Home > Encyclopedia of Nursing & Allied Health > Heart Failure

Definition

"Heart failure" is a broad term—often used inter-changeably with "congestive heart failure" (CHF)—to describe the heart's inability to consistently pump enough blood to the body's organs and tissues. Heart failure occurs either from a structural or a functional abnormality. Since blood carries oxygen and vital nutrients to cells throughout the body, a decrease in blood supply interferes with the ability of organs and other tissues to function properly.

Description

According to the American College of Cardiology, approximately 4.8 million Americans live with CHF. Patients ages 65 and older are hospitalized for complications from CHF more often than for any other medical condition, accounting for about 875,000 hospital admissions each year. Anywhere between 400,000 and 700,000 cases of CHF are discovered annually, bringing the cost of treating patients in the United States between $10 billion and $30 billion. CHF is either a direct or contributing cause of death for as many as 250,000 people per year. As the population ages, the incidence of heart failure increases.

The term "congestive heart failure" describes its course of action. When the heart fails for some reason to deliver adequate blood supply to the body's tissues, edema (swelling, or fluid buildup) develops. Where the edema occurs in the body depends on the part of the heart that is failing in some way. For example, when the left ventricle (lower left chamber of the heart) is damaged, blood fails to get out to other parts of the body as quickly as it returns from the lungs. When blood cannot get back to the heart, it backs up inside blood vessels in the lungs. Some of the fluid in the blood is then forced into the breathing space of the lungs, causing pulmonary edema. Pulmonary edema causes varying degrees of breathing difficulty. The degree of severity depends on the amount of excess fluid in the lungs and can be life-threatening in severe cases. Abnormalities in heart structure or rhythms can also cause left-ventricular CHF. Patients often complain of feeling very tired, due to the lack of circulating oxygen and nutrients caused by an inadequate blood supply.

When the right side of the heart fails, the right ventricle (lower right chamber of the heart) cannot pump blood to the lungs as quickly as blood returns from areas throughout the body, via the veins. The blood then engorges the right side of the heart and veins. Fluid begins to back up in the veins and pushes out into the tissues, causing edema, most often in the feet, ankles, and lower legs. Abnormalities of the heart valves and lung disorders often cause right-ventricular CHF.

The failing heart keeps pumping, but not as efficiently as it should. Sometimes the heart tries to compensate for its lack of pumping ability by becoming hypertrophic (larger). When this happens the heart chamber grows larger and the muscle in the wall of the heart thickens, sometimes helping to improve the pumping ability of the heart. Another way in which the damaged heart tries to compensate for declining pumping ability is by stepping up the frequency of heartbeats to improve blood output and circulation. Eventually the kidneys join the fight to compensate for the failing heart; they hold on to more salt and water in order to increase blood volume. But this extra fluid can also cause edema. This can further complicate the situation and make treatment even more difficult. As the condition worsens over time, these compensatory measures are not enough to keep the heart pumping enough blood to meet the body's demand.

For most people, heart failure is a chronic disease with no real cure. However, depending on the individual circumstances, heart transplantation is considered in some cases when all other treatment options fail. While there is no cure, heart failure can often be managed and treated effectively using medications, proper diet, modified exercise, and other lifestyle changes as needed.

Causes and symptoms

The most common causes of heart failure are:

• coronary artery disease (CAD)
• heart attack (which may be "silent")
• cardiomyopathy
• high blood pressure (HBP, or hypertension)
• heart valve disease
• infection of the heart valves or heart muscle
• congenital structural abnormality
• alcohol and drug abuse

CAD is the most common cause of heart failure. The arteries that supply the heart muscle with blood begin to narrow over time. Eventually they may become completely blocked. When the blood cannot reach a specific area of the heart, a heart attack occurs. Some heart attacks are so slight that they go unrecognized, while others prove lethal. The heart muscle is damaged when the blood supply is greatly reduced or blocked entirely. If the damage markedly impairs the heart's pumping ability, heart failure follows.

