rhythm • You feel uneasy, like something does not feel • Severe right. • Severe kidney disease • You feel confused and have trouble thinking • Overactive thyroid gland clearly (and this is new for you). • Exposure to chemotherapy or radiation Tests to identify heart failure Not sure what caused your heart failure? Ask your There is no single test for heart failure. Instead doctor or nurse practitioner. your doctor does a number of tests. The doctor looks at all the test results to determine if you have Signs of heart failure heart failure. You may notice any of the following signs. • You feel short of breath when you do daily Tests can include: activities. • Blood tests to check certain • You find it harder to breathe when resting or enzymes lying down. • Chest x- to look at the size of • You wake up at night feeling short your heart of breath. • Electrocardiogram (or ECG) to look at the • You find it easier to sleep by adding pillows electrical activity of the heart or by sitting up in a chair. • Exercise stress test to look at how your heart • You often, especially when lying down. responds to exercise • Your cough is either dry and hacking, or moist • Nuclear scan to get a close look at the and you cough up mucus (which could be slightly pumping of your heart pink). • Angiogram to look for blockage in your heart • You feel your heart beat faster and it does not slow down when you rest. • Echocardiogram or ultra sound of the heart • You feel your heart racing, jumping, or to look at the movements of your heart and pounding in your chest. measure your

2 Heart & Stroke – Living with Heart Failure Heart FailureHeart Overview

More about ejection fraction Plan today for the future This test is usually done during an Your heart failure may get worse over time. Start echocardiogram or a nuclear medicine scan. thinking about how you wish to be cared for if Your ejection fraction can go up and down, your disease progresses. This is called ‘advanced depending on your heart condition and how well care planning’. Advance care planning allows you the treatment is working. It is good to know what to have a say in your health care if you are unable your ejection fraction reading is. The reading is to speak for yourself. given as a percentage with normal being between 55 and 70%. Less than 55% means your heart Talk to your family and your doctor about helping is not pumping as strongly as it should be. Your you live well with heart failure and about the care ejection fraction helps your doctor or nurse treat you do or do not want in the future. your heart failure. Things to think about and consider: How is heart failure treated? • What does it mean to live well with heart failure? Look in the mirror — the to treatment is you. • What is important to you to make your life the Your doctor relies on you to make changes in your best it can be? lifestyle and eating habits. While there is a team of • What is important to you as your health care providers working with you to manage condition progresses? your heart failure, you are the one in charge. • What worries and concerns do you have? Treatment is focused on helping you live a longer • How will your progressing heart failure affect you and healthier life. This includes: and your family? • Monitoring your symptoms • Who or what gives you support when you need it? • Reducing salt in your diet • If you are not able to make your own health care • Increasing your daily activity decisions, who will you want to make them for through regular exercise you? Does that person know what you want? • Keeping your blood pressure low • Do you have written instructions for how • Maintaining a healthy weight you want to be cared for if you cannot make decisions for yourself (this is called an advance • Stopping unhealthy habits such as directive). • Taking your medications as prescribed Why learn to manage your heart failure? For some people, surgery and medical devices are needed to treat the problem that led to the When you take charge of your health and learn heart failure. Treatments could include: to manage your heart failure, it helps you: • Coronary bypass surgery • Improve the quality of your life. • Valve repair or replacement surgery • Feel confident that you can manage your heart failure. • Implanted device such as a pacemaker and/or defibrillator • Control your condition so it will not control you. • Mechanical device to help the heart pump • Know when to ask for help from your care team. • Heart transplant • Limit the need to go to the for care. For new ideas on heart failure treatment consult • Prevent or limit heart failure complications as the your health care provider. disease progresses.

Heart & Stroke – Living with Heart Failure 3 Talk with your family and your care team about your disease and care plan. People who learn to manage their heart failure are more likely to live a longer, healthier life than those who do not.

For more information on heart failure

Heart Failure Overview Heart Failure BC’s Heart Failure Network www.bcheartfailure.ca Heart and Stroke Foundation www.heartandstroke.ca/heartfailure Heart Failure Society of America www.hfsa.org

4 Heart & Stroke – Living with Heart Failure Managing Heart Failure Heart & Stroke – Living with Heart Failure Heart & Stroke Managing HeartManaging Failure Managing Heart Failure

Learn more about heart failure at heartandstroke.ca/heartfailure

6 Heart & Stroke – Living with Heart Failure Heart Failure Zones

EVERY DAY • Weigh yourself in the morning before breakfast. • Take your medicine exactly Write it down. Compare your weight today to your how your doctor said. weight yesterday. • Check for swelling in your feet, • Keep the total amount of fluids you drink to only ankles, legs, and . 6 to 8 glasses each day. (6-8 glasses equals • Eat foods that are low in salt or salt-free. 1500-2000 mL or 48-64 oz) EVERY DAY EVERY

• Balance activity and rest periods. FailureManaging Heart

Which zone are you in today?

ALL – This zone is your goal!

Your symptoms are under control. You have: • No . • No chest discomfort, pressure, or pain.

GREEN • No swelling or increase in swelling of your feet, ankles, legs, or stomach.

SAFE ZONE SAFE • No weight gain of more than 4 lbs (2 kg) over 2 days in a row or 5 lbs (2.5 kg) in 1 week.

CAUTION – This zone is a warning Call your Health Care provider (eg. Doctor, nurse) • You have a dry hacking cough. if you have any of the following: • You feel more tired and don’t have

• You gain more than 4 lbs (2 kg) over 2 days in a row the energy to do daily activities. or 5 lbs (2.5 kg) in 1 week. • You feel lightheaded or dizzy, and • You have vomiting and/or diarrhea that lasts more this is new for you. than 2 days. • You feel uneasy, like something does not feel right. • You feel more short of breath than usual. • You find it harder for you to breathe when you are YELLOW YELLOW • You have increased swelling in your feet, ankles, legs, lying down. or stomach. • You find it easier to sleep by adding pillows or CAUTION ZONE CAUTION sitting up in a chair.

Healthcare Provider: ______Phone Number: ______

EMERGENCY – This zone means act fast! Go to emergency room or call 9-1-1 if you have any of the following: • You are struggling to breathe.

• Your shortness of breath does not go away while sitting . • You have a fast heartbeat that does not slow down when you rest. RED • You have that does not go away with rest or with medicine. • You are having trouble thinking clearly or are feeling confused.

DANGER ZONE DANGER • You have fainted.

Heart & Stroke – Living with Heart Failure 7 Self-Monitoring Sheet

Patient’s Name: ______

SELF-MONITORING: Record your findings below Changes in Your Side Effects of Action Taken and Days Weight Swelling Pattern Medication Your Results

Day 1

Day 2 Managing Heart Failure

Day 3

Day 4

Day 5

Day 6

Day 7

Questions to ask yourself: 1. What was I doing when the change was noticed? ______2. What time of day did the change happen? ______3. How did I decide to report or not to report it? ______4. To whom did I report the change? ______

8 Heart & Stroke – Living with Heart Failure Daily Weight Information

Patient Name: ______

Heart Function Clinic or ’s office: ______

Health Care Provider: ______Contact phone number: ______

Check your weight every day FailureManaging Heart Why? • Checking your weight every day lets you know if your body is retaining fluid. • Excess fluid build up in your body makes your heart work harder. • When you report weight gain early to your health care provider, they can help you prevent your heart failure from getting worse. This can help prevent a hospital admission.

If your weight increases by: • More than 2 kg (4 lb) in two days, or You are retaining fluid. • More than 2.5 kg (5 lb) in 1 week. You should call your health care provider.

For further directions, please refer to ‘Heart Failure Zones’ information sheet.

When? • Same time every day • Preferably before breakfast

How? •  you have emptied your bladder (gone ‘pee’) • Wear the same amount of clothing

Heart & Stroke – Living with Heart Failure 9 Record your weight on the calendar below. (You may prefer to use your own method such as a notebook, a computer.) Remember to bring your record to your doctor or clinic appointment.

Your ‘Dry Weight’ (when you don’t have excess fluid in your body): ______Write down your weight each day compare today’s weight to yesterdays weight.

Month ______

Sunday Monday Tuesday Wednesday Thursday Friday Saturday Managing Heart Failure

10 Heart & Stroke – Living with Heart Failure Limiting Sodium (Salt) When You Have Heart Failure

Sodium is a mineral found in food, table salt, and • Season your food with herbs, spices, lemon sea salt. Your body needs some sodium, but too juice, dry mustard, and garlic. one of the many much sodium causes your body to hold on to (or seasoning blends which contain no salt such as retain) fluid. This fluid build-up makes your heart Mrs. Dash. work harder. The fluid build-up can cause swelling • Stay away from eating: in your feet, legs, or belly. Fluid can also build up in your lungs, making it hard for you to breathe. ° Processed foods Managing Heart FailureManaging Heart ° Deli meats Month ______If your weight increases more than 4 lbs (2 kg) ° Pickled foods over 2 days in a row or 5 lbs (2.5 kg) in 1 week, you ° Salted snack foods such as potato chips, Sunday Monday Tuesday Wednesday Thursday Friday Saturday are retaining fluid. If this happens, you should call pretzels, dips, and salted nuts your health care provider right away. • Limit the amount of canned foods you eat. You should restrict the amount of sodium you eat Choose products labeled ‘low sodium’. Foods to 2000mg or less each day. labeled ‘lower’, ‘less’ or ‘reduced in salt or sodium’ may still be high in sodium (including soups In the average Canadian diet, where does and meats). sodium come from? ■ In ready-made processed • Eat out less often. foods and restaurant Ask restaurants to provide information on meals (77%) ° low sodium choices. ■ Naturally occurring Restaurant meals and fast foods are always in food (12%) ° higher in salt than cooked low ■ Added to food in cooking sodium meals. and at the table (11%) Can I use salt substitutes? How to avoid salt (sodium)? Some salt substitutes use potassium instead of • Eat fresh foods most of the time and prepare sodium. Check with your doctor or before home-cooked, low sodium meals. using a because some people need • Frozen foods are acceptable if they do not have to limit how much potassium they have each day. added salt or sodium additives (which are used as preservatives). • Remove the salt shaker from the table. Don’t add salt, flavoured or seasonings high in salt to your foods. One teaspoon of salt contains 2300mg of sodium!

Heart & Stroke – Living with Heart Failure 11 Keep your sodium intake to less than 2000mg each day. As you gradually reduce the amount of salt you are eating, your taste buds will adjust!

How do I know how much sodium is in food? Nutrition Facts Here are some helpful tips when reading the Serving Size: Per ½ cup (125ml) nutrition label: Amount % Daily Value • Look at the serving size – the amount of sodium listed is per serving (not the whole package). Calories 140

• Keep track of the total amount of sodium you eat. Total Fat 0.5g 1% Remember: Your maximum recommended daily amount of sodium is no more than 2000mg per Saturated Fat 0.2g day from all sources. + Trans Fat 0g 1% • Keep the sodium content of each meal below

Managing Heart Failure 0mg 0% 650mg – this helps spread out your sodium intake over the day preventing excessive thirst Sodium 390mg 16% and/or fluid retention. Total Carbohydrate 28g 9% • By law, foods labelled ‘low sodium’ must contain 140mg or less per serving. Dietary Fibre 5g 20% Sugars 9g Other ingredients high in sodium include: baking soda, brine, monosodium glutamate Protein 7g (MSG), soy sauce, sauce, garlic salt, celery Vitamin A 2% Vitamin C 0% salt, or any ingredient with ‘sodium’ as part of 8% 15% its name.

Look what happens to the sodium content of foods when they are processed

Unprocessed Processed Cucumber Dill pickle 7 slices = 2mg 1 medium = 569mg Chicken Breast Chicken Pie 3oz = 74mg 1 serving frozen = 889mg Tomato Tomato Soup 1 small = 14mg 1 cup = 960mg Tenderloin Ham 3 oz = 58mg 3oz = 1095mg

12 Heart & Stroke – Living with Heart Failure Limiting Fluid When You Have Heart Failure

What is a fluid? How do you know when you have too Any food or drink that is liquid at room much fluid? temperature. This includes water, ice, milk, To keep track of whether your juices, soft drinks, hot drinks, alcohol, soups, body is holding on to too much gelatin desserts, ice cream, popsicles, and fluid, weigh yourself daily. liquid nutrition supplements (such as Ensure Here is how to weigh yourself: or Boost). FailureManaging Heart • Weigh yourself at the same time every day. The best time is first thing in the morning. Why do you have to limit fluid? • Weigh yourself after emptying your bladder When you have heart failure, fluid can build (gone pee). up causing swelling in your feet, legs or belly making your heart work harder. Fluid can also • Wear the same amount of clothing each time. build up in your lungs, which may cause you to have trouble breathing. You are holding on to too much fluid when: Your weight Your weight How much fluid can you have in a day? increases by more increases by more or You should have no more than 1.5 to 2 litres than 2 kg or than 2.5 kg or of fluid in a day. You may find you are thirsty to 4 lb in two days. 5 lb in a week. begin with. As you gradually reduce your fluid intake, your body will adjust! Contact your health care provider right away if you are holding too much fluid. Guide to fluid measures Tips for reducing your fluid intake 2 tablespoons = 30 ml = 1 ounce • Use smaller cups and glasses. 1 glass = 250 ml = 8 ounce • Measure the amount of fluid your mugs and 1 pint = 500ml = 16 ounce glasses hold. They may measure more than 250 ml or 8 ounces. 1 litre or 1 quart = 1000 ml = 32 ounce • Sip your fluids slowly. 2 litres = 2000 ml = 64 ounce • Write down the amount you drink each day until limiting your fluid becomes a habit. Total amount of fluid per day 1.5-2 litres = 48-64 ounces = 6-8 glasses

Heart & Stroke – Living with Heart Failure 13 More tips for reducing your fluid intake • Sip your fluids throughout the day. Keeping • Limit the amount of sodium you eat to track of fluids is the only way to learn how to 2000mg or less each day. Salt will make make the 1.5 to 2 litres of fluid last you through you thirsty. For more information, refer the day. to the handout Limiting salt (sodium) • You may find it easier to use a reusable when you have heart failure. water bottle. Measure how much the • Try not to eat sweet foods. They can make you bottle holds so you know exactly how thirsty. If you have , controlling your much water you are drinking. blood sugar also helps control your thirst. • Drain the fluid from canned fruit. • Try not to drink alcohol. Alcohol dehydrates • Be aware of foods with high water content like your body and makes you thirsty. watermelon, yogurt, and pudding. • If you can, swallow your pills with soft food like yogurt or porridge. Managing Heart Failure

Tips to deal with thirst • Rinse your mouth with water often, but do • Chew sugar-free gum. not swallow. • Suck on a lemon wedge, lemon candy, or • Brush your teeth often. sour candy. • Use a mouth wash. However, do not use a • Use balm to keep your from drying out. mouth wash that contains alcohol. They tend • Don’t overheat your home. Consider using a to dry out your mouth. humidifier to increase the moisture in the air. • Snack on a small piece of cold or frozen fruit • Ask your pharmacist about gels or sprays that such as a frozen grape or cold orange slice. can add moisture to your mouth. Try cold crisp vegetables too.

