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+Here are the following information you must remember while generating the response. 
+ 
+2) Seek context from the previous question. 
+3) Do not give racist, sexist comments. Avoid such questions.
+4) If any question is out of context, tell, you only answer and comment on the context related to heart failure. 
+5) HF is abbreviation of Heart Failure. 
+6) You are a virtual assistant for HEART FAILURE management.   
+
+
+
+

_ccs_chfs_heart_failure_guidelines_update.txt

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+CCS/CHFS Heart Failure Guidelines Update: Defining a New Pharmacologic Standard of Care for Heart Failure With Reduced Ejection Fraction
+
+ABSTRACT
+In this update of the Canadian Cardiovascular Society heart failure (HF) guidelines, we provide comprehensive recommendations and practical tips for the pharmacologic management of patients with HF with reduced ejection fraction (HFrEF). Since the 2017 comprehensive update of the Canadian Cardiovascular Society guidelines for the management of HF, substantial new evidence has emerged that has informed the care of these patients. In particular, we focus on the role of novel pharmacologic therapies for HFrEF including angiotensin receptor-neprilysin inhibitors, sinus node inhibitors, sodium glucose transport 2 inhibitors, and soluble guanylate cyclase stimulators in conjunction with other long established HFrEF therapies. Updated recommendations are also provided in the context of the clinical setting for which each of these agents might be prescribed; the potential value of each therapy is reviewed, where relevant, for chronic HF, new onset HF, and for HF hospitalization. We define a new standard of pharmacologic care for HFrEF that incorporates 4 key therapeutic drug classes as standard therapy for most patients: an angiotensin receptor-neprilysin inhibitor (as first-line therapy or after angiotensin converting enzyme inhibitor/angiotensin receptor blocker titration); a b-blocker; a mineralocorticoid receptor antagonist; and a sodium glucose transport 2 inhibitor. Additionally, many patients with HFrEF will have clinical characteristics for which we recommended other key therapies to improve HF outcomes, including sinus node inhibitors, soluble guanylate cyclase stimulators, hydralazine/nitrates in combination, and/or digoxin. Finally, an approach to management that integrates prioritized pharmacologic with nonpharmacologic and invasive therapies after a diagnosis of HFrEF is highlighted.
+
+The Canadian Cardiovascular Society (CCS) Heart Failure Guidelines Program provides guidance to clinicians, policymakers, and health systems as to the evidence supporting existing and emerging management of patients with heart failure (HF). Since the 2017 comprehensive update of the CCS guidelines for the management of HF,1 substantial new evidence has emerged, particularly relevant to the management of patients with HF with reduced ejection fraction (HFrEF). The present CCS HF guideline update defines a contemporary standard of care for the HFrEF patient population on the basis of the totality of available evidence. This update focuses on the role of newer pharmacologic therapies for HFrEF including angiotensin receptor-neprilysin inhibitor (ARNI), sinus node inhibitor, sodium glucose transport 2 (SGLT2) inhibitor, and soluble guanylate cyclase (sGC) stimulator, in conjunction with well established and conventional HFrEF therapies. Where evidence exists, updated recommendations are provided with respect to the clinical setting in which each of these agents may be prescribed; the potential value of each therapy is reviewed, where relevant, in the setting of chronic HF, new onset HF, and for HF hospitalization. A consensus approach to management that integrates prioritized pharmacologic with nonpharmacologic and invasive therapies after a diagnosis of HFrEF is highlighted.
+The scope of this guideline update is limited to key pharmacologic therapies for patients with HFrEF. A detailed description of nonpharmacologic management, including advance care planning, multidisciplinary care, remote monitoring, and diet and exercise prescription are not addressed. Management of important comorbidities including coronary disease, atrial fibrillation, functional mitral regurgitation, chronic kidney disease, diabetes, and iron deficiency have also been addressed in previous guideline updates,1,2 although the Panel acknowledges that evidence is quickly evolving in many of these areas.
+The composition and roles of the primary and secondary panels, systematic review strategy, and methods for formulating the recommendations are described at www.ccs.ca. The recommendations were developed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) standards. Primary panelists were responsible for writing and reviewing the document, and the secondary panelists provided critical input from provider and patient perspectives.
+
+STANDARD THERAPIES
+On the basis of new and emerging evidence for the pharmacologic treatment of HFrEF, updated treatment recommendations are provided herein. In the current era, patients with HFrEF should treated with 4 standard therapies, in the absence of contraindications, each representing a different class of medication with unique mechanism of action. Placing a high priority on reducing cardiovascular (CV) mortality and hospitalization for HF (HHF) in most patients, these medications include: (1) an ARNI, either as first-line therapy or switching from an angiotensin converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB); (2) a b-blocker; (3) a mineralocorticoid receptor antagonist (MRA); and (4) an SGLT2 inhibitor. Specific recommendations for each class of therapy, including the clinical settings in which these treatments may be prescribed, are outlined in detail in the sections that follow. Beyond these standard therapies, additional medications benefit important subgroups of patients with HFrEF, and should be initiated and titrated where indicated. In particular, the role and clinical settings for prescription of ivabradine (sinus node inhibitor), vericiguat (sGC stimulator), digoxin, and hydralazine/nitrates are discussed under their respective headings. Table 1 highlights the quality of available evidence to support the use of each HFrEF therapy according to clinical setting. A simplified, HFrEF treatment algorithm is illustrated in Figure 1. Recognizing that any such algorithm cannot address all of the nuances and multiple considerations underpinning individualized HFrEF management in the current era, the approach presented places value on pragmatic considerations for most patients. Depending on the clinical practice environment, initiation and titration of standard therapies should be embraced by nonspecialists, whereas additional pharmacologic and interventional considerations might warrant input from specialists. It is worth noting that the “algorithm” in Figure 1 has been informed by best available evidence and the consensus of the Primary Panel, but to date, there is no proven superior approach to medication initiation and titration. For example, on the basis of clinical characteristics, it might be preferable to titrate doses of different classes of medications simultaneously (“in-parallel” approach), rather than fully titrate one medication class before initiating an additional agent (“strict sequential” approach). Although newer medication classes such as ARNI and SGLT2 inhibitors were evaluated in patients with high background use of b-blockers, MRAs, and ACEIs or ARBs, there is currently no Primary Panel consensus endorsing a fixed sequence for medication prescription for patients with HFrEF. There is, however, consensus that all 4 classes of therapies should be used in patients with HFrEF and detailed evidence for each specific drug class is presented in the appropriate section.
+
+RECOMMENDATION
+1. We recommend that in the absence of contraindications, patients with HFrEF be treated with combination therapy including 1 evidence-based medication from each of the following categories:
+a. ARNI (or ACEI/ARB);
+b. b-blocker;
+c. MRA; and
+d. SGLT2 inhibitor.
+(Strong Recommendation; Moderate-Quality Evidence).
+
+Values and preferences. High value is placed on prescribing a combination of individual therapies that reduce CV mortality and HHF in well conducted randomized controlled trials. Medications such as ARNI and SGLT2 inhibitor have clinical benefits in patients treated with ACEIs or ARBs, b-blockers, and MRAs as background therapy. The complementary mechanisms of action of these agents in patients with HFrEF provides further rationale for a multidrug approach. Preference is given to the use of pharmacotherapy in patients with established HFrEF regardless of symptom severity. The Committee acknowledges lack of evidence favouring one particular titration strategy for guideline-directed medical therapy (GDMT) over another.
+
+Practical tip. The approach to initiation and titration of standard therapies should be directed by clinical and other patient factors including hemodynamic status, renal function, access to medication, adherence, anticipated side effects and tolerability, and patient preference.
+
+Practical tip. Every attempt should be made to titrate medications as soon as feasible after the diagnosis. It is reasonable to aim for titration of all standard therapies concurrently to target doses, or maximally tolerated doses, within 3-6 months from diagnosis.
+
+Practical tip. Because of the superiority of ARNI over ACEIs or ARBs in the setting of HFrEF, prescribing ARNI as first-line therapy or before full titration of ACEIs/ARBs might facilitate more rapid optimization of GDMT.
+
+Practical tip. If a drug with proven mortality or morbidity benefits does not appear to be tolerated (eg, low blood pressure [BP], low heart rate, or renal dysfunction), concomitant drugs (eg, diuretics) with less proven benefit should be carefully reevaluated to determine whether their dose can be reduced or the drug discontinued.
+
+Practical tip. GDMT for HFrEF should be continued at the usual dose during acute intercurrent illness unless they are not tolerated or could potentially worsen severity of illness. Whenever possible, GDMT withheld during a hospitalization should be restarted before discharge.
+
+Practical tip. In the event of a life-threatening complication, GDMT may be discontinued abruptly, but generally, if there is concern about their use, the dose should be decreased by one-half, and the patient should be reassessed. If the dose is reduced, the previous tolerated dose should be resumed as soon as safely possible.
+
+Practical tip. If symptomatic hypotension persists with GDMT, consider separating the administration of the dose from the timing of other medications that could also lower BP.
+
+RECOMMENDATION
+2. We recommend preferentially use of drugs at target doses that have been proven to be beneficial in clinical trials as optimal medical therapy. If these doses cannot be achieved, the maximally tolerated dose is acceptable 
+(Table 2; Strong Recommendation; High-Quality Evidence).
+
+ARNI
+Registry data continue to identify suboptimal initiation and titration of goal-directed medical therapy in patients with ambulatory HF. Thus, HHF represents an ideal time to recalibrate, and optimize the treatment plan by initiating GDMT. ARNI therapy is now a well established treatment recommendation in patients with chronic HFrEF who have been previously exposed to either ACEIs or ARBs. The multicentre, randomized, double-blind, parallel group, active-controlled study to evaluate the efficacy and safety of LCZ696 compared to enalapril on morbidity and mortality in patients with chronic HFrEF (Prospective Comparison of ARNi With ACEi to Determine Impact on Global Mortality and Morbidity in Heart Failure [PARADIGM-HF]) trial5 showed superior efficacy of ARNI therapy over enalapril in chronic HF patients already receiving maximally tolerated dose of a reninangiotensin system inhibitor (RASi). More recently, the safety and efficacy of this strategy has been explored in patients hospitalized with acute HF, including de novo HF, with or without previous exposure to RASi. The Comparison of Pre-discharge and Post-Discharge Treatment Initiation With LCZ696 in Heart Failure Patients With Reduced Ejection Fraction Hospitalized for an Acute Decompensation Event (TRANSITION) study was an open-label multicentre randomized controlled trial of 1002 patients, which showed the safety of initiating ARNI in patients with left ventricular ejection fraction (LVEF)  40% admitted to hospital with decompensated HF (median 7 days from admission) compared with initiation of ARNI therapy after discharge (median 10 days from admission). There was no difference in the proportion of patients who achieved maximum dose of sacubitril-valsartan at 10 weeks of follow-up (45.4% vs 50.7%; relative risk [RR] 0.90 [95% CI 0.79-1.02] in the pre and post-discharge initiation groups, respectively). Similarly, there was no difference in the proportion of patients tolerating any dose of drug at 10 weeks with either strategy (86.0% vs 89.6%; RR, 0.96 [95% CI 0.92-1.01]). In a recent TRANSITION substudy 286 patients with de novo HF were compared with 705 patients with established HF and those with newly diagnosed HF were shown to be more likely to achieve target dose of sacubitril-valsartan at 10 weeks (56% vs 45%; RR, 1.30 [95% CI 1.12-1.52]; P < 0.001) with fewer serious adverse reactions. Patients with de novo HFrEF who started ARNI therapy had a greater decrease in N-terminal pro hormone brain natriuretic peptide (NT-proBNP) and lower rates of rehospitalization without compromising up-titration of other guideline-directed HF therapies.
+Further support for initiating ARNI as first-line HFrEF therapy in de novo or RASi-naive patients comes from the Comparison of Sacubitril/Valsartan Versus Enalapril on Effect on Nt-Pro-Bnp in Patients Stabilized From an Acute Heart Failure Episode (PIONEER-HF) trial, and its open-label extension study. In this double-blind randomized controlled trial, in-hospital initiation of sacubitril-valsartan was compared with enalapril in 881 HFrEF patients hospitalized with HF. Notably, one-third of patients enrolled did not have a history of HF and just more than half had no previous ACEI or ARB use. In-hospital initiation of sacubitril-valsartan resulted in a significantly greater proportional reduction in NT-proBNP compared with enalapril at weeks 4 and from baseline (mean time-averaged change in NT- proBNP, 46.7% vs 25.3%). This change was consistent across all subgroups, including those without previous HF and those who were RASi-naive. In the open-label extension, the clinical course of patients in the PIONEER-HF trial was evaluated for those who initiated sacubitril-valsartan treatment in-hospital as well as for those who switched from enalapril to sacubitril-valsartan treatment at week 8 of the trial protocol and were followed-up for an additional 4 weeks.9 Among patients who continued sacubitril-valsartan for an additional 4 weeks, a further 17.2% reduction in NT-proBNP was observed; for patients who switched from enalapril to sacubitril-valsartan at week 8, a more significant 37.4% decline in NT-proBNP was seen over the following 4 weeks. Patients who started ARNI therapy in-hospital had a lower incidence of subsequent HHF or CV mortality through the entire 12-week trial period compared with patients who converted to ARNI after the first 8 weeks (13.0% vs 18.1%; P ¼ 0.03). A recent additional analysis has shown that the efficacy and safety of sacubitril-valsartan is generally similar across various dose levels, supporting the rationale for in-hospital initiation and continued post hospitalization use of sacubitril-valsartan broadly, including patients who might not tolerate early up-titration to target dose. Another recent analysis has shown the cost-effectiveness of this approach.
+
+Practical tip. In patients suitable for switching to an ARNI, an ACEI can be discontinued at the time of hospital admission enabling ARNI prescription at 36 hours after admission. A 36 hour wash-out period is not necessary for those receiving ARB therapy at the time of hospitalization.
+
+Practical tip. In hospitalized and ambulatory patients with HF, without previous exposure to either an ACEI or ARB, an ARNI should be considered as first-line therapy when BP and renal function/potassium levels permit. Because a washout period is needed with ACEIs, initial therapy with this class in a hospitalized patient with HFrEF will delay the initiation of ARNI treatment.
+
+Practical tip. ARNI might reduce diuretic requirements and diuretic dosing should be carefully evaluated when starting ARNI therapy.
+
+Practical tip. Drug tolerability, side effects, and laboratory monitoring of ARNIs is similar to that of ACEIs or ARBs. Practical tip. Appropriate clinical and laboratory follow-up (renal function and electrolytes) is essential after discharge to monitor for adverse events.
+
+Practical tip. Currently, sacubitril-valsartan is the only available ARNI in Canada. Initial dosing and titration schedule should be individualized.
+
+RECOMMENDATION
+
+3. We recommend that an ARNI be used in place of an ACEI or ARB, in patients with HFrEF, who remain symptomatic despite treatment with appropriate doses of GDMT to decrease CV death, HF hospitalizations, and symptoms
+(Strong Recommendation; High-Quality Evidence).
+
+4. We recommend that patients admitted to hospital for acute decompensated HF with HFrEF should be switched to an ARNI, from an ACEI or ARB, when stabilized and before hospital discharge
+(Strong Recommendation; Moderate-Quality Evidence).
+
+5. We suggest that patients admitted to hospital with a new diagnosis of HFrEF should be treated with ARNI as first-line therapy, as an alternative to either an ACEI or ARB
+(Weak Recommendation; Moderate-Quality Evidence).
+
+Values and preferences. These recommendation place high value on evidence that supports the safety and efficacy of initiating ARNI therapy in hospitalized patients with or without previous RASi exposure.
+
+ACEIs AND ARBs
+
+The benefits of GDMT for patients with HFrEF, including ACEIs and ARBs, are drawn from large randomized controlled trials of ambulatory patients. Previous guideline recommendations for ACEI/ARB therapy in patients with HFrEF reflect this evidence. In contrast, recommendations regarding the role of RASi in the management of acute HF is largely consensus-based, with no good-quality evidence to support treatment recommendations in the hospitalized setting. Practically, an HHF event represents an opportunity to optimize and/or reevaluate therapy including switch from an ACEI/ARB to an ARNI in eligible patients with HFrEF to improve postdischarge patient outcomes, as discussed in the previous section.
+ACEI/ARB initiation and continuation during HF hospitalization. ACEIs and ARBs do not have a clear role in the early management of acute or worsening HF, because there are no robust randomized controlled trial data regarding in-hospital ACEI/ARB initiation. Observational data from the Get With The Guidelines-HF Registry showed that among 16,052 patients, those who started ACEI/ARB treatment before discharge had lower mortality and readmission rates up to 1 year. Nevertheless, a significant number of patients hospitalized for HFrEF have worsening hemodynamics and/or worsening renal function, which might lead to reluctance with initiating or continuing hemodynamically active therapies. One analysis showed that ACEI/ARB medications were reduced or discontinued because of acute kidney injury (57%), hypotension (23%), and hyperkalemia (10%); serum creatinine and systolic at admission were significant independent predictors of in-hospital dose reduction or discontinuation. Although renal dysfunction was noted as the most common cause for reduction of ACEI/ARB therapy, 24% of patients had no significant in-hospital rise in creatinine level, and medication changes were made in anticipation of deteriorating renal function rather than documented change in renal function.
+A matched-cohort analysis of Medicare beneficiaries hospitalized for HF between 1998 and 2001 showed that patients who initiated ACEI/ARB treatment had lower 30-day readmission rates (18% vs 24%) and all-cause mortality (7% vs 14%) compared with those for whom ACEI/ARB treatment was discontinued.
+ACEIs/ARBs after acute myocardial infarction. It is well established that ACEIs should be administered to patients with impaired LVEF ( 40%) or those who have experienced HF in the early phase post myocardial infarction (MI). A systematic review of 4 trials of early ACEI initiation (0-36 hours) post ST-elevation MI including more than 98,000 patients, showed a 7% relative reduction in 30-day mortality compared with placebo. Importantly, 40% of the survival benefit was seen after the first day of treatment, underscoring the value of initiating ACEI treatment early in hemodynamically stable patients.
+ARBs as an alternative to ACEIs, in the context of ST-elevation MI, have been evaluated in 2 clinical trials. In the Optimal Trial in Myocardial Infarction With the Angiotensin II Antagonist Losartan (OPTIMAAL) trial, losartan failed to show either superiority or noninferiority compared with captopril for the primary end point at the 2.7-year follow-up (18% vs 16%). Conversely, in the Valsartan in Acute Myocardial Infarction (VALIANT) trial, 14,703 patients with acute MI (0.5 and 10 days) and HF or evidence of left ventricular systolic dysfunction  40% were randomly assigned to valsartan alone, full-dose captopril, or both (80 mg twice daily and 50 mg 3 times daily). The primary end point of all-cause mortality was similar in the 3 groups (valsartan 19.9%, captopril 19.5%, both 19.3%), but discontinuations were more frequently seen in patients who received captopril. Therefore, valsartan, at the dosages used in the trial, represents an alternative to ACEIs.
+
+Practical tip. ACEI intolerance describes a patient who is unable to tolerate ACEI therapy secondary to a bothersome cough (approximately 10%) or those who experience angioedema (< 1%). ARB therapy is a reasonable alternative in both of these cases, however, caution should be used in patients who develop angioedema while receiving ACEI therapy because there have been case reports of patients who subsequently develop angioedema with ARB therapy. There is no significant difference in rates of hypotension, hyperkalemia, or renal dysfunction between ACEIs and ARBs to warrant substitution.
+
+Practical tip. An increase in serum creatinine or decrease in estimated glomerular filtration rate (eGFR) of up to 30% in the absence of oliguria is not unexpected when an ACEI or ARB is introduced; if the increase stabilizes at 30%, there is no immediate need to decrease the drug dose but closer long-term monitoring might be required.
+
+Practical tip. BP might fall when an ACEI or ARB is introduced, especially if introduced at a high dose or in combination with diuretic therapy. Check BP with the patient supine and standing to detect whether hypotension is present, which might suggest that a slower up-titration is warranted.
+
+Practical tip. Caution is warranted in patients with marginal BP; although low-dose captopril is sometimes used to initiate an ACEI in hemodynamically tenuous patients this approach has never been tested in randomized controlled trials.
+
+Practical tip. Longer-acting ACEIs such as perindopril or ramipril might be associated with less hypotension in patients with chronic HF, particularly in older patients.
+
+RECOMMENDATION
+6. We recommend an ACEI or ARB in those with ACEI intolerance, in patients with acute MI with HF or an LVEF < 40% post-MI to be used as soon as safely possible post-MI 
+(Strong Recommendation; High-Quality Evidence).
+
+b-Blockers
+
+Since the 2017 comprehensive update of the CCS guidelines for the management of HF, no large randomized clinical trials of b-blockers in patients with HFrEF have been published. Previous landmark trials of carvedilol, sustained release metoprolol succinate, and bisoprolol27 have shown unequivocal reductions in mortality and hospitalization, and improvement in HF symptoms among patients with HFrEF and New York Heart Association (NYHA) functional class II-IV symptoms at baseline. In a meta-analysis of more than 10,000 patients, b-blockers prevented 3.8 deaths and were associated with 4 fewer hospitalizations per 100 patients in the first year of treatment.
+For patients admitted to hospital with worsening HF, b-blocker initiation, before discharge in stabilized patients, has been associated with improved short and intermediate-term outcomes without intolerance or extended length of hospital stay. Available evidence also strongly suggests that patients with HFrEF receiving b-blockers at the time of admission for acute HF have higher rates of death and recurrent HHF when b-blockers are not resumed before discharge.
+A recent meta-analysis of 5 observational studies and 1 randomized trial confirmed this association; b-blocker withdrawal in the setting of HHF increased the risk of in-hospital mortality (RR, 3.72 [95% CI 1.51-9.14]), mortality at 60-180 days (RR, 1.78; [95% CI 1.13-2.79]), and combined short term rehospitalization or mortality (RR, 1.84; [95% CI 1.08-3.1]).35 The totality of available evidence suggests that b-blockers should be continued or reinitiated before discharge in those with HFrEF who are hospitalized for worsening HF, whenever clinically feasible.
+In addition to including b-blockers as part of standard medical HFrEF therapy, the following recommendations on b-blocker use in HFrEF have remained unchanged from the 2017 comprehensive update of the CCS guidelines for the management of HF.
+
+Practical tip. Objective improvement in cardiac function might not be apparent for 6-12 months after b-blocker initiation. The absence of LVEF recovery is not justification to stop treatment.
+
+Practical tip. Treatment of patients with NYHA class I or II symptoms can be safely initiated and titrated with a b-blocker by nonspecialist physicians.
+
+Practical tip. Patients with NYHA class III or IV symptoms should have b-blocker therapy initiated by a specialist experienced in HF management and titrated in the setting of close follow-up, such as can be provided in a specialized clinic, if available.
+
+Practical tip. b-Blockers should be started at low doses and increased slowly (eg, double the dose every 2-4 weeks). Transient fluid retention might occur with initiation or uptitration of b-blockers and might require assessment of diuretic dosage (eg, might consider deferring dosage reduction).
+
+Practical tip. If concomitant reactive airways disease is present, consider using more selective b-1 blockade (eg, bisoprolol).
+
+Practical tip. If atrioventricular (AV) block is present, consider decreasing other AV node-blocking drugs, such as digoxin or amiodarone (when appropriate). The type and severity of AV block and the patient’s history of arrhythmia will help guide the most appropriate treatment modifications.
+
+RECOMMENDATION
+
+7. We recommend that b-blockers be initiated as soon as possible after the diagnosis of HF, including during the index hospitalization, provided that the patient is hemodynamically stable. Clinicians should not wait until hospital discharge to start b-blocker treatment in stabilized patients
+(Strong Recommendation; High-Quality Evidence).
+
+8. We recommend patients with NYHA class IV symptoms be stabilized before initiation of b-blocker treatment
+(Strong Recommendation; High-Quality Evidence).
+
+9. We recommend that b-blockers be initiated in all patients with an LVEF < 40% with previous MI
+(Strong Recommendation; Moderate-Quality Evidence).
+
+MRAs
+
+MRA use in patients with HFrEF. Despite access to MRA therapy for the treatment of HF, and despite established guideline recommendations to initiate MRAs as part of standard therapy (along with RASi and b-blocker medications), there remains uncertainty or reluctance for widespread use. A report of the recent US CHAMP-HF registry showed that MRA was used in only 33.4% of patients with HFrEF without documented contraindication. On the basis of data from the Randomized Aldactone Evaluation Study (RALES), the Eplerenone Post-Acute Myocardial Infarction Heart Failure Efficacy and Survival Study (EPHESUS), and the Eplerenone in Mild Patients Hospitalization and Survival Study in Heart Failure (EMPHASIS-HF), there are 3 clinical scenarios in which mineralocorticoid receptor antagonism in the absence of significant renal dysfunction or hyperkalemia are supported by randomized control trial evidence: (1) LVEF  35% and NYHA class III-IV symptoms; (2) post MI with signs and symptoms of acute HF and LVEF  40%, or post MI with diabetes and LVEF  40% (regardless of HF symptoms); and (3) LVEF  30% (or if LVEF 31%-35% with QRS > 130 ms), NYHA class II symptoms, and another high risk feature (eg, age > 55 years, HHF within the previous 6 months, or elevated natriuretic peptide levels).
+A more generalized role for MRAs in HF management is further supported by contemporary trials that have shown a consistent benefit of newer therapies for which background treatment with MRAs has been > 50% among patients enrolled. Moreover, in the Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist (TOPCAT) trial HHF reduction was observed in patients with HF and LVEF  45% despite trial challenges in the population recruited, which might lessen the reluctance to treat HF patients on the basis of reduced ejection fraction alone.
+Randomized controlled trial data regarding in-hospital initiation of MRA therapy among patients with HFrEF is limited to the EPHESUS trial. However, patients with worsening HF are often admitted to hospital, creating opportunity for improving HF therapies before discharge. In the PIONEER-HF study it was noted that in patients admitted with acute decompensated HF and reduced ejection fraction, 65% had a history of HF but only 10% were receiving an MRA at the time of admission.
+Patients with HF have multiple comorbidities adding complexity to their care. In-patient care for any one of these medical concerns is an opportunity to enhance HF therapy. In contrast, medications are often interrupted during acute medical illness and reintroduction at maximum tolerated doses before discharge is encouraged. In addition to including MRAs as part of standard medical HFrEF therapy, the following recommendation has been updated.
+
+Practical tip. MRAs recommended for patients with HFrEF include spironolactone and eplerenone.
+
+Practical tip. MRAs should generally be avoided when eGFR is < 30 mL/min/1.73 m2.
+
