Living with Heart Failure

A G U I D E F O R PAT I E N T S

WakeMed Health & Hospitals

Table of Contents
What Is Heart Failure? ...................................3
What Causes Heart Failure?...........................4
Testing for HF ................................................5
Signs & Symptoms of HF ..............................6
Take Charge of Your HF ................................7
Weigh Yourself Each Day ............................7
Limit Salt/Sodium .......................................8
Reading Food Labels....................................9
Limit Fluids................................................12
Lifestyle Changes .......................................14
Medication ................................................14
Exercise/Activity.........................................17
Other Treatment Options .............................18
Managing Your HF Using the Zones...........19
Important Contacts.......................................20
My Medicines ...............................................22

Living with Heart Failure

If you have been told you have heart failure (HF), you may feel anxious or scared. HF is
serious and there is no cure, but with proper medicine and careful management, many
people lead normal lives. Learning about your condition and involving yourself in the
treatment can help you maintain a rich and productive life.
This book will help you understand heart failure and show you how to manage your
symptoms. If you have questions, please ask your nurse or doctor. The more you know, the
better equipped you will be to manage your health.
Your WakeMed Heart Failure Team

What Is Heart Failure?

Heart failure, also known as congestive heart failure (CHF) means your heart isnt
pumping enough blood to meet your bodys needs. It does not mean that your heart has
stopped or is about to stop.

Right Atrium

Left Atrium

Left
Ventricle
Right Ventricle
Normal Heart
The heart has four chambers. The upper two chambers are the atria and the lower two are
the ventricles. These four chambers work together in powerful contractions or heartbeats
to pump blood through your body. Valves (little doors in the heart) keep the blood flowing
in the right direction.
3

Heart walls
may thicken

Heart
doesnt
pump well

The Heart with HF

Over time, the heart can no longer keep up with the normal demands placed on it to
pump blood to the body. The ventricles, lower chambers of the heart, may become stiff and
not fill adequately between the beats.
The heart muscle can also dilate (stretch) to the point where it is too weak to pump blood
efficiently. The term congestive heart failure comes from blood backing up into the
lungs, liver, abdomen and legs.

What Causes HF?

HF usually develops after other conditions have damaged or weakened your heart. These
include:
Coronary Artery Disease: Coronary artery disease is the most common form of heart
disease. The arteries that supply blood to the heart become narrow from a buildup of fat
and cholesterol. The narrowed arteries cause blood to move more slowly, leaving some
areas of your heart weak and without enough oxygen-rich blood. Your heart will not
function as well as it did before you had coronary artery disease.
Heart Attack: A heart attack occurs when the plaque formed by the fatty deposits in
the artery rupture. This causes a blood clot to form and block blood flow to an area of
the heart. As the heart heals, a scar forms and the hearts pumping ability is weakened.
High Blood Pressure: Blood pressure is the force your heart uses to pump blood to all
parts of the body. If your blood pressure is too high, your heart has to work harder than
it should to pump blood throughout the body. The heart may become thicker enlarging
the heart or causing it to become too stiff or weak to effectively pump blood.
Heart Valve Problems: The valves are little doors in the heart that keep the blood
flowing in the proper direction through the heart. Leaky or damaged valves force the
heart to work harder. Over time, this extra work can weaken the heart.
4

 Congenital Heart Disease: Heart defects that are present at birth, if not corrected, can
cause the heart to work harder, leading to heart failure.
Cardiomyopathy: Heart muscle damage is called cardiomyopathy. There are many
causes of it. These causes include infections, alcohol abuse and the toxic effect of drugs
such as cocaine. In addition, diseases including lupus and thyroid problems can damage
heart muscle.
Abnormal Heart Rhythms: Heart arrhythmias such as atrial fibrillation can cause the
heart to beat too fast, creating extra work for your heart. Heartbeats that are too slow
may prevent your heart from getting blood out to the body and can also lead to HF.
Other Diseases: Chronic diseases such as diabetes, severe anemia, thyroid disorders and
lung disease (emphysema) can contribute to heart failure. Viruses can attack the heart.
Severe infections, allergic reactions, or blood clots in the lungs can contribute to HF.

