CHF

Running head: CONGESTIVE HEART FAILURE

Congestive Heart Failure

Leslie Wiley
The Robert B. Miller College

BSRN 400 Pathophysiology

Theresa Dawson/Faith Vruggink
March 10, 2010
Congestive Heart Failure
Introduction
The heart is a vital organ that delivers oxygen rich blood to the body in order to meet
certain needs. There are two atria, a left and right, that make up the top portion of the heart. The
lower portion of the heart consists of two ventricles, a right and a left. Congestive heart failure
occurs when the heart cannot pump enough blood to the bodys other organs. The heart tries to
pump blood at the normal rate; however, it is not as efficient. Blood flow out of the heart slows
down and blood returning to the heart through the veins gets backed up causing congestion in the
tissues. This results in edema of the legs and ankles. Lungs are also affected due to fluid backup
leading to difficulty breathing, especially when lying down. The kidneys will have trouble
getting rid of sodium and water making edema even worse (Mayo Clinic, 1998-2010).
The pumping action of the ventricles may be impaired due to a myocardial infarction or
myocarditis, an infection of the heart. Systolic dysfunction, muscle weakening causing

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inefficient ventricular pumping, occurs. Contraction of the ventricles is known as systole. Once
systole happens the ventricles need to relax to allow proper filling of the chamber. The
relaxation stage is known as diastole. Certain diseases, such as hemochromatosis, cause
impairment by stiffening of the heart muscle. When this occurs the ventricles are unable to relax
and allow blood to fill resulting in diastolic dysfunction. The most common cause of thickened
or hypertrophied heart is prolonged high blood pressure (Mayo Clinic, 1998-2010).
There are many causes of congestive heart failure. Some common causes are coronary
artery disease, high blood pressure, disorders of the heart valves, and alcohol abuse. Heart
failure is broken down into four categories. The most common is left-sided heart failure. Fluid
will back up into the lungs causing shortness of breath. Another is right-sided heart failure
which often occurs with left-sided heart failure. Edema of the legs, feet, and abdomen occur due
to fluid backup. Systolic heart failure is a pumping problem in which the ventricles cannot pump
vigorously enough. The last category of heart failure is diastolic heart failure. The left ventricle
does not fill properly due to a lack of relaxation (American Heart, 2010).
Risk factors for congestive heart failure are high blood pressure, myocardial infarction,
coronary artery disease, irregular heartbeats, diabetes, and certain diabetic drugs such as Avandia
or Actos. Also listed are sleep apnea, congenital heart defects, alcohol use, kidney conditions,
and certain viruses. A lot of these risk factors can be prevented with screening and lifestyle
change. It is important to have regular checkups, especially if any of these disease processes run
in a patients family. Heredity plays a huge role in our health and we can make a difference just
by being proactive (American Heart, 2010).
Prevention is a top priority for heart failure. Healthcare professionals are making an
effort to teach people risk factors and ways to prevent disease processes. Heart failure may
possibly be avoided just by not smoking, controlling blood pressure, and staying physically
active. Patients with high cholesterol or diabetes need to be well managed and controlled so as

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not to impair their heart. Weight plays a large percentage to heart failure, therefore, teaching
should be done to educate on eating healthy. Stress should be managed in a healthy manner not
only to prevent heart failure but other conditions as well (American Heart, 2010).
History of patient
In this case study we will discuss a 60 year old gentleman who presents to the emergency
room with shortness of breath, especially when lying down. This would initially be a sign of
left-sided heart failure. Weakness and fatigue, as well as confusion and disorientation may be
from lack of oxygen. He also complains of wheezing and rattling with a blood tinged fluid when
coughing. This would be occurring with fluid backup in the lungs and pulmonary edema.
Urination issues may be caused from a compensatory mechanism related to left or right sided
heart failure. This gentleman has experienced ankle swelling during the day, a sign of right-sided
heart failure which can accompany left-sided heart failure. The presence of pain in the upper
right quadrant and occasional nausea and vomiting may be from the presence of ascites which is
a backup effect of right-sided heart failure.
Blood pressure was 110/60 with a weak pulse. He did show some jugular distention, a
backup effect of right-sided heart failure. On auscultation there were moist inspiratory rales and
on percussion there was found to be bilateral pleural effusion. These are signs of left-sided heart
failure. Auscultation of the heart showed tachycardia and a harsh murmur. Both are signs of
compensation for right and left sided heart failure. The ankles and lower extremities had pitting
edema.
Upon diagnostic testing more information was received. ECG results showed left
ventricular hypertrophy. Chest x-ray proved our thoughts that both ventricles were enlarged.
Pulmonary edema is present with butterfly patterns in the perihilar areas. Ultrasound shows
aortic stenosis and left ventricular hypertrophy. Liver enlargement is revealed on abdominal xray. A urinalysis is performed showing proteinuria and granular casts. The patients blood urea