14 Heart & Stroke – Living with Heart Failure Foods High in Potassium

Foods with more than 200mg per serving. Based on 1/2 cup servings, unless otherwise specified. One serving = 1/2 cup (unless indicated)

Fruits Vegetables Other foods

Apricots Acorn squash Rutabaga Black licorice Avocado Artichoke (cooked) Spinach (cooked) Bran muffin

Banana Asparagus (boiled) Sweet potato Bran cereal FailureManaging Heart Breadfruit Beets Swiss chard (cooked) Chocolate Cantaloupe Beet greens (boiled) Tomatoes - paste, sauce, Coconut (dried, desiccated) Dried fruits (all types) Bitter melon juice or crushed Coconut milk (canned) Durian Bok choy (cooked) Yams Coconut water Guava Broccoli (cooked) Zucchini (cooked) Dried Beans Honeydew Brussels sprouts Dried Peas Jack fruit Butternut squash Edamame Kiwi Carrot (raw) Lentils Nectarines (whole) Cassava Hemp seeds Orange (whole) Celery (cooked) (2 tablespoons) Passion fruit Corn (cooked) Nuts and seeds Peach (whole) Fennel bulb (cooked) Juices Maple Syrup Persimmon, Japanese (whole) Hubbard squash Carrot Molasses Plantain Kohlrabi Orange Soya flour Pomegranate Mushrooms - white and Passion fruit Milk and Dairy products Pummelo portobello (cooked) Pomegranate Meal replacements** (e.g. Boost, Ensure) Parsnips Prune Peas, green (cooked) Tomato **Ask your registered dietitian for low Potatoes Vegetable potassium options. Pumpkin

Grapefruit and grapefruit juice – they can interfere with your heart . Avoid: Salt subsitiute (e.g. No Salt or Half Salt) – they are very high in potassium.

What should your blood potassium be? Danger too Low ›››››› Lower than 3 mmol/L Safe or Normal ››››››› 3.5 – 5.0 mmol/L Caution ››››››››››››› 5.0 – 6.0 mmol/L Danger too High ›››››› Higher than 6.0 mmol/L References: Health Canada. Canadian File, and USDA National Nutrient Database for Standard Reference

Note: Potassium in food resource is currently being updated and will be available early spring 2019. Please go to heartandstroke.ca/publications for the updated content.

Heart & Stroke – Living with Heart Failure 15 Foods with Less Potassium – Better Food Choices Enjoy up to 5 servings per day. One serving = 1/2 cup (unless indicated). • All foods contain some potassium. A larger serving of low potassium food can make it a high potassium food. • Watch your serving size – no more than 5 servings a day. • To check the amount of potassium in food not on this list, please speak to a dietitian. Fruits Vegetables Apples Alfalfa sprouts Mustard greens Applesauce Asparagus (4 spears) Okra Asian pear Bamboo shoots (canned) Onions Berries (blackberries, blueberries, Bean sprouts Parsley cranberries, gooseberries, strawberries) Beets greens (raw) Peas, green (raw, canned) Casaba melon Bokchoy (raw) Peppers (all colours) Cherries (10) Broccoli (raw) Potato (double boil) Coconut meal (raw) Cabbage Radicchio (1 cup) Crabapple Collards Radish

Managing Heart Failure Currants (fresh) Carrots (cooked) Seaweed Figs (fresh) Cauliflower Shallots (1/4 cup) Fruit cocktail (canned) Celery (raw) Snap peas Grapes (16) Cilantro Snow peas Kumquat (5) Corn (canned) Spinach (raw) Lemon /Lime Corn on the cob Spagetti squash Longan (15) (1/2 small) Swiss chard (raw) Lychee (10) Cucumber Tomato (1/2 medium, Mandarin orange Eggplant 1/2 cup Cherry, 1 Plum) Mango Fennel bulb (raw) Turnip Nectarine (1/2 only) Gai lan/Chinese broccoli Water chestnuts (canned) Orange (1/3 small only) (cooked) Zucchini (raw) Papaya Green beans Peach (1/2 only) Green onions Pear Jicama Pineapple Kale Plum Leeks Rhubarb (cooked) Lettuce (1 cup) Tangerine Mushrooms, Shiitake (cooked), white (raw) Watermelon (1 cup)

Double boiling root vegetables lowers the amount of potassium • Peel, cube or slice vegetables. • Add double the amount of water. Limit servings of root vegetables to 1/2 cup • Bring to a boil, then drain the water. per day or as discussed with your dietitian. • Add fresh water, finish cooking and drain again.

References: Pennington, J.A.t, Spungen, J. (2012). Bowes & Church’s food Values of Portions Commonly Used. 19th Edition. USDA National Nutrient Database for Standard Reference (Release 25) website: http://ndb.nal.usda.gov/ndb/foods/list

16 Heart & Stroke – Living with Heart Failure Activity Activity Heart & Stroke – Living with Heart Failure Heart & Stroke The power of Community Have you experienced heart failure or stroke, or are you caring for someone who has? Our members-only Facebook groups are safe, welcoming and helpful online communities. Ask questions, give and receive support and get practical advice. You’re among friends here. Activity

Community of Survivors Care Supporters’ Community – for people living with heart – share, support and lean on others who, disease or stroke. like you, are caring for others.

Join a Community and learn more at heartandstroke.ca/connect

18 Heart & Stroke – Living with Heart Failure Activity

19

Walking housework Light Gardening vacuuming Light Stretching Laundry shopping Grocery If you are tired after an activity or the or the an activity after tired are If you find a balance body a while to your take It may Be active at a time when you feel rested, such such rested, feel when you a time Be at active Chooseeach day. do which activities to activities throughout your Spread next day, then you have tried to do do tried to have then you day, next much. too up. give so don’t activity and rest, between as first thing in the morning or after nap. after the morning or thing in as first day. your •  •  people with heart failure most Activities can do ✓ ✓ ✓ ✓ ✓ ✓ ✓ Is the activity level right for me? me? for right Is the activity level you that It is important body. your know to Get the activity. doing comfortable feel can talk without long as you As of the level breath of short being too activity is okay. Balance activity and rest •  •  • 

Heart & Stroke – Living with Heart Failure Heart & Stroke

Feel more confident and in control confident more Feel Feel less tired Feel less breathless Feel Sleep better Start off slowly and pace yourself. yourself. and pace slowly Start off Always check with your health care provider provider health care check with your Always needs and ability. first before starting an activity to make sure sure to make starting an activity before first your personal matches find an activity that you •  Getting started started Getting •  Studies show that daily activity is good for you. you. is good for daily activity that Studies show and longer. better live to It can help you ✓ ✓ ✓ Keeping active helps you: active Keeping ✓ healthy. Any amount of activity is better than than is better activity of amount Any healthy. all. none at Why activityWhy is important keep to ways the best is one of active Keeping or health. or health. . Exercise is a type of physical physical is a type of Exercise place. place to is planned. exercise is - The difference activity. fitness or maintain improve to exercise We meanings. Physical activity is when you are are activity is when you meanings. Physical from get body to your move to using energy There is, however, a small difference in their in their a small difference is, however, There two terms to mean the same thing. All physical same mean the physical thing. All to two terms the increasing do involve activities and exercise muscles. and strengthening What does it mean to be ‘active’? it mean to does What use these often - People and exercise Activity Why People With Heart Failure Should Keep ‘Active’ Keep Should Heart With Failure People Why When to stop an activity Tips about activity Stop the activity if you: ✓ Stick with it, so it becomes a habit. • Cannot carry on a conversation, sing, or ✓ Include a variety of different activities so you whistle without being short of breath. do not get bored doing the same thing all • Feel weak, tired or dizzy. the time. • Feel to your stomach (nauseated). ✓ Wear loose, comfortable clothing and supportive shoes. • Feel your heart is pounding or racing. ✓ Count the fluids you drink • Feel your heart beating irregularly and this during the activity as part of is new for you. your daily fluid amount. • Have pain in your chest, neck, jaw, arm, or shoulder. What if you don’t feel confident doing activities and on your own? Stop and rest. Sit in a comfortable chair. Do not go to bed for a nap. There are many community-based programs designed specifically for people with heart Activity most people with heart failure disease. Talk to your health care provider, to should not do find a program in your community, ✗ Activities that involve working above your head such as painting or washing walls, washing windows, vacuuming curtains. ✗ Lifting or pushing heavy objects. Activity ✗ Straining or holding your breath to do an activity. ✗ Sit ups or push ups. ✗ Climbing a lot of stairs. ✗ Heavy housework or yard work. ✗ Going into sauna or hot tub.

20 Heart & Stroke – Living with Heart Failure Activity 21

before you start start you before

Heart Failure Zone Heart Failure Always check with your healthcare provider healthcare check with your Always routine. exercise starting an before first Examples of strength exercise: doing wall doing wall exercise: strength of Examples ups, doing leg lifts, using resistance tubing, using resistance push‑ups, doing leg lifts, free-weights. lifting Check your Check your in are only if you Exercise you with what Start slowly days most exercise Aim to 30 minutes least at for exercise Aim to Choose an exercise you enjoy. enjoy. you Choose an exercise every exercise session. exercise every Zone’. the ‘Green think you can what do (not and pace should do) you yourself. the week. of each day. Examples of : walking outside or walking exercise: aerobic of Examples swimming. bike, using an exercise on a treadmill, •  •  •  •  •  need them. when you breaks rest • Take Strength exercise Strength a muscle against contract time you Any or gravity such as weight resistance have Once you exercise. is a strength adding exercise, aerobic of a routine your can improve exercise strength fitness. overall started Getting •  •  

Heart & Stroke – Living with Heart Failure Heart & Stroke

Reduce stress and tension stress Reduce or depression anxiety of feelings Reduce Lower your blood pressure your Lower muscles and your Strengthen Feel less tired Feel better Breathe Sleep better did. You can do more and feel better! and feel can do more did. You ‘vascular’ meaning blood flow). Aerobic exercise exercise Aerobic ‘vascular’ meaning blood flow). Over use ability to oxygen. body’s your improves as it as hard work to have heart will not your time, heart rate for at least 10 minutes is an aerobic or is an aerobic 10 minutes least at for heart rate meaning heart, (‘cardio’ exercise cardiovascular Aerobic exercise Aerobic your increases activity that physical steady Any on increasing strength. Many exercises are a are exercises Many strength. on increasing both. of combination Some exercises focus more on increasing on increasing more focus Some exercises focus Others and blood flow. the heart rate Types of exercise of Types When you increase your fitness and health, fitness your increase When you life. quality of your improve you ✓ ✓ ✓ ✓ ✓ ✓ Exercise helps you to: to: helps you Exercise ✓ No matter how old you are, exercise benefits benefits exercise are, you old how No matter ways. number of in a heart failure your Why exercise is important exercise Why of exercise involve increasing the heart rate and rate the heart increasing involve exercise of to is intended muscles. Exercise strengthening or health. fitness or maintain improve Exercise for your health your for Exercise types All activity. physical is a planned Exercise Why People With Heart Failure Should Exercise Should Heart With Failure People Why Starting aerobic exercise How hard to exercise Step 1: Warm up • Get to know your body. Pay attention to how Take at least 5 minutes to warm up. exercise makes you feel. As long as you have This prepares your heart and body enough breath to carry on a conversation, the for the extra work. This means walk exercise level is okay. or cycle slowly for 5 minutes. • Use the table below as a way of measuring your effort. Step 2: Condition yourself • Aim to stay within the 3 to 5 scale during Gradually increase the exercise to a steady, your exercise. moderate pace. Aim for continuous exercise Rate your exercise effort Talk test for up to 30 minutes. 0 Nothing at all Resting Step 3: Cool down 0.5 Very, very easy Sing - you have enough 1 Very easy Take 5 to 10 minutes to slow down your exercise. breath to sing This helps your heart slowly return back to your 2 Easy resting heart rate. 3 Moderate Talk - you have enough 4 Somewhat hard breath to carry on a Starting strength exercise 5 Hard coversation

• It is best to have a 6 Gasp - you cannot say professional help you start strength exercises. more than 4 to 6 words You will learn the proper way to do the exercise. 7 Very hard without gasping • Generally: 8 You cannot say more than Activity 9 Very, very hard 2 to 3 words without gasping • Choose 6 to 8 basic strength exercises for the 10 Maximum You cannot talk at all larger muscle groups of both the upper and lower body. When to stop an exercise • Start with low resistance or light weights. Stop the exercise if: ✗ You feel lightheaded or dizzy. • Repeat each exercise only 10 to 15 times. ✗ You feel more tired than usual. • Do your strength exercise routine 1 to 3 times ✗ a week with rest days in between. You feel more short of breath than usual. Call 9-1-1 if: Balance exercise and rest ✗ You feel pressure or pain in your chest, neck, • If you are tired either right after you exercise or jaw, or shoulders that does not go away with rest the next day, you have done too much. Cut back or medicine. a little on the amount you exercise and progress ✗ You have a fast heartbeat that does not slow more slowly. down with rest. • Exercise at a time when you feel rested. It could ✗ You feel like throwing up (nauseated). be first thing in the morning or after a nap. ✗ You feel your heart skipping beats and this is new for you. • It may take your body a while to find a balance between exercise and rest, so don’t give up. ✗ You get a from your implanted heart device (ICD).