Testing for HF
To diagnose your condition, your doctor will ask you about your medical history and
perform a physical examination. Many tests can be used to evaluate heart failure. Your
doctor may order several of these.
Blood Tests: Blood tests can show your doctor how well your kidney and thyroid
function. Your blood can also tell your doctor if you have diabetes and other diseases or
disorders that can affect the heart. A blood test to measure your brain natriuretic
peptide (BNP) can help in diagnosing HF.
Chest X-ray: X-ray images allow the doctor to see if there is fluid buildup in your lungs
or if the heart is enlarged.
Electrocardiogram (ECG): This test records the electrical activity of your heart. It can
reveal heart rhythm problems and damage to your heart from a heart attack.
Nuclear Stress Tests: A nuclear stress test measures blood flow to your heart at rest and
with activity.
Echocardiogram: The echo is an ultrasound image of your heart, used to check heart
structure and pumping function.
Multiple Gated Acquisition (MUGA) Scan: The MUGA scan produces a video image
of your beating heart. Your doctor will be able to see how well your heart pumps blood.

Ejection Fraction
Your ejection fraction is measured during an echo, nuclear stress test, or MUGA. It is an
important measurement of how well your heart is pumping. It is also used to determine
the type of HF you have and the treatment that will work best for you. A normal ejection
fraction is 55-60 percent, meaning that over half of the blood that fills the ventricle is
pumped out with each heart beat.

Signs & Symptoms of HF

You may experience one, some or all of the following signs and symptoms of heart failure.

Tiredness
Shortness of breath

Coughing

Pulmonary edema
(excess fluid in lungs)
Pumping action of
heart grow weaker

Pleural efflusion
(excess fluid
around the lungs)
Swelling in abdomen
(ascites)

Swelling in ankles
and legs

HOW CAN I FEEL

MY BEST?

Take Charge of Your HF

You dont have to go it alone! Your WakeMed Heart Failure Team
will help you create a plan to manage your HF. They will also be
available in the weeks, months and years ahead to help you make
changes to your plan if necessary. Your successful HF management
plan will include the following key parts:

Stick to your heart failure

management plan by
watching your:

1. Weigh yourself each day

Sodium

2. Limit salt/sodium

Fluid intake

3. Limit your fluid intake

Medication compliance

4. Lifestyle changes

Activity level

Weight

5. Medication
6. Regular visits with your doctor or nurse
7. Exercise/activity
How well you feel will directly depend on how well you follow your HF plan.
1. Weigh Yourself Each Day
This is one of the best ways to keep track of your HF. A sudden weight gain of 2 pounds
over night or 3 to 5 pounds in a week may be a sign that fluid is building up in your body
and your HF is getting worse.
Weigh yourself each morning, after you have urinated, but before breakfast.
Wear the same clothing.
Use the same scale. Scales should be placed on hard surface, not carpet.
Write your weight on a calendar.
Ask your doctor what you should do if you gain 2 pounds overnight or 3 to 5 pounds in
a week.
Maintain a healthy weight Extra pounds add more work for the heart.

DO YOU KNOW?
Call your doctor if you suddenly gain 2 pounds
overnight or 3 to 5 pounds in a week.

2. Limit Salt/Sodium
Eating food high in salt (also called sodium) can make your body retain
water. It increases your risk of heart failure, high blood pressure, kidney
disease and stroke. Always look at the amount of sodium in the product
and factor it into your total sodium for your meal. You should not have
more than 600 mg of sodium per meal and no more than 2,000 mg of
sodium per day.Thats about the same as 1 teaspoon of salt.
Your taste buds may need time to adjust to less salt. After a few weeks,
youll be amazed to discover some new flavors.
Ways to Decrease Salt/Sodium
Get rid of your salt shaker.
Cook without salt.

SALT
SUBSTITUTES
Always check with
your doctor before

Flavor your food with spices, lemon, or vinegar instead of

using salt or high-sodium bottled dressings or marinades.

you use a salt

Use low-sodium recipes.

salt substitutes

Buy sodium-free, low-sodium, no salt added or

reduced-sodium foods.

contain potassium

Look for unsalted varieties of popcorn, pretzels, potato chips

and crackers. Snack on fruit, fresh vegetables or unsalted nuts.

not recommended

Be aware that processed foods, frozen dinners, canned soups,

and entrees with gravies or sauces may be high in sodium.

have HF.