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nitrogen was also slightly elevated. All other blood work was within normal limits. These tests
confirm the diagnosis of congestive heart failure of the left-side as well as the right-side. The
pulmonary problems may have occurred first therefore causing the right-sided heart failure.
Criteria for diagnosis
Congestive heart failure is diagnosed clinically by the patients pertinent medical history,
physical examination, and certain laboratory tests. Symptoms present may be fatigue, usually
the first to appear, and not generally a symptom that would signal a patient to get medical
attention. Also present may be edema, shortness of breath, increased urination at night, nausea,
abdominal pain, and decreased appetite. As well as diagnosing by the presence of symptoms, a
significant history of coronary artery disease, prior heart attack, hypertension, diabetes, and
significant alcohol abuse can be factors. Physical examination may show extra fluid in the body
and issues with the heart such as murmurs, heart size, and pulse. Healthcare professionals should
obtain an electrocardiogram and chest x-ray which can show heart enlargement, arrhythmia,
previous heart attacks, and fluid around and in the lungs. Echocardiogram, an ultrasound, is the
most useful tool in diagnosing heart failure. This ultrasound will image the heart muscle, valve
structures, and blood flow patterns. Nuclear medicine studies help to check the overall pumping
capability of the heart. Heart catheterization is used to see the arteries leading to the heart by
using contrast die and x-ray. A biopsy of heart tissue may be taken in order to diagnose specific
diseases. Brain natriuretic peptide (BNP) is a laboratory test to detect heart failure and the
severity of it (MedicineNet, 1996-2010).
The 60 year old gentleman shows significant signs of heart failure. As discussed earlier
he has numerous symptoms such as shortness of breath, weakness and fatigue, wheezing and
rattling with blood tinged sputum, ankle edema, nausea and vomiting with right upper quadrant
pain. He also has jugular distention, moist inspiratory rales, bilateral pleural effusion,

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tachycardia and a murmur, left ventricular hypertrophy. Liver enlargement and a slightly
elevated BUN lab test are present. The next step is to find treatment option for him.
Treatment options
Lifestyle modification is the most important, yet the most neglected, treatment for
congestive heart failure. Restricting salt and fluid intake may help decrease fluid accumulation
and cut down on edema (MedicineNet, 1996-2010). Teaching needs to be started immediately
with our 60 year old gentleman. He should have no more than 2 grams of sodium per day and 2
quarts of fluids. It is a lot harder to change lifestyle than to just take a pill. Regular aerobic
exercise, tailored to the patients tolerance level, may increase quality of life. The patient must
be stable to engage in physical activity (MedicineNet, 1996-2010). Our gentleman would not be
a candidate for exercise at this point because he is not stable. Depending on the cause of heart
failure, an option for treatment may be coronary artery surgery, angioplasty, or stenting. Valve
surgery is also available if the underlying cause is a valve problem. If blood pressure is
chronically uncontrolled then medication must be administered. This can alleviate symptoms of
heart failure. If alcohol abuse is a factor then abstaining from alcohol can alleviate issues arising
from heart failure (MedicineNet, 1996-2010).
Medications are commonly used in the treatment of congestive heart failure. Ace
inhibitors have proven not only to reduce symptoms but to prolong the survival rate. Clinical
trials show that these medications, such as Captopril or Vasotec, can prevent heart failure and
heart attack. Ace inhibitors block the formation of angiotensin II and therefore should be
considered in all patients with congestive heart failure. If these medications are not tolerable for
the patient then healthcare professionals may try angiotensin receptor blockers, also known as
ARBs. ARBs block the formation of angiotensin directly at the receptor site. Beta-blockers are
typically used in conjunction with ace inhibitors. These drugs block the action of stimulating
hormones such as epinephrine and norepinephrine on the beta receptors. If a beta-blocker is

