The American Heart Association defines self-care as the decision-making process patients use to maintain physiological stability (7
). Self-care includes multiple components, such as adhering to medications, following diet and exercise recommendations, as well as actively monitoring for congestion. Self-management extends this concept to the self-adjustment of the treatment regimen. Self-management is therefore a complex process: patients have to recognize a change in themselves (such as increasing edema), evaluate the symptom, decide to take action, implement a treatment strategy (taking an extra diuretic dose), and evaluate the response to therapy (7
). Self-care and self-management behaviors are ultimately the responsibilities of the patient, even if they are frequently seen in the office or telephoned at home.
However, there are multiple challenges with self-care for the patient. Although checking daily weights is an important part of HF self-management (8
), fewer than half of patients with HF weigh themselves daily, even among those recently discharged for a HF exacerbation (9
). But even if they did so, an increase of greater than two kilograms over 24–72 hours has only a 9% sensitivity for detecting clinical deterioration (10
). Furthermore, patients may delay seeking care for HF symptoms for days or fail to bring new symptoms to the attention of their providers when they are seen (11
Multiple comorbidities often compound the challenges in self-care. Other conditions may require additional, possibly conflicting, medications, and it is common for HF patients to take nine to twelve pills per day, without a good understanding of their treatment regimen (12
). Symptom monitoring may also be more uncertain: patients with chronic obstructive pulmonary disease often cannot distinguish HF versus their lung disease as the cause of shortness of breath. Patients with diabetes may have fewer symptoms and more difficulty interpreting them (7
). Patient with HF may also have lower health literacy levels and cognitive impairment. In a study of Medicare enrollees, 27 to 44% were found to have marginal or inadequate health literacy (13
). Additional factors such as social isolation or concurrent depression also hamper self-care. Altogether, these obstacles frequently prevent HF patients from fully implementing self-management through medication taking, dietary and lifestyle adherence, symptom monitoring and decision-making.
Although self-care for HF has been strongly advocated, this approach has not been well testing in prospective randomized clinical trials. The Heart Failure Adherence and Retention Trial (HART) was a multiple-hospital randomized controlled trial testing the value of self-management counseling in 902 patients with mild to moderate HF (14
). This study found no impact of this intervention on reducing death or heart failure hospitalizations. Although there is a paucity of evidence that patients with HF benefit from self-management counseling on important clinical end points, it remains possible that if self-care were coupled with other interventions such as technology-assisted remote monitoring, benefits would emerge.