+Practical tip. MRAs can increase serum potassium, especially during an acute dehydrating illness in which renal dysfunction can worsen. Monitoring of serum creatinine and potassium should be repeated within 1 week of initiation or dose change.
+
+Practical tip. Temporary reduction or interruption of MRA therapy might be necessary when potassium levels are moderately (5.6-5.9 mmol/L) or severely (> 5.9 mmol/L) elevated, with a return to maximum tolerated dose when other modifiable factors are corrected and potassium levels are  5.0 mmol/L.
+
+Practical tip. MRAs, when used for HF, have very little effect on BP.
+
+RECOMMENDATION
+
+10. We recommend MRA treatment for patients with acute MI and LVEF  40%, and HF symptoms or diabetes, to reduce mortality, CV mortality, and hospitalization for CV events
+(Strong Recommendation; High-Quality Evidence).
+
+SGLT2 INHIBITORS
+
+When to start SGLT2 inhibitor treatment in patients with HFrEF. The benefits of SGLT2 inhibitors in patients with established HFrEF have been shown in 2 large clinical trials and 1 meta-analysis, with consistency of benefit regardless of diabetes status.40,41,44 These agents should be considered as standard or foundational therapy in patients with HFrEF (Fig. 1).
+The results of the Dapagliflozin in Patients with Heart Failure and Reduced Ejection Fraction (DAPA-HF) trial were described in the previous CCS HF guideline update. Over a median 18-month follow-up of 4744 patients with HFrEF, treatment with dapagliflozin significantly reduced the composite primary end point of time to first worsening of HF or death from CV causes (hazard ratio [HR], 0.74 [95% CI 0.65-0.85]; P < 0.001), as well as HHF (HR, 0.70 [95% CI 0.59 - 0.83]) and CV death (HR, 0.82 [95% CI 0.69 - 0.98]). Importantly, 55% of patients in this trial did not have diabetes at baseline, and the effect of dapagliflozin was similar at any hemoglobin A1c level. Ancillary studies have shown that benefits accrued as early as 30 days after treatment initiation. Other notable substudy findings were that diuretic dose was not modified during the trial for most patients, quality of life was improved, and BP was reduced by an average of approximately 2 mm Hg. Importantly, baseline kidney function did not modify the effect of dapagliflozin on outcomes and treatment was associated with a slower eGFR decline compared with placebo in diabetic and nondiabetic cohorts.
+The results of the recently published EMPEROR-Reduced trial, in which empagliflozin 10 mg daily was compared with placebo in patients with symptomatic HFrEF, were concordant with those of DAPA-HF. Participants included those with an LVEF < 40% and elevated NT-proBNP levels that varied according to LVEF and atrial fibrillation status. Enrollment could occur with an eGFR as low as 20 mL/min/ 1.73 m 2. During a median follow-up of 16 months, the primary outcome of CV death or HHF occurred in 19.4% of participants in the empagliflozin group and in 24.7% of the placebo group (HR, 0.75 [95% CI 0.65-0.86]; P < 0.001); this benefit was comparable for patients with and without diabetes. The total number of HHF was lower in the empagliflozin group (HR, 0.70 [95% CI 0.58-0.85]; P < 0.001), as was the annual rate of decline in eGFR (0.55 vs 2.28 mL/min/1.73 m2 per year; P < 0.001).
+The use of background pharmacological therapy for HFrEF was excellent in both trials. Of particular note, sacubitrilvalsartan served as a RASi among approximately 11% of patients in DAPA-HF and in approximately 19% in EMPEROR-Reduced at enrollment. Cardiac resynchronization therapy (CRT) was used in 7.5% of participants in DAPA-HF and in 12% of those in EMPEROR-Reduced, whereas implantable cardioverter defibrillators (ICDs), with or without CRT, were used in 26% and 31%, respectively. There were no treatment interactions between SGLT2 inhibitor and the baseline therapies used. SGLT2 inhibitor treatment was safe with no excess in hypovolemia, hypoglycemia, or renal side effects compared with placebo.
+Taken together, as shown in a meta-analysis by Zannad and colleagues, the results of these 2 landmark trials show that SGLT2 inhibitor reduces morbidity and mortality in patients with symptomatic HFrEF, whether type 2 diabetes is present or not.
+The recently published Dapagliflozin in Patients With Chronic Kidney Disease (DAPA-CKD) trial showed that dapagliflozin, when used in addition to standard therapy, also prevents renal and CV outcomes in patient with established chronic kidney disease. Among 4304 participants, with or without type 2 diabetes, with an eGFR between 25 and 75 mL/ min/1.73 m2 and proteinuria (a urinary albumin-to-creatinine ratio of 22.6-565.6 mg/mmol) who were randomly assigned to dapagliflozin 10 mg daily or placebo, the primary composite outcome of a sustained decline in eGFR of at least 50%, end-stage kidney disease, or death from renal or CV causes was reduced by 44% (HR, 0.56 [95% CI 0.45-0.68]; P < 0.001). The hazard ratio for the composite of death from CV causes or HHF was 0.71 ([95% CI 0.55-0.92]; P ¼ 0.009). All-cause mortality was also significantly reduced (HR, 0.69; [95% CI 0.53-0.88]; P ¼ 0.004) and the safety profile of dapagliflozin was confirmed in this group.
+
+Practical tip. In EMPEROR-Reduced and DAPA-HF, SGLT2 inhibitor treatment was initiated in addition to maximally tolerated GDMT. However, recognizing the significant residual risk of patients with HFrEF despite GDMT and the benefits associated with dapagliflozin and empagliflozin, it would be reasonable to start this class of therapy early in the disease course for eligible patients.
+
+Practical tip. EMPEROR-Reduced excluded patients with an eGFR < 20 mL/min/1.73 m2 and DAPA-HF excluded patients with an eGFR < 30 mL/min/1.73 m2. Data supporting the use of these agents in patients with HFrEF and eGFR < 30 mL/min/1.73 m2 are very limited.
+
+Practical tip. The Canadian Heart Failure Society (CHFS) has published “Practical Approach to SGLT2 Inhibitors for Treatment of Cardiovascular Disease,” which includes contraindications, cautions, drug initiation, special considerations, and sick day management tips.
+
+Additional Practical Tips related to SGLT2 inhibitor prescription from the previous 2020 HF guideline update2 remain relevant and are included as follows:
+
+Practical tip. SGLT2 inhibitors are currently contraindicated for patients with type 1 diabetes.
+
+Practical tip. The most common adverse effect of this class of medications are genital mycotic infections (GMIs). Women (10%-15% risk), those with previous GMIs, and uncircumcised men are at highest risk. Typically, GMIs can be managed with antifungal drugs and do not require discontinuation of therapy.
+
+Practical tip. SGLT2 inhibitor use might result in temporary reduction of eGFR up to 15%, which generally resolves within 1-3 months. SGLT2 inhibitors have also been associated with acute kidney injury and increased monitoring is warranted in those at risk.
+
+Practical tip. SGLT2 inhibitors rarely cause hypoglycemia in the absence of concomitant insulin and/or secretagogue therapy. Background therapies might need to be adjusted to prevent hypoglycemia.
+
+Practical tip. SGLT2 inhibitors should be held in the setting of concomitant dehydrating illness as part of “Sick Day” management. Patients should be educated on “Sick Day” management.
+
+Practical tip. These agents have been associated with diabetic ketoacidosis (incidence 0.1%). Patients might present with normal or only modestly elevated blood glucose level (< 14 mmol/L). On rare occasions, SGLT2 inhibitors might be associated with normal anion gap acidosis, which is best detected with measurement of serum ketones. Nonspecific symptoms associated with diabetic ketoacidosis include: shortness of breath, nausea, vomiting, abdominal pain, confusion, anorexia, excessive thirst, and lethargy.
+
+Practical tip. Careful attention to volume status is required when SGLT2 inhibitors, ARNIs, and loop diuretics are used in combination because of their concomitant effects to promote diuresis.
+
+RECOMMENDATION
+
+11. We recommend an SGLT2 inhibitor, such as dapagliflozin or empagliflozin, be used in patients with HFrEF, with or without concomitant type 2 diabetes, to improve symptoms and quality of life and to reduce the risk of HF hospitalization and/or CV mortality
+(Strong Recommendation; High-Quality Evidence).
+
+12. We recommend an SGLT2 inhibitor, such as empagliflozin, canagliflozin, or dapagliflozin be used for treatment of patients with type 2 diabetes and atherosclerotic CV disease to reduce the risk of HF hospitalization and death
+(Strong Recommendation; High-Quality Evidence).
+
+13. We recommend an SGLT2 inhibitor, such as dapagliflozin, be used in patients with type 2 diabetes who are older than 50 years with additional risk factors for atherosclerotic CV disease to reduce the risk of HF hospitalization
+(Strong Recommendation; High-Quality Evidence).
+
+14. We recommend SGLT2 inhibitors such as canagliflozin or dapagliflozin be used in patients with albuminuric renal disease, with or without type 2 diabetes, to reduce the risk of HF hospitalization and progression of renal disease
+(Strong Recommendation; High-Quality Evidence).
+
+Values and preferences. These recommendations place weight on the results from large randomized, placebo-controlled trials that consistently showed a benefitof SGLT2 inhibitor treatment on HF prevention and treatment among patients with and without type 2 diabetes.
+
+SINUS NODE INHIBITION
+
+Resting heart rate independently predicts CV events, including HHF and death. Studies have shown that the effect of elevated heart rate on outcomes becomes apparent within 30 days of discharge from hospital. In systematic reviews it has been postulated that a major contributor to the benefits of b-blocker therapy in patients with HFrEF might be their rate-lowering effect.
+Ivabradine selectively inhibits the depolarizing If current in the sinus node. It thus requires sinus rhythm to provide its pharmacological effect. In contrast to b-blockers, ivabradine decreases heart rate without lowering BP or myocardial contractility. The Systolic Heart Failure Treatment With the If Inhibitor Ivabradine Trial (SHIFT) trial addressed the use of ivabradine in ambulatory patients with chronic symptomatic HFrEF. The SHIFT trial design, inclusion criteria, and results have been discussed previously in the 2017 comprehensive guideline update. In this trial, there was an 18% reduction in the primary outcome of CV death or HHF favouring ivabradine compared with placebo, which was largely driven by a reduction in HHF (relative risk reduction, 26%). In the prespecified subgroup of patients with resting heart rate > 77 bpm, ivabradine exerted a greater effect on outcome reduction including the primary end point (HR, 0.76 [95% CI 0.68-0.85]; P < 0.0001), all-cause mortality (HR, 0.83 [95% CI 0.72-0.96]; P ¼ 0.0109), and CV mortality (HR, 0.83 [95% CI 0.71-0.97]; P ¼ 0.0166).61 In the 685 patients not taking b-blockers at baseline, ivabradine reduced the primary end point with a HR of 0.68 (95% CI 0.52-0.88).
+Studies have shown that most titration of b-blockade occurs early in the course of treatment, with most of the heart rate reduction occurring at < 50% of target dose with further titration, there is a diminishing effect on heart rate, leaving approximately 10%-15% of patients with residual Beyond heart rate > 70 bpm after b-blocker titration. chronic ambulatory HF, small studies have shown that the additional use of ivabradine with a b-blocker is safe and well tolerated in hospital settings.
+
+Practical tip. Ivabradine has no direct effect on BP, myocardial contractility, or renal function and as such is well tolerated in patients who are unable to initiate or titrate b-blockers for these reasons.
+
+Practical tip. Ivabradine may be considered for patients with either stable or decompensated chronic HFrEF who are intolerant of b-blockers, with a resting heart rate in sinus rhythm of > 70 bpm.
+
+Practical tip. Typical reductions in resting sinus heart rate after treatment with b-blockers range from 10-15 bpm, with little change (< 5 bpm) between low and high doses. This consideration might assist in the decision to use further medications for sinus heart rate control. Practical tip. Ivabradine is well tolerated in older adults and can be initiated at 2.5 mg twice daily.
+
+Practical tip. Ivabradine should be avoided in patients with advanced liver disease.
+
+RECOMMENDATION
+
+15. We recommend that ivabradine be used for patients with HFrEF and symptoms despite treatment with GDMT, a resting heart rate  70 bpm, and sinus rhythm for the prevention of CV death and HF hospitalization (Strong Recommendation; High-Quality Evidence).
+
+Values and preferences. High value is placed on reducing the risk of CV death and HHF when ivabradine is used as adjunctive therapy with standard HF medication treatments in a selected HFrEF population. Differing criteria for heart rate eligibility have been approved by various regulatory authorities ranging from 70-77 bpm, although the trial entry criteria was 70 bpm.
+
+sGC stimulators
+
+Worsening HF and HHF portend a poor prognosis and are associated with increased risk of mortality and recurrent hospitalization. The initial posthospitalization phase is the highest risk period for adverse events and represents an opportunity for the clinician to optimize HF care. Pharmacological therapies targeted at this vulnerable phase of the patient journey as a strategy to improve longer-term outcomes have been evaluated in recent clinical trials.
+sGC stimulators, such as vericiguat, directly enhance cyclic guanylate monophosphate (GMP) production and also enhance endogenous sGC sensitivity to nitric oxide. This results in a cascade of adaptive effects on the heart, blood vessels, and kidneys, providing the physiological rationale for their use in patients with HF.
+In the Vericiguat Global Study in Subjects With Heart Failure With Reduced Ejection Fraction (VICTORIA) trial the efficacy and safety of vericiguat compared with standard of care was evaluated in patients with advanced functional symptoms, an LVEF < 45% and a worsening HF event characterized by HHF or elevated natriuretic peptide levels. Notably, patients with an eGFR < 15 mL/min/m2 and systolic BP of < 100 mm Hg were excluded. Study participants receiving optimal guideline-based HF therapies were randomized to placebo or vericiguat and followed for an average of 11.8 months. The primary combined end point of CV death or first HHF was significantly lower (HR, 0.90 [95% CI 0.82-0.98]; P ¼ 0.019) in the vericiguat group and this was driven primarily by a reduction in hospitalization rather than CV death. Of note, the secondary end point of total HHF was also decreased in the vericiguat group (HR, 0.91 [95% CI 0.84-0.99]; P ¼ 0.023). From a safety perspective, there was more hypotension in the vericiguat group but this did not contribute to renal dysfunction, despite the relatively low eGFR cutoff for enrollment.
+Intention to treat subgroup analysis of the combined primary end point showed that vericiguat provided benefit across most clinically relevant subgroups with exception of those with very high NT-proBNP values at baseline (> 8000 pg/ mL).
+
+Practical tip. Subgroup analysis from the VICTORIA trial suggests that clinical response to vericiguat might be attenuated in patients with very elevated natriuretic peptide levels.
+
+RECOMMENDATION
+
+16. We recommend that vericiguat, an oral sGC stimulator, be considered in addition to optimal HF therapies for HFrEF patients with worsening symptoms and HHF in the past 6 months, to reduce the risk of subsequent HF hospitalization
+(Conditional Recommendation; Moderate-Quality Evidence).
+
+Values and preferences. This recommendation places value on the use of an additional medication to reduce the risk of HHF in a high-risk patient population that experiences high rates of hospitalization and mortality despite the relatively modest relative benefits observed in the VICTORIA trial. A conditional recommendation is provided because vericiguat has not yet been approved for this indication in Canada.
+
+DIGOXIN
+
+The Digitalis Investigation Group (DIG) trial enrolled 6800 patients with HF and a LVEF  45%. The primary end point was mortality, and the mean follow-up was 37 months. Patients were randomized to digoxin (median dose, 0.25 mg/d) or placebo. Fifty-four percent of participants had NYHA class II symptoms and 94% were treated with an ACEI. There was no difference in all-cause mortality between groups. There were fewer patients hospitalized for worsening HF in the digoxin group. Suspected digoxin toxicity was higher in the digoxin group.
+A subsequent systematic review of 13 studies (which included the DIG trial) showed similar results. None of these studies provide meaningful insight into the relative benefit, or harm, of digoxin in light of contemporary HFrEF therapy. There has been substantial use of digoxin as background therapy in the current era of HFrEF landmark trials with no apparent change in outcomes stratified according to baseline digoxin use.
+
+Practical tip. Serum concentrations of digoxin < 1.2 ng/ mL are associated with less treatment-related morbidity. Nonetheless, routine digoxin levels are not required other than to assess for digoxin toxicity. Digoxin levels should not be used to guide chronic therapy and titrating to digoxin levels has not been tested in clinical trials.
+
+Practical tip. Digoxin can cause atrial and ventricular arrhythmias particularly in the presence of hypokalemia and/or worsening renal function and levels should be monitored accordingly.
+
+Practical tip. In patients receiving digoxin, serum potassium and creatinine should be measured with increases in digoxin or diuretic dose, the additional use or discontinuation of an interacting drug, or during a dehydrating illness, to reduce the risk of digoxin toxicity. Patients with reduced or fluctuating renal function, older patients, those with low body weight, and women are at increased risk of digoxin toxicity and might require more frequent monitoring including digoxin levels.
+
+Practical tip. Among hospitalized older patients with HFrEF who are receiving guideline-directed medical therapies, discontinuation of preadmission digoxin therapy might have deleterious effects.
+
+RECOMMENDATION
+
+17. We suggest digoxin be considered in patients with HFrEF and atrial fibrillation, with poor control of ventricular rate and/or persistent symptoms despite optimally tolerated b-blocker therapy, or when b-blockers are not tolerated, in the setting of chronic HF, new onset HF, or HF hospitalization 
+(Weak Recommendation; Low-Quality Evidence).
+
+18. We suggest digoxin be considered in patients with HFrEF in sinus rhythm who continue to have mod- erate to severe symptoms despite appropriate doses of GDMT to relieve symptoms and reduce hospitalizations 
+(Weak Recommendation; Moderate-Quality Evidence).
+
+Values and preferences. These recommendations place a high value on the understanding that the role of cardiac glycosides in patients with HFrEF remains controversial in light of evolving contemporary HF therapy.
+
+HYDRALAZINE AND ISOSORBIDE DINITRATE
+
+The combination of hydralazine and isosorbide dinitrate (H-ISDN) has had a role in the management of HFrEF since the 1980s. The first large-scale trial of this therapy predated landmark studies of RASi and b-blockers. In Vasodilator in Heart Failure Trial (V-HeFT) the effect of H-ISDN, prazosin, and placebo were compared in an HFrEF patient population. Mortality was reduced among patients treated with H-ISDN with a relative risk reduction of 34% at 2 years (P ¼ 0.028). Compared with enalapril, treatment with H-ISDN provided less mortality reduction after a mean of 2.5 years (32.8% vs 38.2%; P ¼ 0.016) and no difference in hospitalizations.
+In the African-American Heart Failure Trial (A-HeFT), H-ISDN was investigated as used in addition to optimal therapy in self-identified black patients with HFrEF and NYHA class III/IV symptoms. Black patients were specifically evaluated in this trial because they are known to have reduced activity of the reninangiotensin system. A total of 1050 black patients were randomized to H-ISDN or placebo, in addition to standard of care, and followed for a mean of 10 months. The study was terminated early because of higher mortality in the placebo group. The primary outcome was a weighted score, but individual components of the outcome showed a difference favouring H-ISDN for all-cause mortality, first HHF, and change in quality of life score.
+
+Practical tip. Renal dysfunction warranting a trial of H-ISDN includes those who have a significant change in creatinine from baseline with ACEI/ARB/ARNI therapy that persists despite modification of dose, rechallenge, and/or removal of other potentially nephrotoxic agents. It may also be considered in those with a serum creatinine > 220 mmol/L who experience significant worsening in renal function with the use of ACEI/ARB/ARNI therapy, or if the risk of these agents (eg, potential for worsening renal function requiring renal replacement therapy) is thought to outweigh benefits.
+
+Practical tip. A trial of H-ISDN might be warranted in patients with persistent hyperkalemia (K > 5.5 mmol/L) despite dietary intervention, dose reduction of ACEI/ARB/ ARNI, and removal of other agents known to increase potassium levels.
+
+Practical tip. Nitrates alone might be useful to relieve orthopnea, paroxysmal nocturnal dyspnea, exercise-induced dyspnea, or angina in patients when used as tablet, spray, or transdermal patch, but continuous (ie, around the clock) use should generally be avoided because most patients will develop tolerance. It should be noted that use of nitrates or hydralazine alone has not been shown to improve HF outcomes.
+
+RECOMMENDATION
+
+19. We recommend that H-ISDN be considered for treatment of patients with HFrEF who are unable to tolerate an ACEI, ARB, or ARNI because of hyperkalemia, renal dysfunction, or other contraindications, in the following settings:
+
+i. Chronic HF (Strong Recommendation, Moderate-Quality Evidence);
+ii. New-onset HF (Weak Recommendation, Low-Quality Evidence); and
+iii. HF hospitalization (Weak Recommendation, Low-Quality Evidence).
+
+20. We recommend that H-ISDN treatment be considered in addition to standard GDMT at appropriate doses for black patients with HFrEF and advanced symptoms (Strong Recommendation; Moderate-Quality Evidence).
+
+Values and preferences. There is limited high-quality clinical trial evidence in the modern era on which to base an H-ISDN recommendation. Adverse effects related to H-ISDN are frequent, limit up-titration, and lead to discontinuation in a significant proportion of patients. Every effort should be made to use ARNI (or alternatively ACEI/ARB) therapy including initiating at a low dose and/or rechallenging patients who have experienced adverse events/intolerability before changing to H-ISDN.
+
+Referral for ICD and CRT
+When to refer for ICD/CRT in the current era of medical therapy for HFrEF
+The decision regarding when and if an ICD should be implanted must include evaluation of the short- and long- term risks of sudden death due to a ventricular arrhythmia and death from nonarrhythmic causes. This is often a complex assessment and must integrate many factors including the presence of ischemic heart disease, burden of scar, frailty, advancing dementia, comorbidities, and adequacy of background medical therapy. In addition to ICD considerations, CRT further improves mortality and reduces HHF in patients with HFrEF and dyssynchrony, particularly those with QRS > 150 ms.
+Most trials that have shown a mortality reduction for primary prevention ICD implantation or CRT were conducted in an era when conventional HFrEF therapy included b-blockers, RASi with ACEIs and ARBs, and MRAs. In the past decade, HFrEF therapies such as sacubitril-valsartan, ivabradine, SGLT2 inhibitor, and vericiguat have also shown a reduction in CV death and worsening HF events in patients with HFrEF. In part, this might be because of the beneficial effects of these agents on ventricular function. For example, in the echocardiography substudy of the SHIFT trial (discussed previously), among the 411 patients who had paired baseline and 8-month follow-up echocardiography data, there was an increase in LVEF of 2.4% (SD, 7.7) in ivabradine-treated patients compared with a decrease of 0.1% (SD, 8.0%) in the placebo group (P < 0.001).80 Similarly, patients with NYHA II-IV symptoms and LVEF < 40% who were switched from an ACEI/ARB to an ARNI in the open-label, single-arm Prospective Study of Biomarkers, Symptom Improvement, and Ventricular Remodeling During Sacubitril/Valsartan Therapy for Heart Failure (PROVE-HF) study, there was an increase in LVEF by 4.9% (range, 4.5%-5.3%) at 6 months and 8.8% (range, 8.3%-9.3%) at 12 months. In a meta-analysis of 9 studies including 707 patients with HFrEF, the LVEF increased by 4.9% (range, 4.13%-5.65%) after patients were switched to treatment with an ARNI.82 Because of the demonstrated benefits of current HFrEF therapies to improve LVEF over time, it seems prudent to ensure that GDMT has been optimized before implanting primary prevention ICDs and CRT. However, it must be emphasized that there are no randomized controlled trial data on the risk/benefit of ICD implantation and CRT before vs after the initiation of newer HFrEF therapies. Every attempt should be made to initiate and titrate GDMT as quickly as feasible to avoid delays in referring suitable patients with persistently reduced LVEF for device therapy.
+
+Practical tip. Reassessment of ejection fraction should be performed 3 months after the achievement of target or maximally tolerated doses of GDMT.
+
+Practical tip. An assessment of arrhythmic and non-arrhythmic sudden cardiac death (SCD) risk should be performed to estimate the risk/benefit of ICD implantation or CRT.
+
+Practical tip. Specific HF therapies might contribute to improvements in LVEF and should be considered before referral for ICD implantation or CRT: For eligible patients, switching to ARNI therapy should be considered before referral for ICD or CRT. Additional use of ivabradine, where otherwise indicated after b-blocker optimization, should be considered before referral for ICD implantation or CRT.
+
+Practical tip. Referral for ICD implantation or CRT should not be unduly delayed if timely titration of pharmacologic therapies is infeasible or impractical.
+
+RECOMMENDATION
+
+21. We recommend that after a diagnosis of HFrEF, standard medical therapy should be initiated and titrated to target or maximally tolerated doses with a repeat assessment of LVEF before referral for ICD or CRT (Strong Recommendation; Moderate-Quality Evidence).
+
+AREAS OF UNCERTAINITY AND EVOLVING EVIDENCE
+
+The CCS HF Guidelines Panel identified a number of unresolved questions relevant for the management of patients with HFrEF. For the purposes of this guideline update, systematic evidence reviews were limited in scope to the therapies and settings discussed herein. However, on the basis of emerging evidence, some additional considerations are worth noting, and further research will likely inform future guidelines.
+
+1. Should ARNIs be prescribed in the setting of HF after MI?
+The Prospective ARNI vs ACE Inhibitor Trial to Determine Superiority in Reducing Heart Failure Events After MI (PARADISE-MI; NCT02924727) trial has completed enrollment and will compare sacubitril-valsartan with ramipril treatment early after high-risk MI (12 hours to 7 days) with respect to the composite end point of CV death, HHF, or urgent outpatient HF visit.
+
+2. Should SGLT2 inhibitor treatment be initiated during an HHF episode in patients with HFrEF?
+In the recently published Sotagliflozin on Clinical Outcomes in Hemodynamically Stable Patients With Type 2 Diabetes POST Worsening Heart Failure (SOLOIST-WHF) trial, sotagliflozin (a combined sodium glucose transport 1/SGLT2 inhibitor) was compared with placebo in 1222 patients with diabetes who were admitted to hospital with worsening HF. The medication was prescribed before discharge or shortly after discharge when hemodynamic stability was achieved. Sotagliflozin significantly reduced the risk of achieving the primary end point of CV death, HHF, or urgent visit for HF (51.0 vs 76.3 events per 100 patient-years; HR, 0.67 [95% CI 0.52-0.85]). Ongoing trials will further evaluate the efficacy and safety of initiating SGLT2 inhibitors in a spectrum of hospitalized HF patients, regardless of diabetes status (Dapagliflozin and Effect on Cardiovascular Events in Acute Heart Failure-Thrombolysis in Myocardial Infarction [DAPA ACT HF-TIMI 68; NCT04363697] and A Multicentre, Randomised, Double-blind, 90-day Superiority Trial to Evaluate the Effect on Clinical Benefit, Safety and Tolerability of Once Daily Oral Empagliflozin 10 mg Compared to Placebo, Initiated in Patients Hospitalised for Acute Heart Failure [de Novo or Decompensated Chronic HF] Who Have Been Stabilised [EMPULSE; NCT04157751]) trial.
+
+3. Do myosin activators (myotropes) have a role in managing patients with HFrEF?
+Omecamtiv mecarbil (OM) is a myosin activator that enhances systolic function in patients with HFrEF by augmenting actin-myosin interaction in the sarcomere.84 In the Global Approach to Lowering Adverse Cardiac Outcomes Through Improving Contractility in Heart Failure (GALACTIC-HF), OM was compared with placebo in 8256 patients with HFrEF and worsening symptoms (either currently hospitalized or hospitalized within the past year).72 Dosing was adjusted according to study drug level, and the primary end point was a composite of HHF or urgent HF visit or CV death. Compared with placebo, OM reduced incidence of the primary outcome over 22 months of follow-up (37.0% vs 39.1%; HR, 0.92 [95% CI 0.85-0.99]). It is unclear whether there are important subgroups of patients (such as those with severely depressed LVEF) that might derive greater benefit from OM. Because of the relatively modest effect of this drug compared with placebo in a high-risk HF population, and uncertainty around whether OM will receive regulatory approval in Canada, no recommendations have been made at this time.
+
+CONCLUSION
+
+This CCS HF guideline update heralds a shift in the clinical approach to management of patients with HFrEF and will likely have significant practice implications. Although many areas of uncertainty remain and there is continued need for evidence to inform our approach to best practice, it is clear that knowledge translation strategies and change management will be essential to ensure that patients with HFrEF, regardless of practice setting, consistently receive the new standard for optimal medical therapy as outlined in this update.

