Management of fatigue

Management of fatigue and breathlessness should go hand in hand as the two are inextricably linked in heart failure. The fatigue of heart failure is multi-factorial and potentially reversible factors should be sought and treated. Side-effects related to medication including hypokalaemia from loop diuretics, over-diuresis and the tiredness associated with beta-blockade are common. Timing and intensity of diuretic use may impinge on quality of sleep, and exacerbate a common problem contributing to impaired quality of life in patients with heart failure.

Normochromic normocytic anaemia (the so-called anaemia of chronic disease) is common in advanced heart failure and appears to reflect the severity of disease. It is also difficult to treat. Silverburg et al. treated 40 octegenarians with resistant severe heart failure and anaemia (Hb, 12 g/dL) with subcutaneous erythropoietin and intravenous iron.46 They report a marked improvement in cardiac function, breathlessness, and fatigue, together with a reduction in hospitalisation. The authors suggested that anaemia was itself contributing to the progression of heart failure but more research is required to evaluate the cost effectiveness of such treatment.

Evidence is mounting that low intensity exercise programmes are safe and effective in patients with chronic stable heart failure in terms of improving symptoms of fatigue and breathlessness47'48 and prognosis.49 Patients often need reassurance as they may be very wary of inducing dyspnoea during physical exercise, believing it to precipitate further cardiac events. However rehabilitation programmes are an important and too often neglected part of optimal management. Encouraging patients to be more active can be very helpful with reduced social isolation and depression, and a management by a multidisciplinary team may be required to ensure optimum progress. Finally, both the patient and their carers may need time and assistance to adjust to their limitations and access provided to professionals with experience in simple cognitive behavioural techniques to promote problem solving and psychological self-help.

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