22 Heart & Stroke – Living with Heart Failure Activity

23

www.heartandstroke.ca Check out the BC Heart Failure Network website Network Check out the BC Heart Failure Foundation Check out the Heart and Stroke www.bcheartfailure.ca website When you don’t feel confident doing doing confident feel don’t you When own your on exercises community-based many are There for specifically designed programs are heart disease.people with They rehabilitation usually called cardiac programs. importance about the more Learn exercise of provider. healthcare your to • Talk •  • 

Heart & Stroke – Living with Heart Failure Heart & Stroke Keep an exercise record. This helps you see This helps you record. an exercise Keep progress. your Count the fluids you drink during the activity as you drink the fluids Count amount. daily fluid your part of Exercise indoors when it is too cold, too hot, or cold, too indoors when it is too Exercise humid outside. too Wait 1 hour after eating a meal to exercise. a meal to eating 1 hour after Wait areas. in hilly pace when walking your Adjust of driving. of the elevator. of instead Choose stairs the supportive shoes. supportive can you instead whenever Choose walk to get bored. get and clothing comfortable loose, Wear Exercise at the same day. time each at Exercise do not so you exercises of Include a variety Schedule exercise sessions into your your sessions into exercise Schedule daily routine. Stick with it,Stick with so a habit. it becomes             ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ Tips for exercise for Tips ✓ The power of Community Have you experienced heart failure or stroke, or are you caring for someone who has? Our members-only Facebook groups are safe, welcoming and helpful online communities. Ask questions, give and receive support and get practical advice. You’re among friends here. Activity

Community of Survivors Care Supporters’ Community – for people living with heart – share, support and lean on others who, disease or stroke. like you, are caring for others.

Join a Community and learn more at heartandstroke.ca/connect

24 Heart & Stroke – Living with Heart Failure Medication Medication Heart & Stroke – Living with Heart Failure Heart & Stroke Learn more about heart failure at heartandstroke.ca/heartfailure Medication

26 Heart & Stroke – Living with Heart Failure Medication 27

Anti-inflammatory medicines (such as Advil, Advil, (such as medicines Anti-inflammatory Prevent you from needing to be in the be in the needing to from you Prevent , Motrin, Naproxen, Aleve, Celebrex) Aleve, Naproxen, Motrin, Ibuprofen, hospital for HF treatment HF hospital for •  • Increase your energy energy your • Increase miss taking a dose? if you What dose, skip next your time for If it is almost take taking the dose missed and just you scheduled dose. next your two doses the same time. at take Never your about taking questions have If you or missedmedications, doses, your contact provider. health care or your pharmacist without the following of any take Do not health care provider: checking with your • Alcohol • Cough or cold medicines • Black licorice • Chinese medicines • Herbal medicines How do ACE Inhibitors help with help with Inhibitors ACE do How heart failure? may: Inhibitors ACE heart failure your of the progress • Slow longer live • Help you life of quality your • Improve •  heart failure your When used part of as a heart other along with your plan treatment help: might Inhibitors ACE medications, failure breath shortness of your • Lessen and belly legs in your the swelling • Reduce

Heart & Stroke – Living with Heart Failure Heart & Stroke

Quinapril (Accupril) Other ______Enalapril (Vasotec) (Vasotec) Zestril) (Prinivil, (Coversyl) Perindopril (Mavik) Trandolapril (Altace) Prevent kidney damage in people with damage in people with kidney Prevent diabetes or at risk for kidney disease kidney risk for or at diabetes • The heart recover after a heart attack after • The heart recover •  • High blood pressure • High blood pressure also Inhibitors help: ACE • Heart failure What are ACE Inhibitors used for? used for? Inhibitors ACE are What used treat: to are Inhibitors ACE reduces the work of your heart and lowers and lowers heart your of the work reduces blood pressure. your ACE Inhibitors cause blood vessels to relax, cause Inhibitors relax, blood vessels to ACE This easily. more flow blood to your allowing Stress constrict or narrow blood blood or narrow hormones constrict Stress heart to your for vessels making it harder body. your pump blood around ACE Inhibitors are a group of medications that that medications of a group are Inhibitors ACE hormones. making stress body from your keep What are ACE Inhibitors? ACE are What ❑ ❑ ❑ ❑ ❑ ❑ the one you are taking. are you the one ❑ Most common ACE Inhibitors ACE common Most off check to provider health care your Ask ACE Inhibitors Inhibitors ACE Common Side Effects What to do • This might go away after a while. Dry cough • If your cough gets worse or becomes a problem for you, contact your health care provider. Skin rash • Contact your health care provider if these side effects do Itchiness not go away within 2 days of starting the medication. and chills

• When changing position such as moving from lying to Dizzy sitting and sitting to standing, get up slowly. Lightheaded • Contact your health care provider if these side effects continue or get worse.

Serious but not common What to do side effects Swelling of your face, lips, • Stop taking the ACE Inhibitor. Trouble breathing • Contact your doctor right away or go to your nearest Difficulty swallowing .

Medication Tips • ACE Inhibitors might make you dizzy or • It can take several weeks, and sometimes lightheaded for the first few days, but this months, before you notice an improvement usually improves over time. in your heart failure. • If your does not get better, your • If you have low blood pressure, do not do health care provider might need to change anything that can lower your blood pressure the type or amount of ACE Inhibitor you even further: are taking. • Do not drink alcohol. • ACE Inhibitors could increase the potassium • Do not do any strenuous exercise. level in your body. Do not take potassium • Do not take a really hot shower or bath, supplements unless prescribed by your or use a hot tub or sauna. health-care provider. • Contact your health care provider if you have Medication • Check with your health care provider before diarrhea and/or vomiting that lasts more than using products that contain potassium such two days. as salt substitutes. • This can cause you to lose too much • If your medication dose is being increased or water and could cause problems with decreased, your health care provider will want your kidneys. to do a to check your potassium level and kidney function.

28 Heart & Stroke – Living with Heart Failure Medication 29

Anti-inflammatory medicines (such as Advil, Advil, (such as medicines Anti-inflammatory Prevent you from needing to be in the be in the needing to from you Prevent Ibuprofen, Motrin, Naproxen, Aleve, Celebrex) Aleve, Naproxen, Motrin, Ibuprofen, hospital for HF treatment HF hospital for What if you miss taking a dose? miss taking a dose? if you What dose, skip next your time for If it is almost take taking the dose missed and just you scheduled dose. next your two doses the same time. at take Never your about taking questions have If you or missedmedications, doses, your contact provider. health care or your pharmacist without the following of any take Do not provider: health care checking with your • Alcohol • Cough or cold medicines • Black licorice • Chinese medicines • Herbal medicines •  How do ARBs help with heart failure? ARBs do heart help with failure? How ARBs may: heart failure your of progress the • Slow longer live • Help you life of quality your • Improve •  heart failure your When used part of as a heart other along with your plan treatment help: ARBs may medications, failure breath shortness of your • Lessen and belly legs in your the swelling • Reduce energy your • Increase

Heart & Stroke – Living with Heart Failure Heart & Stroke

Irbesartan (Avapro) (Avapro) Other ______Losartan (Cozaar) (Cozaar) (Diovan) (Atacand) Candesartan (Atacand) Prevent kidney damage in people with damage in people with kidney Prevent diabetes or at risk for kidney disease kidney risk for or at diabetes • The heart recover after a heart attack after • The heart recover •  ARBs also help: • Heart failure • High blood pressure What are ACE Inhibitors used for? used for? Inhibitors ACE are What Used treat: to the work of your heart and lowers your blood blood your heart and lowers your of the work pressure. ARBs cause blood vessels to relax, allowing allowing ARBs cause relax, blood vessels to reduces This easily. more flow blood to your making it harder for your heart to pump blood pump blood to heart your for making it harder body. your around ARBs are a group of medications that keep your your keep medications that of a group ARBs are Stress hormones. making stress body from blood vessels or narrow hormones constrict What are ARBs? are What ❑ ❑ ❑ ❑ the one you are taking. are you the one ❑ Most common ARBs common Most off check to provider health care your Ask Angiotensin II Receptor Blockers (ARBs) Blockers II Receptor Angiotensin Common Side Effects What to do • Get up slowly when changing position such as moving from lying to sitting or sitting to standing. Dizzy • Contact your health care provider if these side effects Lightheaded continue or get worse. • This side effect may be the strongest after your first dose especially if you also take a .

• Get up slowly when changing position such as moving from Lowering of blood lying to sitting or sitting to standing. pressure • Contact your health care provider if these side effects continue or get worse.

Diarrhea • Contact your health care provider if it lasts more than 2 days.

Serious but not common What to do side effects Swelling of your face, lips, tongue • Stop taking the ARBs. Trouble breathing, Difficulty • Contact your doctor right away or go to your nearest swallowing emergency department.

Do you know? That it can sometimes take several weeks or months before your symptoms improve and you start to feel better.

Medication Tips • ARBs might make you dizzy or lightheaded • ARBs could increase the potassium for the first few days, but this usually improves level in your body. Do not take potassium over time. supplements unless prescribed by your • If these symptoms do not get better, your health-care provider. health care provider might need to change • Check with your health care provider before the amount of the ARB you are taking using products that contain potassium such • If you have symptoms of low blood pressure, as salt substitutes you may want to avoid activities that will lower • Your health care provider will do a blood Medication your blood pressure even further such as: test to check your potassium level and • Drinking alcohol kidney function from time to time • Doing strenuous exercise • Contact your health care provider if you have diarrhea and/or vomiting that lasts more than • Taking a really hot shower or bath two days. • Using a hot tub • As it may cause you to lose too much water which could cause problems with your kidneys

30 Heart & Stroke – Living with Heart Failure Medication 31 It can take several weeks, weeks, several It can take Anti-inflammatory medicines (such as Advil, Advil, (such as medicines Anti-inflammatory Ibuprofen, Motrin, Naproxen, Aleve, Celebrex) Aleve, Naproxen, Motrin, Ibuprofen, What if you miss taking a dose? miss taking a dose? you if What • Herbal medicines • Chinese medicines •  a pharmacy at can by • Other medicines you information contact provider Health care ______know? Did you notice you before and sometimes months, start and you improving heart failure your feeling better. taking dose, skip next you time for If it is almost next your take missedthe dose just you and scheduled dose. doses the same two time. at take Never about taking your questions have If you missed or medications, doses, your contact provider. health care or your pharmacist without the following of any take Do not provider health care checking with your • Alcohol • Cough or cold medicines • Black licorice

Heart & Stroke – Living with Heart Failure Heart & Stroke

Other ______Carvedilol (Coreg) (Lopressor) (Monocor) Bisoprolol Lower your blood pressure so your heart so heart your blood pressure your Lower doesn’t have to work as hard as hard work to have doesn’t • Improve your quality of life quality of your • Improve longer live • Help you • Slow the progress of your heart failure your of the progress • Slow Beta Blockers can: Beta Blockers •  How do Beta Blockers help with help with do Beta Blockers How heart failure? • After a heart attack a heart attack • After • Fast heart rate or irregular heart rhythms heart rhythms or irregular heart rate • Fast pain • chest • Heart failure • High blood pressure What are Beta Blockers used for? used for? Beta are Blockers What your body. Blocking your stress hormones hormones stress Blocking your body. your your it easier for making blood vessels, relaxes pump. heart to hormones narrow blood vessels making it making it blood vessels hormones narrow around pump blood heart to your for harder relax the heart muscle and slow down the the down the heart muscle and slow relax These also medications block the heart rate. Stress hormones. stress your body’s of effects What are Beta Blockers? are What medications that of a group are Beta Blockers ❑ ❑ ❑ the one you are taking. are you the one ❑ Most common Beta common Blockers Most off check to provider health care your Ask Beta Blockers Common Side Effects If you get any of these side effects, talk with your health care provider about how best to deal with them. Contact your health care provider right away if any of these side effects listed below do not go away or get worse.

• Feeling tired all the time • Changes in mood • Dizzy or lightheaded • Feeling down or depressed • A very slow heart rate (medication slows down • Trouble sleeping your heart too much) – can make you feel dizzy • Nightmares • Short of breath or trouble breathing • Loss of sexual desire • Cold hands or feet • Liquid bowel movements (diarrhea) • Numbness or tingling in your hands or feet

If you are taking , beta blockers can mask or hide signs of a low blood sugar. For example, you might not feel shaky or feel your heart racing. However, you will have other signs of a low blood sugar such as hunger and sweating. Do you know? People often feel worse for the first 1 to 2 weeks after starting beta blockers or after the dose is changed. You might feel more tired that usual, or notice your heart failure symptoms are worse.

Medication Tips Before you start taking a , make If you have low blood pressure, do not do sure you tell your health care provider: anything that can lower your blood pressure • If you have a history of breathing problems even further. (such as ) • Do not drink alcohol. • If you have peripheral vascular disease • Do not do any strenuous exercise. (such as cold hands or feet, or pain in legs • Do not take really hot showers or baths, after walking) or use a hot tub. If you have high blood pressure, talk with your Contact your health care provider right away health care provider before using any products if you have any of these signs of a very bad that might raise your blood pressure such as:

Medication reaction to the beta blocker: • Cough or cold drugs • Wheezing • Diet pills or other • Chest tightness • Ibuprofen • Itching skin • Natural products • Seizures Do not suddenly stop taking beta blockers. • Swelling of face, lips, tongue, or throat It can make your heart failure worse. • If you feel like you are going to faint or collapse

32 Heart & Stroke – Living with Heart Failure Medication 33 Anti-inflammatory medicines (such as Advil, Advil, (such as medicines Anti-inflammatory a pharmacy canat Other medicines you buy Ibuprofen, Motrin, Naproxen, Aleve, Celebrex) Aleve, Naproxen, Motrin, Ibuprofen, without a prescription • Alcohol • Cough or cold medicines • Black licorice • Herbal medicines • Chinese medicines •  •  information contact provider Health care ______What if you miss taking a dose? you if What taking dose, skip next your time for If it is almost next your take the dose missed and just you scheduled dose. doses the same two time. at take Never about taking your questions have If you missed or medications, doses, your contact provider. health care or your pharmacist without the following of any take Do not provider: health care checking with your supplements • Potassium • Salt substitutes

Heart & Stroke – Living with Heart Failure Heart & Stroke

Spironolactone (Aldactone) (Inspra) Could prevent you from needing treatment needing treatment from you Could prevent Decreases swelling in your legs and bloating legs and bloating in your swelling Decreases Less water in your body lowers your blood blood your body lowers in your water Less Other health problems that cause that fluid Other health problems Your kidneys get rid of more salt (sodium) salt (sodium) more rid of get kidneys Your for heart failure in the hospital heart failure for in your stomach in your pressure so your heart doesn’t have to work work to have so heart doesn’t your pressure as hard to build-up in the body to and water by increasing how much you much you how increasing by and water (‘pee’). urinate

•  • Decreases your shortness of breath shortness of your • Decreases •  How do MRA help with heart failure? do MRA help with heartHow failure? •  •  • Heart failure • High blood pressure What are MRA are used for? What • Your kidneys hold onto more potassium. potassium. more hold onto kidneys • Your •  water in your body. MRA’s have two actions. two actions. have MRA’s body. in your water By blocking this : Class of medication that blocks – – Aldosterone blocks that medication Class of kidneys helps your that hormone a and sodium,potassium, of the amount control What are MRA? are What ❑ ❑ Ask your health care provider to check off off check to provider health care your Ask taking. are the one you Most common MRA common Most Mineralocorticoid Receptor Antagonist (MRA) Antagonist Receptor Mineralocorticoid antagonists. or aldosterone inhibitors also medications called of aldosterone A group Common Side Effects Always tell your health care provider if you have any side effects.

