Nearly 6 million Americans have congestive heart failure (CHF) costing the healthcare system an astonishing $34.4 billion dollars each year. About half of individuals diagnosed with heart failure die within 5 years of diagnosis. Nurse practitioners must be prepared to diagnose and treat CHF as early diagnosis and treatment improves quality of life and increases life expectancy for people with heart failure.
In individuals suffering from heart failure, cardiac output is insufficient to meet the needs of the body. This results in fluid congestion as the heart is not able to output enough blood volume to meet venous return.
A 67 year old female arrives at the emergency department complaining of shortness of breath for the past five days which has gotten progressively worse. Her shortness of breath is worse when lying down and with exertion. She complains of a cough, especially at night. The patient also notes increased swelling in her legs bilaterally and well as mild substernal chest pressure.
The patient has a history of hypertension, diabetes and a prior myocardial infarction. Her vital signs are as follows: BP 210/106, HR 118, RR 26, T 98.2. On exam you note rales in the lung bases bilaterally as well as 1+ pitting edema in the lower extremities bilaterally. The patient is sitting up and in no acute respiratory distress. Her oxygen saturation is 94%.
Suspecting CHF, you order an EKG checking for arrhythmias, ischemia or infarction and coronary artery disease as possible causes. You order the following lab studies:
- Complete Blood Count (CBC)- Shows signs of anemia or infection, potential causes of CHF
- Urinalysis- Proteinuria may be associated with cardiovascular disease
- Electrolyte Levels- May be abnormal related to renal dysfunction or fluid retention
- Liver Function Tests- Heart failure may result in liver dysfunction
- BUN and Creatinine Levels- Indicate decreased renal blood flow
- B-type Natriuretic Peptide (BNP)- Increased in heart failure
A chest X-Ray shows cardiomegaly and mild pulmonary congestion.
Based on lab findings, EKG, X-Ray results and the patient's symptoms and presentation you suspect CHF and plan to order an echocardiogram to confirm your diagnosis to evaluate the patient's heart function.
Management and Outcome
Both nonpharmacologic and pharmacologic therapies are used in treatment of heart failure. Dietary modifications including salt and fluid restriction can help reduce fluid retention in patients with CHF. Restricting sodium to 2-3g/day is recommended.
Many drugs can be used to improve the heart's function and relieve symptoms associated with CHF. Diuretics are commonly prescribed to CHF in order to reduce edema and provide symptomatic relief. ACE inhibitors can improve left ventricular ejection fraction and increase survival. Beta blockers may also be used to control heart rate and prevent arrhythmia. Digoxin, commonly prescribed in CHF, increases cardiac output and improves heart failure symptoms.
Some patients with severe heart failure may require a pacemaker or defibrillator. These devices help maintain the heart in proper rhythm and prevent sudden death. In very severe cases, heart transplant may be considered.
With so many Americans suffering from heart failure, it is important that nurse practitioners be able to diagnose and treat CHF. While severe cases will require a cardiology referral, NP's are often responsible for diagnosing CHF as well as monitoring nonpharmacologic and basic pharmacologic treatment. It is important that CHF be promptly diagnosed and treated as early diagnosis and treatment improves survival and quality of life.
You Might Also Like: Do Nurse Practitioners Have High Enough Standards for Cholesterol Monitoring?
Ho KK, Pinsky JL, Kannel WB, Levy D. The epidemiology of heart failure: the Framingham Study. J Am Coll Cardiol. 1993 Oct. 22 (4 suppl A):6A-13A. [Medline]. [Full Text].
American Heart Association. Classes of heart failure. Available at http://www.heart.org/HEARTORG/Conditions/HeartFailure/AboutHeartFailure/Classes-of-Heart-Failure_UCM_306328_Article.jsp#.WUcGf-vyuHs. Updated: May 8, 2017; Accessed: June 18, 2017.
[Guideline] Yancy CW, Jessup M, Bozkurt B, et al, American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation. 2013 Oct 15. 128(16):e240-327. [Medline]. [Full Text].
[Guideline] Ponikowski P, Voors AA, Anker SD, et al, for the Authors/Task Force Members. 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure: The task force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur Heart J. 2016 Jul 14. 37 (27):2129-200. [Medline]. [Full Text].
