Heart Failure
Adult-Gerontology Acute Care Practice Guidelines
Definition
A.Inability of the heart to meet the metabolic demands of the body.
B.Left-sided heart failure (HF): Further classified by the functional capacity of the left ventricle via ejection fraction (EF).
1.Heart failure with preserved ejection fraction (HFpEF).
a.EF at least 40%.
b.Occurs when the ventricle is unable to properly fill during diastole (muscle has stiffened).
c.Amount of available blood for circulation is decreased.
2.Heart failure with reduced ejection fraction (HFrEF).
a.EF less than 40%.
b.Occurs when ventricle has lost its normal contractile ability.
c.Force/amount of blood pumped during systole is decreased.
C.Right-sided HF: An additional subtype of HF; usually occurs secondary to HFrEF, but also seen in HFpEF, idiopathic pulmonary arterial hypertension (IPAH), and chronic obstructive pulmonary disease (COPD).
1.Left ventricular dysfunction causes an increase in fluid pressure that travels into the lungs and affects the right ventricle (RV).
2.This results in fluid accumulation in the peripheral system.
D.High-output HF: A subtype of HF where there is an increase in the body’s oxygen demands (i.e., chronic anemia, pregnancy, hyperthyroidism).
1.Increased demand forces the heart to work harder to meet these needs.
2.This eventually results in decreased cardiac function.
E.HF can be defined by the New York Heart Association (NYHA) classification, which is a method to categorize severity of HF based on patient symptoms (see Table 3.4).
Incidence
A.HF affects approximately 5.7 million Americans, with 850,000 new cases diagnosed per year.
B.Prevalence of HF increases with age, doubling with each decade of life and exceeding 10% in males and females older than 80 years.
C.HF is the leading cause of hospital admissions for patients older than 65 years of age.
D.HF is the second most common cardiovascular diagnosis evaluated during outpatient primary care visits.
E.Overall, the United States spends more than 30 billion dollars per year on HF.
TABLE 3.4 NYHA Classification of HF
HF, heart failure; NYHA, New York Heart Association.
Pathogenesis
A.During the aging process, the heart develops a decreased ability to respond appropriately to normal stressors (i.e., physical activity) or disease states (i.e., hypertension [HTN] or myocardial infarctions [MIs]).
B.Four major pathophysiologic changes have been identified.
1.Decreased ability to reach maximum heart rate and contractility under stressful conditions (secondary to impaired beta-adrenergic activity).
2.Increased stiffness of coronary and peripheral vasculature: This affects EF and causes increased afterload.
3.Altered diastolic filling ability.
4.Insufficient amount of energy production (on a cellular level) to meet the needs of the heart under stressful physiologic and/or pathophysiologic conditions.
Predisposing Factors
A.Coronary artery disease (CAD; MI/ischemic cardiomyopathy).
B.HTN/hyperlipidemia.
C.Valvular heart disease (VHD; atrial stenosis [AS], atrial regurgitation [AR], mitral stenosis [MS], mitral regurgitation [MR]).
D.Peripheral vascular disease.
E.Connective tissue diseases (i.e., sarcoidosis).
F.Arrhythmias (new onset/persistent atrial fibrillation, ventricular arrhythmias, bradyarrhythmias).
G.Cardiomyopathies (alcohol related; nonischemic, restrictive, or hypertrophic; medication related).
H.Infectious (myocarditis, pericarditis, endocarditis).
I.High-output HF (anemia of chronic disease, pregnancy, hyperthyroidism, thiamine deficiency, atrioventricular [AV] shunting).
J.Noncardiac etiologies: Pulmonary embolus, pneumonia, exacerbation of COPD.
Subjective Data
A.Common complaints/symptoms.
1.Shortness of breath (SOB) or dyspnea (during activity or rest).
2.Fatigue or generalized weakness.
3.Decreased exercise tolerance.
4.Orthopnea: Manifests as difficulty breathing while supine; relieved with head elevation using pillows.
5.Paroxysmal nocturnal dyspnea (PND): Sudden awakening during sleep secondary to acute SOB.
6.Nonproductive cough (worse at night).
7.Confusion/change in mental status: Due to inadequate cerebral perfusion in late stages of HF.
8.Swelling of extremities: Secondary to volume overload.