Cardiomyopathy is a general term describing disease of the heart-muscle tissue. It can be caused by CAD, an inherited abnormality, severe alcoholism or drug abuse, or a viral infection. When the cause of the condition cannot be identified, it is termed idiopathic cardiomyopathy. Some types of cancer treatments have been associated with the development of cardiomyopathy. Cardiomyopathy brought on by anthracycline or other cardiotoxic agents is termed toxic cardiomyopathy. Regardless of the cause of the condition, the heart muscle weakens and eventually fails.

Sustained and uncontrolled high blood pressure is another common cause of heart failure. The persistent high pressure exerted on arterial walls makes them thicker and less pliable, and resistant to normal blood flow. As a result, the heart compensates by pumping harder, in an attempt to regain normal blood flow. Eventually the heart cannot keep up with the increased demand and heart failure results.

Defective heart valves, congenital heart diseases, severe alcohol and drug abuse, cardiotoxic cancer treatments, and specific viruses can cause the heart to fail.

The patient with heart failure can experience any number of the following symptoms:

• swollen, prominent veins in the neck area
• shortness of breath (causing crackling noises in the lungs)
• frequent coughing, especially when lying down
• swollen feet, ankles, and legs (edema)
• abdominal swelling (acites) and pain (caused by organ engorgement)
• fatigue
• dizziness or fainting
• increased exercise intolerance
• sudden death

The person with left-sided heart failure may experience shortness of breath and increased episodes of coughing caused by fluid buildup in the lungs. Pulmonary edema often causes a patient to cough up bubbly, blood-tinged phlegm. In right-sided heart failure, fluid builds up in the veins and tissues, causing swelling of the lower extremities and the abdomen. When body tissues fail to get the oxygen and nutrients they require, they begin to lose their efficiency, causing increased dizziness and fatigue.

Diagnosis

Physicians base their diagnosis of heart failure on the results of the following evaluations:

• symptoms
• medical history
• physical examination
• blood work
• chest x ray
• electrocardiogram (ECG; also called EKG)
• metabolic exercise testing (stress test with gas-exchange measurement)
• cardiac catheterization

A person's symptoms can provide important clues to the presence of heart failure. Patients who come to see a doctor, whether at the office or in an emergency room, will be examined by a physician, and in some cases also by a physician's assistant, a nurse, nurse practitioner, or nurse clinician. A patient who complains of shortness of breath while performing activities of daily living (ADL) and/or episodes of shortness of breath that wakes him or her from sleep is exhibiting classic symptoms of heart failure.

The health care professional who first examines the patient will also write down the patient's medical history. Often, something in the patient's medical history, such as a history of rheumatic fever or sustained hypertension, can help support the diagnosis of heart failure.

The physician will complete a thorough physical examination. He or she will listen to the heart and the lungs using a stethoscope, looking and listening for signs of heart failure. Irregular heart sounds (gallops), rapid heartbeats, and murmurs of the heart valves may be heard. A crackling sound in the lungs tells the physician that fluid is present in the lungs. Quick or shallow breathing may be present, along with a rapid pulse.

The physician will palpate (press down firmly with the fingertips of both hands) the patient's abdomen to feel if the liver is enlarged. He or she will also check the skin and nail beds on fingers and toes, looking for a bluish tint and a feeling of coolness to the skin. The bluish tint and coolness reflect a lack of oxygen in those regions.

At least one, but preferably two different views of the patient's chest will be taken in the upright position, by a licensed radiologic technologist, to determine whether there is fluid in the lungs and/or the heart is enlarged. Some heart-valve or other structural abnormalities can also be identified on plain chest films. A radiologist (a physician who specializes in radiology) reads the x ray and gives the report to the patient's doctor. If the patient is in distress, the radiologist may call the ordering physician with a "wet" (immediate) reading; otherwise, the chest films will be read and dictated, and the patient's doctor will receive a transcribed report the next day.