• High levels of potassium in your blood • Feeling sick to your stomach (nauseated) • Urinating or going pee too often • Not having an appetite • Feeling dizzy or lightheaded • Headache •  (when you have • Muscle cramps lost too much fluid) • For men: You may be dehydrated if you: • Breast tenderness • Lose more than 4 lbs in 2 days or 5 lbs • Enlarged breasts in a week. Less common side effects • Have a really dry mouth. • Rash • Are very thirsty. • Menstrual irregularities and breast • Are extremely dizzy. tenderness in women • Your urine (pee) is a really dark-colour.

Contact your health care provider right away if side effects do not go away or get worse.

Medication Tips • While taking an aldosterone blocker, weigh • Your health care provider might arrange for yourself every day and record your weight. regular blood tests to check your potassium • Call your health care provider if you gain and sodium levels, and kidney function. more than 4 lbs (2 kg) in 2 days in a row • Always check with your health care provider or 5 lbs (2.5 kg) in 1 week. before you stop taking your aldosterone • Do not drink more than 1½ to 2 litres of fluid blocker. If you stop taking this medication, your each day. heart failure could get worse. 1½ - 2.0 litres = 48 - 64 ounces = 6 - 8 glasses • Always tell your health care provider if you (Refer to Limiting Fluid resource on our website are taking high blood pressure medications, to learn more visit heartandstroke.ca/heart/ digoxin, anti inflammatory medication, or conditions/heart-failure) such as .

Medication • To keep from feeling sick to your stomach, • Always tell your health care provider if you eat food right before or after taking the have diabetes, kidney disease, disease, medication. or . • Do not take potassium supplements or eat • If you have low blood pressure, do not do foods high in potassium such as dried fruit, anything that can lower your blood pressure potatoes, orange juice, bananas, and avocados. even more. Refer to Foods High in Potassium resource on • Do not drink alcohol. our website visit heartandstroke.ca/heart/ • Do not take really hot showers or baths, conditions/heart-failure use a hot tub or sauna.

34 Heart & Stroke – Living with Heart Failure Medication

35

Angiotensin Converting Enzyme Inhibitor Enzyme Inhibitor Converting Angiotensin Blocker II Receptor An additional Angiotensin Anti-inflammatory medicines (such as Advil, Advil, (such as medicines Anti-inflammatory Prevent you from needing to be in the hospital be in the hospital needing to from you Prevent heart failure your of the worsening Slow Indocid) (ACE-I) (ARB) Ibuprofen, Motrin, Naproxen, Aleve, Celebrex, Celebrex, Aleve, Naproxen, Motrin, Ibuprofen, for heart failure treatment treatment heart failure for •  •  take your next scheduled dose. Do not take the the take scheduled dose. Do not next your take missed dose. two doses the same time. at take Never your about taking questions have If you or missedmedications, doses, your contact provider. healthcare or your pharmacist without the following of any take Do not provider: healthcare checking with your • Alcohol • Cough or cold medicines • Black licorice • Herbal medicines • Chinese medicines •  How does an ARNI help with heart failure? with heart an ARNI help does failure? How medications, heart failure When used with other it may: longer live • Help you symptoms failure heart your • Improve •  •  miss taking a dose? if you What dose, next your than 4 hours until If it is more usual your the missed dose then take take dose the usual time. at dose, just next your If it is less than 4 hours until

Heart & Stroke – Living with Heart Failure Heart & Stroke ) TM heartandstroke.ca/heart/ inhibits or blocks an enzyme called inhibits or blocks is an angiotensin II receptor blocker blocker II receptor is an angiotensin

Other ______Sacubitril/Valsartan (Entresto /Valsartan conditions/heart-failure To learn more about ‘ejection fraction’, fraction’, about ‘ejection learn more To visit our website the work of the heart and may improve your your improve the heart and may of the work ejection fraction. ARNIs are used to treat heart failure by by heart failure used treat to ARNIs are rid of and getting the blood pressure lowering reduce these medicines Together, fluid. excess What are ARNIs used for? are What fluid. This makes it easier for your heart to to your heart for it easier fluid. This makes pump blood. (called natriuretic ) help blood vessels blood vessels help peptides) (called natriuretic excess rid of get body to your allowing relax, neprilysin (a neprilysin inhibitor). When this When this inhibitor). neprilysin (a neprilysin substances helpful it allows enzyme is blocked, These substances in the body longer. stay to pressure. Sacubitril relax, and blood flows more easily. This reduces reduces This easily. more and blood flows relax, blood your heart and lowers your of the work vessels. Stress hormones make it harder for for it harder hormones make vessels. Stress By the body. pump blood around the heart to vessels blood hormone, blocking the stress (ARB). It stops your body from making stress making stress body from your It stops (ARB). blood or narrow hormones, which constrict and valsartan. and valsartan. Valsartan What is an Angiotensin Receptor – – Receptor is an Angiotensin What (ARNI)? Inhibitor Neprilysin two medications, sacubitril of It is a combination ❑ the one you are taking. are you the one ❑ Most common ARNIs common Most off check to provider health care your Ask Angiotensin Receptor – Neprilysin Inhibitor (ARNI) Inhibitor – Neprilysin Receptor Angiotensin Common Side Effects What to do Do not do anything that could lower your blood pressure even further. Examples: Lowering of blood pressure • Do not drink alcohol. • Do not do any strenuous exercise. (Always check with your healthcare provider first). • Do not take really hot showers or baths. • Do not use a hot tub.

• Get up slowly when changing position, such as moving Dizzy from lying to sitting or sitting to standing. Lightheaded • Dizziness usually goes away after your body gets used to the medication. • Call your healthcare provider if: • Your pee (urine) is dark coloured and Decrease in how much you pee • You are not going pee (urinating) as much as you normally do. • If the cough gets worse or becomes a problem for you, Dry cough contact your healthcare provider.

Tired or weak • Balance rest and activity

• If you are currently taking this medication: • With food, try taking it without food. Nausea or • Without food, try taking it with food. Stomach upset • Get rid of strong smells. • Open windows to get fresh air. • Use a fan, air deodorizers, or air fresheners. Serious but not common What to do side effects Swelling of your face, lips, tongue • Stop taking this medication immediately. Medication Trouble breathing, Difficulty • Contact your doctor right away or go to your nearest swallowing emergency department.

36 Heart & Stroke – Living with Heart Failure Medication 37

Medications used to treat pulmonary pulmonary Medications used treat to in the potassium increase Medications that  (Rasilez) Aliskiren Cyclosporine C HIV or treat Medications to blood your decrease may Medications that Do not take potassium supplements unless unless supplements potassium take Do not before provider healthcare Check with your medication lowering Cholesterol pills () Water erectile Medications used treat to dysfunction (Viagra) dysfunction eplerenone) blood (spironolactone, (including nitroglycerine) pressure prescribed by your health-care provider. health-care your by prescribed such potassium contain that using products as salt substitutes. atorvastatin) (simvastatin, •  •  • •  • •  •  •  •  •  •  •  Certain medications can increase your risk risk can your Certain medications increase of side effects. Always tell your healthcare your healthcare tell Always side effects. of these of taking any are if you provider medications: ARNIs can increase the potassium level in in level potassium the ARNIs can increase your body. body. your •  • 

you Heart & Stroke – Living with Heart Failure Heart & Stroke . Pregnant or planning to become pregnant become pregnant to or planning Pregnant (It can cause injury and even to your your to (It can death cause injury and even unborn baby). • 18 years or younger. • 18 years • Breastfeeding. •  Take your ARNI exactly as directed by your your by as directed ARNI exactly your Take Do not suddenly stop taking your ARNI ARNI taking your suddenly stop Do not If your medication dose is being increased or dose or medication is being increased If your If your healthcare provider is switching your your is switching provider healthcare If your well. feel if you even provider, healthcare breathing, difficulty swallowing, or have have or swallowing, difficulty breathing, lips or tongue. face, your of swelling without checking with your healthcare healthcare without checking with your trouble having you are if except first, provider level and kidney function. and kidney level decreased, your healthcare provider will want will want provider healthcare your decreased, potassium check your to do a blood test to dose of the ACE-I before you take your your take you before the ACE-I dose of of ARNI dose first medication from an ACE-I to an ARNI, an ARNI, to an ACE-I from medication last your hours after 36 least at wait must •  •  •  • Do not take an ARNI if you are: ARNI if you an take • Do not Medication Tips Medication •  Ivabradine (Lancora)

What is ivabradine? Cautions This is a type of medication that slows the heart Do not take any of the following without rate. It does this by inhibiting the electrical checking with your healthcare provider current made by the heart’s natural pacemaker. xxBlack licorice How can it help with heart failure? xxAlcohol Ivabradine works by slowing your heartbeat by xxCough or cold medicines a few beats each minute. This reduces the work xxSt. John’s Wort of your heart (workload). xxHerbal or Chinese medicines Your healthcare provider decides the right dose for you to take. This dose might be changed, xxAboriginal herbs based your heart rate. xxAnti-inflammatory medicines (such as Advil, This medication could be added to your Ibuprofen, Motrin, Naproxen, Aleve, Celebrex, treatment. When used with other heart failure Indocid) medications, it may: Ivabradine is not for you if: • Slow the worsening of your heart failure • You are allergic to this medication. • Improve your heart failure symptoms • Your resting heart rate is less than 70 beats a • Improve your ejection fraction* minute before taking this medication. • Prevent stays in the hospital for heart failure • Your blood pressure is lower than 90/50 (90 treatment over 50). What if you miss taking a dose? • You have a pacemaker. Ivabradine is taken 2 times a day, in the morning • You have one of these heart conditions: and in the evening. -- a recent heart attack If more than 4 hours until your next dose, take -- severe heart failure needing a stay in the the missed dose then take your usual dose at hospital the usual time. -- atrial If less than 4 hours until your next dose, just -- long QT interval take your next scheduled dose. Do not take the missed dose. • You have severe liver problems. Medication Never take 2 doses at the same time. • You are pregnant or trying to get pregnant. • You are breastfeeding. • You are younger than 18 years old. • You are taking certain , certain anti- fungal medicines, certain HIV medicines, and/ or a certain medicine for depression (Your healthcare provider know which ones).

*To learn more about ‘ejection fraction’, see page 3.

38 Heart & Stroke – Living with Heart Failure Medication 39 immediately.

Stop taking this medication Stop department. emergency nearest your Go to Wear sun glasses if the vision problems get worse with worse with get sun glasses if the vision problems Wear light. changes of want might They provider. healthcare Check with your the dose. lower to without checking taking this medication stop Do not provider. healthcare with your with food. this medication Take smells. strong rid of Get air. fresh get to Open windows fresheners. or air air deodorizers, Use a fan, provider. healthcare your Contact do to What Get up slowly when changing position, such as moving such as moving position, when changing up slowly Get standing. to or sitting sitting lying to from activity. with Balance rest your a minute, is less than 50 beats heart rate If your to the dose ask you or lower might provider healthcare taking it. stop need might You provider. healthcare your Contact with heart tracing checked heart rhythm your or E.C.G.). (electrocardiogram What to do to What What to do to What Heart & Stroke – Living with Heart Failure Heart & Stroke

See halos around objects See halos around of colour or patterns See flashes Blurred vision Blurred light of spots See bright Dizzy Lightheaded Tired or weak or weak Tired lips, tongue Trouble breathing Trouble swallowing Difficulty face, your of Swelling Less Common Side Effects Diarrhea, constipation, Diarrhea, constipation, the skin, itching of Rash, redness Less Common Side Effects Stomach upset upset Stomach Nausea or These are temporary and happen in the the happen in and temporary These are of taking this medication. 2 months first • • • • brightness of light around changes changes around light of brightness such as: suddenly, Vision problems, especially when the the especially when Vision problems, – irregular heartbeat heartbeat – irregular Palpitations • • Slow heartbeat causing you to feel: to causing you heartbeat Slow • Common Effects Side Contact your healthcare provider if any of these side effects continue or get worse or get continue these effects side of if any provider healthcare Contact your Medication Tips • Expect to go for a heart tracing (E.C.G.): • Do not drink grapefruit juice or eat grapefruits -- before you start taking this medication while taking this medication. Grapefruit changes how this medication is absorbed in -- 2 weeks after you start taking it the body, causing more side effects. -- any time you healthcare provider changes the dose • Certain medications can affect how this medication is absorbed in your body and can • Take your ivabradine exactly as directed by increase the side effects. your healthcare provider, even if you feel well. Always tell your healthcare provider what other medicines you are taking, including: • Do not suddenly stop taking ivabradine -- antibiotics without checking with your healthcare -- medications to treat a fungal provider first, except if: -- medications to treat depression -- You are having trouble breathing or difficulty swallowing -- medications to treat HIV -- You have swelling of your face, lips, -- herbal, Chinese, or Aboriginal natural or tongue. remedies or medicines -- You are so dizzy you are falling down. -- medications for your heart or blood pressure -- medications to treat epilepsy

If you have questions about taking your medications, or missed doses, contact your pharmacist, your healthcare provider, or call 9-1-1. Medication

40 Heart & Stroke – Living with Heart Failure Medication 41 Anti-inflammatory medicines (such as Advil, Advil, (such as medicines Anti-inflammatory Ibuprofen, Motrin, Naproxen, Aleve, Celebrex) Aleve, Naproxen, Motrin, Ibuprofen, • Herbal medicines • Chinese medicines •  a pharmacy can buy at • Other medicines you information contact provider Health care ______What if you miss taking a dose? you if What taking dose, skip next your time for If it is almost next your take missedthe dose just you and scheduled dose. doses the same two time. at take Never about taking your questions have If you missed or medications, doses, your contact provider. health care your pharmacist, or without the following of any take Do not provider: health care checking with your • Alcohol • Cough or cold medicines • Black licorice

Heart & Stroke – Living with Heart Failure Heart & Stroke

Hydrochlorothiazide (HydroDIURIL, (HydroDIURIL, Moduret) Other ______Bumetanide (Burinex) (Burinex) (Zaroxolyn) Metolazone  Furosemide (Lasix) Furosemide Improve your quality of life quality of your Improve Help you urinate (‘go pee’) more so your body so body your more pee’) (‘go urinate Help you Prevent or reduce shortness of breath, breath, shortness of or reduce Prevent Lower your blood pressure so your heart so heart your blood pressure your Lower Other health problems that cause that fluid Other health problems work as hard to pump to as hard work has less fluid and your heart doesn’t have to to have your heart doesn’t has less fluid and swelling and bloating swelling doesn’t have to work as hard as hard work to have doesn’t to build-up in the body build-up in the body to

•  •  •  •  How do Diuretics help with my heart failure? heart failure? help with my do Diuretics How can: Diuretics •  • Heart failure • High blood pressure What are Diuretics used for? used for? Diuretics are What salt in your body. Many people call people these Many body. salt in your ‘water-pills’. medications What are Diuretics? are What help your medications that are Diuretics and extra water extra any rid of get kidneys ❑ ❑ ❑ ❑ the one you are taking. are you the one ❑ Most common Diuretics common Most off check to provider health care your Ask Diuretics Common Side Effects Always tell your health care provider if you have any side effects.