B.History of the present illness.
1.Determine chief complaint that is associated with HF and evaluate the onset, provoking factors, palliative factors, quality, and severity and timing of the symptoms.
2.Determine if this is an initial presentation or exacerbation of a previously diagnosed HF.
3.Evaluate the past medical history for known HF, previous MI, HTN, HLD, diabetes mellitus (DM), cardiomyopathies, congenital heart defects, sleep apnea, renal disease, or collagen vascular diseases.
4.Determine if a previous cardiac evaluation was performed (i.e., ECG, stress test, echocardiogram, cardiac catheterization).
C.Family and social history.
1.Determine past and present tobacco use, alcohol consumption, and use of illegal substances.
2.Review daily diet and nutrition information.
3.Determine frequency and degree of physical activity routines.
4.Evaluate family history for cardiac diseases such as HF, MI, HTN, hyperlipidemia, CAD, and cardiovascular equivalents (i.e., DM).
a.If there is evidence of cardiomyopathy, the Heart Failure Society of America recommends an in-depth three-generation family history evaluation for cardiovascular diseases, especially those related to cardiomyopathies.
D.Review of systems.
1.General: Fatigue, malaise, weight changes, appetite changes, and generalized weakness.
2.Skin/nails: Changes in nail shape (i.e., clubbing).
3.Cardiac: Chest discomfort, palpitations, decreased exercise tolerance, and peripheral edema.
4.Pulmonary: Nonproductive cough, SOB, dyspnea on exertion, orthopnea, PND.
5.Gastrointestinal: Bloating, nausea, changes in bowel habits.
6.Genitourinary: Oliguria, nocturia.
7.Neurological: Syncope, near-syncope, confusion, memory impairment, sleep disturbances, headaches.
8.Psychological: Anxiety, irritability.
Physical Examination
A.Assessment of HF patients can vary based on stage of disease and underlying comorbidities.
B.The most common physical examination findings are based on severity (see Table 3.5).
Diagnostic Tests
A.The American Heart Association (AHA), American College of Cardiology (ACC), and Heart Failure Society of America recommend the following tests in the evaluation of HF.
1.Complete blood count: Identify anemias or infections as underlying factors of HF.
2.Complete metabolic panel: Identify electrolyte imbalances (especially important for patients using diuretics).
3.Renal function: Identification of underlying kidney dysfunction (decreased renal perfusion) as a marker for HF.
4.Fasting glucose: Helps identify underlying DM as a contributing factor to overall cardiovascular health.
5.Natriuretic peptides (brain natriuretic peptide [BNP] or pro-BNP): Help evaluate ventricular pressure and volume status.
6.Liver function panel: Evaluate aspartate aminotransferase (AST) and alanine aminotransferase (ALT), which can be elevated in cardiac cirrhosis or congestive hepatomegaly as a result of long-standing HF.
7.Urinalysis: Evaluates for proteinuria, which is a marker of cardiovascular disease.
8.ECG: Somewhat nonspecific but can be useful to detect left ventricular hypertrophy (LVH) or underlying cardiac ischemia or arrhythmias.
9.Chest x-ray: Important evaluation tool for size and shape of the cardiac silhouette and presence of effusions.
a.Can appreciate cardiomegaly.
b.May show Kerley B Lines: Short, thin horizontal lines that are noted near the border of the lung and extend outward as a marker of increased interstitial pulmonary fluid.
c.Can appreciate pleural effusions or pulmonary edema.
10.Echocardiogram: Diagnostic test of choice for suspected HF.
a.Utilized to determine type of HF (i.e., HFpEF or HFrEF).
b.Useful for determining the EF, where a value less than 40% can help delineate between HF with preserved versus reduced EF.
c.Evaluates for VHD, overall dilatation, and/or hypertrophy: In addition, can consider a stress echocardiogram as a measure of underlying cardiac ischemia/CAD.
11.Cardiac catheterization/coronary angiography.
a.Useful in the following scenarios.
i.For refractory HF in patients without CAD.
ii.For HFrEF with concomitant angina, wall-motion abnormalities on echocardiogram, nuclear evidence of reversible ischemia, or if percutaneous revascularization is considered.
iii.If there is a high suspicion of ischemic cardiomyopathy and surgical procedures are a consideration.
iv.If cardiac transplant or device implantation is being considered.