substitute. Many

and are generally

for people who

Avoid bacon, sausage, country ham, hot dogs and processed lunchmeats (bologna, ham,
turkey, chicken).
Use freshly cooked chicken breast, turkey, roast beef and fish for sandwiches and salads.
Eat fresh or frozen foods. If you have to eat canned or processed foods, rinse them
before you cook or eat them.
Be aware that fast food is high in sodium/salt.
If you eat a food that is high in sodium, balance it by eating lower sodium foods.
Look at the ingredients list for different types of sodium that may be added, such as
monosodium glutamate (MSG), sodium bicarbonate (baking soda), baking powder,
sodium nitrate, sodium benzoate, sodium hydroxide and sodium sulfate.
If you have heartburn or a headache, take medicines that do not have sodium
bicarbonate or sodium carbonate in them.
8

Reading Food Labels

Always check the serving size and servings per container. All the
Nutrition Facts information is based on the serving size. Remember:
This serving size on the food label may be different from what you
consider to be a serving size.
If you need to lose weight, check the number of calories per serving.
Label Lingo
When you read the Nutrition Facts on food and beverages, you may
notice some of the following terms. Here is what they mean:
Sodium free or salt free Fewer than 5 mg of sodium per serving
Very low sodium 35 mg or less of sodium per serving
Low sodium 140 mg or less of sodium per serving
Low sodium meal 140 mg or less of sodium per 3 oz. (100 g)
Reduced sodium At least 25 percent less sodium than the regular
version
Light in sodium 50 percent less sodium than the regular version
Unsalted or no salt added No salt added to the product during
processing

When You Eat Out

Do order:
Food that is fresh and broiled, baked or grilled
Mixed green salads or fruit as side dishes
Avoid
Food that is fried, frozen or pre-made
French fries, potato salad, pasta salad
Dips, potato or nacho chips, salsas, pizza or
soups
Dishes made with a lot of sauce
Fast food
Snacks from vending machines

Tips for Ordering

Ask the server if low salt/sodium or heart
healthy items are available.
Ask to have no salt or MSG, cheese or butter
added to your food.
Have dressing and sauces put on the side. Use
just a little of them on your food or dont use
them at all.

Choosing Foods to Lower Your Sodium Intake

Limit Sodium to 2,000 mg/day
LOW in Sodium
Below 100 mg/serving

Food Group

10

MEDIUM Sodium
100-400 mg/serving

Choose More Often

HIGH Sodium
Over 400mg/serving

Choose Less Often

Sauces &
Condiments

Tabasco sauce, vinegar,

tomato paste, fresh
herbs and spices,
Mrs. Dash.

BBQ sauce, salsa,

catsup, chili sauce,
gravies, mustard,
salad dressings,
tomato sauce, tomato
puree, mayonnaise,
Worcestershire sauce

Soy sauce,
teriyaki sauce

Grains

Flour, rice, pasta, noodles,

whole grains, matzo, hot
cereals (except instant),
unsalted popcorn,
Shredded Wheat

Breads and rolls, most

dry cereals, biscuits,
muffins, pies,
doughnuts, cookies,
pastries, pancakes,
waffles

Can or jar spaghetti

sauce, instant pasta
and rice mixes, instant
hot cereals, pretzels,
crackers, salted
popcorn, snack chips

Vegetables
& Fruits

Fruits, fresh vegetables,

most frozen vegetables

Canned vegetables,
frozen lima beans,
frozen peas,
tomatoes, vegetables
with seasoned sauces

Pickled vegetables,
olives, pickles,
sauerkraut, stewed
tomatoes

Beverages

Carbonated beverages,
coffee, tea, mineral waters

Milk, buttermilk

Tomato juice, vegetable

juice

Fish, Poultry,
Meat &
Other Dishes

Fresh meat without salt,

beef & veal, lamb,
poultry, pork, eggs,
unsalted nuts & unsalted
peanut butter, Non-salt
herbs and spices

Fresh shellfish,
peanut butter

Bacon, ham, corned

beef, lunchmeats,
sausages, salami, canned
tuna, canned salmon,
frozen breaded meats,
anchovies, sardines,
prepared entrees,
canned & packaged
soups, salted nuts

