Abstract when the heart is no longer able to adequately provide the body’s organs and tissues with vital oxygen and nutrients, heart failure has occurred.


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CONGESTIVE HEART FAILURE

Jassin M. Jouria, MD

Dr. Jassin M. Jouria is a medical doctor, professor of academic medicine, and medical author. He graduated from Ross University School of Medicine and has completed his clinical clerkship training in various teaching hospitals throughout New York, including King’s County Hospital Center and Brookdale Medical Center, among others. Dr. Jouria has passed all USMLE medical board exams, and has served as a test prep tutor and instructor for Kaplan. He has developed several medical courses and curricula for a variety of educational institutions. Dr. Jouria has also served on multiple levels in the academic field including faculty member and Department Chair. Dr. Jouria continues to serves as a Subject Matter Expert for several continuing education organizations covering multiple basic medical sciences. He has also developed several continuing medical education courses covering various topics in clinical medicine. Recently, Dr. Jouria has been contracted by the University of Miami/Jackson Memorial Hospital’s Department of Surgery to develop an e-module training series for trauma patient management. Dr. Jouria is currently authoring an academic textbook on Human Anatomy & Physiology.

ABSTRACT

When the heart is no longer able to adequately provide the body’s organs and tissues with vital oxygen and nutrients, heart failure has occurred. A well-functioning heart circulates blood throughout the body, and when the heart fails to operate at optimal levels, fluid consisting of mostly water leaks from capillary blood vessels. This fluid interferes with the body’s normal processes, most notably the lungs, causing shortness of breath and general weakness and fatigue. Although science has provided several treatment options that can extend the lives of many patients with congestive heart failure, patients have to follow treatment approaches carefully to avoid repeat hospital readmissions.

Continuing Nursing Education Course Planners

William A. Cook, PhD, Director, Douglas Lawrence, MA, Webmaster,

Susan DePasquale, MSN, FPMHNP-BC, Lead Nurse Planner

Policy Statement

This activity has been planned and implemented in accordance with the policies of NurseCe4Less.com and the continuing nursing education requirements of the American Nurses Credentialing Center's Commission on Accreditation for registered nurses. It is the policy of NurseCe4Less.com to ensure objectivity, transparency, and best practice in clinical education for all continuing nursing education (CNE) activities.

Continuing Education Credit Designation

This educational activity is credited for 3.5 hours. Nurses may only claim credit commensurate with the credit awarded for completion of this course activity.

Pharmacology content is 0.5 hours (30 minutes).

Statement of Learning Need

Heart failure early intervention and early recognition prevent worsening of symptoms and improve patient survival. Nursing involvement in heart failure clinics and follow up improve patient compliance with treatment, disease progression and quality of life.

Course Purpose

To provide nurses and health associates knowledge about congestive heart failure throughout the course of patient care in different health settings.

Target Audience

Advanced Practice Registered Nurses and Registered Nurses

(Interdisciplinary Health Team Members, including Vocational Nurses and Medical Assistants may obtain a Certificate of Completion)
Course Author & Planning Team Conflict of Interest Disclosures

Jassin M. Jouria, MD, William S. Cook, PhD, Douglas Lawrence, MA,

Susan DePasquale, MSN, FPMHNP-BC – all have no disclosures

Acknowledgement of Commercial Support

There is no commercial support for this course.

Activity Review Information

Reviewed by Susan DePasquale, MSN, FPMHNP-BC.

Release Date: 1/1/2016

Please take time to complete a self-assessment of knowledge, on page 4, sample questions before reading the article.

Opportunity to complete a self-assessment of knowledge learned will be provided at the end of the course.

