Running head: CONGESTIVE HEART FAILURE 1

Congestive Heart Failure

Kedene Wellington

Health Alterations 2

Ms. Makepeace

Carleen Health Institute of South Florida

November 14, 2016

CONGESTIVE HEART FAILURE 2

Abstract
Congestive heart failure is an important condition affecting over 5.8 million Americans
and over 23 million peoples worldwide. It has increasingly become a reason for hospitalization
especially among the elderly. However, there exist disparities in heart failure reporting. Several
factors have been shown to propagate the onset of heart failure, but the widely recognized causes
are hypertension and coronary heart diseases. With heart failure, there is an abnormality of
cardiac function is responsible for the failure of the heart to pump blood at a rate commensurate
with the requirements of the metabolizing tissue or to do so only from an elevated filling
pressure. Although there is a wide range of symptoms and signs that can indicate heart failure,
fluid overload and pulmonary congestion, including orthopnea, dyspnea, and paroxysmal
nontunal dyspnea are some of the key signs and symptoms. Diagnosis of heart failure can only
occur after careful consideration of the clinical history, physical examination and diagnostic
testing. Some of the commonly used diagnosis tastings include electrocardiogram, chest
radiograph, and BNP assay. Findings from an EKG of LV hypertrophy, left bundle branch block,
intraventricular conduction delay, and nonspecific ST-segment and T-wave changes. Treating of
heart failure can include modification of lifestyle, use of drugs, device therapies and use of
assistive devices. Prevention and screening is an important part in the fight of heart failure
considering the burden caused by this condition has persistently increased. As such treatment of
high-risk conditions that have been shown to cause heart failure will be important.
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Congestive Heart Failure

Congestive heart failure is a condition that occurs when the heart is unable to pump

adequate blood to meet the bodily needs. When heart failure occurs, there is a failure in pumping

of blood into all the chambers. According to the Braunwald’s definition which is the commonly

used definition, congestive heart failure is a state in which an abnormality of cardiac function is

responsible for the inability of the heart to pump blood at a rate commensurate with the

requirements of the metabolizing tissue or to do so only from an elevated filling pressure.

According to Centers for Disease Control and Prevention (2016), there are approximately 5.8

million adults in the United States with congestive heart failure. Other facts about CHF

according to CDC (2016) are that about half of the people who develop heart failure do not make

it beyond five years after diagnosis. Another fact is that CHF is an enormous burden to the health

care system such that over 30.7 billion U.S dollars are used each year in efforts to treat, and

manage CHF.

Epidemiology of Heart Failure

Congestive heart failure has increasingly become a reason for hospitalization for the last

two decades. As such it represents a major health problem not only in the United States, but also

to other nations around the world. In the United States of America, there are approximately 5.8

million people suffering CHF and another 23 million worldwide. In the year 1997, heart failure

was identified as an emerging epidemic (Butler, 2011). While great efforts have been made in

the diagnosis and treatment of heart failure, CHF remains one of the most important causes of

mortality and morbidity in many countries around the world especially western society because

of the average age of the population. According to Roger (2013), left ventricular dysfunction is

linked to an increased risk of sudden death. HF is linked to constant exacerbation that requires
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treatment intensification most often in hospital and is the most frequent reason for hospitalization

for people aged 65 and above (Butler, 2011).

Important to note is that heart failure statistics are generated from hospital discharges and

these are not always validated by standardized criteria and the shifts in most facilities discharge

diagnoses preferences after the introduction of the Diagnosis-related group’s payment systems

have been documented. As such, it is quite hard to have conclusive statistics on heart failure.

However, as noted by Roger (2013) more than 550, 00 new cases of heart failure are reported

annually.

According to Huffman et al. (2013) heart failure is projected to continue being the most

prevalent cardiovascular disease. Unfortunately, more evidence is pointing to the fact that the

declining fatality rate of acute coronary events resulting in a larger group of persons at increased

risk of developing chronic cardiovascular disease has continued to contribute to increased

incidences of heart failure. Prognosis of heart failure has been indicated to be poor in many

countries, and the economic impact of the condition on individual household and health services,

in general, is huge because of the long-term pharmacological treatment and frequent

hospitalization. The burden of congestive heart failure is projected to continue increasing as the

prognosis of patients with heart failure is highly dependent on timely interventions through

medical and surgical interventions. In addition, as the elderly population continues to increase,

incidences of heart failure are also projected to continue rising. Simulations on heart failure have

indicated a transition from acute to chronic cardiovascular diseases, resulting in a dramatic

increase in age-adjusted prevalence rates of ischemic heart diseases (Butler, 2011).