Milk Products

Ricotta or Swiss cheese,

cream cheese, unsalted
butter or margarine, yogurt

Milk, buttermilk,
salted butter, ice
cream, margarine,
custard, pudding

Blue, cottage or parmesan

cheeses, processed or
American cheeses;
cheddar cheese

Sample Meal Plans

Breakfast
medium banana
cup whole grain cereal dry, unsweetened
1 slice whole wheat toast
1 cup skim milk
1 hard-boiled egg
1 teaspoon soft tub margarine

Breakfast
1 small orange
cup oatmeal
1 slice whole wheat toast
1 cup 1% milk
1 scrambled egg
1 teaspoon soft tub margarine

Lunch
1 cup low sodium bean soup
2 slices whole grain bread
cup tuna
Lettuce & tomato
1 tablespoon light mayonnaise
Fresh apple, small

Lunch
Hamburger bun
2-3 oz. grilled chicken breast
Lettuce & tomato
Carrot sticks
1 tablespoon light mayonnaise
1 small pear

Dinner
2-3 ounce chicken breast
cup lima beans
1/3 cup brown rice
cup steamed broccoli
2 teaspoons oil
cup pineapple
5 vanilla wafers

Dinner
2-3 ounce pork roast
1 small baked potato
1 whole wheat dinner roll
cup steamed green beans
1 tablespoon light margarine
cup light ice cream

Snack
6 whole grain crackers (unsalted)
2 tablespoons natural peanut butter

Snack
1 cup light yogurt
1 cup strawberries

11

3. Limit Fluids
Ask your doctor if you need to limit the amount of fluid that you drink. Some HF patients
need to limit the amount of fluid they drink to 1 - 2 quarts (6 8 cups or 1,500 2,000
ml) each day. A fluid is any food that is liquid at room temperature.
Coffee

Other items that count as fluid:

Water

Crushed ice, cup = cup fluid

Tea

Fruited gelatin, cup = cup fluid

Flavored water

Ice cream, cup = cup fluid

Fruit juice

Sherbet, cup = cup fluid

Fruit drinks

Popsicle, 2 halves = 1/3 cup fluid

Hot chocolate

Fruit ice, cup = cup fluid

Kool Aid

Jell-O, cup = cup fluid

Liquid medicine

Frozen yogurt, cup = cup fluid

Milk

Milkshake, 1 cup = 1 cup fluid

Nectar
Soft drinks

Fluid Restriction Guide

12

Ounces

Cups

ML

2 Tbsp

30 ml

12 cup

120 ml

1 cup

240 ml

32

4 cups
(1 quart)

960 ml

48

6 cups

1,440 ml

64

8 cups
(2 quarts
or gallon)

1,920 ml

Stay on Track!
For at least a week, keep track of how much you drink.
Fill your favorite cup or glass with water. Pour that water
into a measuring cup to see how much the cup holds.
Using a 2-quart container or milk jug, pour 6 (or 8) cups
into the jug and stick a piece of masking tape at the water
line. Each time you drink something, pour the same
amount of water into the jug. When the fluid reaches the
tape line, you have had your fluids for the day.
Try to spread your fluid allowance evenly throughout the
day. Make sure you save enough fluid to take the
medicines you need late in the day.
If You Get Thirsty
Rinse your mouth with water. Spit it out dont swallow.
Add lemon juice to water or crushed ice.
Suck on lemon drops or tart hard candies. Use sugar-free candy or gum if you have
diabetes.
Suck on a lemon slice.
Put an ice cube in your mouth to melt or eat crushed ice. It takes longer to eat ice than
to drink water. You can count 12 cup of ice as just 1/4 cup of fluid.
Eat mandarin oranges, grapefruit sections or grapes.