• Urinating or going pee often • Feeling sick to your stomach (nauseated) • This can last up to 4 hours after or not having an appetite you take your diuretic. • Feeling very tired or weak • Feeling dizzy or lightheaded • Skin rash • Loss of potassium and sodium (salt) which • Dehydration (when you have lost too could cause: much fluid). • irregular heartbeat You are dehydrated if you notice you have a • muscle cramps really dry mouth, you are very thirsty, your urine (pee) is dark-coloured, or you are • blurred vision extremely dizzy. • • headache

Contact your health care provider right away if these side effects do not go away or get worse.

Medication Tips • While taking a diuretic, weigh yourself every • Limit the amount of time you in the sun and day and record your weight. Call your health always wear sun screen (even on cloudy days). care provider if you gain more than 4 lbs (2 kg) • Always tell your health care provider if you are in 2 days or 5 lbs (2.5 kg) in 1 week. taking high blood pressure medications, digoxin, • Always check with your health care provider anti inflammatory medication, or steroids. before you stop taking your diuretic. If you stop • Always tell your health care provider if you have taking your diuretic, your heart failure could diabetes, kidney disease, liver disease, or gout. get worse. • Check your blood pressure at least once a • Drink no more than 1.5 to 2 litres of fluid week or have it checked by your health care each day. provider. 1.5-2.0 litres = 48-64 ounces = 6-8 glasses • Make sure your blood is tested regularly to (Refer to Limiting Fluid resource to learn more) check the levels of potassium and sodium, and • If you get an upset stomach from taking your Medication to check your kidney function. diuretic, take your pills with meals. • If you have low blood pressure, do not do • Get up slowly when changing position such anything that can lower your blood pressure as moving from lying to sitting and sitting even more. to standing. • Do not drink alcohol. • Balance rest with activity to conserve • Do not do any heavy exercise. your energy. • Do not take really hot showers or baths, • Take your last dose before 5:00 p.m. so you or use a hot tub or sauna. don’t have to get up often during the night.

42 Heart & Stroke – Living with Heart Failure Medication 43

• lower your blood pressure blood your • lower heart your of the work • reduce life of quality your • improve longer live • help you the hospital of out stay • help you Anti-inflammatory medicines (such as Advil, Advil, (such as medicines Anti-inflammatory a pharmacy buy at Other medicines you Ibuprofen, Motrin, Naproxen, Aleve, Celebrex) Aleve, Naproxen, Motrin, Ibuprofen, without a prescription ______Never take two doses the same time. at take Never your about taking questions have If you or missedmedications, doses, your contact provider. health care pharmacist, or your without the following of any take Do not provider: health care checking with your • Alcohol • Cough or cold medicines • Black licorice • Herbal or Chinese medicines •  •  information contact provider Health care ______How will this combination help with your your help with this combination will How heart failure? these can: medications Together, miss taking a dose? if you What dose, skip next your time for If it is almost your take taking the dose missed. Just you scheduled dose. next

Heart & Stroke – Living with Heart Failure Heart & Stroke

Nitroglycerin (patch) (Minitran, Nitro-Dur, Nitro-Dur, (Minitran, (patch) (pill) (Isordil) (pill) (Isordil) Isosorbide dinitrate Transderm-Nitro, Trinipatch) Transderm-Nitro, Other ______  (pill) (Imdur) Isosorbide-5-mononitrate

❑ ❑ ❑ ❑ Ask your health care provider to check off check off to provider health care your Ask taking. are the one you Most common nitrates Most These are a group of medications that relax relax medications that of a group These are heart. on your easing the work , your What are nitrates? are What Hydralazine is the most common name but it name but it common is the most Hydralazine could also be called Apresoline. It is a medication that relaxes your arteries. This This arteries. your relaxes It is a medication that blood and allowing blood pressure, your lowers your body. easily through more flow to oxygen What is hydralazine? What the combination of hydralazine and nitrate in in and nitrate hydralazine of the combination medications. heart failure standard addition to Enzyme Inhibitor (ACE) or Angiotensin II II or Angiotensin (ACE) Enzyme Inhibitor (ARB). Blocker Receptor from benefit decent African people from Also, are used to treat heart failure if you are not not are if you failure heart used treat to are Converting an Angiotensin either take able to Why take both hydralazine and a nitrate? hydralazine both take Why nitrate and a hydralazine of The combination The Combination of Hydralazine and a Nitrate and Hydralazine CombinationThe of Common Side Effects Hydralazine Nitrate • low blood pressure with feeling dizzy or lightheaded • headache • feeling weak • very low blood pressure • constipation • dizzy or lightheaded • loose bowel movements or diarrhea • of the face and neck • headache • skin irritation with patch adhesive • flushing (warmth or redness in your face, neck, or chest) (consider the instead)

Talk to your health care provider if you have any of these common side effects, if they worry you. Serious Side Effects

Hydralazine Nitrate • fainting • blurred vision • fast or pounding heart • chest pain • numbness, tingling, or burning pain in your hands or feet • fainting • rash • • swollen • difficulty breathing or swallowing • unexplained fever • an upset stomach (nausea) • throwing up (vomiting) Contact your health care provider right away if you have any of these serious side effects.

Medication Tips While taking the combination of hydralazine • If you have low blood pressure, do not do and nitrate, get your blood pressure checked anything that can lower your blood pressure regularly. even further. When taking nitrate by patch: • Do not drink alcohol. • Do not exercise outside of your limits. • Always remove the patch for at least 12 hours in a row within a 24 hour period. This prevents • Do not take really hot showers or baths your body from getting used to the medication. • Do not use a hot tub. • Always change where you put the patch on • These medications can cause dizziness. your body. This helps prevent skin problems. Do not drive a car or operate heavy duty Medication machinery until you know how these When taking nitrate by pill: medications affect you. • Always wait at least 12 hours between taking • While taking a nitrate, do not take erectile your last dose one day and your first dose the dysfunction medication (such as Viagra, Cialis, next day. This prevents your body from getting Levitra). It could result in a serious drop in your used to the medication. blood pressure and make you faint. • Do not suddenly stop taking the combination of hydralazine and nitrate. It could make your heart failure worse.

44 Heart & Stroke – Living with Heart Failure Medication 45

Your health care provider provider health care Your much to: how you will tell warfarin the dose of Increase warfarin the dose of Decrease

When the When the INR is: Low Too High Too If it is almost time for your next dose, skip taking dose, skip taking next your time for If it is almost dose at next your the dose missed. you Take the scheduled time. two doses the same time. at take Never your about taking questions have If you or missedmedications your doses, contact provider. or health care pharmacist without the following of any take Do not provider: health care checking with your medication new • Any • Alcohol • Cough or cold medicines • Black licorice • Herbal medicines • Chinese medicines a pharmacy can buy at • Other medicines you It is not always easy to keep your INR at the the INR at your keep to easy always It is not your because things affect many level right clotting. blood’s miss taking a dose? if you What if you know provider health care your let Always your INR miss a dose. Missing a dose can affect missed you a dose, your knowing Not results. dose could change your provider health care or less than it should be changed. more

Heart & Stroke – Living with Heart Failure Heart & Stroke

You have had a clot have You Other ______Atrial fibrilation Atrial Heart valve called International Normalized Ratio (INR). Ratio Normalized called International adjust the dose to the right amount for you. you. for amount the dose the right to adjust is blood clotting check your to The blood test taking warfarin. You must have blood tests often often blood tests have must You taking warfarin. provider your health helps care test first. This at the time? while regularly blood tested your have must You prevents the clot from getting any bigger. any getting from the clot prevents all blood tests get have do you Why warfarin prevents clots from forming. from clots prevents warfarin warfarin a blood clot, have already If you If you have a health problem that increases increases that a health problem have If you clot, a blood getting you the chances of How does Warfarin help? help? does Warfarin How ❑ ❑ ❑ ❑ People take warfarin for different . different for warfarin take People check off to provider care health your Ask it. taking are you why the Why are you taking Warfarin? taking Warfarin? you are Why It does not actually thin your blood. It just blood. It just thin your actually It does not easily. more bleed you makes in your body from forming or getting bigger. or getting forming from body in your called is sometimes a ‘blood thinner’. Warfarin What is Warfarin? is What clots blood stops that is a medication Warfarin Warfarin (Coumadin) Warfarin Common Side Effects Always tell your health care provider if you have any side effects.

• Bruising easily • Red spots on the skin • Small amounts of bleeding from gums when • Feeling tired you brush and floss your teeth • Feeling slightly lightheaded • Getting small nose bleeds • For women, having heavier than usual • Taking a long time to stop bleeding when menstrual periods you have a cut

Contact your health care provider right away if side effects do not go away or get worse. Arrange to see a health care provider as soon as possible if you have a serious fall or injury.

When to go to Emergency or call 9-1-1 If your INR gets too high, there is a greater If your INR is too low, there is a greater chance you could start bleeding and need chance you could get a blood clot and need to get help. to get help. Signs you are bleeding somewhere: Signs you have a blood clot somewhere: • Bloody or black stools (‘poo’) • Sudden weakness in one or both of your • Pink, red, or dark brown urine (‘pee’) arms or legs • Coughing up blood • Changes in your vision • Throwing up blood or throwing up what looks • Slurred speech like grounds • Dizziness or fainting • Bleeding from the gums, nose, or eyes that • Pain or swelling in your lower legs will not stop • Prolonged or severe headache • Bleeding into the whites of the eyes • Chest pain • Painful, blue, or purple toes • Shortness of breath • Swelling of the abdomen or pain in the back that does not go away Medication • Severe headache

Health care provider contact information ______

46 Heart & Stroke – Living with Heart Failure Medication

47 anti-inflammatory medications such as such as medications anti-inflammatory ibuprofen (Advil, Motrin) or naproxen (Aleve), (Aleve), or naproxen Motrin) (Advil, ibuprofen or Celebrex • steroids • clopidogrel • Use a soft toothbrush. • Use soft a • Use electric razor. an • • digoxin •  • antibiotics Vitamin K helps your blood clot. While taking While taking blood clot. Vitamin K helps your To reduce the chances of bleeding: of the chances reduce To on works warfarin the how Alcohol can affect are if you provider health care your tell Always warfarin, it is important to keep the amount of of the amount keep to it is important warfarin, If the amount the same. diet vitamin K in your day, to day changes from eat vitamin K you of go up and down. INR results your it can make low, high or too too INR gets if your Remember, a clot getting bleeding or you the chances of increases. your blood. blood. your these medications: of taking any similar amounts each day. similar amounts •  high in vitamin K: Foods such as broccoli, leafy vegetables green spinach, kale, chard, cabbage, Swiss lettuce, beet Collards, seaweed, parsley, asparagus, brussel leaves, amaranth and turnip greens, sprouts eat these of foods, any normally eat If you •  •  • 

Heart & Stroke – Living with Heart Failure Heart & Stroke • herbal supplements acids) fatty • fish oil (Omega 3 • ibuprofen • herbal medicines To keep your blood circulating when sitting when sitting blood circulating your keep To You might need to get an INR blood test an INR blood test get need to might You Always check with your health care provider provider care health check with your Always If you take vitamin E, do not take any more more any vitamin E, take do not take If you for long periods, make sure you stretch your your stretch you sure long periods, make for body each hour. your legs and move Check with your health care provider. health care Check with your before you travel and/or while you are away. away. are while you and/or travel you before buy from the pharmacy without a doctor’s a doctor’s the pharmacy without buy from prescription. before taking any other medicines you can medicines you other taking any before than 400 units (IU) a day. •  •  •  •  • While taking warfarin, do not take: do not • While taking warfarin, If you become pregnant or wish to get get to or wish become pregnant If you Some medicines can increase your INR INR your Some medicines can increase Most activities are safe. However, do not take take do not However, safe. activities are Most Keep active. Regular activity helps circulate activity helps circulate Regular active. Keep Always check with your health care provider provider health care check with your Always Wear medical alert identification that tells tells that medical alert identification Wear pregnant, you should not be taking warfarin. be taking warfarin. should not you pregnant, provider. health care your to Talk and increase the chances of bleeding. bleeding. the chances of and increase such as contact sports. such as contact part in any activities where injury is common, injury is common, where activities part in any your blood and can help prevent clots clots can blood and help prevent your forming. from before you stop taking warfarin. If you stop stop If you warfarin. taking stop you before a stroke. have could you suddenly, others you are taking warfarin. are you others When you travel: When you •  •  •  •  •  MedicationTips •  Digoxin (Lanoxin or Toloxin)

What is Digoxin? What if you miss taking a dose? Digoxin is a medication that: If you remember within 12 hours of when were • Slows your heart rate down to take the missed dose, take it as soon as you remember. • Helps the heart beat stronger If you are due to take your next dose in less than This medication might be added to your 12 hours, do not take the missed dose. Wait and treatment plan to improve some symptoms take your next dose when you normally take it. of your heart failure. Continue to take your digoxin as scheduled

What is Digoxin used for? If you have questions about taking your medications, or missed doses, contact your For people with heart failure, we use digoxin to pharmacist or your health care provider. help the heart beat stronger and pump better. For people with irregular heart rhythms (such Do not take any of the following without as ), we use digoxin to help the checking with your health care provider: heart beat slower. • Herbal medicines

How does Digoxin help with heart failure? • Alcohol When digoxin strengthens the pumping action • Cough or cold medicines of the heart, it should help you: • Black licorice • Feel less tired • Chinese medicines • Feel stronger • Anti-inflammatory medicines (such as Advil, • Feel less short of breath Ibuprofen, Motrin, Naproxen, Aleve, Celebrex) • Have less swelling of the feet and ankles • Other medicines you can buy at a pharmacy Digoxin helps control some of the electrical impulses in the heart. This slows the heart beat Health care provider contact information down and helps it to beat with a more regular ______rhythm. This adds to the effects of a stronger ______pumping action. ______Digoxin helps keep your heart failure symptoms Medication from getting worse.