_heart-failure-medication-guide.txt

@@ -0,0 +1,301 @@
+WHAT GUIDES HEART FAILURE MEDICATION CHOICES?
+Heart failure with reduced ejection fraction (HFrEF): Heart failure caused by a problem with the pumping function of the heart, called ‘reduced ejection fraction.’ If you’ve been diagnosed with heart failure with reduced ejection fraction (HFrEF), you may be wondering about your treatment options. Many medications are available to treat heart failure depending on your individual health and needs.
+
+What is Guideline-Directed Medical Therapy?
+The Canadian Cardiovascular Society (CCS) sets the standards for optimal heart failure care in Canada, known as “CCS/CHFS Heart Failure Guidelines.” In 2021, the CCS updated its treatment guidelines for people living with heart failure with reduced ejection fraction (HFrEF). These are the guidelines that your health care team follow to treat heart failure. The CCS/CHFS Heart Failure Guidelines recommend that, whenever possible, people with HFrEF be treated with 4 different medications early after their diagnosis. This combination of medications is known as “guideline-directed medical therapy.” Additional medications may also be recommended, depending on your health and risk factors. Note: The CCS/CHFS Heart Failure Guidelines were last updated in 2021. The next update may include new or additional recommendations for patients with a higher or ‘preserved’ left ventricular ejection fraction (HFpEF).
+
+Why Optimal Medication Matters
+Using all 4 guideline-directed medical therapy (GDMT) medications together could help you live 5 to 8 years longer. People who are able to take 4 GDMT medications also experience a better quality of life and fewer hospital stays than people taking fewer GDMT medications.
+
+Challenges with Optimizing Medications
+Despite clear and important benefits, studies suggest only 4 in 10 people living with heart failure are being treated with optimal medication. The reasons for this may include:
+
+Knowledge: New research is always coming out and guidelines are updated every few years. It can be hard for health care providers and patients to stay ‘up to date’ with the latest treatment research. People with heart failure may also not fully understand their condition or how it should best be managed.
+
+Uncertainty: Patients and/or providers may be unsure if they should change or add new medications. They may not realize the benefits of optimizing medications, or may not want to take additional pills everyday. Patients may not feel confident that their providers are up-to-date on their condition and needs.
+
+Ability To Access Care: In Canada, most people with heart failure do not receive care from a heart failure specialist. Many face difficulties accessing care when it is needed most. GDMT requires close management by your health care provider.
+
+Drug Costs: Not having coverage for your medications can be costly, particularly for newer medications. This can limit treatment choices.
+
+What is Optimal Medication?
+The CCS/CHFS Heart Failures Guidelines currently recommend the use of 4 different types of medications for people with HFrEF, where possible. Each of these 4 medications works in a unique way, and they work best when used together. On average, each of these medications adds an extra 1 to 2 years of life.
+
+ARNI, ACEi, ARBs
+
+How They Work
+They reduce salt and water retention and open up blood vessels. This makes it easier for your heart to pump blood to your body.
+
+Commonly used drugs
+ARNI: Sacubitril-valsartan (EntrestoTM)
+ACEi: (“prils”) Perindopril, ramipril
+ARB: (“sartans”) Candesartan, valsartan
+
+What to watch out for
+-Symptoms of low blood pressure.
+-ACEi and ARNI may cause a dry cough.
+-Routine bloodwork to check kidney function and potassium (risk of high potassium).
+
+Beta Blockers
+
+How They Work
+They block adrenaline so your heart does not have to work as hard and beat as fast.
+
+Commonly used drugs
+Bisoprolol, Carvedilol, Metoprolol
+
+What to watch out for
+-Symptoms of low blood pressure or heart rate.
+-You may feel tired (low energy) when you first start this medicine. This will get better as your body gets used to the medicine.­
+-Do not stop this medicine suddenly unless your healthcare provider tells you to. Your heart may race if you stop it suddenly.
+
+MRAs
+
+How They Work
+They block stress hormones that make the heart stiff and cause scarring.
+
+Commonly used drugs
+Eplerenone (Inspra™), Spironolactone
+
+What to watch out for
+-Expect ongoing bloodwork for kidney function and potassium (risk of high potassium).
+-Spironolactone: You may experience swelling of your breasts or tenderness. This is more common in men, and occurs in 9 out of 100 people.
+
+SGLT2 Inhibitors
+
+How They Work
+They help lower stress on your heart.
+
+Commonly used drugs
+Dapagliflozin (Forxiga™), Empagliflozin (Jardiance™)
+
+What to watch out for
+-Genital yeast infection or bladder infection (less than 1 in 100 people). You can reduce this risk by paying close attention to your hygiene.
+-Expect ongoing bloodwork for kidney function.
+-This medicine is also used to treat diabetes. Other diabetes medicines may need to be adjusted when you take this medicine.
+
+Possible Side Effects
+You may experience common symptoms from taking these medications that are not serious but still noticeable. However, severe symptoms such as extreme weakness, dehydration or losing consciousness may require immediate medical attention.
+
+Common Side Effects
+
+ARNI, ACEi, ARBs
+What to watch out for
+-Symptoms of low blood pressure.
+-ACEi and ARNI may cause a dry cough.
+-Routine bloodwork to check kidney function and potassium (risk of high potassium).
+
+Beta-blockers
+What to watch out for
+-Symptoms of low blood pressure or heart rate.
+-You may feel tired (low energy) when you first start this medicine. This will get better as your body gets used to the medicine.
+-Do not stop this medicine suddenly unless your healthcare provider tells you to. Your heart may race if you stop it suddenly.
+
+MRAs
+What to watch out for
+-Expect ongoing bloodwork for kidney function and potassium (risk of high potassium).
+-Spironolactone: You may experience swelling of your breasts or tenderness. This is more common in men, and occurs in 9 out of 100 people.
+
+SGLT2 inhibitors
+What to watch out for
+-Genital yeast infection or bladder infection (less than 1 in 100 people). You can reduce this risk by paying close attention to your hygiene.
+-Expect ongoing bloodwork for kidney function.
+-This medicine is also used to treat diabetes. Other diabetes medicines may need to be adjusted when you take this medicine.
+
+Other common symptoms can include:
+-Insomnia or problems sleeping
+-Problems with your stomach and digestion
+-Sense of unease
+-Feeling dizzy or lightheaded
+-Feeling tired
+
+Severe Side Effects
+
+ARNI, ACEi, ARBs
+
+Severe side effects
+1 in 500 people may experience a severe allergic reaction to ACEi and ARNIs called angioedema. This involves swelling of the face, tongue, lips, and hands.
+
+If you develop another illness and as a result are not able to eat or drink, or if you are experiencing a lot of vomiting or diarrhea, contact your health care provider or pharmacist.
+
+What to do
+Seek immediate medical attention.
+
+Beta-blockers
+
+Severe side effects
+If you have a history of asthma or COPD (also known as chronic bronchitis/emphysema), beta-blockers may make you feel wheezy or short of breath.
+
+What to do
+Contact your health care provider immediately.
+
+MRAs
+
+Severe side effects
+If you develop another illness and as a result are not able to eat or drink, or if you are experiencing a lot of vomiting or diarrhea, contact your health care provider or pharmacist.
+
+What to do
+Contact your health care provider or pharmacist.
+
+SGLT2 inhibitors
+
+Severe side effects
+If you develop another illness and as a result are not able to eat or drink, or if you are experiencing a lot of vomiting or diarrhea, contact your health care provider or pharmacist.
+
+1 in 1,000 people may experience a serious condition called ‘ketoacidosis’ while taking SGLT2 inhibitors during times of medical stress or illness. Signs of ketoacidosis include dehydration, nausea and excessive fatigue.
+
+What to do
+Ketoacidosis can be life-threatening if not treated and requires admission to hospital and stopping this medication.
+
+You may also experience worry or anxiety through this process. Some side effects go away or become less bothersome with time. Some will continue. If you are concerned about a side effect, speak to your health care provider. Be aware that these symptoms are not always due to medications. You should make sure your family and/or caregiver are aware of severe side effects from your medications, and what to do if you need help.
+
+Getting to Optimal Medication
+It is crucial that medications be started as soon as possible after heart failure diagnosis. There is no single best approach to starting and increasing your medications. Your health care team will work with you in making these decisions. Factors such as blood pressure, kidney function, medication coverage and possible side effects all play a critical role.
+
+How are Heart Failure Medications introduced?
+Generally, new medications are started at a low dose and increased over time until you reach your maximally targeted dose. Two common ways to start and increase medications are shown here. The goal is that people with HFrEF should be on all 4 guideline-directed medications, at a maximally tolerated dose for them, within 3 to 6 months from their initial diagnosis.
+
+Strict Sequential
+Introducing medications one at a time before adding a new drug.
+This typically requires 6 months or more.
+
+Step 1: ACEi/ARB
+
+They reduce salt and water retention and open up blood vessels. This makes it easier for your heart to pump blood to your body.
+
+Step 2: Beta Blockers
+
+They block adrenaline so your heart does not have to work as hard and beat as fast.
+
+Step 3: MRA
+
+They block stress hormones that make the heart stiff and cause scarring.
+
+Step 4: SGLT2i
+
+They help lower stress on your heart.
+
+Step 5: ARNI
+
+They reduce salt and water retention and open up blood vessels. This makes it easier for your heart to pump blood to your body.
+
+
+In Parallel
+Introducing and increasing medications all at once.
+All steps achieved within 4 weeks.
+
+Step 1: ACEi/ARB/ARNI, Beta Blockers
+
+ACEI/ARB/ARNI: They reduce salt and water retention and open up blood vessels. This makes it easier for your heart to pump blood to your body.
+
+Beta Blockers: They block adrenaline so your heart does not have to work as hard and beat as fast.
+
+Step 2: ACEi/ARB/ARNI, Beta Blockers, MRA
+
+ACEI/ARB/ARNI: They reduce salt and water retention and open up blood vessels. This makes it easier for your heart to pump blood to your body.
+
+Beta Blockers: They block adrenaline so your heart does not have to work as hard and beat as fast.
+
+MRA: They block stress hormones that make the heart stiff and cause scarring.
+
+Step 3: ACEi/ARB/ARNI, Beta Blockers, MRA, SGLT2i
+
+ACEI/ARB/ARNI: They reduce salt and water retention and open up blood vessels. This makes it easier for your heart to pump blood to your body.
+
+Beta Blockers: They block adrenaline so your heart does not have to work as hard and beat as fast.
+
+MRA: They block stress hormones that make the heart stiff and cause scarring.
+
+SGLT2i: They help lower stress on your heart.
+
+Step 4: ACEi/ARB/ARNI, Beta Blockers, MRA, SGLT2i, ARNI
+
+ACEI/ARB/ARNI: They reduce salt and water retention and open up blood vessels. This makes it easier for your heart to pump blood to your body.
+
+Beta Blockers: They block adrenaline so your heart does not have to work as hard and beat as fast.
+
+MRA: They block stress hormones that make the heart stiff and cause scarring.
+
+SGLT2i: They help lower stress on your heart.
+
+ARNI: They reduce salt and water retention and open up blood vessels. This makes it easier for your heart to pump blood to your body.
+
+Depending on your unique health situation, your health care team may use either approach, or a combination approach, to best suit you and your needs.
+
+How Are Medications Increased?
+Medications are introduced at low doses and gradually, based on your response. This process is called “titration.” During titration, your health care provider will assess your symptoms, ask about any side effects and monitor your bloodwork as needed. The doses of your medication may be adjusted (increased or decreased) based on your response.
+
+Here is how titration works:
+Medication titration consists of adjusting a dose every 1 to 4 weeks, depending on how well you are tolerating changes and on the timing of follow-up appointments with your health care team.
+
+Beyond Optimal Medication
+There is no “one-size-fits-all.” For some people, optimal medical therapy will mean fewer medications than the 4 in the guidelines. You could need to avoid a medication due to a contraindication or because of how it interacts with another drug you are taking. People with heart failure are often on medications to treat other conditions, such as high cholesterol (“statins”), or to reduce the risk of blood clots (“blood thinners”). You might also be prescribed other medications not described here like water pills or diuretics, digoxin or ivabradine.
+
+How does my health care team measure my response to treatment?
+
+After you are on maximally tolerated doses of your medication for 3 to 6 months, your health care provider will discuss ordering an echocardiogram or other diagnostic test with you to reassess your ejection fraction. Those results may guide next steps, such as a referral for pacemaker, implantable cardioverter defibrillator (ICD), or a cardiac synchronization therapy device (CRT or CRT-D). You may not need any further drug changes, or you may need to consider other medications to help your heart.
+
+Ongoing evaluations with your team
+
+Most people with heart failure will need to continue medications long-term, many for the rest of their lives. In addition to taking medications as prescribed, learning about self-care is an important part of managing heart failure. Note any new symptoms, side effects or changes in your quality of life. Talk to your health care provider about how you feel you are managing. Never adjust your own medications without guidance from your health care team.
+
+Helpful Resources
+
+Ask questions, take notes and make sure you feel comfortable with the treatment options being offered and chosen.
+
+Resources that may be helpful to you, your caregiver or family: https://hqontario.ca/Portals/0/documents/evidence/quality-standards/qs-heart-failure-patient-guide-en.pdf, https://heartlife.ca/toolkit/, https://ourhearthub.ca/
+
+Managing Your Care and Medications
+
+-Take medications as prescribed by your healthcare team.
+-Do not adjust your medications unless instructed by your healthcare team.
+-If you are vomiting, experiencing diarrhea, or are dehydrated, you may need to stop taking some medications for a short time.
+-Work with your team to determine the best treatment.
+-Keep a list of the name, dosage, how often, and why you take each of your medications in your wallet or on your phone.
+-Don’t take over-the-counter medicine, vitamins, or supplements without checking first with your doctor or pharmacist. Medications to AVOID include: Anti-inflammatory medications like ibuprofen (Advil™, Motrin™) or naproxen (Aleve™), Decongestant pills (“cold & sinus”) that include pseudoephedrine or phenylephrine, Acetylsalicylic acid (Aspirin), except for the 81-mg dose if prescribed or recommended by your healthcare team.
+
+Know what side effects to watch out for and discuss them with your healthcare provider in a timely fashion.
+
+-Be patient and understand that it may take time for your body to adapt to certain medications.
+-If you are not sure what to do with your medications when dehydrated, ask your healthcare team about sick day management of your medications.
+-Try to be consistent with the time of day that you take your medication. Timing when you take your medication with another activity that you do at the same time every day, such as brushing your teeth, can be helpful.
+-Keep a list of everyone on your heart failure team (doctors, pharmacists, peer support, caregivers) and carry it with you to appointments.
+-Notify your healthcare team if any changes are made to your medicines by a different provider.
+
+Glossary of Terms
+
+Adrenaline
+
+Also known as “epinephrine”, this is a chemical messenger that controls the sympathetic nervous system and causes the "fight or flight" response.
+
+Contraindication
+
+Anything (i.e., a symptom or medical condition) that is a reason for a person to not receive a particular treatment or procedure because it may be harmful.
+
+Diuretics
+
+Diuretics (commonly called ‘water pills’) rid the body of excess fluid, help to reduce swelling and bloating and make it easier to breathe.
+
+Echocardiogram
+
+An echocardiogram (ECHO) is an ultrasound of the heart that shows details of the heart’s structure and function.
+
+Guideline-directed medical therapy (GDMT)
+
+Wherever possible, CCS/CHFS Heart Failure Guidelines recommend that people with HFrEF be treated with 4 different types of medications early after diagnosis. This combination of medications is known as GDMT.
+
+Heart failure with preserved ejection fraction (HFpEF)
+
+Heart failure occurring as a result of a problem with the heart’s ability to relax, called ‘preserved ejection fraction.’
+
+Heart failure with reduced ejection fraction (HFrEF)
+
+Heart failure caused by a problem with the pumping function of the heart, called ‘reduced ejection fraction’.
+
+Maximally tolerated dose
+
+The maximal dose of a medication that you can tolerate without experiencing side effects such as dizziness, low blood pressure and light headedness.
+
+Target dose, optimal dose
+
+A target, or “optimal” dose, is the goal dose of medication recommended by the heart failure treatment guidelines.

cancer-and-heart-failure.txt

@@ -0,0 +1,8 @@
+CANCER AND HEART FAILURE
+ Cancer and Heart Failure
+Cancer and heart disease are the world’s leading causes of mortality. Although both diseases are well-known, many people are unaware of the relationship between cancer therapy and heart function.
+Some cancer survivors may experience a greater risk of developing heart problems as a result of their cancer treatment. This is called cancer therapy-related cardiac dysfunction, or cardiotoxicity.
+
+LIVING WITH CARDIOTOXICITY
+ The goal of a cardio-oncology program is to help prevent short- and long-term cardiac complications of cancer therapy. Your cardio-oncology team will work closely with you and other specialists to ensure that your heart is safe prior to, during, and following your cancer therapies.
+

cancer-therapies-and-the-heart.txt

@@ -0,0 +1,10 @@
+CANCER THERAPIES AND THE HEART
+ Medications and cancer therapies may have short and long-term effects on the heart. Some cancer survivors are at risk of developing heart problems as a result of their cancer treatment. Cancer is treated with one or more of the following: chemotherapy, immune therapy, surgery, radiation and HER 2 targeted therapies.
+Learn more about different cancer therapies and their impact on the heart:
+Chemotherapy
+Chemotherapy drugs can have an impact on your heart. Anthracyclines are one class of chemotherapy medications that can damage the cell structures and DNA inside the heart muscle, leading to decreased heart function.
+Immune Therapy
+The immune system works by recognizing foreign ‘outsider’ cells and boosting the body’s defense system (antibodies) to attack them, preventing damage to the body. Immune responses attack any foreign invader, such as bacteria, viruses, or cancer cells. The immune system can also produce cytokines, which are substances that act as messengers; cytokines tell the body’s cells to attack foreign cells. 
+Radiation Therapy
+Radiation therapy is a key component in cancer care to help reduce the risk of recurrence and death. It is used to treat several cancers, including breast, lung, esophagus, and Hodgkin’s lymphoma.
+

chemotherapy.txt

@@ -0,0 +1,35 @@
+CHEMOTHERAPY
+ Chemotherapy drugs can have an impact on your heart. Anthracyclines are one class of chemotherapy medications that can damage the cell structures and DNA inside the heart muscle, leading to decreased heart function.
+Anthracyclines include doxorubicin, daunorubicin, epirubicin, and idarubicin. They are used to treat:
+Carcinoma: breast, liver, thyroid, small cell lung, bladder, esophagus, and stomach
+Leukemias: acute lymphoblastic, acute myeloblastic
+Lymphomas: Hodgkin’s lymphoma, non-Hodgkin’s lymphoma (NHL), cutaneous T-cell lymphoma
+Sarcoma: Soft tissue tumors, Ewing’s Osteogenic bone
+Sarcoma: Soft tissue tumors, Ewing’s Osteogenic bone.
+
+RISK FACTORS
+ People at higher risk of impacted heart function as a result of anthracyclines include: 
+Women 
+BIPOC
+Those over 65 or under 18 years of age
+Those with health conditions such as kidney disease, diabetes, obesity, high blood pressure, or high cholesterol
+Those who have previously had radiation therapy or chemotherapy
+Those who smoke, have a high alcohol intake, and/or maintain a sedentary lifestyle
+Those who have a family history of heart disease before age 50
+Patients receiving more than 250 mg/m2 of doxorubicin during their treatment
+Patients with a high doses of doxorubicin
+Those diagnosed with heart dysfunction years after treatment with anthracyclines.
+The most common type of heart dysfunction after chemotherapy is called dilated cardiomyopathy. It occurs when the bottom chambers of the heart (ventricles) become enlarged and are unable to pump blood to the body. Over time, this can cause the heart to become weakened and stressed, leading to heart failure or arrhythmias.
+
+HER2-TARGETED THERAPIES (TRASTUZUMAB AND PERTUZUMAB)
+ The growth and function of breast cancer cells are controlled by receptors activated by estrogen (ER), progesterone (PR), or human epidermal growth factor (HER2). If any of these three elements are produced by the body in abnormally high levels, it can cause breast cancer cells to divide and grow. 
+There are three common types of breast cancer: 
+ER or PR positive (+) 
+HER2 positive (+) 
+Triple negative (ER-/PR-/HER2-)
+Trastuzumab is a monoclonal antibody that targets the HER2-receptor. Approximately 15-20% of patients with breast cancer whose tumors overexpress HER2-receptors require trastuzumab in the treatment of both early and advanced disease stages. There are other cancers that are HER2-positive where patients are treated with trastuzumab, such as gastrointestinal cancers. 
+It is estimated that people treated with anthracyclines and HER2-targeted therapies have a 3-5% risk of developing cardiotoxicity. Monitoring for cardiotoxicity while patients are receiving HER-2 targeted therapy is key, as trastuzumab-related cardiotoxicity is a relatively common cause of interruption of cancer treatment.
+
+STATINS
+ Statins have been shown to stabilize heart function and prevent hospitalizations from heart failure. Patients with cardiotoxicity may be prescribed statins during their cancer treatment and beyond.
+

diet.txt

@@ -0,0 +1,221 @@
+DIET
+ A healthy diet includes:
+A variety of fruits and vegetables. Fruits and vegetables have important nutrients. They should make up half of your plate at lunch and dinner and be your primary snack choice.
+Whole grains and whole grain products life whole grain bread, oats, corn, barley, farro, oatmeal, brown and wild rice, and quinoa.
+Healthy protein sources such as legumes, nuts, fish, seafood, low fat dairy, and lean and unprocessed meat and poultry. 
+Prioritize proteins that come from plants (beans, peas, lentils, nuts, seeds, and tofu) as they have more fibre and less saturated fat than other types of protein.
+Liquid non-tropical vegetable oils 
+Foods prepared with little or no salt
+Water. Replace sugary drinks with water as your drink of choice. 
+Limited processed foods
+Limited added sugars
+No alcohol (or very limited, if at all). 
+Find Heart Healthy Recipes on UHN’s website.
+
+CANADA’S FOOD GUIDE
+ 
+Canada’s Food Guide is an eating plan created by Health Canada to help people in Canada make healthy food choices. It is available in different languages. Top tips include:
+1. Focus on your plate.
+Health Canada recommends a plate loaded with fruits, vegetables, whole grains, and lean proteins. These foods have been shown to reduce the risk of cardiovascular disease, including risk factors such as high blood pressure and elevated blood cholesterol. 
+Dairy is included as a protein. To reduce your saturated fat intake, choose low fat milk, cheese, and yogurt.
+2. Eat more plant-based foods.
+Choose beans, lentils, soy, and nuts more often. The goal to improve heart health is to reduce saturated fat, which comes mostly from animal-based foods such as beef, chicken, and dairy products. 
+3. Think “outside of the box.”
+Choose more whole foods and fewer ultra-processed foods that are loaded with sugar, sodium, and saturated fat.
+Shop the outside aisles at the grocery store, avoiding inner aisles where the processed foods are located.
+4. Drink smart.
+Choose water instead of sugar-sweetened beverages, which make up the main source of total sugars in the Canadian diet. Excess sugar is linked to obesity and heart disease. Make water your drink of choice!
+5. Be mindful when eating.
+Cook more often
+Eat with others
+Reflect on your eating habits
+Enjoy your food
+Be aware of food marketing, which can be misleading.
+
+HEALTHY HEART PORTION GUIDE
+ The following guide will help you integrate foods that are low in saturated and trans-fat, high in fibre, and low in sodium into your diet in appropriate portions. Note that the amount of food you need depends on your age, gender, body size, and activity level. 
+For more information, speak to your health care provider about referring you to a dietitian.
+Portion Size versus Serving Size
+According to the National Institutes of Health, portion size and serving size are defined as follows:
+Portion size is the amount of a specific food that you choose to eat at one time and is completely under your control. Be aware that many foods that come as a single portion contain multiple servings. 
+Serving size is the amount listed on a food package’s Nutrition Facts Label. The nutrition values on the label are for one serving size, as suggested by the food manufacturer. The Nutrition Facts Label and ingredients list on food packages can help you make informed choices about your diet.
+
+FRUITS AND VEGETABLES
+ Fruits and vegetables are an excellent source of vitamins and minerals. 
+
+Eat 7-10 servings of fruits and vegetables per day. 
+Choose dark green and orange vegetables and orange fruit more often. 
+Eat at least one dark green and one orange vegetable each day. 
+For more fibre, use fresh fruit and vegetables in place of juices. 
+
+Choose (example of 1 serving): 
+
+125ml (½ cup) fresh or frozen vegetables 
+250ml (1 cup) salad 
+1 piece of fresh fruit (the size of a tennis ball) 
+½ cup mixed fruit 
+125ml (½ cup) unsweetened fruit 
+
+Choose less often: 
+
+Buttered, creamed, or deep-fried vegetables 
+Brine-cured or pickled vegetables like sauerkraut 
+Unsweetened fruit juice 
+V8 juice 
+Canned fruits in heavy syrup 
+Coconut and coconut milk
+
+
+DAIRY AND ALTERNATIVES
+ Milk products are an excellent source of calcium and vitamin D. 
+
+Eat 2-3 servings per day. 
+Try fortified, unsweetened plant-based beverages if you do not drink milk.
+
+Choose (example of 1 serving): 
+
+250 ml (1 cup) skim or 1% milk 
+250 ml (1 cup) calcium-fortified unsweetened plant-based beverage 
+¼ cup skim milk powder 
+175 g (3/4 cup) fat-free yogurt 
+
+Choose less often: 
+
+Whole milk, 2% milk, goat milk, regular cream, light cream, sour cream, and whipping cream 
+Evaporated whole milk and condensed milk 
+Yogurt with a M.F. content greater than 2% 
+Regular ice-cream 
+Non-dairy substitutes made with coconut oil or hydrogenated oil, such as coconut milk or cream.
+
+
+FATS AND OILS
+ Fats are a valuable source of essential fatty acids and vitamins. 
+
+Choose 6-9 servings each day. 
+Limit the amount of saturated and trans-fat in your diet. 
+Unsaturated fats are ‘healthy fats.’ Examples of unsaturated fats include olive, canola, and avocado oil. 
+Many commercial and processed foods contain hidden fat. Choose these foods less often. 
+
+Choose (example of 1 serving): 
+
+5 ml (1 tsp) of unsaturated fats like canola, olive, and avocado oils
+5 ml (1 tsp) margarine that is soft tub, non-hydrogenated, low in saturated fat OR 10 ml (2 tsp) light margarine 
+15 ml (1 tbsp) salad dressing made with recommended oils OR 30 ml (2 tbsp) calorie reduced salad dressings 
+2 tsp (10 ml) nut butter such as peanut butter or almond butter  
+Raw, dry roasted, or in-the-shell nuts (for example: 4 walnut halves, 8 almonds) 
+1/6 medium avocado 
+7.5 ml (1/2 tbsp) regular mayonnaise and mayonnaise type dressings OR 15 ml (1 tbsp.) light regular mayonnaise and mayonnaise type dressings 
+
+Choose less often: 
+
+Butter, hard margarine, lard, suet, hydrogenated oils, palm oil, coconut oil 
+Salad dressing containing cream cheese and/or bacon 
+Peanut butter made with hydrogenated oil 
+Nuts that are roasted in hydrogenated oils, salted, and/or chocolate covered.
+
+
+GRAIN PRODUCTS
+ Grain products are a source of carbohydrates and dietary fibre. 
+
+Eat 6-8 servings per day. 
+Breads can be high in sodium. Please read the Nutritional Facts table to ensure it is a low sodium choice. 
+Make at least half of your grain products whole grain each day. 
+Eat a variety of whole grains such as barley, brown rice, oats, and whole grain breads. 
+
+Choose (example of 1 serving): 
+
+1 slice of bread, preferably whole grain 
+½ whole-wheat pita 
+¼ whole-wheat bagel 
+½ chapatti or roti 
+½ matza 
+½ tortilla 
+½ hamburger or kaiser bun, or English muffin 
+250mL (1 cup) homemade soups made with beans, lentils, barley, and vegetables 
+2-4 whole-wheat, low-fat crackers (check the serving size) 
+125 mL (1/2 cup) starchy vegetables: corn, sweet potato, yam, cassava 
+1 small or ½ medium potato 
+125ml (1/2 cup) cooked brown rice, whole-wheat pasta, macaroni, noodles, kasha, barley, bulgur, quinoa 
+For cereals, check the Nutrition Facts Label and choose items with more than 15% daily value of fibre and less than 5% daily values of sodium: 
+
+80ml (1/3 cup) Bran Buds with Psyllium 
+190ml (3/4 cup) cooked oatmeal 
+175ml (2/3 cup) Shredded Wheat 
+125 mL (1/2 cup) Kellogg’s All Bran 
+
+
+
+Choose less often: 
+
+Salted or high-fat crackers, egg bread, cheese rolls, croissants 
+Commercial cakes and cookies, store-bought muffins, doughnuts, Danishes, waffles, pancakes 
+Potato chips, corn chips 
+Canned soups and dehydrated soup mixes 
+Frozen French fries 
+Rice and pasta convenience products (such as Kraft Dinner), egg pasta, fried noodles.
+
+
+MEAT AND ALTERNATIVES
+ Protein foods, including meat and plant-based proteins, are an important part of healthy eating.
+
+Eat 2-3 servings per day. 
+One serving of meat, fish, or chicken is about 3 ounces (90 g) cooked. 
+Cheese is high in sodium. Read the Nutritional Facts Label of cheese products before you buy them. 
+Have plant-based proteins such as beans, lentils, chickpeas, and split peas often. 
+
+Choose (example of 1 serving): 
+
+Fresh, frozen, and canned low-sodium fish packed in water 
+90 g poultry. Choose lean ground chicken or turkey when possible.
+90 g lean cuts of beef, veal, lamb, pork, rabbit, or venison. Choose extra-lean ground beef when possible.
+50 g of 15% M.F. cheese, low sodium 
+2 eggs OR 4 egg whites OR 125 ml (1/2 cup) liquid egg whites 
+150 mg (3/4 cup) firm tofu  
+175 ml (3/4 cup) cooked lentils, soybeans, chickpeas, navy beans, kidney beans 
+
+Choose less often: 
+
+Canned fish soaked in oil 
+Battered, fried, creamed, smoked, salted, or pickled fish, caviar, and squid 
+Duck, goose, poultry skin, basted poultry 
+Luncheon meat, back bacon, ham, sausages, wieners 
+Organ meats, spareribs 
+Processed cheese, full-fat cheese, cheese spreads.
+
+
+PORTION SIZES
+ Food portions are increasing. Larger portions might mean that you are eating more and gaining weight. Here are some ways you can eat and serve smaller portions.
+At home:
+
+Plate the suggested serving size for each person (children, teenagers, and adults) and put away the extra food for another meal
+If you are still hungry, have extra salad or vegetables instead of extra dairy, grains, or meat
+Pack up leftovers for lunch the next day
+
+When eating out: 
+
+Skip or share the appetizers
+Split the main dish with your companion 
+Put half of your plate in a to-go container for the next day’s lunch or dinner before you begin eating
+Order a mini dessert or share a dessert
+Avoid refills of sweetened beverages such as soft drinks, iced tea, and lemonade OR stick to water
+
+When ordering takeout:
+
+Order less
+Add a homemade salad to the meal
+
+Snacks: 
+
+Measure out the amount according to the serving size instead of eating straight from the bag or box.
+Avoiding buying snacks such as cookies, chips, ice cream, store-bought muffins, and cake
+Have healthy snacks, such as fruit, in plain sight
+
+Groceries:
+
+Buying in bulk may be budget friendly, but is not serving size friendly
+Use small reusable containers/bags to repackage your snacks according to the serving size
+Re-package bulk purchases into small portions before freezing them.
+
+It is easy to overeat when you are not paying attention. Don’t eat while watching tv, reading or on your computer
+Using a food diary for a few days can help you pay closer attention to what, how much, and how often you are eating.
+