TABLE 3.5 Common Physical Findings in HF (Grouped by Severity)
HF, heart failure; HTN, hypertension.
b.Patients can undergo unilateral (right-sided) catheterizations, which provide detailed information regarding cardiac hemodynamics, including cardiac output, ventricular filling pressures, and vascular resistance.
Differential Diagnosis
A.Acute respiratory distress syndrome (ARDS).
B.COPD.
C.Pulmonary edema.
D.Cirrhosis.
E.Idiopathic pulmonary fibrosis.
F.Viral pneumonia.
G.Bacterial pneumonia.
H.Pulmonary embolus.
I.MI.
J.Nephrotic syndrome.
K.Acute kidney injury/insufficiency.
- Acute bronchitis.
Evaluation and Management Plan
A.General plan: Utilize pharmacologic and nonpharmacologic mechanisms to achieve the following goals.
1.Improve overall quality of life.
2.Decrease frequency of HF exacerbations and need for hospitalizations.
3.Extend patient survival.
4.Increase exercise/functional capacity and enhance overall patient well-being.
5.Treat underlying comorbidities that may contribute to HF (i.e., cardiac revascularization for ischemia, valvular replacement for compromising VHD, and treatment of HTN).
B.Patient/family teaching points.
1.Strong focus on nonpharmacologic modalities.
a.Emphasize importance of medication and clinic appointment compliance.
b.Discuss signs and symptoms of worsening HF and when to seek medical care.
c.Design daily weight chart for patients with specific instructions regarding weight parameters and when to seek medical care.
d.Educate on dietary guidelines.
i.Sodium: Less than 2.3 g/d.
ii.Fluid restriction: Less than 2.0 L/d.
iii.Low fat and low cholesterol diet.
e.Ensure patients have close follow-up via in-person and phone contact with providers.
f.Educate on tobacco cessation and decreased alcohol intake (if indicated).
g.Collaborate with cardiac rehabilitation specialist to design HF-focused exercise program.
i.Should contain flexibility, strengthening, and aerobic activities.
ii.Encourage daily low to moderate activity with gradual increased intensity over weeks to months with heart monitoring (for most patients).
C.Pharmacotherapy.
1.Angiotensin-converting enzyme (ACE) inhibitors: Work by increasing preload and afterload via vascular dilatation; known to decrease morbidity and hospitalizations while alleviating HF-related symptoms and improving quality of life.
a.Recommended that all patients regardless of symptoms receive an ACE inhibitor.
b.Important to monitor blood pressure, renal function, and electrolytes.
c.Advised to start at low dose and titrate.
d.Caution to avoid nonsteroidal anti-inflammatory drugs (NSAIDs) in combination with ACE inhibitors because NSAIDs are ACE inhibitor antagonists and will decrease ACE inhibitor effectiveness; in addition, NSAIDs promote sodium and water retention.
e.Typically, combination of an ACE inhibitor and diuretic: First-line therapy for most HF patients.
i.Patients who cannot tolerate ACE inhibitors should use angiotensin II receptor blockers (ARBs).
ii.Patients are intolerant to ACE and ARB therapy can utilize a combination of hydralazine and oral or topical nitrates for similar benefits.
2.Beta-blockers: Proven to decrease mortality in post-MI HF patients.
a.In the United States, carvedilol and metoprolol succinate are approved for treatment of NYHA HF classes I, II, and III.
b.Several contraindications to beta-blocker therapy include NYHA class IV HF, significant pulmonary disease, marked bradycardia, baseline hypotension, and all heart blocks except first degree.
3.Mineralocorticoid antagonists.
a.Most commonly used: Spironolactone.
b.Function as a potassium-sparing diuretic that affects aldosterone.
c.Recommended in NYHA HF classes II to IV HF with EF less than 35% or an EF less than 40% in post-MI HF.
d.Contraindicated in patients with renal dysfunction (Cr >2.5 mg/dL) or known hyperkalemia.
e.Caution: In the geriatric population, many patients with underlying renal dysfunction are predisposed to electrolyte abnormalities.