Another important thing to note with regard heart failure statistics is that most of the

studies are focused on the white subjects. However, it must be remembered that the burden of
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congestive heart failure is diverse. According to Huffman, Berry, Ning, Dyer, Garside, Cai and

Lloyd-Jones (2013) in ARIC and multi-ethnic study of Atherosclerosis (MESA) the incidence of

heart failure was reportedly higher in African-Americans than the Caucasians. Therefore, Roger

(2013) reports that there is a need for continued community surveillance of heart failure in

diverse populations as different communities have special risk factors. Reported data on lifetime

risk indicate that developing CHF ranged from 20-30% in predominantly white cohorts.

According to Huffman et al. (2013) lifetime risks for developing HF were reported among a

diverse large groups of 38, 578 participants in different cohorts including the Chicago Heart

Association Detection Project in Industry, the ARIC study and the Cardiovascular Health Study

showed some varying disparities; at age of 45, lifetime risks for heart failure through age 75-95

years were 30-42% among white men, 20-30% in black men, 32% to 39% in white women and

24-46% in black women.

Several heart failure scoring methodologies/criteria have been developed to assist in the

diagnosis. According to Roger (2013), these include the Framingham criteria, the Gothenburg

criteria, Boston Criteria and the European Society of Cardiology Criteria. A common

characteristic among these scoring methodologies is that they are based on symptoms and signs.

In addition, these criteria combine data from a patient’s medical history and physical

examination. With the European Society of Cardiology criteria, a requirement is that objective

evidence of cardiac dysfunction must be available, however, this is not always the case.

Etiology of Congestive Heart Failure

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Several factors have been linked to the onset of a heart failure. As such, heart failure is

the culmination or resulting effect of many different processes that impair cardiac functioning.

Coronary artery disease and hypertension either singly or together have been shown to be the

major cause of heart failure in most developed nations (Butler, 2011). Unlike in the past when

valvular heart disease was closely linked with heart failure, new studies have indicated that its

impact has continuously reduced. In developing worlds, rheumatic valvular heart disease, and

Nutritional cardiac disease are the main causes of heart failure. In addition, unlike in developed

nations where heart failure is common in the elderly, young populace in the developing nations is

at a higher risk. As noted by Hobbs and Boyle (2014) other common etiologies of heart failure

include diabetes mellitus, mitral regurgitation, non-ischemic and cardiomyopathies, and valvular

heart disease.

According to the classification of HF require an understanding of the parameters of left

ventricular function which enables classification of HF as Preserved or reduced ejection fraction.

As such, various threshold of ejection fraction has been suggested where most have been

generated from imaging studies and some are arbitrary in nature (Hobbs & Boyle, 2014). The

main cause of congestive heart failure is Left-sided heart failure- broadly categorized into two-

systolic heart failure and diastolic heart failure (Berry et al., 2015). Diastolic heart failure is also

termed as heart failure with preserved ejection fraction. According to the American Heart

Association (2016), the heart’s pumping action moves oxygen-rich blood as it travels from the

lungs to the left atrium, then on to the left ventricle, which pumps it to the rest of the body. As a

result, the left ventricular systolic dysfunction is the main cause of mortality and this accounts

for approximately 60% of all cases of heart failure. Systolic failure occurs when the heart is
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unable to contract normally thus impairing supply of enough oxygenated blood (Hobbs & Boyle,

2014).

The diabolic failure occurs when the left ventricle loses its ability to relax normally as a

result of may be muscle stiffness and this impairs filling of the heart with blood during the

resting period between each beat (Hobbs & Boyle, 2014). The right Ventricular systolic

dysfunction is as a result of left ventricular systolic dysfunction. Its onset can be triggered by

infarction in the right ventricular, pulmonary hypertension, chronic severe tricuspid regurgitation

or arrhythmogenic right ventricular dysplasia (Hobbs & Boyle, 2014). A least reported cause of

heart failure is a high-output failure which is attributed to thyrotoxicosis, arteriovenous fistulae,

Paget’s disease, pregnancy, or severe chronic anemia. With regard to etiology of systolic heart

failure, 34% is related to ischemic while 66% is non-ischemic. Cause of non-ischemic

cardiomyopathy include; idiopathic, valvular heart disease, hypertensive heart disease,

myocarditis, infiltrate disease, HIV, infiltrate disease, peripartum cardiomyopathy, substance

abuse and medical induced that is doxorubicin (Berry et al., 2015).