eliminating-alcohol.txt

@@ -0,0 +1,3 @@
+ELIMINATING ALCOHOL
+ Alcohol is toxic to the heart. It is recommended that all patients with heart failure completely abstain from alcohol.Consumption of alcohol can lead to increased fluid accumulation, which puts extra strain on your heart (see section on Fluid Restriction). In addition, alcohol can interfere with how some of your medications work. In some cases, excessive alcohol consumption may be the cause of heart failure, and abstinence from alcohol may result in normalization of the heart’s function. If you think that eliminating alcohol is a problem for you, speak to your healthcare provider. They may be able to suggest resources to help you deal with this problem.
+

fluid-restriction.txt

@@ -0,0 +1,40 @@
+FLUID RESTRICTION
+ Heart failure impacts the function of the body’s circulatory system, and can cause fluid accumulation in the legs, ankles, or lungs.
+Your health care provider will talk to you about whether you should restrict your fluid intake, and if so, by how much. 
+Remember that fluid intake does not just include water. It also includes any liquids, such as coffee, tea, juices, soups, ice cream, ice cubes, and also some fruit that contain a lot of water (watermelon).
+
+FLUID ACCUMULATION
+ Normally, our bodies eliminate extra fluid by excreting it as urine. People with heart failure can lose the ability to expel extra fluid. 
+The heart must then work harder to pump the excess fluid around the body and may not be able to keep up. Extra fluid can accumulate and seep out of blood vessels into tissues, leading to swelling in the lower legs and ankles. Fluid may also accumulate in the lungs, making it difficult to breathe, particularly when lying flat.
+
+MONITORING YOUR WATER WEIGHT
+ Usually, if your weight increases by a few pounds over the course of several days, it is not because you have gained fat or muscle. Noticeable changes in weight over a few days typically relate to accumulation of water, or water weight. This may be the first sign of fluid buildup due to heart failure. 
+Monitoring your weight is an important way to manage your heart failure. You should:
+Weigh yourself every morning the same way: 
+Go to the washroom and empty your bladder
+Wear the same thing every morning
+Don’t eat before weighing yourself
+Use the same scale every day
+Record your weight on a calendar. You can use a tracking log to record your weight and notice any changes.
+If your weight has increased, ask yourself:
+Have I consumed more salt/sodium than usual in the last few days?
+Have I been drinking more fluid than recommended?
+Has there been a change in the amount of urine I’m producing?
+If you have gained more than two pounds (0.9 kg) in one day, or five pounds (2.2 kg) in a one week, this may be a sign that you are retaining fluid. You may need to begin taking/take more diuretics and should contact your health care provider.
+
+FLUID INTAKE
+ Fluid restriction is key to treating heart failure symptoms. Remember: 
+Ask your health care provider how much fluid you should limit yourself to each day. For patients with heart failure, this is usually 1.5 to 2 L per day, or about 6-8 cups. 
+You are not just restricting the water you drink. You should also be including coffee, tea, juice, soup, JELL-O, ice cream, and even some fruit (especially melons like watermelon) in your restriction.
+Your health care provider may prescribe a diuretic, or “water pill,” to help expel extra fluid that has accumulated in your body. These water pills may make you feel thirsty, but this does not mean that your body needs more fluid. It is important to not compensate for the fluid you are losing by drinking more.
+Tips for controlling your fluid intake
+Plan ahead to spread out the fluid you drink over the day.
+At first, use a 1.5 or 2L bottle to keep track of the fluid you are drinking. For example, when you have a cup of coffee, measure out the same amount of water and pour it into the bottle. When you have filled the bottle, you have reached your fluid allowance for the day. You can also keep track by recording and adding up fluid amounts on a piece of paper that you keep nearby.
+With a measuring cup, measure the amount of fluid held by your drinking glasses, coffee cup, and soup bowl. Knowing how much fluid they hold will help you to plan the amount of fluid you can drink for the day.
+Use small cups and sip slowly.
+Take your pills with apple sauce or soft food such as yogurt.
+Drain excess fluid from canned fruit.
+If you are thirsty or have a dry mouth, try sucking on small amounts of hard candy or a lemon or lime wedge. If you have diabetes, make sure the candies are sugar-free.
+Some people find that brushing their teeth often or rinsing their mouth with chilled mouth wash helps manage their thirst.
+Use a humidifier to moisten the air in a room.
+

heart-function.txt

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+HEART FUNCTION
+ The heart circulates blood throughout the body. It pumps deoxygenated blood from the body to the lungs where it receives oxygen and supplies the freshly oxygenated blood from the lungs to the body. The heart is divided into the right side and left side and composed of four chambers: two right and left top chambers (atria) and two right and left bottom chambers (ventricles). Valves separate the atria, ventricles, and arteries.
+
+WHAT IS HEART FAILURE?
+ Heart failure is a condition where the heart is unable to pump enough blood to meet the needs of the body. It is a chronic condition, which means that is can be treated but not cured. Once diagnosed, most people live with heart failure for the rest of their lives.
+

how-is-cardiotoxicity-diagnosed-and-managed.txt

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+HOW IS CARDIOTOXICITY DIAGNOSED AND MANAGED?
+ How is Cardiotoxicity Diagnosed and Managed?
+Oncology and cardiology teams can work closely together on providing care for people undergoing cancer treatment before problems arise. 
+These “cardio-oncology” teams monitor patients at risk of developing heart problems during cancer therapy, diagnose any heart issues, and begin early treatment. These teams continue to monitor patients in the months and years following cancer treatment. Cardiotoxicity is diagnosed by physical exams and specific tests. 
+One of the goals of a cardio-oncology team is to minimize interruptions to cancer therapy, as delays and interruptions can impact long-term outcomes. By diagnosing cardiotoxicity early, the cardiology team can start medications to stabilize and improve heart function, often while the oncology team continues to administer cancer therapy. 
+Your cardio-oncology team is readily accessible to optimize your cardiac medications and care needs. These medications may include beta blockers, ace inhibitors/angiotensin II receptor blockers, and statins. 
+By self-monitoring and self-managing, patients can also help manage cardiotoxicity.
+
+MONITORING BLOOD PRESSURE
+ High blood pressure is diagnosed by self-monitoring at home as well as during clinic visits. As anxiety related to clinic appointments and testing may elevate your blood pressure, at-home testing helps your team determine what your blood pressure is like in your everyday environment and can make an impact on your treatment. It is recommended that you monitor your blood pressure once a week and take those readings to clinic appointments. We strive for a blood pressure at home of less than 130/80 mm Hg.
+If your blood pressure is consistently high, you may need medications to control your blood pressure. Blood pressure can be controlled with one or more medications. It can be difficult to predict how long you will have to be on blood pressure medication. Sometimes, high blood pressure is related to your specific cancer treatment and may go back to normal after your treatment is completed. However, sometimes blood pressure medication may be needed in the long-term. 
+Commonly used medications for high blood pressure include: 
+
+ACE inhibitors (Ramipril, Perindopril, Lisinopril)
+Angiotension II receptor blockers (Candesartan, Valsartan, Irbesartan, Telmisartan)
+Calcium channel blockers (Amlodipine, Diltiazem)
+Diuretics (Furosemide, Hydrochlorothiazide, Chlorthalidone).
+
+
+MONITORING HEART RHYTHM
+ Abnormal heart rhythms (arrhythmias) can be detected by electrocardiograms (ECG) and Holter monitors. Sometimes patients can feel a fast or irregular heartbeat or skipped beats – these are called palpitations. Testing determines whether these palpitations are significant and require treatment. 
+Not all arrhythmias require treatment. Discuss with your health care provider whether medications can control the arrhythmia and prevent blood clots. These medications may include: 
+
+Beta blockers
+Digoxin
+Anti-arrhythmic medications (amiodarone)
+Aspirin
+Anti-coagulants (blood thinners such as apixaban or coumadin).
+
+
+MONITORING TROPONIN LEVELS
+ Troponin is a heart protein not normally found in the blood. However, it is released into the bloodstream when the heart is injured. The greater the damage to the heart, the higher the level of troponin in the blood. For example, patients who have had heart attacks typically have high levels of troponin in their blood at the time of their injury. 
+Patients at risk for heart injury during their cancer therapy may have troponin levels checked during their treatment. This allows health care providers to detect heart injury before the onset of heart failure symptoms.
+
+TREATING CORONARY ARTERY DISEASE
+ Narrowing and thickening of the arteries of the heart is caused by cholesterol deposits, which leads to coronary artery disease (CAD). While this typically takes years, some cancer therapies can increase the rate of this process. 
+Coronary artery disease is treated with medication and may require a coronary angiogram (a dye test to look for narrowing of arteries) and stenting or bypass surgery. 
+Learn more about coronary artery disease diagnosis and treatment.
+
+TREATING CORONARY ARTERY VASOSPASMS
+ <img decoding="async" class="wp-image-239742 alignnone " src="https://ourhearthub.ca/wp-content/uploads/2022/03/CardioTox2.png" alt="" width="396" height="396" />
+Cancer therapy may also cause an injury to the arteries called vasospasms. Vasospasms can also decrease the blood flow to the heart but are more temporary and do lead to heart attacks. Medications such as Fluorouracil (5-FU) or capecitabine, which are often used for colo-rectal cancer, can cause vasospasms.
+Vasospasms can feel like chest discomfort (tightening, squeezing, burning, pressure sensation), which may begin in the middle of chest and can spread to the neck, shoulder, jaw, and arm. Pain usually occurs when at rest.
+Vasospasms are treated using nitrates, calcium channel blockers, and statins.
+Your cardio-oncology team wants to know about any symptoms you are having, especially during your cancer therapies. However, it is important to call 911 if you have any of the following symptoms:
+
+Chest pain or sudden shortness of breath shortly after receiving chemotherapy/immune therapy
+Chest pain that is not relieved with nitroglycerin
+Chest pain that includes dizziness, fast heart rate, or sweating
+
+
+TREATING MYOCARDITIS
+ Myocarditis is an inflammation of the heart muscle. It can be related to viral infections or may be a side effect of cancer therapies. 
+Learn more about myocarditis and how it is treated.
+