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taken with an ace inhibitor the studies show an improvement in heart function and survival for
patients with heart failure. Digoxin is a drug that improves the contraction of the heart muscle
and makes it more forceful. Long term survival has not been shown to decrease with the use of
Digoxin. Diuretics, such as Lasix or Bumex, are used to alleviate fluid retention in the lungs and
tissues thereby preventing edema. Potassium levels need to be monitored in patients who take
potassium wasting diuretics (MedicineNet, 1996-2010).
Heart transplantation is another option for patients who continue to deteriorate with other
treatments. Patients who wish to have this procedure must qualify for a new heart. Generally,
one must be under 70 years of age and they must not have irreversible damage to other organs of
the body. A patient must be closely monitored after a transplant since they are taking immune
suppressant drugs to prevent rejection. There are not nearly enough transplantable hearts for the
number of patients that need them (MedicinNet, 1996-2010).
Once stable, the 60 year old gentleman who presented to the emergency room should
have education regarding lifestyle modification. He may need to change his diet and exercise
habits. Teaching on this not only involves the patient but the family as well. Compliance will be
better if all family members are knowledgeable and willing to help. Smoking cessation
techniques and support should be started if he is a smoker. Medications should be started first
even though he is at the age that he would qualify for a heart transplant. Many of the
medications listed above can greatly increase his quality of life and possibly prolong it.
Prognosis
Prognosis for congestive heart failure is poor. A five year survival rate is around 50%.
20% of patients will survive 8-12 years. The difference in short term and long term prognosis
will depend on the patients response to treatment. The estimated mortality rate for congestive
heart failure from incidence and death statistics are a ratio of 12.7%. Annual deaths are roughly
260,000 cases per year with around 400,000 reported new cases annually. Mortality rates are

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estimated for congestive heart failure from prevalence and deaths are a ratio of 1.1%. Deaths are
about 260,000 cases per year with 4,800,000 cases in America (Wrongdiagnosis, 2010).
Expected symptoms are dyspnea, swelling, and tiredness. The see-saw is a feeling of
having good days and bad days. This is normal with congestive heart failure as is a poor sense of
balance. This can be made worse with certain medications such as Coreg or beta-blockers.
Patients should try to stagger medications and not take them at the same time of day. Short term
memory is affected due to a lack of oxygen as well as side effects of medications. Dry cough,
dry skin, and palpitations are a normal reaction to congestive heart failure. The ability to lie flat
becomes harder as fluid will build up in the lungs. Nausea is prevalent in end stage heart failure.
Loss of appetite is common due to dehydration (Manual, 2007).
Our 60 year old patient should be taught to expect these symptoms. It can be fearful for a
patient not to know what to expect. Time should be allotted to answer his questions as well as
his families. A diagnosis of congestive heart failure will be a life changing time for him.
Activities of daily living may become harder and healthcare professionals must be aware that at
some point help may be needed in the home. Education must be given as far as when to seek
medical attention for this gentleman.
Supportive role of teaching/community resources
Teaching is the most important aspect for a patient dealing with congestive heart failure.
A patient must be well informed to have a longer survival rate and a better quality of life.
Medications must be taken as directed. Side effects must be explained. Nonsteroidal antiinflammatory medications such as ibuprofen must be avoided. These can make heart failure
worse. Aspirin doses must be well managed in order to provide the desired effect. High doses of
aspirin may make heart failure worse (Revolution Health, September 2006).
Informing patients of diet and exercise is vital. A diet should be low sodium. This will
help with swelling as well. Fluids should be limited for the same reason. Exercise programs
have been shown to improve quality of life. They can also reduce the adverse cardiac events in