Pathophysiology of Congestive Heart Failure

Several conditions have been known to cause heart failure. One of such example is the

heart muscle damage which is caused by a heart attack or myocardial infarction. In the event that

there is a myocardial infarction, there is generally not enough blood that is being supplied to the

heart muscles making them to be starved of oxygen which leads to the death of the muscle tissue.

As a result, the muscle fails in its function. The measurement of the blood the heart pumps is the

cardiac output (Berry et al., 2015). The first instigating event in the pathophysiology is the insult

to the heart and this can be a myocardial infarction, an episode of viral myocarditis or some of

form of infiltrated disease (Hobbs & Boyle, 2014). The resulting effect is the winking weakening
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of the heart muscle and decreasing contractility which is then manifested by a decrease in the

cardiac output. This is well presented by the frank-starling relationship which states that the

stroke volume of the heart increase in response to an increase in the volume in blood filling the

heart when all other factors are held constant. In heart failure situation where there is a low

cardiac output there is an activation of the sympathetic nervous system as well as a decrease in

renal blood flow (Berry et al., 2015).

Activation of sympathetic nervous system decrease in cardiac output leads to activation

of barrel receptors which then leads to increase activation of the sympathetic nervous system.

The increase in activation of the sympathetic nervous system has three main effects that are

important and cart in congestive heart failure. The first is activation of beta receptors which lead

to the increased stroke volume as well as increased heart rate. Both of these processes serve to

maintain cardiac output (Berry et al., 2015). However, in the pathologic state of congestive heart

failure, further increases in heart and further work on the heart may cause further myocardial

damage which can therefore further exacerbate the problem of decreased cardiac output. The

second thing that happens with the sympathetic nervous system is an increase in sodium

retention thus increasing fluid retention and leading eventually to volume overload. The third

effect of SNS important in the pathophysiology of congestive heart failure is activation of alpha

receptors. Activation of alpha receptors lead to increased blood pressure which can be thought of

as after load and this increase in blood pressure or afterload can further depress cardiac output

causing vicious cycle (Hobbs & Boyle, 2014).

On the other hand, the effects of decreased renal perfusion in the kidney is that when

renal perfusion is decreased in the setting of low cardiac output this leads to an increase in

running production. The increase in renal production leads to an increased angiotensin one and
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then after conversion by the ACE enzyme leads to an increase in angiotensin 2. The end organ

effects of angiotensin lead to increase the blood pressure of afterload which can further decrease

cardiac output. This can lead to a further decrease in renal perfusion the second effect of

angiotensin 2 is to lead to increase aldosterone production which then leads to increased sodium

and fluid retention (Bello et al., 2014).

Signs and Symptoms of Heart Failure

There exists a wide range of Signs and symptoms of heart failure because of different

potential clinical manifestations of HF. However, most patients will have signs and symptoms of

fluid overload and pulmonary congestion, including orthopnea, dyspnea, and paroxysmal

nontunal dyspnea (Hobbs & Boyle, 2014). For patient presenting with right ventricular failure,

there will be jugular venous distention, peripheral edema, hepatosplenomegaly and ascites.

However, and perhaps more important to examining professional is that some congestive heart

failure patients will not have congestive signs and symptoms but may present with signs of low

cardiac output that include but not limited to fatigue, effort intolerance, cachexia, and renal

hypo-perfusion. The New York Heart Association Heart failure symptom classification system

commonly used to assess the severity of the functional limitations has four classes. The first class

classify the level of impairment as ‘no symptom limitation with ordinary physical activity; Level

II level of impairment- ‘ordinary physical activity with somewhat limited by dyspnea such as

long-distance walking, climbing two flights of stairs’, Level III- exercise limited by dyspnea

with moderate workload such as short-distance walking or climbing one flight of stairs. Finally

for level IV, dyspnea at rest or very little exertion (Hobbs & Boyle, 2014).
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Physical Examination

Physical examination of patients with decompensated heart failure may be tachycardic

and tachypneic, with bilateral inspiratory rates, jugular venous distention and edema (Hobbs &

Boyle, 2014). A heart failure patient will present pale and diaphoretic appearance. The first

sound will normally be faint or soft if the patient is not tachycardic. In additional an S3 and an

S4 may be present. Murmurs of mitral or tricuspid regurgitation may be heard by the examining

healthcare professional. Paradoxical splitting of S2 might be evident as a result of a delayed

mechanical or electrical activation of the left ventricle. Patient suffering from compensated heart

failure will most often have clear lungs but displaced cardiac apex. On the other hand, patients

suffering from decompensated diastolic dysfunction will present with a loud s4 which at times is

palpable, rales and in most instances systemic hypertension (Bello et al., 2014).