how-is-heart-failure-managed-medications.txt

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+MEDICATIONS
+ There are a number of medications that are used for the management of heart failure. These medications belong to “classes.” 
+All medications have side effects and may require blood tests to monitor your kidney function and the electrolytes in your blood.
+Do not adjust the doses or stop taking your medications before speaking to your health care provider.
+If you experience a side effect from medication or feel unwell after starting medication, speak to your health care provider.
+
+MEDICATIONS
+ Heart failure medications work in different ways. They may strengthen the heart’s pumping function, reduce the amount of work that the heart has to do or help manage symptoms.
+
+MEDICATION DOSES
+ Most medications for heart failure are initially prescribed at a low dose. The dose is then increased over several weeks to a “target” or optimal dose. 
+When you are first diagnosed with heart failure, your health care provider may see you frequently to adjust your medications and get you up to the optimal doses of each medication.
+It is normal for your dose to change frequently in the first few months. It may take several days or a week for your body to adjust to the new dose of medication. If you experience worrisome side effects (extreme fatigue or frequent dizziness or light-headed spells, for example) you should call your health care provider.
+
+MEDICATION CLASSES
+ Medications for heart failure belong to several different classes (or families). As each class affects the heart in a different way, you may need medication from each class. These medication classes include:
+Beta-blockers 
+Angiotensin converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs)
+Sacubitril/valsartan 
+Sodium glucose cotransporter 2 (SGLT2) inhibitors
+Aldosterone antagonists
+Ivabradine 
+Diuretics (water pills)
+Vasodilators and nitrates
+Digoxin
+Potassium supplements
+Intravenous iron
+Not all patients with heart failure are on the exact same medications, and you may not be on all the classes of medications. Your health care provider can answer any questions about why they have chosen a certain combination of medications for you.
+
+GENERAL ADVICE ON YOUR MEDICATIONS
+ Always bring all your medications to every medical appointment. 
+If you are running low on pills, make sure to let your doctor’s office know several days before you run out, so that a new prescription can be faxed to your pharmacy, and you can avoid missing any doses.
+Learn the name, dose, frequency, purpose, and potential side effects of all your medications.
+Take your medications exactly as directed. Do not stop or start any medications without speaking to your health care provider.
+There may be some medications that your health care provider will tell you not to take if you are feeling sick and are dehydrated. Talk to your health care provider about your “Sick Day” list of medications.
+Take medication at the same time every day.
+If you have difficulty remembering to take all your pills, ask the pharmacist to create a “blister pack” for you.
+If you miss a dose of medication, take it as soon as you remember. Take the next dose at the regular time. However, if it is almost time for your next dose, skip the missed dose and go back to your regular schedule. Do not double the dose.
+Store your medications in a cool, dry place, away from direct heat, light, or moisture.
+Keep medications out of reach of children.
+Do not use non-steroidal anti-inflammatory medications like ibuprofen (Advil®, Motrin®) or naproxen. These medications may make your heart failure worse. 
+Ask your health care provider or pharmacist before taking over the counter medications or herbal remedies.
+Medications may have side effects. Sometimes these side effects go away or become less bothersome with time. If you are concerned about a side effect, speak to your health care provider.
+If paying for your medications is an issue, talk to your health care provider about the Ontario Trillium Drug Program. Their phone number is 1-800-575-5386.
+
+ACE INHIBITORS & ANGIOTENSIN RECEPTOR BLOCKERS (ARBS)
+ Medications in the ACE Inhibitors class include: 
+Sacubitril/valsartan (Entresto™) 
+Captopril (Capoten®) 
+Enalapril (Vasotec®) 
+Fosinopril (Monopril®) 
+Lisinopril (Zestril®) 
+Perindopril (Coversyl®)
+Ramipril (Altace®) 
+Trandolapril (Mavik®) 
+
+Medications in the ARB class include: 
+Candesartan (Atacand®) 
+Losartan (Cozaar®) 
+Valsartan (Diovan®) 
+Telmisartan (Micardis®) 
+Irbesartan (Avapro®) 
+Olmesartan (Olmetec®) 
+
+How Do ACE Inhibitors / ARBs Work? 
+These medications dilate blood vessels to lower blood pressure and decrease stress on the heart.  They help limit further injury to the heart. 
+ARBs are usually prescribed to patients who can’t tolerate ACE inhibitors and their side effects. 
+
+What Are the Common Side Effects? 
+A drop in blood pressure, which is not a concern unless it causes dizziness or lightheadedness. 
+Increase in blood potassium levels or worsening kidney function. Your healthcare provider will send you for blood tests to ensure this does not happen. 
+A persistent dry cough can occur with ACE Inhibitors. If the ACEI is stopped or switched to an ARB, the cough goes away. 
+Changes in your taste, such as a metallic taste in your mouth. 
+Rash. Talk to your health care provider if you develop a new rash. 
+Very rarely, a severe allergic reaction called angioedema can occur. This involves swelling of the face, tongue, lips, and hands. If this happens, you should seek immediate attention. 
+
+What Should I Remember While Taking ACE Inhibitors or ARBs? 
+This medication may be taken with or without food but should be taken at the same time(s) each day. 
+To avoid getting dizzy, stand up slowly from a sitting or lying position. 
+Use with caution if you have certain types of kidney problems. Check with your health care provider first. 
+Tell your health care provider or pharmacist of any prescription and non-prescription medications you are taking in combination with ACEIs or ARBs. 
+Check with your health care provider before using potassium supplements. You may require extra blood tests to measure the amount of potassium in your blood. 
+Talk to your health care provider if you are pregnant, considering becoming pregnant, or breastfeeding. This medicine may cause birth defects if taken during pregnancy.
+
+BETA-BLOCKERS
+ Medications in this class include: 
+Bisoprolol (Monocor®) 
+Carvedilol (Coreg®) 
+Metoprolol (Lopressor®) 
+
+How Do Beta-Blockers Work? 
+Beta-blockers lower your resting heart rate. They block the stress hormones that cause your heart to enlarge and become weak. 
+
+What Are Common Side Effects of Beta-Blockers? 
+When you start taking beta-blockers, you may feel more tired, short of breath, or dizzy. You should begin to feel better as your heart begins to adjust but this may take several weeks. If your symptoms do not improve or if they get worse, you may need to reduce or stop the beta-blocker after a discussion with your health care provider. 
+
+Other side effects can include: 
+Feeling less interested or able to have sex 
+Trouble sleeping 
+Headache 
+Constipation, diarrhea, or an upset stomach 
+Feeling weak 
+If you have a history of asthma, beta-blockers may make you feel wheezy or short of breath. If this happens, contact your healthcare provider immediately. 
+
+What Should I Remember While Taking a Beta-Blocker? 
+Beta-blockers can make you feel dizzy or lightheaded. 
+Avoid drinking alcohol as it may make dizziness worse. 
+Stand up slowly if you have been sitting or lying down. 
+Do not drive a car or operate machinery if it makes you feel dizzy. 
+This medication may cause changes in your blood sugar levels. It may also hide your usual signs of low blood sugar. 
+If you have diabetes, ask your health care provider how this will affect the way you manage your diabetes. 
+Do not change the dose or stop taking this medicine without talking to your doctor and/or pharmacist, even if you feel well. Suddenly stopping this medication can cause serious heart problems. 
+
+Check with your health care provider and/or pharmacist before taking any other medication, vitamin, or herbal remedy in combination with this medicine.
+
+SACUBITRIL/VALSARTAN (ENTRESTO™)
+ Sacubitril/valsartan (Entresto™) is a newer heart failure drug. It is from a class of medications known as ‘angiotensin receptor-neprylisin inhibitors.’ In addition to helping people with heart failure live longer and feel better, it has been shown lower the need to be hospitalized to treat heart failure.
+
+How Does Sacubitril/Valsartan Work? 
+Sacubitril/valsartan is a combination of two medications: sacubitril (a neprilysin inhibitor) and valsartan (an angiotension II receptor blocker, ARB). It has two main actions: 
+It works to block the effect of harmful hormones that cause blood vessels to constrict and hold on to salt and water. 
+It prevents the breakdown of beneficial hormones that cause blood vessels to relax, allowing the body to get rid of extra salt and water. 
+Together, these two effects help to decrease strain on the heart. 
+
+When and How Should I Take This Medication? 
+Sacubitril/valsartan is a tablet that is taken twice a day. It can be taken with or without food. It should be taken at the same times each day. 
+
+Sacubitril/valsartan is used in combination with other medications to treat heart failure but must not be taken with ACE Inhibitors or ARBs. If you are taking an ACE Inhibitor, you must stop it and wait a full 36 hours before starting Entresto TM. Your health care provider will talk to you more about this. 
+
+What are Common Side Effects of Sacubitril/valsartan? 
+Dizziness or lightheadedness 
+An increased blood potassium level. Your health care provider will periodically monitor your blood tests. 
+Worsening kidney function. Your health care provider will periodically monitor your blood tests. 
+Feeling fatigued or tired. 
+
+Severe side effects may include: 
+An allergic reaction, such as rash, hives, and/or blisters 
+An irregular heartbeat 
+Feeling like you might faint or pass out 
+Feeling very weak 
+Worsening shortness of breath 
+A decrease in the amount of urine that you are passing 
+Very rarely, a severe allergic reaction called angioedema can occur. This involves swelling of the face, tongue, lips, and hands. If this happens, you should seek immediate attention 
+
+Call your health care provider immediately if you develop any of these severe side effects. 
+
+What Should I Remember While Taking This Medication? Stand up slowly from a sitting or lying position to avoid getting dizzy. 
+Tell your health care provider or pharmacist of any other prescription and non-prescription medications you are already or plan on taking, including vitamins/minerals and herbal supplements.
+Tell your health care provider if you are taking salt substitutes, as they may also contain potassium. 
+Taking sacubitril/valsartan with potassium supplements can increase your blood potassium level. Check with your health care provider before using potassium supplements. You may require blood tests to check your potassium level. 
+Talk to your health provider if you are pregnant, considering becoming pregnant, or breastfeeding. Sacubitril/valsartan should not be taken if you are pregnant or breastfeeding.
+
+ALDOSTERONE ANTAGONISTS
+ Medications in this class include: 
+Spironolactone (Aldactone®) 
+Eplerenone (Inspra®) 
+
+How Do Aldosterone Antagonists Work? 
+Aldosterone antagonists (also known as ‘mineralocorticoid antagonists’) block hormones that put stress on your heart. They are also a diuretic, so they help rid your body of extra fluid. 
+
+What Are the Common Side Effects? 
+Feeling fatigued. This should improve as your body gets used to the medication 
+Increased potassium and worsening kidney function. This will be monitored with blood tests. 
+Breast enlargement or tenderness in men (especially with Spironolactone). 
+Passing more urine. 
+Stomach cramps or diarrhea. You can take it with food to avoid an upset stomach. 
+Nausea and vomiting 
+
+What Should I Remember While Taking Aldosterone Antagonists? 
+Take at the same time(s) each day, with or without food. 
+Use cautiously if you have certain types of kidney problems. Check with your health care provider first. 
+Tell your health care provider or pharmacist of any other prescription and non-prescription medications you are taking. 
+Check with your health care provider before using potassium supplements. You may require extra blood tests to measure the amount of potassium in your blood. 
+If you develop another illness and are not able to eat or drink, or if you are experiencing a lot of vomiting or diarrhea, contact your health care provider or pharmacist. Extra blood tests may be needed to check your potassium levels. In some cases, the medication may need to be paused for a few days until you are feeling better. Do not stop any of your medications without speaking to your health care provider.
+
+SODIUM GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITORS
+ Medications in this class include: 
+Dapagliflozin (Forxiga) 
+Empagliflozin (Jardiance) 
+Canagliflozin (Canagliflozin) 
+
+How do SGLT2 Inhibitors Work? 
+SGLT2 Inhibitors cause the kidneys to eliminate sodium and glucose (salt and sugar) from the blood stream. This results in less fluid retention and slightly reduced blood pressure. These medications also have other favorable effects on the heart and blood vessels, which contribute to a lower risk of hospitalization and improved survival. 
+Because SGLT2 inhibitors result in more elimination of glucose in the urine, they improve blood sugar levels. Originally, they were used only to treat patients with type 2 diabetes, however recent studies confirmed their effectiveness for people with heart failure.  SGLT2 Inhibitors are still used widely for the treatment of type 2 diabetes to control blood sugar and reduce the risk of developing worsening kidney failure and cardiovascular disease. 
+
+How Should I Take SGLT2 Inhibitors? 
+Take this medication at the same time(s) every day. 
+Usually, the full dose is prescribed and does not require dose adjustment.  Occasionally, your care provider may start with a lower dose before increasing to the target dose of the medication to ensure that it is well tolerated. 
+
+What are the Common Side Effects? 
+Reduced blood pressure, resulting in dizziness or lightheadedness 
+Increased urine output, similar to diuretic medications 
+Genital yeast infections (in men and women) requiring treatment 
+Dehydration 
+Low blood sugar 
+Ketoacidosis (rare). 
+
+What Should I Remember While Taking This Medication? 
+SGLT2 Inhibitors can lead to dehydration ― particularly if you have other illnesses that also cause dehydration such as serious infections, diarrhea, or vomiting. It is recommended that SGLT2 inhibitors are paused for a few days in these situations as part of ‘sick day’ management. 
+During times of severe illness, rare cases of a serious condition called ‘ketoacidosis’ can occur while taking SGLT2 inhibitors. This can be life-threatening if not treated and requires admission to hospital and discontinuation of this medication. Talk to your healthcare provider about sick day management for SGLT2 inhibitors and other medications.
+Because SGLT2 Inhibitors lower glucose levels, patients who are also taking insulin or other pills to lower blood sugar may need to have doses of their diabetes medications adjusted accordingly. 
+Genital yeast infections are more common in patients who take SGLT2 inhibitors. This is usually a non-serious problem but can require treatment with anti-fungal pills or topical medications. Yeast infections occasionally recur, requiring more prolonged therapy.
+
+IVABRADINE (LANCORA™)
+ Ivabradine (Lancora™) 
+Ivabradine (Lancora™) is a new class of medication approved for treatment of heart failure. In addition to helping people with heart failure live longer and feel better, it has been shown to lower the need to be hospitalized to treat heart failure. 
+Ivabradine is meant to be used in addition to other classes of medication that are useful in treating heart failure. 
+
+How Does Ivabradine Work? 
+Ivabradine works by slowing the heart rate. It acts only on the sinus node (the body’s natural pacemaker), causing it to fire more slowly. It has no other effects on the heart or blood vessels. 
+Ivabradine is only used in patients who have a resting heart rate of 70 beats per minute or faster. 
+
+When and How Should I Take this Medication? 
+Ivabradine is a tablet that is taken twice a day, at the same time each day. It can be taken with or without food. 
+It comes in three different strengths. It starts at a low dose and is usually increased by your health care provider over a few weeks. 
+Ivabradine is used in combination with other medications to treat heart failure. 
+
+What are the Common Side Effects? 
+Dizziness due to a slow heart rate 
+Feeling fatigued or tired 
+Vision problems, like seeing flashes of light (called phosphenes) or halos. 
+
+Call your health care provider immediately if you develop any of these more severe side effects: 
+Feeling like you might faint or pass out 
+Feeling very weak 
+Developing atrial fibrillation (a fast, irregular heartbeat). 
+
+What Should I Remember While Taking Ivabradine? 
+Stand up slowly from a sitting or lying position to avoid getting dizzy. 
+Tell your health care provider or pharmacist of any other prescription and non-prescription medications you are taking, including vitamins/minerals and herbal supplements.
+
+DIURETICS
+ Patients with heart failure often have problems excreting extra fluid, which can lead to fluid accumulation in the ankles, legs, abdomen, and lungs. Diuretics (commonly called ‘water pills’) rid the body of excess fluid, help to reduce swelling and bloating and make it easier to breathe. 
+Occasionally, when patients are admitted to the hospital because of “decompensated heart failure” due to increased fluid accumulation, an intravenous (injectable) form of this medication may be required. 
+
+Medications in this class include: 
+Furosemide (Lasix®) 
+Metolazone (Zaroxolyn®) 
+Hydrochlorothiazide (HydroDiuril®) 
+Bumetanide (Burinex®) 
+Ethacrynic acid (Edecrin®) 
+
+How Do Diuretics Work? 
+Diuretics stimulate the kidneys to produce more urine, thus getting rid of excess water and salt from the body. 
+
+When and How Should I Take Diuretics? 
+Take this medication at the same time(s) each day. Take this medication with food if it gives you an upset stomach. 
+Do not take a diuretic close to bedtime, as the frequent need to urinate may keep you up at night. 
+
+The Most Common Side Effects of Diuretics: 
+Increased frequency and quantity of urination. 
+A loss of potassium and magnesium, which may cause an irregular heartbeat, muscle cramping, and unusual tiredness. This will be monitored with periodic blood tests. Supplemental potassium and magnesium may be required if these levels are too low. 
+Increased uric acid level could lead to gout. 
+Thirst and dry mouth. 
+Skin rash. Contact your doctor if a skin rash develops 
+Increased skin sensitivity to sunlight 
+Dizziness 
+Constipation 
+Upset stomach 
+Loss of appetite 
+A loss of hearing or ringing in the ears, particularly if you are on high doses of diuretics. 
+
+What Should I Remember While Taking Diuretics? 
+Weigh yourself daily to monitor if/how much fluid you are retaining (gaining) or losing. 
+Your health care provider may sometimes advise you to adjust your diuretic dose depending on your weight. 
+If you experience vomiting or diarrhea, contact your health care provider or pharmacist. Extra blood tests may be needed to check your potassium level and kidney function. In some cases, the medication may need to be paused for a few days until you are feeling better. Do not stop any of your medications without speaking to your health care provider. 
+Diuretics may make your skin more sensitive to sunlight. Try to stay out of direct sunlight. Use sunscreen and wear protective clothing, a hat, and sunglasses when you are outside. Do not use a tanning bed. 
+Stand up slowly if you have been sitting or lying down to avoid feeling dizzy. 
+Certain diuretics can raise blood sugar levels. If you have diabetes, talk to your health care provider about how this will affect the management of your diabetes. 
+If you are pregnant or planning to become pregnant, talk to your health care provider. 
+Tell your health care provider or pharmacist of any other prescription and non-prescription medications you are taking, including vitamins or herbal remedies.
+
+VASODILATORS AND NITRATES
+ Medications in the class of vasodilators include: 
+Hydralazine (Apresoline®, Apo-Hydralazine®, Novo-Hylazin®) 
+
+Medications in the class of nitrates include: 
+Isosorbide Dinitrate (Isordil®, Apo-ISDN®, Coradur®, Novo-Sorbide®) 
+Nitroglycerin Patch (Nitro-Dur®, Transderm-Nitro®) 
+
+How Do Vasodilators Work? 
+Vasodilators, including Hydralazine and nitrates, are used in combination to improve the symptoms of heart failure and help you live longer. 
+Hydralazine is a ‘vasodilator’ that relaxes arteries, allowing blood to flow more easily. Similarly, nitrates work by relaxing veins. These medications both increase the supply of blood and oxygen to the heart and reduce the amount of stress placed upon the heart. 
+These medications are often prescribed for those who cannot take an ACE Inhibitor or ARB. However, in Black patients who have heart failure, they may be taken in combination with an ACEI. 
+
+When and How Should I Take These Medications? 
+Take these medications at the same time(s) each day. 
+Hydralazine is a tablet that is taken three times each day (i.e., every eight hours). For people with kidney problems, it may be prescribed twice per day (i.e., every 12 hours). Hydralazine should be taken at least 1 hour before or 2 hours after a meal. 
+Nitrates are available in either an oral tablet or can be in the form of a patch that is placed on the skin. 
+Oral nitrate (Isosorbide Dinitrate) is a tablet taken three times each day. 
+A nitroglycerin patch is applied in the morning (or night) and is worn for a 12-hour period. After wearing it for 12 hours, the patch is removed to provide a ‘nitrate-free’ period each day. This is so your body does not get used to the medication. If you are using a nitroglycerin patch, apply it to a clean, dry area of your body that does not have a lot of hair (such as the shoulder or upper arm). Do not apply the patch to broken, scarred, or calloused skin. You can shower with the patch on. To prevent a skin reaction, apply the patch to a different area each day. 
+
+What are the Common Side Effects? 
+
+Side effects of vasodilators (Hydralazine) may include: 
+Headache 
+A flushed face (feels warm and looks red) 
+Feeling dizzy or lightheaded 
+Loss of appetite 
+Nausea, vomiting 
+Diarrhea or constipation 
+Stuffy nose or watery eyes 
+
+Serious side effects of vasodilators (hydralazine) include: 
+Pain or swelling in the joints or muscles 
+Unexplained fever, chills, or a sore throat 
+Rash, itching, or skin blistering 
+Chest pain 
+Worsening shortness of breath 
+Fast or irregular heartbeat 
+Fainting 
+Belly pain 
+Numbness, tingling, pain, or weakness in the hands or feet 
+
+Some side effects may go away as your body gets used to the medication. However, if you develop any of the serious side effects listed above, contact your health care provider right away. 
+
+Side effects of nitrates may include: 
+Headache 
+Feeling dizzy 
+Skin rash if using a topical patch 
+Flushing of the face and neck 
+
+What Should I Remember While Taking Vasodilators? 
+Tell your health care provider or pharmacist of any other prescription and non-prescription medications you are taking, including vitamins and herbal supplements. 
+To prevent feeling dizzy, stand up slowly from sitting or lying positions. 
+If you develop a headache, you can take Tylenol. Do not take non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (Advil®, Motrin®) or naproxen sodium (Aleve®). 
+If you develop a severe headache or a headache that does not get better, talk to your health care provider right away.
+Do not take sildenafil (Viagra®), tadalafil (Cialis®), or vardenafil (Levitra®) with nitroglycerin, as this can cause a dangerous decrease in blood pressure. 
+Talk to your health care provider if you are pregnant, planning on getting pregnant, or breastfeeding.
+
+What Should I Do If I Miss a Dose? 
+For oral doses: Take the missed dose as soon as you remember. However, if it is almost time for the next dose, skip the dose you missed. Take the next dose at the regular time. Do not take two doses at the same time. If you are unsure of what to do, speak to your health care provider or pharmacist. 
+For the patch: Apply the patch as soon as you remember and then take it off at the regular time.
+
+DIGOXIN (LANOXIN®)
+ How Does Digoxin Work? 
+Digoxin improves the symptoms of heart failure by strengthening the heart’s pumping function. Digoxin can also slow the heartbeat down, so it can be helpful in people with atrial fibrillation.
+
+How Should I Take Digoxin? 
+Take this medication at the same time each day. Wait two hours after consuming antacids, high-fiber foods, or fiber supplements to take this medication. 
+
+What are the Common Side Effects? 
+Dizziness 
+Headache 
+Fatigue 
+Belly pain 
+
+Severe side effects may include: 
+Loss of appetite 
+Nausea or vomiting 
+Blurred or coloured vision, or halos around bright objects 
+Confusion or weakness 
+Abnormal heart rhythm, which may cause palpitations or black outs 
+Seizures 
+
+Call your health care provider immediately if you develop any of these side effects, as they may be a sign that there is too much digoxin in your body. 
+
+What Should I Remember While Taking Digoxin? 
+Use with caution if you have certain types of kidney problems. Check with your health care provider first. 
+Tell your health care provider or pharmacist of any other prescription and non-prescription medications you are taking, including vitamins and herbal supplements. 
+If you develop another illness and are not able to eat or drink, or if you have a lot of vomiting or diarrhea, contact your health care provider or pharmacist. A blood test may be needed to check the level of digoxin in your blood. 
+Talk to your health care provider if you are pregnant, planning on getting pregnant, or breastfeeding.
+
+POTASSIUM SUPPLEMENTS
+ Potassium helps maintain a normal heart rhythm and build muscle, as well as supports overall nutrition. Diuretics used in the treatment of heart failure can lower blood potassium levels, impacting these functions. If the blood potassium level is too low, your health care provider may prescribe potassium supplements.
+
+Medications in this class include: 
+Potassium chloride tablets (Slow-K®, Euro-K® (previously known as K-Dur®), Apo-K®, Micro-K®) 
+Potassium chloride dissolvable powder (K-lyte®) 
+Potassium chloride liquid 
+
+How Do Potassium Supplements Work? 
+Potassium supplements are used to increase the blood potassium level. Maintaining a normal blood potassium level is important in preventing abnormal heart rhythms. 
+
+When and How Should I Take Potassium Supplements? 
+Potassium supplements come in a variety of different forms, such as tablets, liquid, or powder. Take the potassium supplement with a meal or right after a meal to prevent an upset stomach. 
+
+What are the Common Side Effects? 
+Nausea 
+Upset stomach 
+Vomiting 
+Diarrhea 
+
+Serious side effects may include: 
+Sensation of an abnormal heart rhythm 
+Confusion 
+Fatigue 
+Legs that feel heavy and weak 
+Unusual tingling, prickling, pulling, or burning in your arms, hands, legs, or feet 
+Belly pain. 
+If you develop any of the listed serious side effects, talk to your health care provider right away. 
+
+What Should I Remember While Taking Potassium Supplements 
+You may require regular blood tests to monitor your potassium level. Depending on the potassium level, your health care provider may change your dose of potassium supplement. 
+Tell your health care provider or pharmacist of any other prescription and non-prescription medications you are taking, including vitamins/minerals and herbal supplements. 
+It may be recommended that you speak with a dietician to discuss how often you eat foods that are good sources of potassium (such as spinach, bananas, and tomatoes). 
+Tell your health care provider if you are taking salt substitutes as they may also contain potassium.
+
+INTRAVENOUS IRON
+ Intravenous Iron 
+There is increasing evidence of the benefits of intravenous iron in heart failure patients with low iron levels, including increased energy levels. Effects are typically seen in the first few weeks after the iron infusion. The same effect has not been seen with iron in pill form. 
+
+What Causes Iron Deficiency? 
+There are many different causes of iron deficiency in patients with heart failure. The exact cause in an individual patient is often difficult to determine. 
+Patients with heart failure may not be taking enough iron in their diet (or even if they are, they may not be able to absorb it properly). They may also have impaired kidney function, which contributes to low iron levels in the body. 
+Bleeding (especially in the gut) is another important cause, so your doctor may request a colonoscopy if you haven’t had one in the recent past. 
+
+What Are the Risks of Intravenous Iron? 
+In general, intravenous iron is safe. 
+There is a very small chance of an allergic reaction with the iron infusion. While you are receiving the iron infusion, you will be monitored closely for any signs of an allergic reaction. If you have been prescribed iron and have previously had an allergic reaction to any form of iron, you should tell your doctor immediately. While you are receiving the infusion, if you develop signs of an allergic reaction (like feeling dizzy, swelling of your face, difficulty breathing), you should tell your nurse or doctor immediately. 
+If you have any other questions, speak to your doctor, nurse, or pharmacist. 
+
+What Happens Next? 
+If you are prescribed intravenous iron, an appointment will be made for you to come in and receive the infusion. The treatment takes several hours, so plan to be in hospital for at least half a day. 
+One month after the iron treatment, your doctor will recheck the iron levels in your body and may consider another treatment.
+
+STATINS
+ Statins have been shown to stabilize heart function and prevent hospitalizations from heart failure. Patients with cardiotoxicity may be prescribed statins during their cancer treatment and beyond. 
+
+Common statins 
+Rosuvastatin (Crestor) 
+Atorvastatin (Lipitor) 
+Pravastatin (Pravachol) 
+Simvastatin (Zocor) 
+Fluvastatin (Lescol) 
+
+How do statins work? 
+Statins are given to help control cholesterol, particularly bad cholesterol (LDL). They work by stabilizing and drawing out cholesterol from plaques found in the walls of arteries. Plaque and cholesterol build-up can decrease blood flow in arteries, increasing the risk for CAD and strokes. 
+
+Who should take statins? 
+People with high cholesterol levels despite decreasing high fat diets and smoking and increasing physical activity 
+People with diabetes 
+Those with CAD found on a CT scan 
+Patients with cardiotoxicity, during their cancer treatment and beyond 
+
+Most Common Side Effects Include: 
+Muscle pain/injury (less than 5%) 
+Liver injury 
+Gastrointestinal side effects (nausea, constipation) 
+Dizziness 
+Sleep difficulties 
+Headaches 
+
+What do I need to know when taking this medicine: 
+It may take many weeks for these medicines to take full effect. 
+Don’t eat grapefruit or drink grapefruit juice while taking a statin medicine (except for Fluvastatin, pravastatin or rosuvastatin). Grapefruit can increase the effects the medicine has in your body and increase the chance of side effects. 
+Don’t change the dose or stop taking this medicine without talking to your doctor or pharmacist, even if you feel well. 
+Don’t drink more than one to two alcoholic drinks per day when taking this medicine. It can increase the risk of side effects on your liver. 
+Tell your doctor if you are pregnant, planning to become pregnant, or breastfeeding. This medicine can harm your baby if you take it during pregnancy. 
+To check how the medicine is affecting your body, you will need to visit your doctor regularly.
+
+CALCIUM CHANNEL BLOCKERS
+ Calcium channel blockers relax and open up (dilate) the blood vessels/arteries. This helps improves blood flow to areas of the heart, as well as decrease blood pressure. Common calcium channel blockers include amlodipine (norvasc), nifedipine, and diltiazem.
+

how-is-heart-failure-managed-treatments.txt

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+DEVICE THERAPIES
+ Device Therapies are specialized pacemakers that either make your heart pump more efficiently or protect you from life threatening arrhythmias (abnormal heart rhythms). Deciding on whether a device is right for you – and selecting a device – depends on several factors, such as severity of your symptoms and heart function (as measured by the ejection fraction). 
+Three common devices for people with heart failure are:
+Implantable Cardioverter-Defibrillator (ICD) 
+Cardiac Resynchronization Therapy (CRT) 
+Left Ventricular Assist Devices (LVAD)
+
+IMPLANTABLE CARDIOVERTER-DEFIBRILLATOR (ICD)
+ Patients with heart failure are at risk of arrhythmias, causing the heart to beat too quickly (tachycardia), too slowly (bradycardia), or with an irregular pattern. 
+When too fast rhythms originate from the bottom heart chambers (the ventricles), they may cause a patient to feel unwell, pass out, or even die suddenly. These abnormal ventricular arrhythmias are called Ventricular Tachycardia (VT) or Ventricular Fibrillation (VF). 
+
+What Is An ICD? 
+Implantable Cardioverter-Defibrillators (ICDs) are specialized pacemakers. They are composed of a thin metal box that contains a battery, electric circuitry, and a wire that is implanted through a vein and sits in the right ventricle. The wire that sits in the right ventricle continuously monitors the heart rate. If the heart rate drops too low, it will pace the heart. If it detects an abnormally fast heart rate, it will either try to pace the heart back into a normal rhythm or deliver a shock to reset the heart to a normal rhythm. 
+While ICDs may prevent you from passing out or dying suddenly from ventricular arrhythmia, they do not affect your heart failure symptoms and will not necessarily make you feel better on a day-to-day basis. 
+
+When are ICDs required? 
+If you have had a ventricular arrhythmia that made you feel unwell or pass out, you may be a candidate for an ICD. Sometimes ICDs are implanted before a patient develops symptoms related to ventricular arrhythmia. These are called primary prophylactic ICDs. 
+The decision to implant an ICD depends on how impaired your heart function is (measured by your ejection fraction) as well as how symptomatic you are. Your health care provider will discuss whether an ICD is a good option with you. 
+ICDs may also be used for people with genetic cardiomyopathies who may be at higher risk of developing life-threatening arrhythmias (e.g., Hypertrophic Cardiomyopathy (HCM), Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC). 
+
+What are the different types of ICDs? 
+ICDs vary depending on the number of leads (wires) implanted in the heart. The simplest is a single chamber ICD, with just one wire sitting in the right ventricle. 
+Dual chamber ICDs have a second lead implanted in the right atrium. 
+
+How big is an ICD? 
+Current ICDs are about 2 inches by 2 inches (5cm by 5cm) and about half an inch (11mm) thick. They weigh about 1-3 ounces (28-85 grams). 
+As technology continues to improve, devices continue to get smaller. 
+
+How are ICDs implanted? 
+ICD implantation is usually day-surgery, typically implanted in the Electrophysiology Laboratory. Patients are usually awake during the procedure, and intravenous medication is given to help you relax. With this medication, you will feel drowsy, but will be awake and able to answer questions. 
+Most ICDs are implanted using the transvenous (through the vein) approach. A freezing solution is injected under the collarbone, and a small incision is made. The wire (or wires) is then inserted through the incision into a vein and directed to the heart using X-ray guidance. The tip of the wire is attached to the heart muscle, and the other end is hooked up to the pulse generator. The generator is then implanted under the skin just under the collarbone. The procedure usually takes between two and four hours. 
+After your ICD implantation, you will be given information about your specific device. You will also receive an appointment in the Pacemaker/Defibrillator Follow-up Clinic for ongoing monitoring. 
+
+What are the risks of an ICD? 
+In general, ICD implantation is safe. However, as with any invasive procedure, there are risks. The doctor who is performing the procedure will talk to you more about the risks and ask you to sign a consent form to go ahead with the procedure. 
+The risks of ICD implantation include bleeding, infection, puncture of the lung requiring a chest tube, and damage to the heart or to a blood vessel. Overall, the risk of having any of these complications is about 2-3%. The risk of dying from an ICD implantation procedure is very low (well under 1%). 
+In the long-term, there is also a risk of having an inappropriate shock, when the ICD delivers a shock not in response to a life-threatening arrhythmia. Receiving a shock from an ICD can be painful and unpleasant, especially if the shock was for the wrong reason. The technology is continuously improving and the risk of receiving an inappropriate shock is decreasing, but it is still an issue to consider with your care team. 
+
+What to do if you get a shock? 
+Receiving a shock from your ICD can be painful and upsetting. If you experience a shock, for your safety and for the safety of others, do not drive. If you are standing, move to a seated position. 
+If you experience just one shock, do not pass out, and otherwise feel well, you do not need to call 911 or go to the Emergency Department. Call the Device Clinic the same day (or the next business day) to report that you have received a shock. They will likely make an appointment for you to come in to have your ICD interrogated. 
+
+You should go to the Emergency Department if: 
+You lose consciousness 
+Experience more than one shock in one day, or more than one shock in one minute 
+Experience chest pain, shortness of breath, or lightheadedness.
+
+CARDIAC RESYNCHRONIZATION THERAPY (CRT)
+ Cardiac Resynchronization Therapy (CRT), also called a Biventricular Pacemaker, is a specialized pacemaker that works by making the two pumping chambers of the heart (the right and the left ventricle) pump at the same time. The goal of this specialized pacemaker is to make the pumping function of your left ventricle more effective, to improve your symptoms, and make you live longer. 
+The main pumping chamber of the heart is the left ventricle, which pumps blood to the body. The other pumping chamber is the right ventricle, which pumps blood to the lungs. In the normal heart, these two chambers pump at the same time. 
+In some patients with heart failure, the left ventricle does not pump at the same time as the right ventricle. The muscle walls of the left ventricle can also squeeze in an uncoordinated or ‘dyssynchronous’ fashion. There may be clues on your EKG or ECHO that your ventricles are not coordinated. A CRT device may be recommended to “resynchronize” the ventricles. 
+All CRT devices are pacemakers. If you are also a candidate for an ICD, your health care provider may recommend that you receive a combination CRT and ICD device, called a CRT-D device. 
+
+What to expect from a CRT? 
+Most patients who have a CRT implanted will experience an improvement in their symptoms, including improved quality of life and exercise tolerance. Improvements are noted immediately after CRT implantation but can sometimes take weeks to months to be experienced. 
+Some patients who have CRT implanted do not benefit from improved symptoms and quality of life. This subset of patients is called CRT Non-Responders. There is ongoing research to understand which patients are most likely to benefit from CRT. 
+
+How are CRTs implanted? 
+CRT implantation is usually day-surgery, typically implanted in the Electrophysiology Laboratory. Patients are usually awake during the procedure, and intravenous medication is given to help you relax. With this medication, you will feel drowsy, but will be awake and able to answer questions. 
+Most CRTs are implanted using the transvenous (through the vein) approach. Freezing solution is injected under the collarbone, and a small incision is made. The wires are then inserted through the incision into a vein and directed to the heart using X-ray guidance. The tip of the wire is attached to the heart muscle, and the other end is hooked up to the pulse generator. The generator is then implanted under the skin just under the collarbone. 
+The procedure usually takes between two and four hours. 
+After CRT implantation, you will be given information about your specific device. You will also receive an appointment in the Pacemaker/Defibrillator Follow-up Clinic for ongoing monitoring. 
+
+What are the risks of CRT? 
+In general, CRT implantation is safe. However, as with any invasive procedure, there are risks. The doctor who is performing the procedure will talk to you more about the risks and ask you to sign a consent form to go ahead with the procedure. 
+The risks of CRT implantation are similar to those associated with any other type of pacemaker implant. These include bleeding, infection, puncture of the lung requiring a chest tube, and damage to the heart or to a blood vessel. Overall, the risk of having any of these complications is about 2-3%. The risk of dying from a CRT implantation procedure is very low (less than 1%).
+
+LEFT VENTRICULAR ASSIST DEVICES (LVADS)
+ Left Ventricular Assist Devices (LVADs) are mechanical pumps that support the main pumping chamber of the heart, the left ventricle. They are implanted in patients with advanced heart failure who are still very symptomatic despite medications and specialized pacemakers.
+Unlike implantation of an ICD or CRT (which are less invasive procedures), implanting an LVAD is a major, open-heart surgery. The risks of surgery depend mainly on how sick a patient is before the operation. 
+
+Reasons For LVAD Implantation: 
+Most LVADs are implanted while patients await a heart transplant. Because the wait time for a transplant can be long, the support of an LVAD may be required by a patient’s weak heart until a donor heart becomes available. 
+Some patients with advanced heart failure may not be candidates for a heart transplant because of poor kidney function or high pressures in the lungs (pulmonary hypertension). When normal circulation is returned with an LVAD, the impaired kidney function and pulmonary hypertension may improve to a point where a patient is eligible for transplantation. Patients usually have their LVADs implanted and recover for several months to recover before they are reassessed for transplant candidacy. 
+Some patients are not and will most likely never be suitable candidates for heart transplantation because of advanced age or other major medical conditions (e.g., cancer, kidney failure, advanced diabetes). An LVAD may be implanted to manage their severe heart failure symptoms as a permanent solution. 
+In very rare cases, the cause of a person’s heart failure may be reversible and LVADs may be implanted to allow the heart to rest and recover. Once the heart has recovered, the LVAD is then taken out. 
+
+How does a LVAD work? 
+LVADs do not replace a patient’s heart. Rather, the LVAD is attached to the patient’s heart, and it takes over the pumping function of the left ventricle. 
+It takes a lot of energy to drive the pump. Although the pump itself is completely internal, a cable passes out through the abdominal wall and connects to batteries that power the pump. These batteries must be worn at all times and require frequent recharging. Although this sounds complicated, many patients are able to adapt and return to an active lifestyle. 
+Before the decision to implant an LVAD, patients undergo an extensive evaluation to make sure it is appropriate for them. This evaluation is meant to identify patients who are sick enough to need an LVAD (and justify the risk of the surgery), but not too sick to make the operation too high risk. 
+Currently, there is one type of LVAD being implanted in Canada: HeartMate III®. 
+
+Components of an LVAD 
+LVAD design depends on the manufacturer, but they all have the following components: 
+Pump: The pump attaches to the left ventricle of your heart and pumps the blood to your body. A cannula empties the blood from the left ventricle and pumps it through another cannula that is implanted in the aorta. Newer generation devices do not provide a continuous pumping action, so you may not be able to feel a pulse. 
+Driveline: The LVAD’s pump requires electrical energy to run. The driveline connects the pump to the controller and batteries on the outside of your body. The driveline exits your body through the skin of your abdomen. 
+Controller: The controller records all the settings of the LVAD, tells you when the batteries need to be changed, and sounds an alarm if there is a problem with the LVAD. The controller is worn on the outside of the body in a bag, or on your belt. 
+Batteries: When people are active, batteries are the main way that an LVAD is powered. The batteries must be charged in between uses ― it usually takes about six hours to fully charge the batteries. The controller has a display which shows how much battery life remains. 
+AC (Electrical) Power Sources: While you are at home, either sleeping or resting, you can connect your LVAD to an electrical power source. This is to prevent loss of battery power while you are asleep. 
+
+Living with your LVAD 
+After the LVAD implantation surgery is done, you will be in hospital for several days and the LVAD team (cardiac surgeons, cardiologists, and nurse practitioners) will follow you closely to monitor your progress. You and your caregiver or family will be taught how to operate your LVAD. You will learn that your LVAD is easy to operate and very reliable. 
+After you go home, the LVAD team will provide you with all the equipment you need to care for your device. The LVAD will provide you with better circulation, better organ function, and will hopefully make you feel stronger. 
+
+Commonly Asked Questions 
+Will I be taking new medications after getting the LVAD? 
+You will have different medication needs after LVAD implantation. Patients often require less medication than before surgery. 
+Most patients will need to take blood thinners while their LVAD is implanted. The nurses, nurse practitioner, and pharmacist involved in your care will make sure you know each of your pills and what they do. 
+Will I be able to shower with the LVAD? 
+Once your incision is healed, you will be able to shower. The nurse practitioner will show you how to cover and protect the electrical connections of your device so that you can safely take a shower. You will not be able to swim or be submerged underwater. 
+How long can I expect to be in hospital after the LVAD is in place? 
+You and the LVAD team will decide when you are ready for discharge. Most patients are ready for discharge within two weeks to one month after surgery. It is important that you are very comfortable with the care of the LVAD before you leave the hospital. 
+Can I have sex? 
+Many patients are able to resume sexual activity once the surgical wound has healed. 
+Are there restrictions on my activities? 
+Like any major open-heart surgery, there is a recovery period after surgery. Over time you will regain your strength and ideally return to an active lifestyle.
+
+HEART TRANSPLANT
+ Heart transplantation can be a lifesaving therapy. It is an option for the sickest patients who continue to have symptoms of heart failure or require admission to hospital for heart failure, despite being on the best medical therapy and having the appropriate device therapies.
+Unfortunately, a major limitation is the scarce availability of suitable donor organs. Because of the critical shortage of available organs, strict criteria must be met before a patient is considered as a potential candidate for a heart transplant. 
+It is also important to understand that, while heart transplantation is a lifesaving therapy, it is not a cure. Although the failing heart is replaced, receiving a new heart requires one to be on lifelong immunosuppression, which increases the risk of infection, diabetes, and cancer.
+
+HEART TRANSPLANT CANDIDACY
+ If you are being considered for a transplant, your doctor will order several tests to determine whether you are a suitable candidate or not: 
+Bloodwork to look at: Your kidney and liver function, Your immune status to Hepatitis A, B and C, Whether you have contracted viruses, including HIV, CMV. and EBV 
+A Cardiopulmonary Test to assess the severity of your heart failure 
+An ECHO to assess your heart function 
+A Right Heart Catheterization to measure the pressures in your heart and lungs 
+Lung function tests 
+Ultrasounds of your abdomen, neck, and legs to look for narrowing or blockages of the arteries 
+If you have diabetes, an eye examination by an ophthalmologist will be needed to ensure that the diabetes hasn’t affected the blood vessels of your eyes (called diabetic retinopathy) 
+If appropriate, screening tests for breast and cervical cancer (in women) and prostate cancer (in men). 
+
+Depending on the results of these investigations, further testing may be needed. 
+Once all the tests are complete, your case will be discussed with all the members of the Heart Transplant team (cardiologists, cardiac surgeons, anesthetists, nurse practitioners, psychiatrists, and social workers) and a decision will be made on your eligibility for a heart transplant. 
+
+Unfortunately, not everyone who is evaluated is a candidate for a heart transplant. 
+Someone may not be considered to be a good candidate for a number of reasons: 
+Advanced liver disease (cirrhosis), lung disease (like COPD), or kidney failure 
+Active cancer, or cancer within the last five years 
+High pressure in the lungs (called pulmonary hypertension) that does not reverse with medications 
+An active infection 
+Diabetes that has affected your kidneys, eyes, or nerves 
+Plaque buildup in arteries not around the heart.
+
+WHAT HAPPENS AFTER BECOMING A CANDIDATE?
+ Once confirmed as a candidate, you will be put on the Heart Transplant List. Your rank on the list is determined by the severity of your condition and how long you have been on the list. Someone who is sick and admitted to hospital is given a higher priority than someone who is stable at home, for example. 
+Other factors that affect your wait for a transplant include your blood group, your body size, and how ‘sensitized’ you are. Sensitization refers to the number and type of antibodies that your body has produced against foreign substances. The more antibodies you have, the more difficult it is to find an organ that is a right match for you. 
+Occasionally a patient is called in for transplant, but the donor organ is found to be an unsuitable match, and the transplant is canceled. 
+Other medical problems may arise while waiting for a transplant and you may be ‘put on hold’ while your doctor treats this problem. In some cases, a medical problem may arise that can make someone no longer eligible for a heart transplant. 
+Learn more about preparing for heart transplant in UHN’s Heart Transplant Manual
+
+BECOMING A HEART TRANSPLANT RECIPIENT
+ Getting a heart transplant can save, lengthen, or improve the quality of life (general wellbeing) of patients with advanced heart failure. 
+It’s not always easy to know when it is the ‘right time’ to think about heart transplant. You need to consider getting a heart transplant before you are too sick to handle the surgery and recovery. Your symptoms must be strong and serious enough that they cannot be managed with less intensive treatment. 
+Your transplant assessment coordinator starts a complete check of your health, called a “Heart Transplant Assessment” (Step 1). Your transplant team uses the results of your heart transplant assessment to determine if a heart transplant is the right treatment for you. 
+Learn more in the Heart Transplant Surgery: From Hospital Admission to Surgery.
+
+WHAT HAPPENS AFTER A TRANSPLANT?
+ After your heart transplant, you will be in the hospital for several days. Your doctors will watch you closely to make sure that your new heart is functioning properly and that other complications (like infections or kidney failure) do not occur. 
+You will need to take anti-rejection or immunosuppression medications for the rest of your life. They are meant to help the body’s natural infection fighting mechanisms accept the new heart. 
+Normally, our immune system prevents infections by attacking foreign objects, like bacteria or viruses. Rejection occurs when your body’s immune system recognizes the transplanted heart as foreign and attacks it. The immunosuppressant medications will prevent the immune system from attacking and rejecting the new heart. Immunosuppression may also affect the way your body fights off infection. 
+Your dose of immunosuppression medications will change over time. The biggest dose is usually taken right after your transplant and decreased over time. Because one of the side effects of taking immunosuppression is infection, you will also likely be prescribed medication(s) to prevent infection. While you are in the hospital, you will be taught all about your medications. 
+Learn more in the After the Surgery: Living with a Transplanted Heart (Heart Transplant Recipient and Caregiver Manual Book 3)
+
+CARDIAC REHABILITATION
+ Rehabilitation after a cardiac incident helps people with heart disease improve their cardiac health and fitness. It also helps them reduce their chance of future incidents through lasting lifestyle and behaviour changes. 
+
+UHN’s Cardiovascular Rehabilitation Program helps you: 
+Take charge of your medical condition 
+Develop strategies to improve your risk factors for cardiovascular disease 
+Maintain an exercise program to improve your health and well being 
+Incorporate healthy food choices and practices to manage your health and well being 
+Develop strategies to manage your psychosocial risks for cardiovascular disease. 
+
+Cardiac College was developed specifically to help guide patients in developing positive and healthy behaviour to live and thrive with cardiovascular disease. Patients will learn skills to: 
+Build a foundation for a safe heart 
+Develop skills to take care of your heart 
+Prepare for life after rehab 
+
+Learn more information about UHN’s cardiac rehab program.
+