Routine blood work can sometimes give insight into both the cause of the heart failure and the extent of damage to the heart. For example, an abnormally low level of sodium can indicate advanced heart failure with a poor prognosis. Conversely, a high creatinine (used to assess kidney function) level can reflect kidney malfunction that either is contributing to the heart failure or is caused by the failing heart. Medical assistants, phlebotomists, medical technicians, and nurses are all trained to draw blood from veins. The blood samples are evaluated in the laboratory by laboratory technicians, medical technologists, pathologists, and/or other trained and licensed medical-laboratory professionals.

An electrocardiogram gives information about heart rhythm and size. It can demonstrate an enlarged heart chamber and whether or not damage to the heart muscle is caused by narrowing or blocked arteries.

Besides a chest x ray, the physician may order an echocardiogram or an ultrasound of the heart to help reach a diagnosis. Echocardiography uses sound waves to make images of the heart. These images can show whether the heart wall or chambers are enlarged, or if there are any abnormalities of the heart valves. An echocardiogram can also be used to find out how much blood the heart is pumping. It helps determine the amount of blood the ventricle pumps each time the heart beats (called the ejection fraction). A healthy heart pumps at least one half the amount of blood in the left ventricle with each heartbeat. A test called a radionucleide ventriculography is sometimes ordered to measure the ejection fraction. It uses very low doses of an injected radioactive substance and is imaged as it travels through the heart.

Cardiac catheterization involves threading a small tube (catheter) into either the arm or groin area and up into the heart. The test is used to measure pressure in the heart and the amount of blood pumped by the heart. It can detect abnormalities of the coronary arteries, heart valves, heart muscle, and other blood vessels. Cardiac catheterization is not always necessary in diagnosing heart failure, but when used in concert with echocardiography and other tests, it can help to pinpoint the cause of the condition.

Chest x rays, echocardiography, cardiac catheterization, and radionucleide ventriculography are all performed by radiologic technologists and radiologists who are specifically trained in these specialty areas. The chest x ray and echocardiogram can be performed using a portable bedside unit if the patient is too ill to travel to the x-ray department.

Metabolic exercise testing provides a noninvasive method for getting a lot of information about the patient in heart failure. It not only gives the physician a good idea of the functional capacity of the heart, but also demonstrates the patient's maximal oxygen consumption during peak exercise. The test offers insight into any functional disability that the patient is experiencing, so that the physician can discuss individualized plans for rehabilitation in light of any physical limitations. This test if often performed by a cardiologist with a nurse, physical therapist, medical assistant, or technician present to assist.

Treatment

Heart failure is most often treated with different medications and lifestyle changes. In some cases, surgery is performed to correct abnormalities of the heart or heart valves. Heart transplantation is a last resort, considered only in certain cases.

Dietary changes designed to help the patient reach and maintain a proper weight and to reduce salt intake to reduce fluid buildup may be required (reducing salt intake helps decrease swelling in the lower extremities and abdomen). An individualized exercise program may be recommended, but only after a full evaluation by the physician. The physician works with cardiac-rehabilitation nurses, physical therapists, and the patient to determine what each patient can tolerate safely. The patient performs the exercise regimen in the cardiac-rehabilitation department for a number of weeks under the careful supervision of staff. The patients are hooked up to monitors, their vital signs taken at intervals throughout their program, to ensure their safety. Once exercise tolerance is established, the patient is encouraged to follow the program consistently and is cautioned not to change it in any way once he or she returns home, in order to avoid complications. The patient is also reminded to report any unusual symptoms to his or her physician. Depending on the patient's specific limitations and exercise needs, walking, bicycling, swimming, or even low-impact aerobic exercises may be recommended. Homebound patients will work with home health care nurses, therapists, and aides in much the same way to help manage their symptoms. Most medium-to larger-size hospitals in the United States have good cardiac-rehabilitation programs.

Other lifestyle changes that may reduce the severity of symptoms associated with heart failure include quitting smoking or other tobacco use, eliminating or reducing alcohol consumption, and not using certain drugs.