1. The following terms are used in the classification of CHF except

a. Acute and chronic heart failure

b. High output and low output heart failure

c. Upper and lower heart failure

d. Left sided and right sided heart failure

2. Left sided heart failure is also known as

a. Systemic failure

b. Pulmonary edema heart failure

c. Respiratory failure

d. circulation failure

3. Which of the following is also termed as systemic failure?

a. Acute heart failure

b. Chronic heart failure

c. Right sided heart failure

d. Biventricular failure

4. Following are the most common causes of CHF except

a. Hypertension

b. Heart attack

c. Ischemic heart disease

d. Appendicitis

5. Deficiency of vitamin B1 leads to which disease?

a. Paget’s disease

b. Beriberi

c. Biventricular failure

d. Scurvy

Introduction

Congestive heart failure is currently one of the most common life-threatening conditions affecting individuals. The main problem with congestive heart failure (CHF) is that the pumping mechanism of the cardiac muscle is no longer effective, causing an adverse effect on the blood tissue perfusion and thereby resulting into many systemic problems. The development of CHF may be considered as either acute or chronic. An acute condition is usually the result of traumatic injuries to the myocardium while chronic conditions may be related to the presence of other cardiac conditions.

Congestive heart failure affects approximately 5 million individuals in the United States alone, but this number can go higher, as there are approximately 550,000 new cases reported each year.1 Most of these individuals diagnosed with CHF are between 55 to 70 years old for both genders. However, it has been found that women have lower risk for the development of this condition before the menopausal stage, but the risk equals those of the male population after cessation of menses.2 In both cases, most of those who were diagnosed to have CHF are reported to die within five to eight years after the initial diagnosis was made.3

The main problem with congestive heart failure is not the entire cessation of the pumping mechanism of the heart, but rather its inability to meet the demand for oxygen and nutrients for the cells of the body.1 When there is insufficient or too little oxygen and amount of nutrients reaching to the cells of the body, the normal physiologic processes of the body cells are adversely affected, contributing to multiple organ system failure and the existence of symptoms, such as, shortness of breath, fatigue, and other systemic symptoms like edema and ascites.4

When an individual is diagnosed with congestive heart failure, his or her quality of life (QOL) severely decreases over time. This is despite the fact that most of those diagnosed with the condition report no symptoms during the earliest stages.1,3 Due to the chronic nature of the condition, the treatment is usually a lengthy process, with pharmacologic and non-pharmacologic measures employed to alleviate the condition. The treatment is totally dependent on the stage at which the individual patient is diagnosed. The lifestyle and dietary changes that need to be followed by the individual is probably one of the most challenging aspects of treatment for nurses and other members of the health care team to implement. The need to drastically shift dietary patterns, give up habits such as alcohol intake and cigarette smoking, are some of the most challenging aspects in the patient’s treatment plan. There is also the presence of psychosocial problems that should be addressed and dealt with not only at the level of the individual but also including his or her family.

Congestive heart failure is explained as a disease process that involves not only a physiologic problem but encompasses the affected individual’s life as a whole. Since the effect of the condition on those affected by it is systemic in nature, it can be said that an understanding and the treatment of CHF requires a holistic approach in order to appropriately deal with it throughout the patient’s course of care.1,3,5

This course addresses the clinical problem that is congestive heart failure, its commonly known classifications or sub-types, causes, signs and symptoms. Moreover, the different diagnostic tools and procedures employed to determine the existence of CHF are discussed in detail; and, in addition, the various treatment options, chronic management and palliative care regimens. Most importantly, this course is specially designed to include practical guidelines for nurses that care for patients with CHF and may benefit from a review of the protocol for follow up assessment and teaching strategies for patients in terms of attaining an improved outcome.

Classifications Of Congestive Heart Failure

The signs and symptoms manifested and felt by the individual who is suffering from congestive heart failure varies depending on how the condition has affected the heart’s ability to function properly and supply the demands placed upon it. A CHF classification system is outlined in this section, which helps health providers to obtain a better understanding of the patient’s level of heart failure depending upon the side of the heart affected, type of failure, and the pathophysiology. Heart failure can be classified as high-output heart failure, low-output heart failure, acute versus chronic heart failure, left-sided failure, right-sided failure and biventricular failure, which are further explained in the sections below.