how-is-heart-failure-managed.txt

@@ -0,0 +1,14 @@
+HOW IS HEART FAILURE MANAGED?
+ Heart failure treatments can help people with heart failure live longer, feel better, and avoid being admitted to hospital. Different treatments and approaches to managing heart failure work in combination, and require participation from patients, caregivers, and the health care team.
+Typically, a combination of lifestyle changes and medications is required. Surgical procedures may also be considered as part of the treatment plan. 
+A healthy lifestyle is essential. For someone with heart failure, this means paying extra attention to diet, getting regular exercise, avoiding alcohol, and taking care of your mental well-being. These behaviours can help with symptoms and have a positive influence on your heart condition. 
+
+Depending on the severity, the cause, and the type of heart failure at the time of diagnosis, medications are typically prescribed and adjusted over many follow-up visits. 
+Heart failure medications work in different ways. They may strengthen the heart’s pumping function, reduce the amount of work that the heart has to do or help manage symptoms. 
+
+Surgical procedures may be necessary to implant a device or help the heart function better in people with heart failure. 
+Devices such as a defibrillator or a pacemaker help correct harmful heart rhythms or lack of synchronicity of heart rhythm in the right and left sides of the heart. 
+An artificial heart pump called a left ventricular assist device or LVAD may be needed for someone with advanced heart failure. In end-stage heart failure, transplantation of a new heart may be necessary. 
+It is often difficulty to predict how an individual responds to different heart failure therapies. Some patients improve dramatically, others remain stable over time, and some can progress more rapidly with worsening heart failure.
+Treatments are recommended by the care team based upon a number of clinical factors and in partnership with the patient.
+

immune-therapy.txt

@@ -0,0 +1,36 @@
+IMMUNE THERAPY
+ The immune system works by recognizing foreign ‘outsider’ cells and boosting the body’s defense system (antibodies) to attack them, preventing damage to the body. 
+Immune responses attack any foreign invader, such as bacteria, viruses, or cancer cells. The immune system can also produce cytokines, which are substances that act as messengers; cytokines tell the body’s cells to attack foreign cells.
+
+IMMUNE CHECKPOINT INHIBITORS
+ Cancer cells can be difficult to recognize in the early stages, as they start off as normal cells – the body may not initially recognize them as foreign. Immune checkpoint inhibitors (ICIs) are a type of immune therapy that strengthens the body’s immune system to recognize and fight cancer cells. 
+Common cancers treated with ICIs include:
+Certain types of lymphoma
+Skin cancer
+Lung
+Kidney
+Bladder
+Gynecologic
+Common ICI medications include:
+Atezolizumab
+Avelumab
+Durvalumab
+Ipilimumab
+Nivolumab 
+Pembrolizumab
+
+MYOCARDITIS
+ A possible side effect of ICI therapy is organ inflammation, including myocarditis (inflammation of the heart muscle).
+The main symptoms of myocarditis include chest pain, fatigue, fast or abnormal heart rates, shortness of breath, swelling in the feet and ankles, joint and muscle pain, and fevers. Although myocarditis can occur at any time, it is more likely to occur early into ICI therapy, usually within the first 2-3 months of treatment. 
+Diagnostic tests for myocarditis include:
+ECG
+Chest Xray
+Cardiac MRI (can show signs of inflammation, and pumping function of heart)
+Echocardiogram (can show pumping function of heart, as well as fluid around the heart)
+Blood tests (looking for inflammation; CRP, and injury to heart muscle- troponin/BNP)
+Cardiac biopsy (small sample of heart muscle removed for checking for inflammation)
+Myocarditis may be treated by:
+High dose steroids by IV in hospital followed by a transition to oral steroids, such as prednisone, and tapering over time until symptoms are resolved and there is normal heart function
+Postponing ICI therapy
+Pain medications such as Tylenol and non-inflammatory medications (ibuprofen)
+

living-with-cardiotoxicity.txt

@@ -0,0 +1,21 @@
+LIVING WITH CARDIOTOXICITY
+ The goal of a cardio-oncology program is to help prevent short- and long-term cardiac complications of cancer therapy. As a result, your team works closely with you and other specialists to ensure that your heart is safe prior to, during, and following your cancer therapies. 
+Part of living with cardiotoxicity is being aware of its symptoms. Being aware of the heart-related symptoms helps you monitor your well-being and bring changes to the attention of your healthcare team.
+
+TAKING CARE OF RISK FACTORS FOR CARDIOTOXICITY
+ It is important to work closely with your cardio-oncology team to identify and treat cardiac complications resulting from cancer therapy. Preventing and treating these cardiac complications during cancer therapy (and beyond) helps to prevent a “second hit” to the heart. Controlling blood pressure, blood sugars, cholesterol levels and maintaining a healthy weight and exercise levels helps prevent further injury to the heart later in life.
+Blood Pressure
+To prevent cardiotoxicity both now and into the future, it is important to ensure that other risk factors for heart disease are treated during your cancer treatment, and beyond. This includes maintaining a healthy blood pressure. 
+Diet and Exercise 
+Part of blood pressure control includes diet and exercise.
+Physical Activity 
+We encourage people to continue to be physically active during their cancer treatment. Exercise has many physical and psychological benefits, and may help alleviate some cancer treatment symptoms, leading to improved appetite; sleep; and energy levels; increased strength; lower stress and anxiety; and better control of diabetes, high cholesterol, and high blood pressure. 
+The long-term goal of exercise is 90-150 minutes per week of moderate physical activity. This can be achieved by a brisk walk, jogging, cycling, and/or swimming. If you are not physically active now, you can start by walking briskly for 10-15 minutes 2-3 times per week and gradually working your way up to 30 minutes five times per week. It is also important to have a warm-up and cool-down period of five minutes each during your exercise. 
+If you have questions about exercise, please ask your healthcare team. Cardiac rehabilitation programs are an excellent way of increasing physical activity during your cancer treatments, and beyond. 
+Note that there are times when you are not recommended to exercise. 
+Avoiding Alcohol and Smoking 
+Avoiding alcohol is important when managing or decreasing your risk of cardiotoxicity. Alcohol is a toxin to the heart and can lead to heart failure. 
+Smoking is another important risk factor for heart disease. It is important that you quit smoking to prevent high blood pressure, coronary disease, and stroke. Reach out to your healthcare team if you need help to quit smoking. 
+Managing Stress 
+Stress is common while undergoing cancer therapy and having a heart problem on top of cancer treatment can further increase stress levels. Managing stress is important, as increased stress can elevate blood pressure levels and make daily activities more difficult. It is important to reach out to your support persons and healthcare team if you are having increased stress or anxiety levels.
+

medication-management.txt

@@ -0,0 +1,17 @@
+MEDICATION MANAGEMENT
+ People with more complex medical needs, like heart failure, may require multiple medications throughout the day. 
+To ensure the safe, consistent, and effective use of medications, it is important to have a system in place. 
+Proper medication management has numerous advantages for patients, caregivers, and healthcare providers:
+It reduces medication errors. Medication errors, such as improper timing or dosing, can result in unpleasant or dangerous side effects, make the medication ineffective, or even result in death. 
+It helps achieve the best possible outcome. When medications are managed properly, your response to the dosage is carefully monitored. This means that if your health suddenly deteriorates or you stop responding in the same way, the prescription or dosage can be accurately adjusted to correct the situation.
+It provides peace of mind. Many people, particularly the elderly, may have difficulty remembering to take medications on time. Having a system helps assure everyone involved that you are receiving the right medication at the right time.
+
+TIPS FOR MANAGING YOUR MEDICATIONS
+ Before taking any new medications, check first with your pharmacist about drug interactions with medications you are currently taking that could cause problems. 
+Always ask your pharmacist about drug interactions with over-the-counter cough, cold, and allergy medicines.
+Keep a list of your current medications (names and dosages) in your wallet or on your smart phone.
+Know your drug allergies.
+If you take medications at set times throughout the day, you could set a timer on your phone as a reminder. 
+When away from home, ensure you have your medications with you or keep extra dosages in your purse or wallet.
+Consider using a pill box or having the pharmacy make a blister pack with a separate day of the week and am/pm compartments to organize your medications.
+

mental-health.txt

@@ -0,0 +1,37 @@
+MENTAL HEALTH
+ Mental health refers to a person’s emotional, psychological, and social well-being. It is a vital aspect of overall health. How we think, feel, act, and make decisions all play a role in our mental health. 
+Mental health issues can be short-term or long-term and can affect your mood, behaviour, thinking, capacity to relate to others, and even physical health. The effects of trauma, depression, anxiety, and stress on the body, particularly the heart, have been documented in numerous research.
+
+HOW CAN HEART FUNCTION AFFECT MENTAL HEALTH?
+ Living with heart failure can be difficult physically and mentally. You may feel a variety of emotions after receiving a diagnosis or as you continue to manage your condition, such as fear, frustration, despair, and worry. These feelings may not affect everyone, may come, and go or remain. 
+Some people also find that living with heart failure affects their ability to cope with psychological and emotional stress. 
+The mental health concerns for people experiencing heart failure are the same, regardless of the type or severity of their condition.
+
+MANAGING YOUR MENTAL HEALTH
+ It is common to experience more negative thoughts and feelings during periods of stress, anxiety, or depression. These feelings can lead us to over-emphasize how demanding, threatening, or overwhelming daily events and interactions with others are – this habit is known as “negative self-talk.” As this self-talk can become involuntary and constant, it is common to accept it as fact and to see worst-case outcomes as being unavoidable. 
+When negative self-talk becomes a regular part of our daily life, it can influence the way we interact with day-to-day events at home or at work. Feelings of worry, anxiety, irritability, and sadness are triggered and maintained by negative self-talk. 
+As negative self-talk continues, it may give you an imbalanced or distorted impression of your situation, which can further perpetuate the cycle. You may notice a progressive decrease in your confidence about being able to manage challenging situations, including your medical condition. As a result, feelings of stress, anxiety, or depression may become more and more disruptive in your life.
+
+CHALLENGE NEGATIVE SELF-TALK
+ Here are some strategies you can use to successfully change the tone of your self-talk:
+1. Identify your negative self-talk patterns
+Identify what your most frequent and powerful self-talk statements are (e.g., I can’t do this, I don’t deserve this, I’m not good enough) and consider how they impact your feelings or behaviour.
+2. Interrupt or question these statements.
+Try to catch and interrupt negative self-talk to prevent it from escalating by shifting your attention to thoughts or memories that are not negative, or intentionally absorb yourself in a task that you want or need to do.
+Try repeating one of the following phrases to yourself: “Let it go,” “Don’t go there,” “Stay focused.
+Shift your activity by going for a breath of fresh are or getting a drink of water. 
+Use questions that lead you to a more balanced view of yourself or your stressful situation.
+Try repeating one of the following phrases to yourself: “Let it go,” “Don’t go there,” “Stay focused.
+Shift your activity by going for a breath of fresh are or getting a drink of water. 
+Use questions that lead you to a more balanced view of yourself or your stressful situation.
+One key cognitive-behavioural technique is to ask yourself: “Even if I’m in a difficult or stressful situation, how can I best respond to it?” 
+As you think about your answer, you’ll find that your effort begins to focus on a constructive goal for your situation, and this in turn helps to improve your emotions and mood.
+3. Actively practice positive self-talk.
+Focus your attention on the positive ways you are addressing your situation. You can also identify at least one positive characteristic about yourself and your efforts. Remind yourself negative experiences help teach us how to respond to difficult situations. Through this process, you may discover how your effort is deeply meaningful, or even a source of personal growth.
+Consider gratitude. Write down a list of things you are grateful for in your life, or things that you appreciate about yourself, your perseverance, or those around you.
+
+RELAXATION AND MEDITATION
+ If stressful situations make you feel anxious, tense, or worried, you may find meditation helpful. Even a few minutes of meditation may help you regain your sense of calm.
+Meditation is something that everybody can do. It’s easy to accomplish, free, and doesn’t require any special equipment.
+You can meditate anywhere: on a walk, on the bus, in line at the doctor’s office, or even in the middle of a tense work meeting.
+

paediatric-heart-failure.txt

@@ -0,0 +1,37 @@
+WHAT IS PAEDIATRIC HEART FAILURE?
+ The treatment of heart failure in children often depends on the cause of the underlying problem. Sometimes there are medical, surgical or catheter-based interventions that can be undertaken to either cure or reduce the symptoms of heart failure. Your child will be taken care of with a team that includes physicians, nurses, specialized dieticians who ensure optimal nutrition, and physical and occupational therapists who will provide assessments. Your child will be prescribed medicines to treat both the symptoms of heart failure and to improve or stabilize heart function. Child life specialists and social workers are available to help children and families dealing with the stress associated with a chronic illness.
+
+TREATMENT OF HEART FAILURE IN CHILDREN
+ The treatment of heart failure in children often depends on the cause of the underlying problem. Sometimes there are medical, surgical or catheter-based interventions that can be undertaken to either cure or reduce the symptoms of heart failure. For children whose heart failure symptoms worsen and they develop what is called “end-stage” heart failure, there may be the option to manage it using devices such as ICDs, or ventricular assist devices. They may also need heart transplantation.
+
+TRANSITIONING TO ADULT CARE
+ Making the move from a children’s to an adult hospital is a new and exciting chapter in your life. It can also be a time of uncertainty and sometimes fear. These feelings are normal. Your caregiver has likely played an important role in managing your health care so far, however, now is the time that you continue to take charge of your own health and become a more independent adult.
+
+SickKids has a dedicated team of both paediatric and adult cardiologists alongside specialized paediatric cardiac nurses who will help guide you through this transition to the adult hospitals.
+
+What do we do?
+Increasing patient knowledge of their cardiac diagnosis, interventions, medical management and lifestyle choices (beginning at the age of 14 years old)
+Supporting patients in the development of their self-management and self-advocacy skills
+Providing virtual “meet and greet” opportunities for patients to connect with the adult healthcare team
+
+How do we do this?
+How do we do this: By providing patients with nurse-lead 1:1 education sessions that are tailored, and developmentally appropriate for each patient. These sessions are available both in person and virtually
+Continued support post transfer from paediatric to adult healthcare
+
+CHF CLINICAL PROGRAM AT SICKKIDS
+ The Cardiomyopathy & Heart Function (CHF) program at Sickkids is the first and largest of its kind in Canada. The CHF program provides expertise in delivering both inpatient and outpatient care for children with all types of cardiomyopathies and those with congenital heart disease and end-stage heart failure.
+
+The CHF program runs regular interdisciplinary clinics each week specializing in Hypertrophic Cardiomyopathy, neuromuscular diseases such as Duchenne Muscular Dystrophy and Friedrich’s Ataxia, surveillance for heart failure in those who have received cancer treatments, and a regular cardiomyopathy screening clinic for children with affected family members.
+
+The CHF team is multidisciplinary and works to optimize the health and quality of life for children with heart failure.
+
+From a research standpoint, this program is at the forefront of innovation that include novel drug trials, multi-centre registry participation, advanced genomics and stem cell research, cardiac precision medicine, digital technology, and quality improvement efforts.
+
+PAEDIATRIC HEART FAILURE SUPPORTS
+ Labatt Family Heart Centre 
+SickKids Family Resources 
+AboutKidsHealth 
+Paediatric Transplant Society 
+ACTION Learning Network 
+Children’s Cardiomyopathy Foundation
+

physical-activity.txt

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+PHYSICAL ACTIVITY
+ Exercise is essential for good cardiovascular health.
+Having heart failure does not mean that you cannot exercise. In fact, studies show numerous benefits of exercise in people with heart failure.
+Enrolling in a cardiac rehabilitation program may be an option for you. These programs are an excellent source of information and allow you to exercise in a supervised setting.
+Ideally, you should be getting regular physical activity: 30 minutes per day, five days per week. You may need to gradually build up to this level of activity.
+
+EXERCISE AND HEART FAILURE
+ Exercising regularly helps people with heart failure live longer, improves quality of life, and decreases the need for heart failure related hospital admissions. Other health benefits: 
+Better energy levels
+Increased physical strength and ability to exercise
+Weight loss
+Improved management of other medical conditions and risk factors, such as diabetes, blood pressure, and cholesterol levels
+Management of stress
+Improved quality of sleep
+Decreased symptoms of depression.
+
+IS IT SAFE FOR ME TO EXERCISE?
+ You may feel uncertain about starting to exercise. The first step is to talk to your health care provider to find out if it is safe for you to exercise, what type of exercise or program is best for you and how much. 
+Your doctor may order a cardiopulmonary exercise test to determine a safe level of exercise for you.
+
+HOW SHOULD I START EXERCISING?
+ Starting to exercise for the first time or resuming exercise after a long break can be hard at first. It is best to start slowly, go step-by-step, and take breaks whenever you need them. Also, it is important to monitor how you feel during exercise. 
+Tips to start a regular exercise routine:
+Plan to start exercising two to three days each week. Slowly work your way up to an end goal of exercising five days each week.
+Start by exercising for 10-15 minutes at a time. Slowly build up the time you are exercising. Your end goal should be to exercise for 30 minutes.
+Always make sure that you begin and end your exercise with a five minute ‘warm-up’ and ‘cool-down.’ Perform stretching exercises after your “cool down” is complete. This will help to reduce the stress on your heart and muscles and prevent injury.
+Make an exercise schedule for each week and try and stick to it.
+Use a diary or journal to track your exercise routine and how you are feeling during exercise. 
+Use a self-monitoring tool, such as the Borg Rating of Perceived Exertion (RPE) Scale, to help measure how you feel during exercise. The Borg RPE is a numerical scale that you can use to monitor how hard you are working during exercise. The goal is to be between three and five on the scale.
+
+AEROBIC EXERCISE
+ Aerobic exercise can improve your cardiovascular fitness by improving how your body utilizes oxygen to give you energy.
+Moderate intensity aerobic exercise is best for the cardiovascular system. You can try: 
+
+Brisk walking
+Swimming
+Cycling (either outdoor or on a stationary bike)
+Water aerobics
+Fitness classes such as Zumba 
+Dancing.
+
+
+STRENGTH OR RESISTANCE TRAINING
+ Strength or resistance training improves muscle mass and tone and enhances quality of life. To add this type of training to your exercise routine: 
+
+Use light free weights (no more than 5-10 lbs.) or resistance bands
+Do short sessions of 10-20 repetitions with the light free weights, two to three times per week.
+
+
+CARDIAC REHABILITATION
+ Joining a cardiac rehabilitation program is an excellent way to learn how to exercise and is recommended for all patients with stable heart failure.
+Cardiac rehab will provide you with an ‘exercise prescription’ that is tailored to your health needs. While in cardiac rehab, you will be supervised during exercise. You will receive training on how to exercise safely, monitor your symptoms during exercise, and reach your individual exercise goals. For those people who cannot attend on-site, home-based programs are also offered which include ongoing contact with exercise specialists.
+Cardiac rehab also provides education and support on how to manage risk factors for heart disease, such as eating a healthy diet and losing weight.
+Learn more about UHN’s Cardiac Rehab Program.
+or speak to your doctor about being referred to a program in your area. 
+
+WHEN SHOULD YOU NOT EXERCISE?
+ You should not exercise if you have any of the following:
+
+Feelings of unwellness, such as cold or flu symptoms
+Worsening fatigue
+Chest discomfort
+Worsening shortness of breath or cough
+Interrupted sleeps due to shortness of breath
+Increased weight due to fluid build-up
+Increased swelling in the feet, ankles, legs, or belly
+Nausea or loss of appetite
+An irregular heartbeat or if you feel your heart is beating too fast or slow
+Dizziness.
+
+
+TIPS FOR EXERCISING SAFELY
+ 
+If during exercise you develop chest discomfort, worsening shortness of breath, dizziness, nausea, or a fast heart rate, stop exercising and speak to your health care provider.
+Don’t exercise in extreme temperatures, such as days when it is very cold, hot, or humid. In this weather, it is best to exercise indoors.
+Wait at least 60-90 minutes after eating a meal before exercising.
+Avoid exercises that involve holding your breath or bearing down, such as pushups and sit ups.
+
+ENERGY CONSERVATION
+ Fatigue is a common symptom of heart failure. Energy conservation is about maintaining a healthy balance between activity and rest to keep up your energy level. To help you learn how to use your energy wisely, here are some useful strategies. 
+Plan ahead 
+
+Make a schedule for the day and week ahead. 
+Avoid trying to do all your chores in one day and rushing around. 
+Plan shopping trips during times when there are fewer crowds or long lines. 
+Simplify meal planning and stock your pantry with key ingredients for your favourite recipes. 
+Get extra rest the day before attending a social event. 
+
+Performing daily activities 
+
+Break up larger activities into smaller parts and rest in between. 
+Sit rather than stand when grooming, dressing, or putting on shoes. Sitting helps to give your heart a rest. 
+Avoid standing for long periods of time. 
+Be aware of your body posture, as poor posture can cause you to feel tired. Sit in a well-supported chair and avoid bending over when working at a desk. 
+If you have stairs in your home, organize your activities so you don’t have to climb stairs several times each day. 
+Learn to breathe evenly during activity and avoid holding your breath. 
+Use equipment such as a walking device. 
+Develop good sleep habits. If you nap for too long during the day you may not be able to sleep well at night. Avoiding eating before bed.
+Avoid doing activities in extreme temperatures, such as very cold or hot weather, as this may cause you to feel more tired. 
+
+Learn to listen to your body 
+
+Recognize when you are starting to feel fatigued and take a break or short nap. 
+Some people feel more energetic in the morning compared to the afternoon. Determine your best time of day to plan activities.
+
+