One or more of the following types of medications may be prescribed for heart failure:

• diuretics
• digitalis
• vasodilators
• beta blockers
• angiotensin-converting enzyme inhibitors (ACE inhibitors)
• angiotensin-receptor blockers (ARBs)
• calcium-channel blockers

Diuretic medication helps eliminate excess salt and water from the kidneys by making patients urinate more often. This increased flushing action helps reduce the swelling caused by fluid buildup in the tissues. It is important to monitor patients for electrolyte imbalance when they used diuretics regularly. Digitalis gives the heart muscle stronger pumping ability. Vasodilators, ACE inhibitors, ARBs, and calcium-channel blockers all help to lower blood pressure via different methods, expanding the blood vessels so that blood can move more freely through them. This expansion makes it easier for the heart to pump blood through the vessels.

Surgery is used to correct certain heart conditions that cause heart failure. Congenital heart defects and abnormal heart valves may be repaired with surgery. Narrowing or completely blocked coronary arteries can be effectively treated with angioplasty or coronary-artery bypass surgery.

In patients with severe heart failure, the heart muscle itself may become so damaged that available treatments cannot help. Patients in this condition are said to be in end-stage heart failure. The only available treatment option for patients in end-stage heart failure and for which all other treatments are no longer working is heart transplantation. However, the patient's age and a number of other health-related issues are taken into account in the decision-making process.

Support staff, including pharmacists, dieticians, physicians' assistants, nurses, technicians, physical therapists, respiratory therapists, and nurses' aides can play an important role in the effective management of the patient with heart failure. In communicating responsibly with one another and with the patient and his or her care-givers, many complications can be avoided and quality of life improved.

Prognosis

Most patients in mild or moderate heart failure can be successfully managed with a combination of dietary and exercise programs and the right medications. Many patients are able to participate in normal daily activities and lead relatively active lives. However, the patient's success with any treatment program depends a great deal on effective communication among members of the health care team and the patient's compliance with treatment recommendations.

Patients in severe heart failure may eventually have to consider heart transplantation. About 50% of patients diagnosed with CHF live for at least five years with the condition. Women who have heart failure often live longer than men with the same condition. However, survival statistics continue to improve some with newer and more advanced treatments.

Health care team roles

Each professional in the health care team plays an important role in helping to diagnose and treat a patient in any stage of heart failure. From the person who writes down the patient's medical history to the pharmacist who explains the patient's medications, attention to detail, effective communication, and a positive attitude are key to the patient's ability to realize good outcomes.

Cardiac-rehabilitation nurses—registered nurses who see the patient either in the hospital or at the doctor's office—will be responsible for assessing the patient's condition from the time the patient first presents with symptoms and complaints, and throughout return visits. All nurses take vital signs and monitor the patient's compliance with medications, diet, and exercise regimens. Nurses are expected to document their findings thoroughly in progress notes and to communicate any problems with the physician or other appropriate health care professional. Nurses explain and teach patients about their disease and different aspects of their treatment programs, and serve as the pipeline between the patient and the physician. They are also the patient's advocate. Nurses spend more time with patients than the other members of the health care team do, so they get a better opportunity to gain insight into the patient's total health picture.

Radiologic technologists are responsible for performing certain diagnostic procedures, either directly or by assisting a radiologist or cardiologist. Prior to the exam, the technician is responsible for explaining any procedure to the patient and for getting a consent form signed whenever contrast material will be injected into the body. The technician needs to ask whether the patient has any known allergies and communicate those findings to the radiologist before any contrast material is injected.

Respiratory therapists and physical therapists are required to explain any procedures or therapy they administer to patients. Dieticians explain different diet plans with patients and family caregivers to help patients get used to buying and preparing foods in ways that reduce both salt and caloric intake.

Patient education

Each member of the health care team is responsible for explaining the connection between his or her specific discipline and the patient's condition. For example, if breathing treatments are ordered by a physician to help keep a patient from getting pneumonia, the therapist needs to explain the procedure and the reason for the procedure to the patient. When a patient gets a chest x ray, the radiologic technologist should tell the patient that he or she will need to take in a deep breath and hold it in, so that the lungs fully expand and the radiologist can determine whether the lungs are clear and get an accurate measurement of heart size.