4.Diuretics.
a.Diuretics are the most effective pharmacologic treatment for fluid balance and decreasing symptoms of edema; however, no proven morbidity/mortality benefits.
b.Either thiazide (less potent) or loop diuretics (more potent) can be used.
c.If the patient is unresponsive to loop or thiazide diuretics, consider the addition of metolazone for enhanced results (caution with metolazone in the elderly, as small doses can result in life-threatening hyponatremia).
d.The most important side effect of diuretics is electrolyte imbalance, particularly hypokalemia, hyponatremia, hypomagnesemia, and increased bicarbonate.
e.All patients, but especially geriatric individuals, utilizing these medications should have routine electrolyte monitoring.
5.Digoxin.
a.Has a positive ionotropic effect.
b.Beneficial in HF patients with EF less than 30%, NYHA HF class IV, or concomitant AF.
c.Has not been shown to decrease morbidity/mortality.
d.Careful monitoring of digoxin levels necessary.
e.Can be added to preexisting therapy with diuretics, ACE inhibitors, or ARBs in patients with severe disease.
D.Additional treatment options.
1.Implantable cardiac defibrillator (ICD) placement: Reduces mortality rate from sudden cardiac death in patients with NYHA class II and III HF and an EF less than 35% (primary prevention) or following cardiac arrest secondary to ventricular arrhythmias (secondary prevention).
a.Note that ICDs help prevent sudden cardiac death but do not improve quality of life.
2.Cardiac resynchronization therapy (CRT): Used in patients with systolic (decreased EF) HF to improve clinical symptoms, exercise tolerance, and overall survival.
a.Procedure requires placement of a biventricular pacemaker (one lead in RV and one lead in the left ventricle via the coronary sinus vein) to assist in pacing the left ventricle: Helps by improving cardiac contractile ability.
b.Works by increasing stroke volume, EF, and cardiac output.
c.Indicated in patients with NYHA HF classes II to IV, EF less than 35%, and QRS duration greater than 150 ms on ECG.
3.Considerations for refractory HF: Defined as advanced structural heart disease and marked HF symptoms at rest or repeated exacerbations despite optimal medical therapy.
a.Consider additional supportive devices such as left ventricular assistive devices (LVADs), right ventricular supportive devices (RVADs), or biventricular assistive devices (BIVADs).
b.Can also consider advanced intravenous ionotropic therapy to increase cardiac output and
strength of contractility (i.e., dobutamine or milrinone).
c.Use extracorporeal membrane oxygenation (ECMO) in settings of worsening cardiomyopathy or HF; indicated in persistent NYHA class IV HF as potential bridge to transplantation.
4.Cardiac transplantation: Can be a consideration in patients with refractory cardiogenic shock, constant dependency on intravenous ionotropic therapy, or persistent NYHA class IV HF with oxygen consumption less than 10 mL/kg/min.
a.However, many contraindications to transplant exist.
b.In-depth evaluation and dedicated cardiac transplant treatment team are necessary.
E.Discharge instructions.
1.Ensure proper transition from inpatient to outpatient management of underlying comorbidities that can exacerbate HF (DM, HTN, and hyperlipidemia).
2.Ensure adequate understanding of modifiable cardiovascular risk factors (i.e., smoking cessation, weight loss, and diet/activity restrictions).
3.Prior to discharge:
a.Ensure that the patient is at optimal volume status with proper transition from intravenous to oral diuretic therapy.
b.Ensure that the patient has had echocardiogram with documented EF.
c.Ensure that the patient has been stable on all oral cardiac medications for 24 hours.
d.Ensure that the patient is receiving optimal oral pharmacologic therapy including an ACE inhibitor and beta-blocker (if decreased EF); if optimal therapy is not prescribed, must document reasoning for deviation from accepted practice guidelines.
e.Consult with physical therapy (and occupational therapy) to ensure patient is stable with ambulation and activities of daily living prior to discharge.
f.Ensure that the patient has follow-up with outpatient cardiologist scheduled for 7 to 10 days postdischarge.
g.Based on the patient’s functional status and degree of HF, consider home health nursing or short-term rehabilitation facilities (or long-term care).
Follow-Up
A.Ensure effective coordination of care between primary care physician and cardiologist. If recent hospitalization:
1.Follow-up within 7 days of discharge, then 1 to 2 weeks until patient is asymptomatic and then every 3 to 6 months thereafter.