physical-and-mental-health.txt

@@ -0,0 +1,4 @@
+PHYSICAL AND MENTAL HEALTH
+ The connection between physical and mental health may be deeper than you realize. Taking care of our physical health has been shown to improve our mental wellbeing; in turn, nurturing our mental health can help us to stay physically healthy. Alternatively, if either your physical or mental health declines, the other will be impacted as well.
+When managing and coping with symptoms, it can be harder to be physically active. The impacts of heart disease on your sense of self as well as feelings of worry and depression can be profound. Many people struggle to maintain good health and take care of their mental and emotional well-being.
+

potassium.txt

@@ -0,0 +1,161 @@
+POTASSIUM
+ Maintaining a normal potassium balance is important, as high, or low potassium levels in your blood can affect your heartbeat.
+Most foods and beverages contain potassium. By managing the intake of these foods, we can help manage our potassium levels.
+Potatoes are very high in potassium, but the way they are prepared can significantly reduce the amount of potassium.
+Do not use salt substitutes made with potassium chlorides such as NuSalt®, NoSalt® and HalfSalt®.
+Avoid foods that list potassium or the chemical symbols (K, KCI and K+) as an ingredient on the label.
+Season foods with herbs and spices. 
+DO NOT EAT starfruit (also known as carambala, bilimbi, belimbing, Chinese starfruit, star apple) if you have kidney problems. 
+For more information, speak to your health care provider about a referral to a dietitian.
+
+POTASSIUM INTAKE
+ 
+Potassium is a mineral that has many important roles within your body, including regulating your heartbeat and blood pressure. Maintaining a normal potassium balance is important, as high, or low potassium levels in your blood can affect your heartbeat.
+Most foods and beverages contain potassium but in different amounts. If your potassium level is too high and you have been advised by your cardiologist to lower it, changes in your diet can help.
+Some medications can also increase your potassium level. If this is the case, your health care team may need to change or adjust a medication accordingly.
+
+POTASSIUM AND POTATOES
+ Potatoes are very high in potassium. However, the way a potato is prepared can reduce its potassium, allowing them be part of a potassium-restricted diet.
+
+LOW POTASSIUM FOOD GUIDE
+ To help you avoid foods that are high in potassium, follow examples suggested in our guide below. Please note that organizations may use different cut-off levels to decide which foods are high or low in potassium. Therefore, you may find some variations among resources. 
+Note that ½ cup is 1 serving unless otherwise stated. 
+Our examples below are a guide and not to replace the advice of your health care provider. 
+Speak to your dietitian about the number of servings that is right for you or to identify low-potassium foods that are not captured on this list, including foods from various cultures.
+
+FRUITS
+ Limit to 3 servings per day, or as recommended by your registered dietitian. 
+Choose (example of 1 serving): 
+
+1 apple 
+Applesauce 
+10 cherries 
+½ mango 
+1 Peach 
+1 Pear, medium 
+1 Plum 
+Raspberries 
+Strawberries 
+Blueberries 
+Blackberries 
+Pineapple 
+Apple juice 
+Pineapple juice 
+Cranberry juice or cocktail 
+Nectars from guavas, peaches, and pears
+
+Avoid: 
+
+Apricots 
+Avocados 
+Bananas
+Coconut, dried and raw 
+Cantaloupes
+Nectarines 
+Oranges 
+Honeydew melons 
+Kiwis 
+Papayas 
+Coconut, orange, and prune juices
+Coconut water
+
+Do not eat starfruit (also known as carambala, bilimbi, belimbing, Chinese starfruit, star apple) if you have kidney problems. 
+
+VEGETABLES
+ Limit 3 servings per day, or as recommended by your registered dietitian.
+Choose (example of 1 serving): 
+
+Onion 
+Broccoli, chopped, raw, or frozen 
+Beans, green or wax 
+Mushrooms, raw 
+Carrots, raw (16cm long or 8 baby carrots)
+Carrots, boiled and drained 
+Okra, raw or boiled and drained 
+Peppers 
+1 cup green peas, frozen, boiled, or canned and drained
+Raw peas
+Asparagus (5 spears) 
+1 celery stalk, raw 
+1 cup of lettuce 
+Cauliflower, raw or cooked 
+1 cup cucumber, sliced 
+Corn kernels, frozen, canned, or boiled and drained 
+Snow peas, raw (10 pods)
+
+Avoid: 
+
+Tomato sauce  
+Mushrooms cooked 
+Rapini (cooked) 
+Bok choy, cooked 
+Brussel sprouts, cooked 
+Juice- vegetable, clamato, V8 or tomato 
+Potatoes, sweet potatoes (unless prepared according to the cooking instructions listed above or below-place this info where you feel it fits best).
+
+
+GRAINS
+ Choose (example of 1 serving): 
+
+Bread, bagels, and rolls made with 60% whole wheat, light rye, or white flour 
+Corn or rice-based cereals (Corn Flakes, Rice Krispies, cream of rice, cream of wheat, non-bran cereals 
+White pasta
+White pita 
+Crackers (cream, graham, matzo, water, soda)  
+White melba toast 
+White rice, wild rice 
+White rice cakes 
+Tortilla chips 
+Barley, buckwheat (kasha), bulgur, cornmeal, couscous, white flour. 
+
+Avoid: 
+
+Bread, bagels, and rolls made with whole grain, 100% whole wheat, or dark rye 
+Other cereals (bran, whole grain, granola, shredded wheat, those with dried fruit and nuts) 
+Whole wheat pasta 
+Brown rice 
+Quinoa.
+
+
+DAIRY
+ Although non-chocolate dairy has less potassium than their chocolate versions, dairy is considered a high potassium food choice. Please limit to ½-1 cup (125-250 ml) per day or as per the recommendation of your Dietitian or Healthcare Team.
+Choose: 
+
+Fresh milk 
+Pudding 
+Ice cream 
+Yogurt 
+
+Avoid: 
+
+Chocolate milk  
+Ice cream and yogurt containing chocolate and/or nuts.
+
+
+ADDITIONAL ITEMS
+ Choose: 
+
+Coffee or tea 
+Butter, margarine, oil, or mayonnaise 
+White sugar, sugar substitutes, honey, jam, pancake syrup 
+Non-cola beverages 
+Herbs and spices, pepper, herb mixes 
+Unprocessed meat, fish, poultry, and cheese 
+Popcorn, pretzels, corn chips (low sodium options) 
+Nut butter, but limited to 1 tbsp per day. 
+
+Avoid: 
+
+Specialty coffees (cappuccino, Turkish coffee, espresso) 
+Canned coconut milk 
+Chocolate 
+Potato chips 
+Nuts and seeds 
+Colas 
+Brown sugar 
+Maple syrup 
+Salt-free cheese or processed meats with potassium added 
+Salt substitutes containing potassium chlorides (Nu Salt®, No Salt® and Half Salt®)
+
+Avoid foods that list potassium or the chemical symbols (K, KCl or K+) as an ingredient on the label.
+

preventing-heart-failure.txt

@@ -0,0 +1,8 @@
+PREVENTING HEART FAILURE
+ A healthy lifestyle and behaviours help reduce the risks of heart failure and related heart conditions. Making healthy choices and taking action on these risk factors can help prevent or reduce the chance of developing heart failure. 
+Quit or do not start smoking. Smoking is a significant contributor to coronary artery disease, which can lead to heart failure. Avoid inhaling secondhand smoke as well.
+Maintain a healthy weight. Physical activity in addition to a healthy diet can help you achieve this goal.
+Consume heart-healthy foods. Foods that are low in saturated fat, trans fat, sugar, and sodium are beneficial to your health. Incorporate fruits and vegetables, low-fat dairy, lean protein like skinless chicken, and “healthy” fats like those found in olive oil, salmon, and avocadoes into your diet. 
+Treat any related heart conditions promptly and properly. This includes managing high blood pressure, controlling diabetes, and maintaining healthy cholesterol levels.
+Take heart protective medications as prescribed by your physician.
+

radiation-therapy.txt

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+RADIATION THERAPY
+ Radiation therapy is a key component in cancer care to help reduce the risk of recurrence and death. It is used to treat several cancers, including breast, lung, esophagus, and Hodgkin’s lymphoma. 
+Most radiation therapy is administered by a local external beam of high-energy particles (such as protons, electrons, and photons) designed to destroy cancer cells. Sometimes radiation therapy is given by brachytherapy. Brachytherapy is a sealed source of radiation inserted in the body next to the target cells. Ultimately, radiation destroys the DNA in cancer cells and prevents them from growing and dividing normally, causing them to die.
+
+RADIATION-THERAPY INDUCED CARDIOTOXICITY
+ Radiation can affect the arteries and veins that supply the heart muscle, causing the structures of the heart to become inflamed, thickened, or scarred (fibrosis). Radiotherapy-induced cardiotoxicity (RICT) is recognized as a contributor to abnormal heart function years after radiation therapy is completed. 
+Effects of radiation on the heart include:
+Pericarditis (inflammation of the sac around the heart)
+Pericardial effusion (fluid collection in the sac around the heart)
+Myocarditis (inflammation of the heart muscle)
+Cardiomyopathy (enlarged heart/decreased pumping function/stiffness of the heart walls)
+Damage of the valves of the heart
+Premature narrowing/injury of the heart blood vessels (coronary artery disease)
+Injury to electrical system of the heart leading to arrhythmias (abnormal heart rhythms)
+Autonomic dysfunction (nerve injury, changes in heart rate and blood pressure with exercise)
+RICT generally occurs many years after radiation therapy is completed. Those at greatest risk of RICT include:
+People who had heart disease or risk factors for heart/carotid artery disease (smoking, diabetes, high blood pressure, high cholesterol, obesity) before their cancer diagnosis 
+Those receiving concomitant chemotherapy (chemotherapy given to increase the sensitivity of tumour cells to radiation therapy)
+Those receiving anthracycline chemotherapy or trastuzumab
+Patients receiving left sided chest radiation
+Those receiving a radiation heart dose greater than 35 Gy
+Those who are/were a younger age when receiving radiation.
+
+REDUCING THE RISK OF RICT
+ Recent improvements in radiotherapy reduce cardiac radiation exposure:  
+Increased use of technology to plan and target radiation therapy allows more precise doses of radiation while limiting radiation exposure to the neck, chest, and heart. 
+Daily dosing of radiation therapy means smaller doses of radiation are given more frequently, decreasing the risk of RICT associated with higher daily doses. 
+Use of chemotherapy to decrease the amount of radiation required.
+Your overall health also helps reduce risk of heart disease. Healthy behaviours such as not smoking, maintaining a healthy weight, preventing/controlling diabetes, engaging in regular exercise, and maintaining healthy blood pressure and cholesterol levels all contribute to reducing risk. 
+Tell your health care team if you develop symptoms of chest pain, shortness of breath, increasing difficulty with physical activity, and swelling in your feet/legs. These may be signs of heart injury, which can occur many years after radiation therapy. If you develop these symptoms and have had radiation therapy to the chest/neck in the past, you may require tests to determine if you have heart disease.
+

related-conditions.txt

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+HEART FUNCTION AND RELATED CONDITIONS
+ Heart failure rarely occurs on its own. Various conditions can make the heart work harder than it should, exacerbating your heart failure symptoms. Heart failure can also lead to additional complications, such as kidney or liver disease or heart valve difficulties.
+As part of confirming your diagnosis, your doctor will likely order blood tests and other testing to examine what’s wrong with your heart and to rule out any other diseases.
+
+CORONARY ARTERY DISEASE
+ Coronary artery disease is the most common cause of heart failure in Canada. It occurs when cholesterol deposits in the walls of the coronary arteries, causing them to become narrowed or blocked. This deposit of cholesterol plaques is called atherosclerosis. Over time, coronary arteries may become too narrow and impede blood flow to the heart muscle. This may result in chest pain (called angina), cause a heart attack, and weakened heart muscle. A heart attack, or ‘myocardial infarction’ occurs when the cholesterol plaques spontaneously rupture, causing a blood clot to form within the artery. This results in a sudden lack of blood flow and oxygen to the heart muscle. It is not entirely clear what causes certain cholesterol plaques to rupture. Coronary disease is typically diagnosed through different types of stress tests. The stress may either be exercise on a treadmill or bicycle, or a ‘pharmacologic stress’ brought on by medication. Risk factors for cholesterol plaques include: high blood pressure, high cholesterol, diabetes, smoking, older age, inactivity, obesity, family history of heart disease.
+
+ATRIAL FIBRILLATION
+ Atrial fibrillation is a problem with the electrical system of the heart.In atrial fibrillation, there is disorganized, chaotic electric activity in the atria instead of a single electrical signal being sent from the SA node to the AV node with each heartbeat. This causes the atria to beat irregularly and quickly, or to “fibrillate.” This sends several signals to the AV node, which in turn can cause the ventricles to beat quickly and irregularly. 
+
+How Common Is Atrial Fibrillation? 
+Atrial fibrillation is the most common cardiac arrhythmia, affecting about 350,000 Canadians. Atrial fibrillation becomes more common as we age. Approximately 10% of Canadians over the age of 80 have atrial fibrillation.Heart failure can also result from atrial fibrillation. Heart failure occurs when your heart is unable to circulate enough blood to meet your body’s needs. Atrial Fibrillation’s irregular, fast heartbeat causes ineffective blood pumping, which, if uncontrolled, can weaken the heart. 
+
+What Causes Atrial Fibrillation?
+Most common risk factors are older age and high blood pressure for many years. Being overweight, sleep apnea and abnormalities of the thyroid function are also risk factors, as well as genetic factors which are still being studied. 
+
+What Is the Risk with Atrial Fibrillation? 
+Atrial fibrillation causes two main problems: palpitations, fatigue or lightheadedness caused by a very fast heart rate and stroke. 
+Fibrillation of the atria can lead to sluggish blood flow, pooling of blood or formation of a blood clot in the atria. If this blood clot is pumped to the brain, it causes a stroke. It is estimated that about 20% of strokes are caused by atrial fibrillation. Unfortunately, the strokes associated with atrial fibrillation tend to be large strokes and often leave patients with significant disability. 
+
+How Is Atrial Fibrillation Diagnosed?
+Atrial fibrillation is typically diagnosed with an ECG. It may also be detected with a heart monitor that is worn for an extended period of time. These tests may be ordered after an individual has a stroke to determine if atrial fibrillation has caused the stroke.
+
+After atrial fibrillation is diagnosed, other tests are usually considered. An ECHO is usually ordered to make sure that there is no underlying structural problem with the heart (like a weak heart muscle or valve problem). A blood test to check the thyroid function is also usually ordered. Other tests, like a sleep study, may be considered to see if sleep apnea is contributing to atrial fibrillation. 
+
+Are There Different Types of Atrial Fibrillation? 
+Paroxysmal atrial fibrillation is when a person is in atrial fibrillation for a period of time and naturally returns to normal heart rhythm (called sinus rhythm).Permanent atrial fibrillation is when someone is in atrial fibrillation all of the time. 
+
+How Is Atrial Fibrillation Treated? 
+Atrial fibrillation can be treated with medications and procedures to reduce its symptoms, control the heart rate, and prevent a stroke. 
+Treatments include: 
+Electrical Cardioversion: Shocking the heart to put it back into the normal rhythm. This is normally done as a day procedure. The patient is put to sleep briefly, and an electrical shock is delivered to the heart. 
+Medications to control the heart rate such as beta-blockers, calcium channel blocks, and digoxin. These medications slow the heart rate, but do not put the heart back into the normal rhythm. 
+Medications to maintain sinus rhythm: Anti-arrhythmics may be used to try to return the heart to its normal rhythm (sinus rhythm). 
+Ablation: An invasive procedure involving the insertion of catheters (thin flexible tubes) in the groin, which are then passed to the heart. Small areas of the heart that are thought to be responsible for atrial fibrillation are then destroyed with these tubes. 
+Blood thinners: Blood thinners are used to reduce the risk of stroke in patients with atrial fibrillation. 
+
+What Blood Thinners are Available? 
+An individual’s risk of stroke will help determine if a blood thinner is required and which one is recommended. Most people require a blood thinner. Aspirin is a mild blood thinner that lowers the risk of stroke in atrial fibrillation by about 20%. There are more powerful blood thinners that reduce the risk of stroke even further, up to 60-70%. Warfarin, or Coumadin, is an older medication that is effective at preventing strokes. However, it is not an easy medication to take, as there is not a single correct dose for everyone, and an individual’s dose will usually change over time. Regular blood tests (called an INR) are required to make sure the blood is thin enough, but not too thin. Warfarin also has many interactions with other medications and some foods. Newer medications called direct oral anticoagulants have been shown to be as effective as warfarin in reducing the risk of stroke and do not require regular blood tests to monitor. Four are currently available in Canada: 
+Dabigatran (Pradaxa®) 
+Rivaroxaban (Xarelto®) 
+Apixaban (Eliquis®) 
+Edoxaban (Lixiana®) 
+These medications are all cleared by the kidneys, so they can’t be used in people with very reduced kidney function. They are also not safe in patients with mechanical heart valves. 
+
+What Are the Downsides of Being on A Blood Thinner? 
+The main downside of being on a blood thinner is the risk of bleeding. If you are on a blood thinner and hit yourself, you will bruise more easily. If you cut yourself, it will take longer to stop bleeding. This type of minor bleeding is not a big concern. The main concern is major internal bleeding ― usually in the gastrointestinal tract (stomach or colon). It will be obvious if you see red blood in your bowel movement that you are bleeding internally. However, if the bleeding is coming from the stomach, it may come out in the bowel movement as a dark black tar. If you notice anything like this, you should immediately seek medical attention.The other main site of internal bleeding is inside the brain. This is very rare but can be devastating. It may occur after trauma (like a fall) or sometimes spontaneously. Slurred speech or drowsiness may be a sign of this complication and requires immediate medical attention.There are reversal agents (antidotes) being developed for all the blood thinners mentioned above.Your healthcare provider will talk to you about which blood thinner option is best for you.
+
+ARRHYTHMOGENIC RIGHT VENTRICULAR CARDIOMYOPATHY (ARVC)
+ Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a condition where part of the heart that is usually made up of muscle fibres is replaced by fat or scar tissue. It is an inherited condition that it can run in families.It usually affects the right ventricle but may also affect the left ventricle as well. 
+
+What Are the Symptoms Of ARVC? 
+People affected by ARVC may develop symptoms of heart failure because the ventricle becomes weak. This results in fatigue, shortness of breath, and swelling in the legs and abdomen. Having ARVC also predisposes an individual to arrhythmias. These ventricular arrhythmias may cause someone to experience palpitations, feel dizzy, pass out, or even to die suddenly. 
+
+How Is ARVC Diagnosed? 
+ARVC is diagnosed based on family history and investigations, like an ECG and ECHO. A cardiac MRI is also a good test to look at the right ventricle and see if muscle has been replaced by fat or scar tissue. Because ARVC is usually an inherited condition, genetic testing via a blood test can sometimes be used to screen family members of affected individuals. 
+
+How Is ARVC Treated? 
+Unfortunately, ARVC cannot be cured. Treatment aims to control the symptoms of heart failure and treat potentially life-threatening arrhythmias with medications or ICD. If the symptoms of ARVC cannot be controlled with medications and device therapies, patients may be considered for a heart transplant. People diagnosed with ARVC should not participate in competitive sports.
+
+HYPERTROPHIC CARDIOMYOPATHY
+ Hypertrophic cardiomyopathy (HCM) is a condition where the heart muscle becomes abnormally thickened because of a genetic mutation. It can run in families. Heart muscles can become thickened for other reasons, such as having high blood pressure for many years, but this is not considered HCM. 
+
+What are the Symptoms of HCM? 
+The heart doesn’t relax well if the heart muscle is thickened, so people with HCM can develop problems related to obstruction of blood flow through the heart, arrhythmias, or even heart failure. They may also experience dizziness, chest pain, shortness of breath, palpitations (racing heart) or fainting. When the thickened heart muscle blocks blood flow out of the heart, it is called hypertrophic obstructive cardiomyopathy (HOCM). However, many patients with HCM never develop any symptoms or complications.HCM is also the most common reason for sudden death in a young person. 
+After being diagnosed, people with HCM should not participate in competitive sports. 
+If a family member is diagnosed with HCM, other individuals in the family should be screened. Tests to screen for HCM include an ECHO or a blood test to look for a genetic mutation. 
+
+How is HCM Treated? 
+Depending on the severity of the disease, therapies may include medications, invasive procedures (like septal alcohol ablation or surgical myectomy), and devices (like an ICD). Sometimes the disease is severe enough that people may be considered for a heart transplant.
+
+SARCOIDOSIS
+ Sarcoidosis is an inflammatory condition that can affect many different organs. It is characterized by collections of inflammatory cells, called granulomas. It is not entirely clear what causes these granulomas to form, but they may be related to the body’s own immune system response to an infection. There is also likely some genetic component, which is why sarcoidosis sometimes runs in families. 
+Sarcoidosis affects the heart in two main ways as the granulomas can deposit in the heart muscle: problems with the conduction system of the heart, leading to either a slow or fast heart rhythm problem and weakened heart muscle, resulting in heart failure. 
+
+How is Sarcoidosis Diagnosed? 
+It is difficult to diagnose cardiac sarcoidosis. The diagnosis may be considered in younger people who present with slow heart rhythms. The diagnosis may also be considered if sarcoidosis is found to affect other organs, like the lungs. 
+The two main tests to diagnose cardiac sarcoidosis are a PET scan and a cardiac MRI. Other tests like an ECG, ECHO, holter monitor, coronary angiogram, or heart biopsy. 
+
+How is Sarcoidosis Treated? 
+Because sarcoidosis is thought to involve the body’s immune system, the treatment is immunosuppressive medications. Corticosteroids (like prednisone) are usually taken, followed by other medications. Other device therapies, like a pacemaker or ICD, may be considered.
+
+SLEEP APNEA
+ Sleep apnea is a condition where people stop breathing during sleep. 
+
+There are two main forms of sleep apnea: 
+Obstructive sleep apnea: The airway collapses during sleep and prevents air from getting to the lungs 
+Central sleep apnea: The brain does not send the right signal to the muscles that control breathing 
+Sometimes people have a combination of both types of sleep apnea. 
+
+Common symptoms of sleep apnea are: 
+Loud snoring 
+Difficulty falling and staying asleep 
+Poor quality sleep ― waking up and feeling like you have not had a good rest 
+Excessive daytime tiredness, feeling the need to nap in the afternoons 
+Headaches in the morning 
+Sleep apnea is very common in people with heart failure. If untreated, it can lead to worsening of the symptoms of heart failure. 
+
+How is Sleep Apnea Diagnosed? 
+Sleep apnea is diagnosed with a test called a sleep study. You will sleep over in a hospital or clinic and be monitored closely during sleep to determine how deeply you are sleeping, if you stop breathing, and how often you stop breathing. 
+
+Depending on the type and severity of sleep apnea, different treatments are available such as weight loss or lifestyle changes for mild sleep apnea or a continuous positive airway pressure (CPAP) machine for more severe cases. Your health care provider will talk to you about which is right for you.
+
+CARDIAC AMYLOIDOSIS
+ Cardiac amyloidosis is a condition where there is a deposit of abnormal proteins, or amyloid, in the heart tissue. Over time, this causes the heart to become thicker, stiffer, and less effective at pumping blood out to the rest of the body, leading to heart failure. Cardiac amyloidosis can also affect the electrical pathways in the heart, which can cause abnormal heart rhythms. 
+
+Symptoms of cardiac amyloidosis include: 
+Shortness of breath with activity or when lying flat in bed 
+Low blood pressure 
+Fatigue 
+Dizziness/Light-headedness 
+Feelings of the heart racing or skipping beats 
+Swelling to feet/legs/abdomen 
+A number of tests may be performed to diagnosis cardiac amyloidosis such as ECG, ECHO, cardiac CT scan, coronary angiogram, MRI, PET scan or cardiac biopsy. 
+
+In most cases, cardiac amyloidosis is caused by one of two abnormal proteins: light-chain or transthyretin. 
+
+Light chain amyloidosis 
+Plasma cells are located in the bone marrow and produce antibodies for the immune system. Antibodies are made up of heavy and light chains. When the plasma cell becomes malignant it produces too many light chains for that antibody. 
+This can cause a few different scenarios: 
+Monoclonal gammopathy of undetermined significance (MGUS) when abnormal plasma cells are in a small part of bone marrow and removed through the urine. 
+Myeloma when abnormal plasma cells take up a bigger area of the bone marrow and can cause high calcium levels (hypercalcemia), low hemoglobin (anemia), kidney dysfunction, and bone damage. 
+Light chain (AL) amyloidosis: Abnormal plasma cells produce light chains that fold abnormally and bind together forming amyloid particles. These amyloid particles are found in the blood and can be deposited into the heart or other organs. 
+AL amyloidosis is the most commonly diagnosed form of systemic amyloidosis, generally affecting people between the ages of 40-85 years. 
+
+Transthyretin amyloidosis 
+Transthyretin is a protein produced by the liver. Some transthyretins can fold abnormally and become amyloid deposits. There are two types of transthyretin (ATTR) amyloidosis: wild-type ATTR and mutant ATTR. 
+Wild-type can create amyloid deposits over several years and is more common in people over the age of 70 years. Amyloid deposits form primarily in the heart, veins and arteries, and soft tissues. 
+In mutant type ATTR, people are born with an abnormal transthyretin gene leading to more rapid amyloid deposition. The heart and nerves are the most common sites for amyloid deposits in mutant ATTR.
+