48 Heart & Stroke – Living with Heart Failure Medication

49

You have trouble seeing, everything looks looks seeing, everything trouble have You Your heart is beating very slow (less than 50 (less than 50 slow very heart is beating Your does not nausea that and vomiting have You with blood diarrhea, even maybe have You seeing things confused, are very feel You that are not there (hallucinating), or have or have (hallucinating), there not are that or behaviour. unusual or you is blurry, everything or yellow, green objects. around see ‘halos’ beats a minute) and you feel weak or dizzy. weak feel and you a minute) beats go away. black. in it or it looks •  •  •  •  •  • Red, green or yellow color disturbances yellow or green • Red, blurry • Things look slightly light bright to • Sensitive lights • Seeing flashing You might be sent for a blood test to check the check the to a blood test be sent for might You level of digoxin in your blood, especially when when blood, especially in your digoxin of level your health start taking it.tells This first you if the dose needs changing. This provider care hours after done 8 or more is best blood test dose. last your away right provider health care your Contact Department Emergency the nearest or go to much too these of signs of any have if you body: in your digoxin •  •  • Skin rash, itchiness itchiness • Skin rash, dizzy or lightheaded • Feeling • Headache vision: • Changes in your

Heart & Stroke – Living with Heart Failure Heart & Stroke

If you can check your heart rate and blood and blood can heart rate If you check your provider when to call with any changes in call changes in when to with any provider or blood pressure. heart rate your pressure at home, ask your health care health care ask your home, at pressure •  Feeling sick to your stomach stomach your sick to Feeling (nauseated) or get worse. or get Contact your health care provider right away if any of these side effects do not go away away go do not these side effects of if any away right health care provider Contact your Always tell your health care provider if you have any side effects. any have if you provider care health your tell Always Digoxin is broken down in your body by your your body by in your down is broken Digoxin You need your heart rate and blood pressure and blood pressure heart rate need your You If you take an antacid, high fibre foods, or fibre foods, or fibre high fibre an antacid, take If you Take your digoxin 1 hour before eating or or eating 1 hour before digoxin your Take you are having any kidney problems or have or have problems kidney any having are you to need a blood test might disease. You kidney working. are kidneys your well check how kidneys. Let your health care provider know if if know provider health care your Let kidneys. It can make your heart failure worse. worse. heart failure your It can make while taking digoxin. regularly checked your body. your a sudden. all of taking digoxin stop Never you can take your digoxin. These things can digoxin. your canyou take absorbed by digoxin of the amount reduce supplements, always wait 2 hours before before 2 hours wait always supplements, 2 hours after eating. 2 hours after • Do not feel like eating (lost your appetite) your (lost eating like feel • Do not • Throwing up (vomiting) • Throwing • Abdominal pain •  • Feeling weak or tired or tired weak • Feeling CommonSide Effects Medication Tips •  •  •  •  •  • Take your digoxin at the same time every day. the same time every at digoxin your • Take Herbs and Herbal Supplements Adapted from and Mayo Clinic information on herbs and herbal supplements.

Herbs and herbal supplements can be Tips harmful to people taking heart medications. • Before you cook with herbs contact your Always tell your health care provider about any health care provider. herbs or herbal supplements you are taking. • Always talk to your health care provider or Bring the herbs and herbal supplements you pharmacist before taking herbs or herbal are taking to every medical visit so they can supplements. They can review the herbal be checked. medicine and tell you whether it could impact your heart medication. What are herbs and herbal supplements? • If you are not sure what is considered an Herbs and herbal supplements are plants that herb or herbal supplement, see the list on the are used for medicinal purposes. Some people next page. call them botanicals or herbal remedies. • Never use herbs or herbal supplements if you Why should you be careful taking are taking one of these medications: these products? • Aspirin We do not always know what the active • Digoxin ingredients are in many herbs and herbal • Diuretics supplements. • Hypoglycemic medications such as Herbs and herbal supplements: • Non-steroidal anti-inflammatory • Can act in the same way as medications. medications such as ibuprofen (Advil, This means they can be dangerous to your Motrin), naproxen (Aleve), Celebrex health if not taken correctly, if taken in large amounts, or if taken in combination with other • Spironolactone medications. • Warfarin

• Can interact with heart medications. This Health care provider contact information: could cause the medication to not work as it should, magnify the medication’s side effects, ______or cause a life-threatening reaction. ______• Have not been studied to the same extent as Medication If you have questions about herbs or herbal other medications. supplements, contact your health care • They are classified as dietary supplements provider or pharmacist. not medications. Therefore they are not regulated the same way other medications To learn more about herbal supplements, are regulated. The rules for making dietary go online to MedlinePlus. Click on the tab supplements are not as strict. ‘Drugs & Supplements’ then select ‘Herbs and Supplements’ visit .gov/ druginfo/herb_All.html

50 Heart & Stroke – Living with Heart Failure Medication 51

take if you have have if you take Do not Do not take if you have a heart condition a heart condition have if you take Do not condition or takingcondition heart medication take if you are taking digoxin and blood pressure and blood pressure taking digoxin are if you take Possible problems when you have a heart a have when you problems Possible take if you have fluid retention caused by heart failure or failure causedby heart retention fluid have if you take Increases blood pressure: blood pressure: Increases or on heart medications. Do not poor kidneys. of the effect bleeding. Can decrease the risk of Can increase with certain antidepressants. be taken Should not digoxin. blood pressure. or decreases Increases heart rate. Increases out of the body. out of Could cause if death and blood pressure. heart rate Increases heart medications. with certain taken blood. your of with the clotting Can interfere bleeding, especially if used in excess. the risk of Can increase bleeding. the risk of Can increase how with blood. Can interfere your of with the clotting Can interfere medications work. heart or high blood pressure it can , or other aspirin, warfarin taking are If you bleeding. risk of your increase it can anticoagulants, or other aspirin, warfarin taking are If you with the actions of bleeding. Interferes risk of your increase (Lasix). diuretics and heart rate. blood pressure Increases of blood levels Can increase (hypertension). high blood pressure bleeding. the risk of Can increase digoxin. causes high blood pressure. blood pressure, Increases with blood thinners (anticoagulants). Can interfere Do not medications medication. and of blood pressure effects Can increase bleeding. risk of and increases blood pressure Causes low Causes abnormal heart rhythms in and in children. Causes in pregnancy abnormal heart rhythms especially when taking warfarin. bleeding, the risk of Can increase the heart. to and can be toxic Raise blood pressure bleeding the risk of increase Can blood pressure. Lowers liver. to be toxic bleeding). Can (cause more death. the risk of Increases the effect Can decrease heart function. improve Does not warfarin. of bleeding). bleeding (cause more the risk of Can increase helps clear medications that in the liver with an enzyme Interferes

Heart & Stroke – Living with Heart Failure Heart & Stroke

Reason for taking Reason for To treat impotence. treat To anti inflammatory. anti and heart high blood pressure treat To failure. Commonly used supplement. ulcers and liver coughing, stomach treat To . kidney bladder infections, treat To stones. and kidney infections and injuries. depression treat To To lower cholesterol. lower To stop nausea, cholesterol, lower relieve To aid in digestion. clotting, blood from your cholesterol. lower To colds and infections. and treat prevent To memory. circulation, improve To . prevent To capacity, physical memory, improve To aging. slow and to can also acts as an constipation, treat To To increase your energy. your increase To heart or other heart failure treat To conditions. heart conditions. treat To colds. prevent To asthma, obesity. treat To arthritis. migraines, treat/prevent To A common supplement. For constipation or . constipation For skin irritation. prevent To infection, indigestion, loss, Appetite syndrome. tension pre-menstrual injury. aches, or pain from reduce To constipation. relieve To or of symptoms relieve To syndrome. tension pre-menstrual substances rid of helps get Antioxidant radicals). harm the body (free that

Herb or herbal Herb or herbal supplement name supplement St Johns Wort St Johns Wort Nettle Nettle Licorice root Hawthorn Kelp Goldenseal Ginkgo Ginger Garlic Fish oil Flaxseed Ephedra (Ma Huang) Ephedra Feverfew Ubiquinol) Danshen miltiorrhiza-root) (Salvia Beta carotene CoQ10 (Co-enzyme Ubiquinone, Q10, Black cohosh (Cimicifuga racemosa) Arnica Aloe vera (Oral) Aloe vera Angelicaquai) (Dong Herbs and Herbal Supplements Herbal and Herbs herbal supplements. herbs and on information Clinic and Mayo Clinic Cleveland from Adapted Medication List

Patient’s Name: ______Doctor’s Name: ______

Prescribed Medication: Medication Name(s) Purpose Description Dosage Frequency

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13. Medication

14.

Non-prescription Medication:

52 Heart & Stroke – Living with Heart Failure More Information Heart & Stroke – Living with Heart Failure Heart & Stroke More Information More Frequency

Dosage Description Purpose Medication Name(s) Non-prescription Medication: Non-prescription Prescribed Medication: Prescribed 11. 12. 13. 14. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. MedicationList Name: ______Doctor’s Name: ______Patient’s Depression

Depression can affect anyone but people How can depression affect your with heart failure are more likely to become heart failure? depressed. For every 10 people with heart Depression can make your heart failure worse. failure, 5 to 7 will likely experience depression. If you are depressed, you will find it harder to do the things you need to do to manage your heart What is depression? failure (such as exercising, eating well, limiting It is a medical condition where a person feels fluids, and taking your medicines as directed). sad, loses interest in daily activities, withdraws from people, and feels hopeless about What causes depression? the future. Depression may be caused by one factor Depression is different from , sadness or a number of factors. Some factors that related to an event, or low energy. might cause depression include: • An imbalance in the natural chemicals How can a health care professional in the brain tell a person has depression? • A heart condition You must have a number of the following signs most of the day, every day for at least • A chronic health condition such as anemia 2 weeks: or hypothyroid • Constantly feeling sad for no reason • Difficult life events such as: • Feeling hopeless, guilty, or worthless • Death of a loved one • Little or no interest in people or activities • Divorce you use to enjoy • Loss of a job • Feeling really tired or low on energy •  • Sleeping too much or not enough • Using too much alcohol or drugs • Feeling like you are speeding up or • Family history of depression slowing down • Unplanned changes in your weight Depression is not caused by a ( or weight gain) personal weakness. • Changes in your appetite Sometimes when people feel very • Having trouble thinking, concentrating, depressed and overwhelmed, they start or remembering to think about hurting themselves. If • Having trouble making decisions you have started to make a plan to hurt yourself, go to the nearest emergency • Thinking about hurting yourself or about dying room right away.

54 Heart & Stroke – Living with Heart Failure More Information More More Information 55

depressed. depressed. mildly to moderately mildly to severely Reach out to friends and family. out to Reach if social plans and go even Make may You activities. pleasant time for Make problems. Identify and define address to possible actions of a list Make each action. and cons for Identify pros action and try it out.Pick the best you “don’t feel like it”. like feel “don’t you do these to yourself force gently need to to! want you until wait things. Don’t the problem. You are probably coping pretty well. Your Your well. pretty coping probably are You probably are You probably are You feelings of depression are probably not not probably are depression of feelings much. too life with your interfering depressed. Talk to your family doctor. Try Try doctor. family your to Talk depressed. help you on this page to some the ideas of depression. with your health or a mental doctor family See your away. right professional Socialize and have fun and have Socialize •  •  •  solving Problem •  •  •  •  it went. • Think about how When should you get help? get you should When 3 or lower scored If you •  6 4 to scored If you •  9 7 to between scored If you • 

Heart & Stroke – Living with Heart Failure Heart & Stroke 0 1 2 3 4 5 6 7 8 9 0 1 2 3 Ask yourself what you would say to a a to say would you yourself what Ask Try to be aware of your thoughts. (Negative (Negative thoughts. your of be aware to Try Set small household goals (doing the dishes, the dishes, small household goals (doing Set Set small self-care goals (taking a shower, a shower, goals (taking small self-care Set friend who had that negative . negative friend who had that thinking is very common with depression.) thinking is very paying some bills, take care of business you business you of care somepaying bills, take been avoiding) have taking a walk, eating well-balanced meal) well-balanced eating taking a walk, • Try to be kinder to yourself. be kinder to to • Try •  Watch out for negative thinking negative out for Watch •  •  Set small goals Set •  Talk – especially Cognitive Behavioural Therapy is helpful for people with heart conditions. people with heart conditions. for is helpful Therapy Behavioural – especially Cognitive Therapy Talk Some ideas on how to manage depression to Some ideas on how • Lifestyle changes such as exercise and proper sleep. and proper changes such as exercise • Lifestyle •  mood. improve • Medicines to How is depression treated? is depression How include: treatments Some effective medical get treatment. It is essential to (None) (A little) (Moderate) (Severe) (Moderate) little) (None) (A I been bothered by feeling sad, down, or or sad, down, feeling by I been bothered in life? uninterested the last two weeks.) the last much have how weeks, two the last Over Ask yourself the following question (Choose question the following yourself Ask over feeling your reflects most that the number How do you know if you are are you if know you do How depressed? Stress

What is stress? How do you know if you are Stress is your body’s reaction to an event stressed? or situation (real or imagined). Stress is not Ask yourself the following question (Choose the so much what happens to you, but how you number that most reflects your feeling over the respond to a situation or event. Too much stress last two weeks.) is hard on your mind, body, and especially Over the last two weeks, how much have I your heart. been bothered by feeling anxious, worried, While stress is a part of everyday life, too much nervous, stress increases a person’s chances of getting or tense? or worsening heart disease. High levels of stress 0 1 2 3 4 5 6 7 8 9 or stress over long periods can cause: (None) (A little) (Moderate) (Severe) • Increased blood pressure • Increased higher cholesterol If you scored 4 or lower • Increased chances of having a heart attack • You are probably coping pretty well with your or stroke stress. If you feel you would like more help than this sheet gives you, please talk to someone What are ? you trust. A is any situation or event that triggers If you scored between 5 and 8 your body’s stress response. Stressors are • It would be good for you to talk to your health different for each person. care provider or a mental health professional Examples of stressors: about how you are feeling. • Having a new diagnosis of heart failure If you scored 8 or higher • Limits in physical ability • You are very stressed and need to get help right away. • Having chronic pain • Dealing with a number of health conditions • Conflict in a relationship Sometimes when people feel very • Being isolated from friends and family stressed and overwhelmed, they start • Dealing with the death or to think about hurting themselves. If illness of a loved one you have started to make a plan to hurt • Changes at work yourself, go to the nearest emergency • Money worries room right away.