13

4. Lifestyle Changes
Stop Smoking: Smoking makes the heart work harder by increasing blood pressure,
heart rate and the force of each heartbeat. It can make HF worse. You should also avoid
second-hand smoke.
Limit or Avoid Alcohol: Excess alcohol damages heart muscle. Alcohol makes it harder
for the heart to work.
Stress: Stress increases your blood pressure and makes your heart work harder. It may
make your HF symptoms worse. The first step in controlling stress is to recognize it and
identify what causes it for you. It is not possible to get rid of all the stress in your life,
but you can take steps to reduce the amount of stress you feel.
5. Medication
Medication plays a key role in treating HF. Research has shown that people who take
medication as prescribed:
Live longer
Have fewer HF symptoms
Increase their activity level
Stay out of the hospital
Doctors usually treat HF with a combination of medications. You might take one or more
of these medications, depending on your symptoms:
Angiotensin-converting enzyme (ACE) inhibitors: ACE inhibitors are drugs that
widen blood vessels to lower blood pressure, improve blood flow and decrease the
workload on the heart.
Antiotensin II Receptor Blockers (ARBs): These drugs have many of the same benefits
as ACE inhibitors and may be an alternative for people who cant tolerate them.
Beta Blockers: Slow your heart rate and lower blood pressure. These medicines also
reduce the risk of some abnormal heart rhythms. Beta blockers may reduce HF
symptoms and improve heart function.
Diuretics (Fluid or water pills): Help the kidneys rid the body of SALT (not fat) and
water. They make you urinate more often and help reduce swelling.
Aldosterone Inhibitors: Aldosterone is a hormone that causes your body to hold sodium
and water. These drugs act as diuretics and have other benefits in HF.
Vasoactive agents: These relax the walls of blood vessels and help lower blood pressure.
14

 Digoxin: Makes the heart pump more strongly and helps control irregular heartbeats.
Antiarrhythmic Drugs: Help prevent abnormal heart rhythms.
Non-prescription (over-the-counter) Medicines
Always tell your doctor and pharmacist about ALL of the medicines you take. Many overthe-counter drugs, vitamins and herbal supplements can affect how well your prescription
medicines work.
Medications to Avoid
In particular, talk to your doctor or pharmacist before taking any of the medicines below:
Decongestants
Decongestants make the heart work harder.
Pseudoephedrine (Sudafed)
Phenylpropanolamine
Many cold and flu products, including some antihistamines, contain decongestants. Ask
your pharmacist if the product you want to take is acceptable.
Pain Relievers
Some pain relievers can cause fluid retention and kidney problems. These interact with
many drugs.
Ibuprofen - Advil, Motrin
Naproxen - Aleve, Orudis
Check with your doctor or pharmacist before using any
drugs for increased stomach acid. These include:
Tagamet/Cimetidine
Zantac, Pepcid, Axid

NON-STERIORIADAL DRUGS
(NSAIDS Drugs that contain ibuprofen
or naproxen) Motrin, Aleve, Advil,
Daypro or Celebrex. If you take these
drugs for arthritis or other painful
conditions, talk to your doctor.

Safer Medications
Some over-the-counter medications are considered safer than others. Even though they
are, you still need to tell your doctor and pharmacist that you use these drugs. They
include:
Antihistamines
Chlor-Trimeton
Chlorpheniramine
Benadryl
15

Many cold and flu products, including some

antihistamines, contain decongestants. Ask your
pharmacist if the product you want to take is acceptable.
Pain Relievers
Acetominophen - Tylenol
Tips for Taking Medication
Take medication at the same time each day.
Do not change doses, skip doses or stop taking
medication without talking to your doctor.
Take only the medication your doctor tells you to
take.
Check with your pharmacist about foods that may
interact with your medications.
Call your doctor if you experience side effects, such
as dizziness, increased weakness, increased fatigue,
muscle cramps, dry cough, nausea, poor appetite or
vision changes.
Keep medications in a cool, dry place away from
children.
Make a chart and check off each dose as you take it
or place your medication in a pillbox with separate
containers for each day of the week.

NON-HF
MEDICATIONS
TO AVOID
Certain over-thecounter drugs,
prescriptions for nonHF health conditions,
vitamins and herbal
remedies can interfere
with your HF
medications and
worsen your HF
symptoms. Always tell
your doctor about any
medications you plan
to take. In general, you
should avoid:
Non-steroidal drugs
(NSAIDS) Ibuprofen,
Naproxen, Ketaprofen
Heartburn/headache
medications containing
sodium bicarbonate or
sodium carbonate.

Refill your prescriptions before you run out.

If you travel, carry enough medication to last on the trip and carry the
medication with you. Do not put it in your suitcase that you plan to
check.
If you forget to take a dose, take it as soon as you remember. However, if
it is almost time for your next dose, skp the missed dose and go back to
your regular schedule. Do NOT take two doses to make up for the one
you missed. If you have questions or concerns, please talk to your doctor.

16

6. Regular Appointments with Your Doctor

Make and keep your appointments with your doctor to maintain
your health.