2.All providers should ensure efficient communication regarding a patient’s current clinical status, medication regimen, diagnostic test results, and goals of care.
B.Ensure medication compliance and importance of all clinic visits.
C.Create patient-centered exercise plan: Consider referral to cardiac rehabilitation.
D.Provide instruction about daily home weight monitoring.
1.If weight gain is more than 2 lb. in 24 hours or 5 lb. above target in 1 week, notify healthcare provider.
2.Discuss weight loss if indicated (body mass index [BMI] ≥30 kg/m²).
E.Educate on proper dietary habits including low fat, low cholesterol, and low salt (<2,300 mg/daily).
1.Consider possibility of fluid restriction.
F.Provide smoking cessation and decreased alcohol consumption information, if necessary.
G.Ensure patient understanding regarding symptoms of worsening HF (cough, weight gain, worsening or rest dyspnea, orthopnea, and edema) and importance of seeking early medical care.
Consultation/Referral
A.Recommend consultation with cardiologist and HF specialist.
B.Refer to interventional cardiologist and cardiothoracic surgeon for device implantation or if cardiac catheterization/revascularization is needed. Consider referral to transplant surgeon in special cases where cardiac transplantation is a consideration.
C.Recommend consultation with nutritionist to assist with dietary restrictions of HF.
D.Recommend referral to cardiac rehabilitation for assistance with physical activity plan (newly approved for NYHA classes II to IV, EF less than 35%, and on optimal medical therapy for at least 6 weeks).
E.Consider consultation with physical therapy, occupational therapy, and case manager during hospitalization to evaluate patients’ functional capacity and assist with discharge planning.
F.Refer to palliative/hospice care for end-stage HF.
Special/Geriatric Considerations
A.Additional considerations for HF.
1.Considerations for hospitalization.
a.Hypotension or other hemodynamic instability.
b.Worsening renal function or significant electrolyte disturbance.
c.Change in mental status.
d.Dyspnea at rest (resting tachypnea) or oxygen saturation less than 90%.
e.New-onset or worsening arrhythmia such as atrial fibrillation or a ventricular arrhythmia.
f.HF with concomitant ACS.
g.Evidence of worsening pulmonary congestion on physical examination (rales, jugular venous distention [JVD]).
B.Geriatric considerations.
1.HF in the geriatric population can manifest with nondescript symptoms.
a.Malaise.
b.Weight loss.
c.Decreased exercise tolerance.
d.Changes in mental status (confusion, changes in mood/irritability, sleep disturbances).
e.Gastrointestinal dysfunction (nausea, abdominal pain, anorexia, alterations in bowel habits).
2.Note that geriatric patients also experience typical HF symptoms, especially orthopnea; inquire about sleeping in a recliner (to alleviate SOB) and elevated JVD (noted on physical examination).
3.The mnemonic DEFEAT (Diagnosis, Etiology, Fluid volume status, Ejection frAction, and Treatment) may be useful in the geriatric population.
a.General principle for the treatment of HF in older adults is similar to that of younger adults: Divided between symptom-relieving and disease-modifying treatment.
b.All geriatric HF patients should receive an ACE inhibitor or an ARB; can also utilize a low dose beta-blocker such as metoprolol.
c.Can also utilize an aldosterone antagonist (i.e., spironolactone) in advanced HF; however, use caution in those with impaired renal function (common in geriatric population) due to risk of hyperkalemia.
d.Recommend to avoid digoxin in geriatric patients but could consider in low doses if patient remains symptomatic despite maximal medical therapy with other pharmacologic classes.
e.Diuretics should be used to achieve euvolemia using lowest dose possible with careful monitoring of electrolytes.
f.Realize that HF is a debilitating condition in the geriatric population: Fewer than 25% will survive greater than 5 years. It is important to:
i.Have comprehensive discussions with patients and families regarding end-of-life wishes and ensure that appropriate referrals to palliative care and hospice are made when the patient’s condition declines.
ii.Understand patients and family members’ wishes regarding aggressiveness of clinical interventions before designing treatment plans.
1)Recommend that risk versus benefit analysis for geriatric patients be considered with regard to device implantation.
2)Understand that patients with low life expectancies (12–18 months) are unlikely to benefit from ICDs and patients older than 80 years of age are likely to experience major complications following device placement.
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