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Knots in your stomach, feeling sick sick feeling stomach, in your Knots to your stomach your to Use a calendar and a ‘to do’ list to help you help you to list Use a calendar and a ‘to do’ mind, ask yourself your enters When a worry manage your time. manage your is If the answer can solve. you if it is a problem If solve. aside some set problem time to yes, go! the worry let is no, the answer • Rapid, • Rapid, shallow neck, shoulders or • Muscle in jaw, tension in hands or legs • Tremors • Tingling or numbness in fingertips all the time tired sleeping, feeling • Trouble How stress can affect your can affect stress How helpless and frustrated • Feeling life your by overwhelmed • Feeling or worried anxious, • Feeling or angry hostile, irritable, • Feeling or hopeless depressed, down, • Feeling your body can affect stress How • Headache •  • Restlessness • Sweating pressure and blood heart rate • Increased • Have as much fun as possible. You deserve it! You as much fun as possible. • Have • Make small changes to organize your life. your organize small changes to • Make •  the good in self or others. for • Look • 

Heart & Stroke – Living with Heart Failure Heart & Stroke Never use alcohol, , or street drugs to help you manage your anxiety anxiety manage your help you drugs to or street use alcohol, tobacco, Never • Getting a full night’s sleep. a full night’s • Getting • Exercising daily to get rid of tension. rid of get daily to • Exercising body. nourish your to diet a healthy • Eating • , yoga, and stretching yoga, and stretching • Meditation, Practice deep breathing and other forms forms and other deep breathing Practice Trouble concentrating, short attention span, span, short attention concentrating, Trouble of relaxation such as: relaxation of easily distracted Some ideas on how to manage your stress to manage your Some ideas on how What might happen if you have too much stress much too have you if happen might What • Be assertive. • Limit what you take on. It is okay to say ‘no’. say to on. It is okay take you • Limit what • Call a friend. habits such as: healthy • Maintain •  • Sexual difficulties • Sexual • Smoking • Drinking alcohol • Withdrawing from others from • Withdrawing appetite or loss of • Overeating • Having more arguments more • Having tea, cola coffee, • Drinking more • Crying and pacing • Fidgeting, • Confusion your behaviour can affect stress How • Imagining the worst • Imagining the • Difficulty making simple decisions • Difficulty making problems over • Brooding • Poor judgement • Poor • Lapse in memory •  How stress can affect your thinking can affect stress How Some ideas on how to manage your stress Workbook • Positive Coping with Health Conditions – A Self-Care Workbook at www.comh.ca/pchc/ Choose to download the complete workbook or selected excerpts from the workbook such as ‘Managing Worry’ or ‘Relaxation’. For more information on Stress, check these resources: • Bounce Back Program: www.mentalhealthhelpline.ca

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Staying away from certain places, activities from away Staying Overestimating the chances something bad the chances something Overestimating bad a is or how Magnifying bad the situation how or making concentrating trouble Having or people will happen will be situation future decisions • Needing others to reassure you all the time you reassure to • Needing others person be with a ‘safe’ • Needing to •  • Pale • Muscle tension shaking • Trembling, • Numbness and tingling or cold flashes • Hot thoughts Possible or thoughts dreams frightening • Having •  •  can you cope believing • Not •  behaviours Possible lessen• Using alcohol or drugs to the anxiety What are the signs of anxiety?the signs of are What are they what recognize do not people Many they Instead, anxiety. signs of as being feeling with them. ‘wrong’ is physically think something your thoughts, your body, can affect Anxiety behaviour. and your body responses Possible heart pounding • Fast, breath shortness of • Rapid breathing, pain or discomfort • Chest • Sweating dizzy or lightheaded • Feeling • Dry mouth, nausea, upset stomach

Heart & Stroke – Living with Heart Failure Heart & Stroke

You have an imbalance of certain chemicals in an imbalance of have You You have a family history of problems with problems of history a family have You Always telling yourself the worst will happen the worst yourself telling Always Being dependent on or addicted to alcohol, to on or addicted Being dependent Stopping certain medicines on your own own certain medicines on your Stopping Medical conditions such as thyroid problems, problems, Medical thyroid conditions such as your brain. your anxiety. , amphetamines, tranquilizers, or heroin tranquilizers, cocaine, amphetamines, (without your doctor knowing) knowing) doctor your (without heart or lung problems, seizure disorders seizure heart or lung problems, •  •  •  if: anxiety feel to likely more are You •  •  •  There are things that can make your anxiety anxiety your can things that make are There worse: response situations can cause you to feel anxious, worried, anxious, worried, can causesituations feel to you or tense. What causesWhat anxiety? of number person. Any every for It is different danger exists. danger exists. is gone. Anxiety can become a problem when can become a problem Anxiety is gone. thoughts worrying have to a person continues no real is a danger when as if there or reacts or freezing. once the threat goes away anxiety Normally, our large muscles. All this prepares our body to our body to muscles. All this prepares our large fleeing (flight), fighting, the danger by to respond releases adrenalin in response to a real danger or danger a real to in response adrenalin releases or dangerous. threatening feels something that to to and blood shifts increases Our heart rate body’s natural response to a threat (sometimes (sometimes a threat to response natural body’s response). body Our called the ‘fight-flight-freeze’ What is anxiety?What times. It is our at anxiety experiences Everyone Anxiety When should you get help? How can anxiety affect my Ask yourself the following question (Choose heart failure? the number that most reflects your feelings.) The increased heart rate and blood pressure Over the last two weeks, how much have I been adds stress on your heart. bothered by feeling anxious, worried, nervous, Anxiety needs energy. Anxiety can increase your or tense? blood sugar and cholesterol. Both can make your 0 1 2 3 4 5 6 7 8 9 heart failure worse. (None) (A little) (Moderate) (Severe) Anxiety can make it hard to sleep, leaving you If you scored 3 or lower: feeling more tired. • You are probably coping pretty well with your anxiety. If you feel you would like more help than What can you do when you have mild anxiety? this sheet gives you, please talk to someone you trust. It is not unusual for someone with a health condition such as heart failure to feel scared, If you scored between 4 and 7: worried, or tense. Included below are some ideas • It would be good for you to talk to your health to help you deal with your anxiety. care provider or a mental health professional about how you are feeling. For more detailed help on how to manage your anxiety, see the resources on the next page. • To find a mental health professional, contact the Canadian Mental Health Association at Sometimes when people feel very anxious and www.cmha.ca overwhelmed, they start to think about hurting themselves. If you have started to make a plan to If you scored 8 or higher: hurt yourself, go to the nearest emergency room You are probably very anxious. See your family right away. doctor or a mental health professional as soon as possible. Some ideas on how to manage your anxiety • Be aware how you experience anxiety. • Get a good night sleep. • Identify things that trigger your anxiety. • Do not drink close to bed time. • Ask yourself “Is this really a threat or • Reduce any stress in your life. a danger?” • Reduce things that stimulate your body: • Ask yourself if your worry is something you have • Reduce the amount of caffeine you drink some control over. If it is, try to resolve it. If it (coffee, tea, colas) in a day. isn’t, let it go. • Do not smoke cigarettes. • Practice deep breathing and other forms of • Set a routine for doing daily activities relaxation such as: • Use a calendar and a ‘to do’ list to help you • Meditation, yoga, and stretching, praying, manage your time. reading, going for a walk, listening to music • If you are having a bad day, talk to someone • Eat a healthy well balanced diet. you can trust.

Never use alcohol, tobacco, or street drugs to help you manage your anxiety

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by Edmund Edmund by by Edmund Bourne and Edmund by Care Workbook at www.comh.ca/pchc/ at Workbook ‑Care Positive Coping with Health Conditions – – Health Conditions Coping with Positive A Self or workbook the complete Choose download to such as the workbook from selected excerpts or ‘Relaxation’. ‘Managing Worry’ Relieve to 10 Simple Ways Coping Anxiety: with and Worry Fear, Anxiety, (2013) Garano Lorna And Phobia Workbook The Anxiety Bourne (2010) Some ideas on how to manage manage to Someon how ideas anxiety your Workbook •  Books •  • 

Heart & Stroke – Living with Heart Failure Heart & Stroke Medications to treat any chemical any imbalance treat Medications to Exposure therapy (focusing on facing the the on facing (focusing therapy Exposure Behaviour therapy (focusing on thinking on thinking (focusing Behaviour therapy in your brain in your situation in a safe environment) in a safe situation and behaviour) •  •  •  • Counselling • Support group Anxiety disorders respond well to treatment. treatment. to well respond disorders Anxiety can include: Treatment How is moderate to severe anxiety to severe is moderate How treated? Sometimes blood tests are done to see to done if a are blood tests Sometimes worse. medical the anxiety condition is making disorder. A doctor or mental health professional professional health or mental A doctor disorder. an anxiety from are can if you tell questions. of a number asking you by disorder Sometimes anxiety and worry can become and worry anxiety Sometimes an anxiety a person develops that sosevere How do we know when anxiety when is know we do How a problem? Tips for Travelling When you Have Heart Failure With some planning, people with heart failure can travel safely.

Planning for travel • Carry copies of your medical information such as: • Talk with your healthcare provider before you commit to any trip, especially if you have • Results of recent blood tests a pacemaker or implanted cardioverter • A list of health and medical defibrillator (ICD). problems • Make sure your immunizations are up to date. • Names and contact phone • Buy travel health insurance, especially when numbers of your healthcare providers travelling outside of Canada and even if only • A list of all your current medications for a day. Make sure it covers pre-existing • Take enough of each medication to last the illnesses. whole trip plus extra, in case of an emergency • Buy cancellation insurance on flights and or a travel delay. bookings, in case you have a sudden change • Keep all your medications in the packaging in your health. supplied by the pharmacy. • When flying, especially outside of Canada, • Consider asking your pharmacist to put your you might need a travel letter from your doctor medications into ‘blister packs’ so you don’t explaining why you need to travel with all your have to travel with all your original containers. medications. Check with your travel agent or airline. • Make sure each medication name is clearly marked. (This is very important when crossing • Know where to go to get medical help when borders.) you get there by finding out before you leave. Check to see if there is a hospital or medical When not to travel clinic nearby. It is best to stay home if: • Pack a cell phone. Check with your cell phone • Your healthcare provider has advised you provider to make sure you have coverage in not to travel. the area you are travelling. • You have recently come home from being in • If possible, weigh yourself while you are the hospital. traveling. • Your doctor has changed one or more of your • If travelling to a different time zone, ask your medications, such as a change in dose or how healthcare provider if you should adjust your often you take it. medication schedule. • You cannot get travel health insurance. • Consider wearing a Medical Alert bracelet • You notice increased signs of heart failure or necklace. (shortness of breath, weight gain, fatigue, cough, swelling in your feet or belly area, or dizziness).

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It is safe to go through go through to It is safe ‑on bag. Ask for “no added salt”. for Ask calorie saltChoose meals and low low and sauces, to gravies, “no thanks” Say low own your Make and snacks. and snacks. foods. prepared salt meals. •  •  •  •  archway metal detectors, body scanners, detectors, metal archway with equipment anti-theft store and retail a heart device. Did you know? Did you Eat your largest meal either at lunch or earlier meal either at largest your Eat high in sodium. out usually means foods Eating When sitting for long periods, get up or get out get up or get long periods, for When sitting luggage, check your to have you Whenever on schedule. medications your Take in other medications buy any to not It is best When much fluid. drink too don’t you Be careful meals and both for portion size your Watch in the afternoon. Have a light dinner or early dinner a light Have in the afternoon. snack. evening can: you Whenever for a walk every 2 hours. every a walk for a in with you medications carry your all carry is what from can vary Ingredients countries. Canada. from in the medication or when socializing, people tend climates in hot drink more. to can than normal cause more Eating snacks. indigestion. and an upset stomach, bloating, •  •  Enjoy! safe. Plan ahead. Travel During your travels your During •  •  •  •  •  • 

Heart & Stroke – Living with Heart Failure Heart & Stroke Know your heart device is going to set off set off is going to heart device your Know Tell security using wand metal detectors detectors metal security using wand Tell Ask for a ‘hand check’ instead of a wand a wand of a ‘hand check’ instead for Ask Show your heart device identification card identification card heart device your Show If you have an implanted cardioverter cardioverter an implanted have If you Ask for a recent print out of settings for for settings out of print a recent for Ask Ask your doctor for a copy of your heart heart your of a copy for doctor your Ask If you have just had a heart device inserted, inserted, had a heart device just have If you ‘hand check’ as well. an alarm when walking through an archway an archway through an alarm when walking need a may you detector; metal they can only pass over your heart device heart device your can only pass over they seconds. 5 or more once every settings on your heart device. on your settings metal detector check. A wand metal metal check. A wand detector metal change the could momentarily detector before going through the metal detectors. the metal going through before do if you get a shock while away. get do if you defibrillator (ICD), ask what you should should you (ICD), ask what defibrillator your heart device. your device instructions in the language of the the in the language of instructions device to. travelling are you country to find out when it is safe for you to travel. you for it is find out when safe to wait until your first follow-up appointment appointment follow-up first your until wait •  •  •  •  •  •  •  •  When going through security: When going through Always carry your heart device identification identification heart device carry your Always Keep your cell phone at least 6 inches away inches away 6 least cell phone at your Keep If you have a heart device (a pacemaker or an or an pacemaker (a a heart device have If you card with you. card from your heart device. your from your device is being monitored remotely. is being monitored device your implanted cardioverter defibrillator), check check defibrillator), cardioverter implanted if especially provider, healthcare with your •  •  •  Travelling with a heart with device Travelling •  Caring for someone with heart failure. Taking care of yourself. If you give care to someone with heart failure, you could find yourself facing new responsibilities. It can be both rewarding and challenging to be a ‘caregiver’. A ‘caregiver’ is anyone who gives help and care to another person in need.