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patients with congestive heart failure. Exercising for 30 minutes per day, every day of the week,
is the regimen that should try to be attained. This will help with weight loss and that will help
the cardiac workload. Weight must be monitored on a regular basis to evaluate fluid retention
(Revolution Health, September 2006).
Smoking must be ceased to prevent further heart disease. This will make it easier to
exercise as well. Breathing may be easier by sitting up. A patient may need to sleep in a recliner
so as not to lay flat. Alcohol should be limited to no more than 2 drinks per day for men and 1
drink per day for women. Anything more is considered excessive and can cause problems for
heart failure patients (Revolution Health, September 2006).
Education must be given in regards to respiratory infections. Vaccinations should be
given. A respiratory infection can aggravate symptoms of congestive heart failure and patients
will have more trouble breathing. Patients need to be consistent with medical care and keep
appointments with all doctors. Support groups are available in communities and can be found by
visiting the American Heart Association website (Revolution Health, September 2006).
In the case of our 60 year old patient who may be a newly diagnosed patient, education is
pertinent. Compliance will be better if he is informed. Teaching will need to be reinforced by
every healthcare professional at every appointment. This also needs to be tailored to his learning
style. Explaining, visual materials, and hands on may be needed. It is our duty as medical
personnel to make his quality of life as good as possible.
Future
The future for patients living with congestive heart failure can be better by the clinical
trials out there. Research is being done to discover if patients with certain genes have a better
chance at recovery when presenting with the recent onset of primary cardiomyopathy. Another
study is called Topcat. Topcat is a study to see if adding the drug spironolactone to the current
treatment can improve heart failure. Spironolactone is currently approved for treatment of heart

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failure; however, this study is using a lower dose not yet approved by the Food and drug
administration. Viagra is being tested in patients with diastolic heart failure to see if it can
improve the ability to exercise and quality of life (Mayo Clinic, 2001-2010).
Investigational treatments are currently underway in the study of congestive heart failure.
Percutaneous heart valve repair is small devices placed under the skin, without surgery, to reduce
and prevent leakage of heart valves. Implantable sensors record the pressure changes in the heart
and electronically transmit to a doctors office. This can allow the doctor to treat the condition
before symptoms become severe enough to require emergency intervention. These are used right
now in pulmonary hypertension and right-sided heart failure. A new surgical approach involves
wrapping the heart in a mesh bag to prevent a weakened heart from enlarging.
Xenotransplantation is the use of animals as donors. Currently research is being conducted on
using pigs to transplant into humans (Mayo Clinic, 2001-2010).
Depending on how our gentleman does with treatment, he may become a patient in a
future study. Congestive heart failure is a leading cause of death in the United States and
deserves our attention. Medical staff must be current in their studies in order to catch a sign or
symptom that may not stand out but that can make a difference if it is caught. This may save a
life. Every one of us should support the cause of heart failure prevention and treatment as the
probability is great that there is someone in every family that is affected by this disease.

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10

References
American Heart Association. (2010). Congestive heart failure. Retrieved from
http://www.americanheart.org/presenter.jhtml?identifier=4585
Mayo Clinic. (1998-2010). Heart failure. Retrieved from
http://www.mayoclinic.com/health/heart-failure/DS00061
Mayo Clinic. (2001-2010). Congestive heart failure. Retrieved from
http://www.mayoclinic.org/congestive-heart-failure/clintrials.html
MedicineNet. (1996-2010). Congestive heart failure. Retrieved from
http://www.medicinenet.com/congestive_heart_failure/page3.htm
Parks, R. (2006, September 1). Living with heart failure. Retrieved from
http://www.revolutionhealth.com/conditions/heart/heart-failure/prevention/prevention?
id=hw44415&section=section_10
The Manual. (2007). CHF. Retrieved from http://www.chfpatients.com/CHFinfo.htm
Wrong Diagnosis. (2010). Prognosis of congestive heart failure. Retrieved from
http://www.wrongdiagnosis.com/c/congestive_heart_failure/prognosis.htm