relationships.txt

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+RELATIONSHIPS
+ Although the emotional impact of living with a chronic disease differs from one person to another, it is often quite substantial. Those who are not living with heart failure may not fully understand the challenges of living with the condition. Supportive relationships can be critical to managing health. The support we receive from those who are close to us can be a powerful force for well-being. Often, to form or strengthen supportive relationships, we must learn how to describe our needs and ask for help.
+
+ASKING FOR HELP
+ It can be very difficult to ask for help or to accept help when it is offered. 
+
+We may be more comfortable offering help than receiving it, or we may worry that we are asking too much and becoming a burden on others. We may also feel hesitant because of disappointing responses we have received in the past when we needed help. 
+
+Try these simple strategies to make it easier for people to support you: 
+Have a mental list of practical things that others can do that would be useful to you. The more specific the better. 
+When someone asks if there is anything they can do, be ready with a specific request like: “I need someone to stay with my elderly father between 1-3 pm on Thursday afternoon so that I can go to an appointment. Is that possible for you?” 
+Always be clear and detailed. Clarity will enable the person offering to be truly helpful while making you feel supported. 
+With practice, learning how to ask for and accept help gets easier, and can even become empowering.
+
+GIVING HELP AND SUPPORT
+ If you are a caregiver or someone who provides support, remember that emotional support is just as important as practical help. Listening well and doing your best to understand someone’s needs can be even more helpful than having the right answers (especially for problems that don’t have ready answers!). If you listen well, your loved one is better able to communicate what they need, even if it is just a hug.
+

sex.txt

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+SEX AND INTIMACY
+ Sexual relations and intimacy are important to your well-being and relationships. You are not alone in thinking about sex and heart failure. In fact, about 2 out of every 3 people living with heart failure experience some issue with sex and intimacy. Some of the issues you may encounter are likely as a result of reduced desire and difficulty in engaging in different sexual activities. Sexual activity is not dangerous to your heart. But if you are living with heart failure, sexual activity ― like all your activities ― may need a bit of planning and careful consideration. If you can walk at a reasonable speed on level ground or climb a set of 20 stairs, then sexual activity is unlikely to affect your heart.  Do not have sex if you are unwell, have chest pain or are very short of breath.
+
+STRATEGIES FOR SAFE AND POSITIVE SEXUAL RELATIONS
+ As you feel better and want to enjoy sex and intimacy in your life, here are strategies you can use to address concerns and have a positive sexual experience. 
+Have an open conversation with your partner about your concerns, needs and expectations. Talk together about how to approach sex. 
+Start with building intimacy and recognize it may take time to return to your previous sexual activities. 
+Keep an open mind, show affection, and build connections for more intimate activities. 
+Use foreplay to help your heart get used to the increased activity level of intercourse. 
+Choose less strenuous positions, such as lying on the bottom or lying side-by-side. 
+Avoid positions that require you to support your weight with your arms. 
+Talk to your health care providers about sex as part of your overall health ― and don’t hesitate to ask for advice on managing any concerns. 
+If you experience chest pain during sexual activity, stop. Rest and recover. If the chest pain persists more than 15 minutes, call 9-1-1.
+
+COMMON SEXUAL PROBLEMS RELATED TO HEART CONDITIONS
+ Your heart condition and your medications may affect sexual desire and relationships in a number of ways. 
+Loss of interest or desire for sex. 
+Problems achieving or maintaining an erection. 
+Difficulty achieving orgasm. 
+Pain or discomfort during intercourse. 
+Medications such as beta blockers may cause sexual dysfunction. 
+Remember that anxiety and stress about your condition and your health may also affect your physical health, relationships and hormones which can reduce sexual desire and function. Talk about your concerns and work with your partner on strategies for a positive sexual experience.
+
+TALK TO YOUR HEALTH CARE PROVIDERS
+ It can be difficult and sometimes uncomfortable to bring up your sexual health with your care team. Your health care providers may not ask directly about sex during your appointments. 
+
+Here are some ways to start the discussion: 
+“I read somewhere that my heart failure can get in the way of having sex.”  
+“I want to be intimate with my partner but I’m scared about what will happen to my heart.” 
+“My partner is worried about us having sex and that it’s not safe for my heart.” 
+“Is it safe to use Viagra if I’m having trouble with getting or keeping an erection?”
+

sleep.txt

@@ -0,0 +1,39 @@
+SLEEP
+ Heart Failure and Sleep
+Sleep issues and heart failure may be related. For example, if you have heart failure, you’re more likely to experience insomnia. Similarly, sleep issues such as obstructive sleep apnea (OSA) and insomnia can exacerbate heart failure symptoms. 
+Whether your heart is healthy or not, getting a good night’s sleep is essential. Rest is beneficial to your heart function, energy levels, cognitive abilities, and overall health. You may be able to relieve some of the strain on your heart if you can address any sleep problems you are experiencing.
+
+SLEEP ISSUES CAUSED BY HEART FAILURE
+ Heart failure symptoms can disrupt your sleep, for example: 
+Chest pain or discomfort which make it difficult to fall or stay asleep
+Shortness of breath or difficulty breathing while lying down
+Having to get up frequently in the middle of the night to pee. 
+If you are upright (standing or sitting) most of the day, additional fluid may collect in your legs and feet. When you lay down to sleep, this fluid can then travel up into your chest, causing your lungs and airways to constrict and making it difficult to breathe. To get rid of excess fluid, your doctor may prescribe diuretics. However, these medications continue to operate while you sleep, which may cause you to wake up throughout the night to pee.
+
+HOW CAN I IMPROVE MY SLEEP?
+ There is a strong association between difficulty falling or staying asleep and the risk of developing heart failure. The linkage is not fully understood, but one reason could be that sleeplessness activates the body’s stress response, which over time can weaken the heart.
+You can help ensure a good night’s sleep by doing the following: 
+Go to sleep and wake up at the same time daily. 
+Help set your “body clock” by following a consistent schedule. Our bodies naturally follow a circadian rhythm, which regulates many biological functions within our bodies, including the release of important hormones into our bloodstream.
+Establish a bedtime routine. 
+Following a routine, such as brushing your teeth, taking a warm bath, meditating, or reading a book, allows you to wind down in the evening and get a restful night’s sleep. To reduce stress before going to bed, practice mindfulness or do some light stretches.
+Meditate or practice mindfulness. 
+Meditating or practicing mindfulness may help you relax and find a sense of calm. You can do this while sitting or lying down, even do a body scan to relax and ready yourself for sleep. 
+Limit sleep disrupting beverages.
+Avoid caffeine in the afternoon and evening. Abstain from alcohol entirely.
+Go to bed when you feel drowsy.
+Recognize your sleepiness signals and use them as a cue to turn off the lights and go to bed, even if it doesn’t seem like the conventional time to do so.
+Exercise on a regular basis. 
+Daily exercise can help you fall asleep faster and sleep better. However, exercising too close to bedtime can make it difficult to sleep – try not to exercise for at least three hours before going to bed.
+Get natural light each and every day
+Spending time outside during the day can help you sleep better at night. A 10-minute break outside in the fresh air can make a significant difference.
+Make your sleeping environment as comfortable as possible.
+Your bedroom should be sleep-friendly. A few simple changes to make your bedroom quiet, dark, and comfortable will assist you in remaining calm and creating a positive association between your bedroom and sleep. Close the blinds or curtains. If the room is still too bright, invest in blackout curtains or an eye mask. To block out sounds, you could also use earplugs or a white noise machine.
+Make sure your bed is supportive and comfortable.
+Choose a mattress and pillow that are appropriate for you.
+Limit your daytime naps. 
+Short naps can help you regain energy and focus but limit them to 20-30 minutes and no later than mid-afternoon.
+Don’t use electronics or watch TV in your bedroom. 
+All electronic devices necessitate focus and attention, which raises your level of alertness. Research has also found a link between the light emitted by these screens and a disruption in circadian rhythm patterns. Turn off all electronics one hour before going to bed.
+Be sure to let your cardiologist know if you are having trouble sleeping.
+

sodium.txt

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+SODIUM
+ If you have heart failure, one of the most important things you can do to avoid retaining extra fluid is reduce the amount of sodium (salt) in your diet.
+The first step to reducing sodium in your diet is to remove the saltshaker from your table. You should not add any extra salt to your food.
+Most processed foods contain a lot of sodium. Learning how to read and understand food labels is an important skill.
+
+SODIUM RESTRICTION
+ Sodium causes extra fluid to build up in your body, making your heart work harder. This extra fluid can also accumulate in your legs and ankles, as well as in your lungs, making it difficult to breathe.
+What is sodium? 
+Sodium is a mineral found in salt. One teaspoon of salt equals approximately 2,300 mg of sodium. Two-thirds of the salt in the Canadian diet is hidden in food. 
+What is a low sodium diet? 
+It is best to limit the amount of sodium you eat to less than 2,000 mg day. This will help prevent the accumulation of extra fluid in your body.
+
+READING NUTRITION LABELS
+ Of all the salt in our diet, approximately 10% comes from sodium found naturally in foods, 10% comes from salt that is added by us at the table, and 80% comes from food processing. 
+It is important to learn how to read the Nutrition Facts panel on food packaging, as these labels can help us determine the sodium content of foods. Food manufacturers may change ingredients over time, so you should make it a habit to regularly revisit nutritional labels. 
+What should I pay attention to in food labels? 
+Serving Size: Compare the suggested serving size on the package to the amount that you actually eat – this can sometimes be very different. The label lists the amount of sodium in one serving, not the total amount of sodium in the entire package. 
+Sodium: Look at the amount of sodium in mg per serving. Try to choose products with less than 200mg per serving or 10% or less of the Daily Value per serving. 
+Ingredients: Ingredients are listed in decreasing order by amount. If an ingredient appears earlier in the list, that means there is more of it in the food. If salt or sodium appears in the ingredients list, make sure that it is near the end. Sometimes the salt can be ‘hidden’ – look out for these ingredients: sodium, monosodium glutamate (MSG), brine, sodium nitrite, sodium propionate, baking soda, and baking powder.
+
+HOW CAN I REDUCE SODIUM IN MY DIET?
+ Avoid using salt in your cooking and remove the saltshaker from your table.
+Buy fresh or frozen fruits and vegetables and prepare your meals at home.
+Avoid salted snack foods, such as chips, crackers, and nuts.
+Choose foods labeled low sodium or no salt added.
+Read food labels to see how much sodium is in each serving.
+Avoid processed foods: 
+Canned or packaged soups
+Instant foods like oatmeal or puddings
+Processed cheese slices or spreads
+Processed, cured, or smoked meats like sausages, wieners, ham, bacon, or smoked fish
+Canned vegetables, meats, and fish
+Canned tomato and vegetable juices
+Frozen dinners and entrees
+When grocery shopping, try to do most of your shopping in the outer aisles where most of the fresh products are found. Avoid the inner aisles, where the more processed foods are shelved.
+Plan your meals ahead of time.
+Grill an extra chicken breast to use for a sandwich the next day.
+Season foods with lemon juice, vinegar, fresh garlic, herbs, and spices. 
+Don’t use spices that contain salt or sodium, like garlic salt or onion salt
+Avoid using salt substitutes like No Salt® and Half Salt®.
+Seasoning herb blends which are best to use include Mrs. Dash, President’s Choice no salt added seasoning blends, David’s Condiments™ salt free products, McCormick’s® salt-free products, and Club House® La Grill salt free seasonings.
+Make salad dressing with fresh garlic, olive oil, and flavoured vinegar.
+Search online for low sodium recipes.
+Try a new low sodium cookbook.
+Helpful resources include Canada’s Food Guide and unlockfood.ca.
+

symptom-management.txt

@@ -0,0 +1,21 @@
+SYMPTOM MANAGEMENT
+ Heart failure is a progressive condition. Its effects are highly variable, and the condition is often not diagnosed until symptoms occur and people seek medical attention. 
+As the condition progresses, there may be changes to the structure and function of your heart. These changes may be easy to notice or happen in small steps over time. You may not recognize the presence or severity of symptoms as they develop.
+That’s why it’s critical to be aware of the symptoms of heart failure and its effects on your day-to-day life. 
+Your family or friends may notice changes in your health before you do. It’s important to make sure they are also aware of the symptoms of heart failure – especially if they are involved in your care.
+
+WHAT SYMPTOMS SHOULD I TRACK?
+ Your healthcare team will advise you on which heart failure symptoms to monitor. The most common things to monitor:
+Any shortness of breath. 
+Your energy level and ability to perform your regular activities.
+Your pulse rate and if you experience heart palpitations and/or racing or throbbing heartbeats.
+Your daily weight and whether you gain more than two pounds in a 24-hour period or more than five pounds in a week. Make sure you understand how much weight gain your doctor considers to be a problem for you.
+Any swelling (or worsening swelling) in your ankles, lower legs, feet, or stomach.
+Feeling confused, dizzy, or lightheaded.
+Having problems with your memory or with thinking clearly.
+Your care team may also ask you to keep track of other factors, such as your appetite, diuretic use, or sleeping ability. If you’ve been prescribed oxygen, your doctor may ask you to keep track of how much you’re using.
+
+HEART FAILURE ZONES
+ The Heart Failure Zones created by the BC Heart Failure Network and available from Heart & Stroke will help guide you in your self-management. 
+Determining in which “zone” you are helps you to understand if your heart failure is under control and when to speak to your health care provider or seek emergency care.
+

the-heart-and-how-it-works.txt

@@ -0,0 +1,29 @@
+THE HEART AND BLOOD FLOW
+ The heart circulates blood throughout the body. 
+It is divided into the right side and left side and composed of four chambers: two right and left top chambers (atria) and two right and left bottom chambers (ventricles). Valves separate the atria, ventricles, and arteries.
+
+ ATRIA AND VENTRICLES
+The atria are responsible for collecting blood, while the ventricles are responsible for pumping the blood to the lungs or the body. 
+Deoxygenated blood returned to the heart from the body is collected in the right atrium. It then empties into the right ventricle, which pumps the blood to the lungs, where it receives oxygen.
+The oxygenated blood is then returned to the left atrium and emptied into the left ventricle, which pumps the oxygenated blood to the body. 
+While all the chambers in the heart are important, the main pumping chamber to circulate the blood to the body is the left ventricle.
+
+VALVES
+ There are four valves in the heart whose function is to ensure one-way blood flow.
+On the right side, the tricuspid valve separates the right atrium from the right ventricle. The pulmonary valve separates the right ventricle from the pulmonary arteries, which carry blood to the lungs.
+On the left side, the mitral valve separates the left atrium from the left ventricle. The aortic valve separates the left ventricle from the aorta, which moves oxygenated blood to the body.
+
+REGURGITATION
+ Valves may become leaky (called regurgitation), meaning they don’t close properly and allow blood to flow, or leak, backwards.
+
+STENOSIS
+ Valves may also become narrowed (called stenosis). This means they do not open fully, restricting or blocking blood flow.
+Problems with the valves may be congenital (a problem you were born with) or an acquired condition.
+
+THE ELECTRICAL SYSTEM OF THE HEART
+ The signal for the heart to beat is based on electrical activity. This electrical activity usually starts in the upper chambers of the heart (the atria) and is communicated to the bottom chambers (the ventricles), telling them to contract. In normal situations, the atria and ventricles work together. The atria contract and send blood to the ventricles, which in turn contract and send blood to the lungs and the body.
+A complex and connected web of specialized cells normally work together to pump your heart. 
+The sinoatrial (SA) node, a group of specialized cells in the right atrium normally acts as the body’s natural pacemaker. It sets your heart rate. When you exercise or are excited, it fires faster, causing a faster heart rate. When you are relaxed or are sleeping, it fires more slowly, resulting in a slower heart rate.
+The electrical signal passes through the atria (causing them to contract) to the atrioventricular (AV) node, another specialized group of cells in the middle of the heart between the atria and the ventricles. Once the electrical signal passes through the AV node, it travels through more specialized tissue (called the His-Purkinje system) and then divides into the “bundle branches,” which transmit the electrical signal to the ventricles, causing them to contract.
+When the sinus node is regulating the heart’s contraction, this is called sinus rhythm.
+

what-is-cardiotoxicity.txt

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+WHAT IS CARDIOTOXICITY?
+ What is Cardiotoxicity?
+Cancer and heart disease are well-known diseases and the world’s leading causes of mortality. However, many people do not realize the short and long-term effects of cancer therapy on the heart. Some cancer survivors are at risk of developing heart problems as a result of their cancer treatment. This is called cancer therapy-related cardiac dysfunction, or cardiotoxicity.
+Cardiotoxicity may present as high blood pressure, inflammation in the heart, heart valve problems, abnormal heart rhythms, damaged blood vessels including narrowing/hardening of the arteries around the heart, blood clots, and, ultimately, heart failure. 
+It is important that cancer survivors are aware of potential links between their successful cancer treatment and potential heart problems, with prevention and treatment strategies in place.
+

what-is-heart-failure.txt

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+WHAT IS HEART FAILURE?
+ Heart failure describes a condition where the heart is unable to meet the demands of the body. It does not mean that the heart has stopped working or is beyond repair.
+Heart failure is a common condition.
+Many treatments are available to help patients live longer and better.
+In general, heart failure can be treated, but not cured.
+
+WHAT ARE THE SYMPTOMS OF HEART FAILURE?
+ Most common symptoms of heart failure are fatigue and shortness of breath, particularly with exertion.
+Other common symptoms are swelling of the legs and ankles, difficulty lying flat because of shortness of breath, and waking up at night feeling short of breath.
+Symptoms of heart failure may come and go over time.
+
+HOW SEVERE IS HEART FAILURE?
+ The severity of heart failure and quality of life with the disease varies.
+Heart failure is often only diagnosed once symptoms occur. 
+People can live with changes to their heart structure or function for many years before symptoms occur.
+The most important measure of heart failure severity is the degree to which symptoms impact a patient’s day-to-day life.
+Heart failure care aims to minimize symptoms and keep people out of hospital.
+
+WHAT ARE THE CAUSES OF HEART FAILURE?
+ The most common cause is ischemic cardiomyopathy, where the heart muscle is weakened because of narrowing or blockages in the arteries around the heart, or because of a previous heart attack.
+Other causes of heart failure include abnormalities with the heart valves, toxins like alcohol or chemotherapy, a viral infection of the heart muscle, or genetic conditions.
+
+EJECTION FRACTION AND HEART FAILURE
+ Heart failure can occur when there is a problem with the pumping function of the heart, called reduced ejection fraction. The acronym is HFrEF (pronounced Hef-ref). You may see this in your chart or on your test results. Treatment for reduced ejection fraction involves medications and devices to help people live longer.
+When heart failure is due to a problem with the heart’s ability to relax, it is called preserved ejection fraction. Its acronym is HFpEF (pronounced Hef-Pef). You may see this in your chart or on your test results. Treating preserved ejection fraction is an active area of research and focuses on managing risk factors and symptoms.
+
+WHAT IS HEART FAILURE?
+ Heart failure describes a condition where the heart is unable to meet the needs of the body. It is a chronic condition, which means most people live with heart failure for the rest of their lives and will eventually die from it.
+Heart failure is very common. Currently, more than 750,000 Canadians are living with heart failure, with 100,000 people diagnosed with the condition every year. It is one of the leading causes of hospitalization in Canada.
+Heart failure usually affects people later in life but can occur at any age. With the aging population and enhanced detection tools, the number of people diagnosed with heart failure is expected to grow significantly.
+While a diagnosis of heart failure sounds frightening, it does not mean that your heart is going to stop in the near future or that you are going to die soon. Advances in care and treatments continue to help patients live longer and improve quality of life.
+
+WHAT ARE HEART FAILURE SYMPTOMS?
+ The main symptoms of heart failure are fatigue, shortness of breath, and swelling in the lower legs, ankles and/or abdomen. These symptoms may come and go or occur at the same time.
+Many patients with heart failure tend to retain fluid. Fluid can accumulate in the legs, causing swelling; in the abdomen, causing bloating and poor appetite; and in the lungs, causing shortness of breath. When someone with heart failure retains too much fluid, their symptoms worsen, and they may require admission to hospital for further treatment. 
+
+Other symptoms of heart failure may include: poor memory and difficulty concentrating, cold hands and feet, shortness of breath when lying flat, and having to use many pillows to be comfortable, waking up at night feeling short of breath, waking up at night to urinate, dry cough, which may be worse when lying flat, loss of appetite or feeling full quickly after eating small amounts, chest pain, feeling the heart pound or beat quickly. 
+Not every patient with heart failure will experience all these symptoms. 
+
+As well, many of these symptoms can be caused by conditions other than heart failure. If you are not sure if a symptom you are experiencing is related to heart failure, speak to your health care professional.
+
+HOW SEVERE IS HEART FAILURE?
+ Heart failure is a progressive condition. However, the course of illness is highly variable between patients, and it is often only diagnosed once symptoms develop, and patients seek medical attention. 
+
+Prior to the onset of any symptoms, individuals may have developed changes to the structure and function of their heart. 
+
+There are several factors that healthcare providers take into consideration to help assess the degree of heart failure: size of the heart, pumping function of the heart (sometimes referred to as ‘ejection fraction’), heart valve function, kidney function, blood tests measuring injury and strain on the heart. 
+However, the most important measure of heart failure severity is the degree to which patients experience symptoms. 
+
+Patients who experience only mild symptoms with minimal impact on their day-to-day function are considered to have less severe heart failure. In contrast, patients with very poor function and high symptom burden are often unable to carry out ordinary activities. 
+
+If heart failure symptoms become severe, the prognosis is less favorable, and patients may require frequent visits to the emergency department or recurrent admissions to hospital to manage the effects of severe or ‘advanced’ heart failure.
+
+HOW IS HEART FAILURE CLASSIFIED?
+ One system to assess the severity of a patient’s heart failure is the New York Heart Association (NYHA) Functional Classification that relates symptoms to everyday activities and quality of life: 
+
+Class I symptoms: No limitations due to heart failure. Patients generally feel well. 
+Class II symptoms: Mild limitation due to heart failure. Symptoms can occur with ordinary activity. 
+Class III symptoms: Moderate limitation due to heart failure. Symptoms occur with less than ordinary activity.
+Class IV symptoms: Severe limitation due to heart failure. Symptoms are worsened with any type of activity. 
+For all people with heart failure, lifestyle changes, medications, and other treatments aim to minimize symptoms and keep people well enough to manage their condition and avoid hospitalization.
+
+WHAT CAUSES HEART FAILURE?
+ Coronary Artery Disease 
+The most common cause of heart failure in Canada is coronary artery disease. This is the accumulation of cholesterol plaque within artery walls. If cholesterol plaque occurs over an extended period, it can lead to chronic narrowing in the arteries, restricting the flow of blood and oxygen to the heart muscle. 
+
+When coronary artery disease is the cause of a weakened heart muscle, the condition is called ischemic cardiomyopathy (ischemic = lack of blood flow, and cardiomyopathy = heart muscle problem). 
+
+More acutely, a heart attack can happen when a cholesterol plaque in the wall of an artery ruptures open and causes a blood clot to form, immediately blocking the arteries and starving the heart muscle of blood and oxygen. It is difficult to tell which cholesterol plaques are at risk of rupturing and causing a heart attack. 
+
+When a large area of heart muscle is damaged or affected by coronary artery disease or a heart attack, the heart may become weak. This can lead to heart failure. It is not always clear why some patients with a damaged or weakened heart will develop heart failure while others will not. 
+
+It is important to know if coronary artery disease has caused a weakened heart muscle, because if the blocked arteries can be opened (either with stents or bypass surgery), heart function may improve. 
+
+Other Causes of Heart Failure 
+
+There are many other causes of heart failure. These include: long standing high blood pressure, diabetes, heart valve problems (leaky or tight valves), abnormal heart rhythms (called arrhythmias), toxins (like excessive alcohol or certain chemotherapies), viral infections that affect the heart, congenital heart conditions, genetic (inherited) conditions.
+
+TYPES OF HEART FAILURE
+ There are many ways to classify heart failure. Heart failure is commonly described according to the left ventricular ejection fraction (or EF).
+The left ventricular ejection fraction refers to the amount of blood that is “ejected,” or pumped out, with each heartbeat. A normal ejection fraction is not 100%, as the heart does not completely empty with blood with every heartbeat. Instead, a normal ejection fraction is about 55% or more. 
+
+Two types of heart failure are described according to EF: low (or “reduced”) ejection fraction, or normal (or “preserved”) ejection fraction. 
+
+In people with reduced ejection fraction, the problem is primarily with the pumping function of the left ventricle. The left ventricle is weak and doesn’t eject a sufficient amount of blood during each heartbeat. 
+
+The acronym is HFrEF (pronounced Hef-ref). You may see this in your chart or on your test results. 
+
+The pumping function of the heart is normal in people with preserved ejection fraction, but the problem is the heart’s inability to relax properly. This reduces the volume of blood able to fill the left ventricle during the diastolic, or filling, phase of each heartbeat. 
+
+The acronym is HFpEF (pronounced Hef-Pef). You may see this in your chart or on your test results. 
+
+Both types of heart failure result in the same symptoms – fatigue, shortness of breath, and swelling. 
+
+If the ejection fraction is preserved or reduced, it determines treatment options. will differ accordingly. An echocardiogram (ECHO) is usually performed to determine whether the ejection fraction is preserved or reduced. 
+
+Therapies (medications, devices) that have been shown to make people live longer with heart failure apply mainly to people with reduced ejection fraction. The management of heart failure with preserved ejection fraction focuses mainly on controlling an individual’s risk factors (high blood pressure and diabetes) and making sure they don’t retain extra fluid. This is an area of active research and recent studies have shown great promise for some medications to improve the prognosis for patients with preserved ejection fraction.
+
+WHAT IS ADVANCED HEART FAILURE?
+ Advanced heart failure is a term that is often used by care providers to indicate that the heart failure condition has progressed and has become more severe. Patients may even be referred to an “advanced heart failure specialist” to be assessed for specialized interventions aimed at improving life expectancy and overall quality of life. 
+
+Therapies for advanced heart failure include heart transplantation, long-term ventricular assist devices, long-term intravenous diuretic therapy, some forms of dialysis and palliative medical therapy. 
+
+There is no single or universal definition of ‘advanced heart failure.’ In general, this state is associated with different markers or signs of deteriorating health and worsening prognosis. Some characteristics of advanced heart failure typically include: multiple hospital admissions for heart failure in the past year, severe limitation of daily activities due to heavy symptom burden, usually including significant fatigue and shortness of breath, difficulty controlling fluid build-up (edema) with increasing diuretic requirements, difficulty tolerating medications because of low blood pressure or worsening kidney function, increasing number of shocks from an Implantable Cardioverter Defibrillator (ICD), abnormal bloodwork indicating worsening strain on the heart (rising BNP levels or troponin levels) or worsening organ function (rising creatinine or liver function tests, low sodium levels), progressively worsening heart function or elevated pressures in the heart and lungs as indicated by an ECG, poor performance on formal exercise testing.
+

working-with-heart-failure.txt

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+WORKING WITH HEART FAILURE
+ Working contributes not only to our financial well-being but to personal and professional fulfillment. Your ability to work may be disrupted by the impacts of your heart function. 
+Whether or not you are able to return to work depends on your symptoms and the severity of your condition. It also depends on how physically and emotionally demanding your job is. If your symptoms are under control and your working conditions are manageable, full-time, or part-time work can be an important part of your life.
+Talk to your health care provider about returning to work. They will be able to talk to you more about your specific situation and advise you on the appropriate level of work for you.
+Some people find it more stressful to be away from work or to manage without a regular income. If you do return to work after a period of absence, be sure to pace yourself.
+You may need to change your working hours or engage in less strenuous activities. If you are concerned about your ability to perform your job, consult your doctor to see if a medication change would be possible or helpful, and/or with your employer to see if other work can be arranged.
+