High output congestive heart failure

High output congestive heart failure is usually diagnosed when an individual manifests with a condition in which the cardiac output is relatively higher than the expected norm, or larger than the usual demand of the body. This occurs due to the unusually high demand of blood by the body; and, means that the cardiac output reported in patients are usually higher than 8 liters of blood per minute, as compared to the normally accepted cardiac output range of 4 to 8 liters per minute.6,7 When a condition of high output happens it causes overload of the blood in the circulation (circulatory overload). This overload leads to the presence of backflow of blood into the pulmonary cavity (pulmonary edema). The presence of pulmonary edema is usually a result of the elevation of the diastolic pressure in the left ventricle of the heart, which is responsible for pumping out oxygen and nutrient-rich blood into the systemic circulation.

Most patients with high output congestive heart failure reveal normal systolic pressures upon assessment, but are seen with other symptoms related to heart failure. The literature suggest that because of the imbalance between the systolic and diastolic functioning of the heart, there is presence of an underlying heart problem associated with high output heart failure.7,8 Moreover, since the persistence of a larger workload given to the cardiac muscles and higher pressures within the left ventricle results in further deterioration of the heart muscle, which can lead to other physical cardiac defects such as dilatation of the ventricles, cardiac hypertrophy, valvular anomalies, persistence of symptoms such as tachycardia and palpitations and an eventual failure of systolic functioning.8

Several factors have been linked to the development of high output congestive heart failure. One of the primary reasons pointed out is the presence of impairment in the systemic vascular resistance. This is a result of defects in the shunting between the arterial and venous systemic circulations or dilation of vessels in the peripheral regions of the body. When either of the two conditions occur the systemic arterial blood pressure can suffer from a substantial drop, which also happens to be one of the primary signs seen in those with low output congestive heart failure. When this happens, activation of the sympathetic nervous system occurs, causing a compensatory reaction to increase the cardiac output and activation of the neurohormonal mediators such as vasopressin and the rennin-angiotensin-aldosterone system (RAS). This series of reactions can result in retention of sodium and water in the systemic circulation and can be the cause of overt congestive heart failure symptoms.7,9

Apart from the mechanisms mentioned above, high output congestive heart failure may also be a result of excessive administration of fluids or blood transfusion, or water retention secondary to steroid therapy. Other health conditions may also be the cause of high output failure such as anemia (in most cases, the severe form of the disease), the presence of arteriovenous (AV) shunts or fistulas, severe renal disease, liver disease, Paget’s disease of the bone, hormonal imbalances such as hyperthyroidism, sepsis and other health conditions. Furthermore, conditions such as obesity and pregnancy are also linked to the existence of high output congestive heart failure. The common denominators among these conditions are their ability to cause an increase in the blood pressure of the individual, systemic and/or peripheral vasodilatation and rise of the total circulating blood volume.8-10

Common signs and symptoms seen in patients with high output heart failure include shortness of breath, or dyspnea, upon exertion. There may also be reports of easy fatigability, activity intolerance, edema and tachypnea. As the condition progresses, patients may also be assessed for other signs and symptoms such as jugular vein distension, tachycardia, presence of pleural effusion and pulmonary rales.8,9 Since the nature of high output failure is mostly related to several underlying causes, its treatment is usually geared towards addressing these causes. If the patient is reported to have the problem due to sodium and water retention, diuretics may be given to reduce circulating blood volume and decrease cardiac workload. In other cases, drugs such as vasopressin are given to promote vasoconstriction in the peripheral vessels (epinephrine and phenylephrine may also be prescribed). Patients with respiratory symptoms are treated with mechanical ventilation or PEEP (peek end-expiratory pressure).9

From a prognostic point of view, high output congestive heart failure generally results in good long-term recovery and most of the cases are curable provided timely treated. Since the heart is normal in the high output syndrome, the treatment is more effective than other types of heart failure.9

Low output congestive heart failure

Low output congestive heart failure is usually diagnosed when the patient manifests with a relatively low cardiac output. This means that the cardiac output that is usually obtained from the patient falls below 3 liters of blood pumped in 60 seconds. In this condition, there is an inability of the heart to meet the demand of the body for blood under normal conditions.11 There are two subtypes of low output heart failure: systolic dysfunction and diastolic dysfunction.