7. Exercise/Activity
Activity including exercise, work and sex is healthy and safe for
most people with HF. People who exercise regularly:
Have more energy
Cope more easily with stress/Feel less tense
Increase resistance to fatigue
Look better

DONT OVERDO IT!

If you have any of these
symptoms, slow down. If the
symptoms dont go away, call
911 or EMS for your area.

Burn off extra calories to help lose pounds or stay at ideal weight

Irregular heart rate

Check with your doctor before beginning any exercise program.

Ask if a referral to the WakeMed Cardiac Rehab Program would
be right for you.

More shortness of breath

(You cant talk or you are
short of breath after
resting)

Exercise needs to be aerobic, meaning the body uses oxygen to

produce the energy needed for the activity. This can include
swimming, walking or bicycling. Choose an activity and set aside a
regular time each day to do it.
Be active for 30 minutes each day. You do not have to exercise 30
minutes at a time You could, for example break the exercise into
three 10-minute blocks. Begin exercise slowly and gradually increase
the time you spend doing the activity. Remember you should be able
to walk, talk and breathe, all at the same time! If you cant, you may
be working too hard and should slow down.

More tired than usual

Dizzy or lightheaded
Chest pain or tightness
Pain in your jaw, neck,
shoulders or arms
Nausea or vomiting

It is important to be active, but do not push yourself until you are

exhausted. Avoid exercising in extreme temperatures, such as very
hot or very cold weather. Do not exercise just after you eat or if you
do not feel well. Avoid activities where you have to hold your breath
or bear down such as lifting weights.

17

Other Treatment Options

If you have a heart rhythm problem, an implantable device to monitor and
correct your rhythm disorder may help you.

Implantable Devices
Pacemaker: These are primarily used to treat slow heart rates.
Implantable Cardioverter Defibrillator (ICD): ICDs are used to treat
dangerous, fast rhythms in the lower chambers of the heart, which are called
ventricular tachycardia (VT) or ventricular fibrillation (VF).
Biventricular Pacemakers: In some HF patients, the lower chambers of the
heart beat in an uncoordinated way. Biventricular pacemakers coordinate this
beat.
Biventricular ICD: The biventricular ICD contains both a pacemaker to
coordinate the beating of the lower chambers of the heart and a defibrillator
to treat very fast rhythms, VT or VF.
If you have one of these devices, it is important that you continue to follow your
Heart Failure Action Plan.

18

Managing your Heart Failure Using the Zones

19

Important Contacts
These are the key people who are involved in your care. Remember,
if you have a medical emergency, always call 911 immediately for help.
The WakeMed Heart Failure Program
WakeMed Raleigh Campus
3000 New Bern Avenue
Raleigh, NC
919-350-5732
WakeMed Cary Hospital
1900 Kildaire Farm Road
Cary, NC
919-350-0875

My Primary Care Doctor

Doctors Name
Address/City/State/Zip

Phone/Fax

My Cardiologist
Cardiologists Name
Address/City/State/Zip

Phone/Fax

20

My Emergency Contacts
Primary Contact
Name

Relationship

Home Phone

Work Phone

Cell Phone

Secondary Contact
Name

Relationship

Home Phone

Work Phone

Cell Phone

21

My Medicines
Medicine Name

22

Dose
(How much to take)

Time to
take medicine

Reason for
medicine

My Medicines
Medicine Name

Dose
(How much to take)

Time to
take medicine

Reason for
medicine

23

WakeMed North Healthplex, Brier Creek Healthplex, Garner Healthplex,

Clayton Medical Park, Raleigh Medical Park, Zebulon/Wendell Outpatient
Rehabilitation, Wake Forest Road Outpatient Rehabilitation, Kerr Family YMCA
and Alexander Family YMCA are operated by WakeMed Raleigh Campus.
WakeMed Apex Healthplex, Kraft Family YMCA and
Cary Family YMCA are operated by WakeMed Cary Hospital.

WakeMed Health & Hospitals

www.wakemed.org

Raleigh Campus Cary Hospital

North Healthplex Apex Healthplex
Brier Creek Healthplex Garner Healthplex
Raleigh Medical Park Clayton Medical Park
WakeMed Outpatient Rehabilitation Facilities
Home Health WakeMed Physician Practices
Capital City Surgery Center
WakeMed Public Relations, January 2014