Diagnosis

Making an accurate diagnosis and thoughtful diagnosis of heart failure requires the

synthesis of info gathered in clinical history, physical examination and diagnostic testing.

However, preliminary evaluation of a new onset congestive heart failure must include an

electrocardiogram, chest radiograph and BNP assay. Findings from an EKG of LV hypertrophy,

left bundle branch block, intraventricular conduction delay, and nonspecific ST-segment and T-

wave changes are all essential in making a heart failure diagnosis (Bello et al., 2014). Q waves in

contagious leads may be an indication of previous myocardial infarction and coronary artery

disease as the cause. Findings of a chest radiographic can include cardiomegaly, pulmonary

vascular redistribution, pulmonary venous congestion, Kerley B lines, alveolar edema and

Pleural effusions (Bello et al., 2014).

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In diagnosis of heart failure, the most useful or widely used method is the

echocardiogram, which is important in differentiation of systolic and diastolic dysfunction. In the

event that a patient is suffering from systolic dysfunction, a regional wall motion abnormalities

or LV aneurysm will indicate an ischemic diagnosis of heart failure (Carson et al., 2015). On the

other hand, a global dysfunction will indicate a nonischemic cause of heart failure (Hobbs &

Boyle, 2014). Echocardiography remain a useful testing because it is important is determining

other causes of heart failure such as cardiac tamponade or pericardial constriction.

Echocardiography provides essential clues on infiltrative and restrictive cardiomyopathies. In

addition an Echocardiography can provide pertinent prognostic information about a diastolic

function, magnitude of hypertrophy, valvular abnormalities, and chamber sizes. Nevertheless, it

is practically impossible to deduce the exact cause of heart failure using Echocardiogram.

Cardiac catheterization is also an important process in the diagnosis of heart failure as it

can detect coronary atherosclerosis. As a result of the prevalence of coronary artery disease,

coronary angiography must be performed regularly so as to rule out it presence (Carson et al.,

2015). In case that coronary artery disease is noted, an assessment of myocardial viability with a

goal of revascularization must be conducted (Hobbs & Boyle, 2014). In most facilities, coronary

computed tomographic angiography or radionuclide myocardial imaging is widely used as an

alternative so as to rule out the presence of coronary artery disease. Magnetic resonance is

mostly conducted to assess for arrhythmogenic right ventricular dysplasia, myocardial viability

and infiltrative cardiomyopathies (Carson et al., 2015). Exercise testing is necessary in the

diagnosis of heart failure because it can generate important objective information about

functional capacity. Exercise testing can distinguish ventilator from cardiac limitations among

patients experiencing exertional dyspnea. BNP assay is also an important test used in heart
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failure diagnosis. BNP levels correlate with severity of heart failure and reduce as a patient

reaches a compensated state. BNP can be important in differentiating heart failure from

pulmonary diseases. This is especially important for patients who smoke.

Treatment

Treatment can be through lifestyle modifications where intake of sodium and fluid

restriction is implemented in all patients suffering from congestive heart failure (Ziaeian &

Fonarow, 2013). Medical treatment options can include angiotensin-converting enzyme

inhibitors, angiotensin receptor blockers, beta blockers, digoxin, diuretics, aldosterone

antagonists, and hydralazine and nitrates. Other medical therapies available to heart failure

patients include aspirin and statin (Ziaeian & Fonarow, 2013). Intravenous inotropes and

vasodilators can also be used to treat heart failure and available options include; dobutamine,

milrinone, nitroglycerin, sodium nitroprusside, and nesiritide. Different devices therapies have

also been developed and are important in the management of heart failure. Some of the devices

available include cardiac resynchronization therapy, defibrillator therapy, and ultrafiltration

therapy. Surgical options include LV assisted devices and cardiac transplantation.

Prevention and Screening

Patients suffering from hypertension, obesity, those using cardio-toxins, diabetes mellitus

and those from families with heart failure history are all classified in class A and are at a higher

risk of heart failure. Prevention therapy can include early treatment of lipid disorders and

hypertension, ceasing to smoke, ensuring one engages in regular physical exercise, avoiding

excess consumption of alcohol and other substances. For patients classified with stage B heart

failure, therapies are aimed at preventing LV remodeling.

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