Systolic dysfunction is a problem that is characterized by impairment of the left heart ventricular contraction. In patients who are diagnosed to have congestive and chronic cases of heart failure, one of the primary causes of low output failure is the disturbance of the signals that serve to regulate cardiac rhythm and contractions. This disturbance causes a marked decline in the inotropic capacity of the heart muscles, otherwise known as its contractility.

The loss or reduction of an effective contracting mechanism of the heart results in a compensatory reaction of raising the preload and a subsequent reduction in the stroke volume. The compensatory increase in the preload (usually measured as the pulmonary capillary wedge pressure or the end-diastolic pressure of the ventricles) is due to the activation of the Frank-Starling mechanism in an effort to maintain an adequate stroke volume despite the contractile problem. The rise of the preload in such cases is needed to prevent the further loss of stroke volume occurring due to decreased contractile power of the heart. In most instances, this results in hypertrophy of the ventricles, dilation or even a mixture of the two problems.12,13,14,15

The usual causes of systolic dysfunction are structural defects in the heart muscle itself as in cardiomyopathies and valvular heart disorders. It can also be a complication of other conditions such as coronary artery disease and severe hypertension.13,15 Whereas, diastolic dysfunction is a condition in which a reduction in the performance of one or both ventricles of the heart occurs during the diastolic phase of the cardiac cycle.

The diastole is the phase in which there is relaxation of the heart muscle and the blood coming from the systemic circulation is routed to the right atrium via the superior and inferior vena cavae. Conversely, the blood that is oxygenated in the lungs is also routed into the left atrium via the pulmonary veins in this phase. Most patients that have diastolic dysfunction will present with little or no symptoms. When the symptoms are elicited during the individual assessment there is usually a determination of the pathologic cause of the symptoms. However, it should be also noted that some degree of diastolic dysfunction could occur in an otherwise healthy elderly person.11,12,13 The problem occurs when the process of filling up the atria cannot be completed during the diastolic phase because the walls of the heart are either too rigid or thick to allow for filling. This in turn results into a form of hypertrophy that is considered to be concentric hypertrophy of heart.

Individuals that are diagnosed to have diastolic dysfunction usually present with an elevation of the diastolic pressure despite having a normal end diastolic volume. Usually the clinical findings include ventricular hypertrophy, an increase in the deposition of collagen in the interstitial spaces of the cells of the myocardium and a marked reduction in the ability of the heart muscles to distend and stretch in response to the demands placed upon it. Because of the lack of the heart’s capacity to adjust, the cardiac output is decreased, and the oxygen tissue perfusion becomes affected.13

Causes of diastolic dysfunction are often related to processes that can cause the left ventricle to stiffen. As a consequence, it produces difficulty for the blood to enter into the left atrium, leading to back flow of blood to the lungs resulting in pulmonary edema. Hypertension, especially in chronic cases, has been pointed out as one of the most common causes of left ventricular stiffness. There is also a link to aortic stenosis, diabetes mellitus, and cardiomyopathies. In some patients, a history of constrictive pericarditis and conditions such as Amyloidosis and Sarcoidosis has also been pointed out as possible causes of diastolic dysfunction.12,15

From a prognostic point of view, low output congestive heart failure carries a relatively poor prognosis in comparison to the high output heart failure since here the problem is with the heart muscles itself. Evaluation of the functioning state of the patient is important to determining the prognosis of the case.
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