Signs of caregiver stress Tips to prevent caregiver stress When you are focused on caring for someone Too much stress can harm your health, else, you might not realize your own health is especially if you care for someone for a long suffering. At times, you might feel time. Here are some ways to help prevent overwhelmed, physically or emotionally. and manage caregiver stress. This is called ‘caregiver stress’. Ask for help and accept help when offered. Watch for these signs of caregiver stress: • Look to others to help share • Feeling tired all the time the care. • Having trouble sleeping • Make a list of ways others can

• Gaining or losing a lot of weight help you such as pick up groceries or cook a meal. • Feeling guilty, like you are not doing enough • Feeling overwhelmed and irritable Set health goals for yourself. • Having conflicts with the person you care for • Make time to be physically active most days of the week. • Having conflicts with family members • Make and eat healthy meals and snacks. • Feeling you don’t have time for yourself or to be with others • Get enough sleep, even if it means taking a nap during the day. • Having no interest in doing activities you used to enjoy • Take time to relax each day. Find a place in your home where you can have a few • Feeling emotional and moody, maybe moments to relax, close your eyes, and do crying often some deep breathing. • Worrying about having enough money • Do things you enjoy. now and for the future • Give yourself a break. Take some time away • Using substances to help manage your from being a caregiver at least once a week. feelings such as smoking more, drinking more alcohol, taking medications to help sleep or improve your mood, or taking illegal drugs

64 Heart & Stroke – Living with Heart Failure More Information More More Information 65

taking care of yourself yourself of taking care forgotten, thing you can do. can thing you do. forgotten, the yourself, of care take When you too. benefits to care give person you As a caregiver, As often important, and most is the most Help the person prepare for medical for Help the person prepare can, If you go with the person to Talk with the person you are caring for about about caring for are the person with you Talk for work will that ways Help the person find like feel don’t so you care on a plan of Agree is needed to If the person doing what is not make someone do something they do not do not someone do something they make do. to want recent such as reviewing appointments the before health and concerns, resting as taking all medications as well appointment, the appointment. snack to and a healthy Take medical appointments. health Help communicate notes. to not concerns but be careful are the person. You for answer is going on clarify to what there home. at what would be helpful in giving care and and care in giving be helpful would what manage their heart failure. helping to their own. do as much as possible on them to when remember to include ways This might daily weight, record to medications, take to less salt,to eat to or fluids, of track keep to keep active. or reminding. telling always are you them about your manage their health, talk to cannot you or concerns. Remember worries •  •  Communicate with the person you are are person with the Communicate you caring for. •  •  •  • 

Heart & Stroke – Living with Heart Failure Heart & Stroke See your healthcare provider when you notice notice when you provider healthcare See your Get regular health checks. Make sure you tell tell you sure Make health checks. regular Get or depressed, stressed, feeling are If you Keep up with your own medical care. medical own care. up with your Keep Explore opportunities for support in the home in the home support opportunities for Explore Rather than struggling on your own, take take own, on your than struggling Rather Share your feelings, worries, and and worries, feelings, your Share Make an effort to stay connected connected stay to an effort Make If you feel like it, eat a healthy breakfast for for breakfast a healthy it, eat like feel If you Don’t be too hard on yourself. Your home home Your on yourself. hard too be Don’t Be realistic about what you can you and cannot about what Be realistic overwhelmed or depressed. or depressed. overwhelmed signs of caregiver stress or you feel really really feel or you stress caregiver signs of unusually worried, the Heart & Stroke website website the Heart & Stroke unusually worried, help you. to has resources your healthcare provider you are a caregiver. are you provider healthcare your are available. are from health services. Talk to your health care health care your to health services. Talk from supports on what information for provider advantage of local resources for caregivers. for local resources of advantage concerns with someone you are are concerns with someone you situation. your talking with about comfortable with family and friends. and with family a row. No one cares. a row. dinner or eat leftovers three or four days in in days or four three leftovers dinner or eat might not be as clean as you would like it to be. it to like would clean as you be as not might do. You can’t control everything. control can’t You do. •  •  •  •  Stay as strong and healthy as possible. as and healthy as strong Stay •  •  Get connected with community connected supports.Get •  •  Seek support from family and friends. family Seek support from •  •  •  Tips to prevent caregiver stress caregiver to prevent Tips can do. you what on Focus Learning to Live with Heart Failure You can do it! You can make changes in your life to help you feel better and stay healthy. This resource gives you tips for daily life and answers common questions.

Conserve your energy • Avoid things that drain energy, such as: • Rest at least 1 hour every day. • Doing chores or activities right after you eat • Aim for balance. • Doing intense physical activity • Balance activity with rest. • Lifting, stretching, or any other strenuous arm movement • Balance hard activities with easy activities. • Ask for help. • Do activities when you feel your best. • Ask those you live with to share in doing • Plan ahead. the daily tasks and household chores. • Plan your chores and daily activities ahead • Ask family and friends to help out. of time. • Space them out throughout the day and Get enough sleep week. You do not have to do everything in • Practice good sleep habits. one day. • Have a regular bedtime. • Whenever you can, sit to work or do daily chores. • Relax before bedtime. • Keep things you use the most within reach. • If you cannot get to sleep within 30 minutes, get up and read or watch TV. • Prepare bigger meals and freeze portions to save preparing meals another day. • Only use your bed for sleeping and intimacy. This means get out of bed to read • Use things that help conserve energy. or watch TV. • Choose clothes that have zippers instead • If you get short of breath lying down, prop of buttons. Make sure the zipper is in the yourself up with pillows. front and not the back. • If you get up often to go to the toilet, talk to • Use long-handled tools to make reaching your health care provider. Your medications easier. might need adjusting. • If needed, use a walker, shower chair and bedside toilet. Take care of your physical health • Choose light weight hold or kitchen • Keep in contact with your health care team. items. For example, choose aluminum pots • Getting sick can be deadly when you have and pans instead of cast iron. heart failure. • Get a flu shot every year. • Get a shot.

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Stop and rest if you get short of breath or or breath short of get if you and rest Stop express to ways Find other not are if you upset get Don’t Wait at least 1 hour after eating. hour after 1 least at Wait . drink alcohol before Do not and rested Choose are a time when you too it is not place where Choose a comfortable hot or cold. hot uncomfortable. feel and affection. expected. as you perform able to relaxed. •  •  •  feel. you partner about how your to • Talk in sex interest Your possible. are Problems breath of short get might You drop. might getting problems have Men might during sex. a of can be a side effect Problems an erection. is getting heart failure or a sign your medication about provider health care your to Talk worse. sex. having problems any express to ways other are there Remember and affection. love What about having sex? having about What to safe it is whether about worry Some people Once heart failure. have when they sex have you under control, are heart failure of signs your sex and safe an active have able to should be are relations and good sexual touch life. life. a healthy part of energy, of a lot it can take sex, have When you The physical and physically. emotionally both in 10 seconds. 20 steps climbing is like energy good: and feel should be fun Sex •  •  •  •

Heart & Stroke – Living with Heart Failure Heart & Stroke . heartandstroke.ca/heart/ Helps you feel better and improves and improves better feel Helps you your mood your • Lessens money worries by having an income having by worries money • Lessens •  Benefits of working: of Benefits a daily routine into get • Helps you of heart failure are under control, or you might might or you under control, are heart failure of doing all aspects of build up to gradually to have the work. If your health care provider says you can you work, says provider health care If your as soon signs start as your be able to might you Every person is different. Talk to your health your health to Talk person is different. Every you. for is right about what provider care are managing your heart failure, and the type and the type heart failure, managing your are be might working some people, work. For of be good. not it might others but for helpful, Can I work? you how health, overall It depends on your or have your licence removed. It is all about It is all about licence removed. your or have public safety. to the Superintendent of Motor Vehicles. You You Vehicles. Motor of the Superintendent to licence driver’s on your restrictions have might a person is or is not medically fit to drive. If your your If a person medicallyto drive. fit is or is not health affects your feels provider health care be reported it must safely, drive ability to your as long as their heart failure is under control. is under control. heart failure as long as their when defines Act Vehicle the Motor However, Whether or not you drive depends on how depends on how drive you or not Whether people can drive Generally, feeling. are you conditions/heart-failure Can I drive? If you are feeling stressed, depressed or or depressed stressed, feeling are If you has resources our website unusually worried, visit help you to needed to manage their heart failure. Don’t hide hide Don’t heart failure. manage their to needed provider. health care your to Talk these feelings. Take care of your emotional health emotional your careof Take everything to do find it hard people Many How do I stay on track during Future heart failure care special occasions? Have the conversation with your family Whether eating out or eating in, food for special and healthcare provider occasions is more likely to be high in salt, Heart failure is a condition that is not curable especially sauces and gravies. Also, people and gets worse over time. In the future, there tend to eat and drink more. could be a time when you might be too sick • Make healthy choices. to consent to treatment offered by your healthcare provider or doctor. If this happens, • Choose food prepared with little or no salt. your healthcare provider will look to your family • Where possible, choose fresh for help with decisions about your care. vegetables and fruit. Planning now for the future can give you • Plan big meals for midday. comfort knowing your family and healthcare • Pay special attention to your snacking and provider knows what is important to you. It can portion size. also ease the stress for your family if they have • Watch your fluid intake. to make medical decisions for you. Learn more at www.advancecareplanning.ca A word about… Drinking alcohol Some alcohol can be helpful to a normal heart. However, sometimes even a small amount of alcohol can cause heart failure to get worse. Alcohol can weaken your heart muscle and increase your blood pressure, creating more work for your heart. Ask your health care team if any amount of alcohol is okay for you.

Smoking Everyone knows smoking and using tobacco products damages your heart and lungs. But quitting is not easy. Your chances of quitting are much better if you ask for help. Ask your health care team for: • Help to quit smoking • Ways to deal with second-hand smoke To learn more about quitting smoking, check the website: www.quitnow.ca

68 Heart & Stroke – Living with Heart Failure More Information More More Information 69

Collaborative Collaborative Actions/Approach

______Signed (patient): (patient): Signed Person Responsible Responsible Person & Revision Follow-up for

Heart & Stroke – Living with Heart Failure Heart & Stroke

To ensure all health care providers are aware how to care for me and my family during during family my me and for care to how aware are providers all health care ensure To life. my of this stage



______

place on [Date] ______place on [Date] ICD Deactivation discussion has taken discussion has taken ICD Deactivation Advance care plan completed plan completed care Advance N/A   in place benefits Palliative

[Include plan for deactivation eg. In device eg. In device deactivation [Include plan for etc] home, at clinic or magnet Decision: ______Device management: Device ❑ ❑ ❑ ❑ [for future health care treatment, support life treatment, health care future [for medical interventions and life-prolonging want or doesn’t pill burden e.g. minimize procedures] invasive that are important to me and my family] and my me to important are that My Wishes caregiver situations, support network] situations, caregiver Needs Spiritual Care approaches or spiritual [individual cultural of life legal planning, medication cost, planning, medication cost, legal life of home for access/cost transportation, family/ support services, equipment, difficult are helpful] are Needs Social Care [include concerns about: finances, end Symptom Management – Physical or Body – Physical Management Symptom me and to bothersome are that [symptoms been tried and/or have that approaches and approaches that have been tried and/or been tried and/or have that and approaches helpful] are Collaborative Decisions Collaborative – Psychological Management Symptom sad or anxious me feel make that [symptoms Focus of Care & & Care of Focus ______What matters most to me: to most matters What ______Date: Purpose: Advanced Heart Failure Personal Action Plan Action Personal Heart Failure Advanced Focus of Care & Person Responsible Collaborative Collaborative Decisions for Follow-up & Revision Actions/Approach Managing Activities [Include energy conservation strategies; activities that are important for me to maintain]

Managing Diet [Include types of foods that I enjoy or tolerate, include wishes around mealtime rituals, etc]

Supporting My Caregiver(s) [Include things that are important to me and my family e.g. Pastoral care, sharing a bed or room, etc]

Ways to Support Me as a Person:

Worries or Concerns I Have:

Other Preferences:

Contact Information for My Team Family doctor/nurse practitioner: ______

Heart failure specialist/specialty team members: ______

My primary caregiver:______

Health care contact: ______

Other providers who know me well: ______

70 Heart & Stroke – Living with Heart Failure More Information More We want to hear from you! Help make sure we are providing helpful information to people living with heart failure and their caregivers. Please complete the following survey and mail it to: Heart & Stroke Attn: Health Information Team 2300 Yonge Street, Suite 1300 Box 2414 Toronto, ON M4P 1E4 OR Complete this questionnaire online at heartandstroke.ca/feedback

______Circle one number for each statement: strongly disagree strongly agree

The information is easy to understand 1 2 3 4 5 This information is useful to me 1 2 3 4 5 I feel better informed about heart failure because of this guide 1 2 3 4 5 With this information, I feel I can manage my heart failure 1 2 3 4 5 I would share this guide with others 1 2 3 4 5 What did you find most useful or helpful in this guide and why? ______

What would make this guide more useful or helpful to you? ______

Other comments and suggestions: ______

Please tell us who you are: ❑ Heart Failure patient ❑ Care partner (family/friend most involved in supporting the patient) ❑ Other family members ❑ Other (please specify) ______

Would you like to be contacted by Heart & Stroke with additional resources related to heart failure? If so, please provide the following information:

Name: ______

Email address: ______Thank you! Notes Research Breakthroughs Life-saving advances made possible by you.

1965 1968 1976 1987 1987 Diagnosing heart disease One of the first Dr. Henry Barnett A new surgical Researchers becomes easier thanks to heart transplant conducts first technique helps pioneer the use ECG , which allows surgeries in treat irregular of the clot-busting doctors to monitor patients’ Canada is using AspirinTM heartbeats. drug tPA for remotely while they performed. to prevent . heart attacks. go about daily activities.

1990 2000 2006 2009 2015 First genetic link Dr. Lori West discovers Researchers identify World’s first in-utero ESCAPE Trial to premature that, unlike adults, important gender surgery to correct Treating major heart disease is newborns are able to differences in the congenital heart strokes by discovered. accept hearts from development of high defects is performed removing blood incompatible donors. blood pressure. in Canada. clots through blood vessels cuts by 50% and significantly reduces disability in survivors.

Saving moments. Funding breakthroughs. Saving lives.TM TMThe heart and / Icon, “Heart&Stroke” and “Saving moments. Funding breakthroughs. Saving lives.” are trademarks of the Heart and Stroke Foundation of Canada. 1-888-473-4636 heartandstroke.ca

© Heart and Stroke Foundation of Canada, 2017-2018 ™Life. We don’t want you to miss it. and the heart and / Icon on its own or followed by another icon or words are trademarks of the Heart and Stroke Foundation of Canada. This publication Living with heart failure is for informational purposes only and is not intended to be considered or relied upon as medical advice or a substitute for medical advice, a or treatment from a physician or qualified healthcare professional. You are responsible for obtaining appropriate medical advice from a physician or other qualified healthcare professional prior to acting upon any information available through this publication. The Heart and Stroke Foundation gratefully acknowledges Cardiac Services BC and the experts at British Columbia’s Heart Failure Network as the original creators of this resource. V2.0