Nursing staff teach patients about the signs and symptoms of heart failure, treatment interventions, and expected outcomes. They are required to teach the patient about his or her specific heart failure and why certain interventions are necessary. For example, if a patient tells the nurse that he or she gets very short of breath walking from one end of the house to the other, the nurse can suggest that the patient choose a point in between to sit down for a few moments to rest. Nursing staff look for physical signs and symptoms of heart failure, chart assessments and vital signs, and review treatments with patients, keeping an eye out for compliance issues and whether treatment appears effective.

Patients who undergo cardiac catheterization are asked a number of questions before the procedure takes place, and then are asked to sign a consent form. Contrast material will be injected into the patient through a small catheter that may require a small incision in the groin or elbow area. The radiologist or technologist explains what physical sensations to expect while the contrast media is being injected, as well as any allergic-reaction potential, including symptoms and side effects.

Patients who undergo metabolic exercise testing will be monitored carefully throughout the procedure and asked to let the doctor know immediately if they feel any chest pain or dizziness during the procedure.

Prevention

Heart failure is usually caused by the effects of some type of heart disease. The best way to try to prevent heart failure is to eat a healthy diet and get regular exercise, but many causes of heart failure cannot be prevented. People with risk factors for coronary disease (such as high blood pressure and high cholesterol levels) should work closely with their physician to reduce their likelihood of heart attack and heart failure.

Heart failure can sometimes be avoided by identifying and treating any conditions that might lead to heart disease. These include HBP, alcoholism or drug abuse, obesity, and CAD. Regular blood-pressure checks and seeking immediate medical care for symptoms of CAD, such as chest pain, will help to get these conditions diagnosed and treated early, before they progress and damage the heart muscle.

Finally, diagnosing and treating heart failure before the heart becomes severely damaged can improve the prognosis. With proper treatment, many patients may continue to lead active lives for a number of years.

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KEY TERMS

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Angioplasty—A technique used for treating blocked coronary arteries by inserting a catheter with a tiny balloon at the tip into the artery and then inflating it.

Angiotensin-converting enzyme (ACE) inhibitor— A drug that relaxes blood-vessel walls and lowers blood pressure.

Arrhythmia—Abnormal heartbeat.

Atherosclerosis—Buildup of a fatty substance called a plaque inside blood vessels.

Calcium-channel blocker—A drug that relaxes blood vessels and lowers blood pressure.

Cardiac catheterization—A diagnostic test for evaluating heart disease; a catheter is inserted into an artery and passed into the heart.

Cardiomyopathy—Disease of the heart muscle.

Catheter—A thin, hollow tube.

Congenital heart defects—Abnormal formation of structures of the heart or of its major blood vessels, present at birth.

Congestive heart failure—A condition in which the heart cannot pump enough blood to supply the body's tissues with sufficient oxygen and nutrients; backup of blood in vessels and the lungs causes buildup of fluid (congestion) in the tissues.

Coronary arteries—Arteries that supply blood to the heart muscle.

Coronary artery bypass—A surgical procedure to reroute blood around a blocked coronary artery.

Coronary artery disease—Narrowing or blockage of coronary arteries by atherosclerosis.

Diuretic—A type of drug that helps the kidneys eliminate excess salt and water.

Edema—Swelling caused by fluid buildup in tissues.

Ejection fraction—A measure of the portion of blood that is pumped out of a filled ventricle.

Heart valves—Valves that regulate blood flow into and out of the heart chambers.

Hypertension—High blood pressure.

Hypertrophic—Enlarged.

Idiopathic cardiomyopathy—Cardiomyopathy without a known cause.

Pulmonary edema—Buildup of fluid in the tissue of the lungs.

Vasodilator—Any drug that relaxes blood-vessel walls.

Ventricles—The two lower chambers of the heart.

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Susan Joanne Cadwallader