[Guideline] Lindenfeld J, Albert NM, Boehmer JP, et al, for the Heart Failure Society of America. HFSA 2010 comprehensive heart failure practice guideline. J Card Fail. 2010 Jun. 16(6):e1-194. [Medline]. [Full Text].
Stiles S. FDA approves heart sympathetic activity imaging agent for HF evaluation. Medscape News from WebMD. March 22, 2013. Available at http://www.medscape.com/viewarticle/781309. Accessed: April 5, 2013.
Braunwald E. The pathogenesis of congestive heart failure: then and now. Medicine. 1991 Jan. 70(1):68-79. [Full Text].
Braunwald E, Ross J Jr, Sonnenblick EH. Mechanisms of Contraction of the Normal and Failing Heart. 2nd ed. Boston: Little Brown & Co; 1976.
Greyson CR. Pathophysiology of right ventricular failure. Crit Care Med. 2008 Jan. 36 (1 suppl):S57-65. [Medline].
Haddad F, Doyle R, Murphy DJ, Hunt SA. Right ventricular function in cardiovascular disease, part II: pathophysiology, clinical importance, and management of right ventricular failure. Circulation. 2008 Apr 1. 117 (13):1717-31. [Medline].
Onwuanyi A, Taylor M. Acute decompensated heart failure: pathophysiology and treatment. Am J Cardiol. 2007 Mar 26. 99 (6B):25D-30D. [Medline].
Ross J Jr, Braunwald E. Studies on Starling's law of the heart. IX. The effects of impeding venous return on performance of the normal and failing human left ventricle. Circulation. 1964 Nov. 30:719-27. [Medline]. [Full Text].
Gheorghiade M, Pang PS. Acute heart failure syndromes. J Am Coll Cardiol. 2009 Feb 17. 53 (7):557-73. [Medline].
Kajstura J, Leri A, Finato N, Di Loreto C, Beltrami CA, Anversa P. Myocyte proliferation in end-stage cardiac failure in humans. Proc Natl Acad Sci U S A. 1998 Jul 21. 95 (15):8801-5. [Medline]. [Full Text].
Cohn JN. Structural basis for heart failure. Ventricular remodeling and its pharmacological inhibition. Circulation. 1995 May 15. 91 (10):2504-7. [Medline].
Cody RJ. Hormonal alterations in heart failure. In: Hosenpud JB, Greenberg BH, eds. Congestive Heart Failure: Pathophysiology, Diagnosis and Comprehensive Approach to Management. Philadelphia, PA: Lippincott Williams & Wilkins; 2000. 199-212.
Anversa P, Nadal-Ginard B. Myocyte renewal and ventricular remodelling. Nature. 2002 Jan 10. 415 (6868):240-3. [Medline].
Leri A, Claudio PP, Li Q, et al. Stretch-mediated release of angiotensin II induces myocyte apoptosis by activating p53 that enhances the local renin-angiotensin system and decreases the Bcl-2-to-Bax protein ratio in the cell. J Clin Invest. 1998 Apr 1. 101 (7):1326-42. [Medline]. [Full Text].
Kajstura J, Leri A, Castaldo C, Nadal-Ginard B, Anversa P. Myocyte growth in the failing heart. Surg Clin North Am. 2004 Feb. 84 (1):161-77. [Medline].
Henes J, Rosenberger P. Systolic heart failure: diagnosis and therapy. Curr Opin Anaesthesiol. 2016 Feb. 29 (1):55-60. [Medline].
Nicoara A, Jones-Haywood M. Diastolic heart failure: diagnosis and therapy. Curr Opin Anaesthesiol. 2016 Feb. 29 (1):61-7. [Medline].
Feldman AM, Combes A, Wagner D, et al. The role of tumor necrosis factor in the pathophysiology of heart failure. J Am Coll Cardiol. 2000 Mar 1. 35 (3):537-44. [Medline].
Gary R, Davis L. Diastolic heart failure. Heart Lung. 2008 Nov-Dec. 37 (6):405-16. [Medline].
Morris DA, Gailani M, Vaz Perez A, et al. Right ventricular myocardial systolic and diastolic dysfunction in heart failure with normal left ventricular ejection fraction. J Am Soc Echocardiogr. 2011 Aug. 24 (8):886-97. [Medline].
Jousilahti P, Harald K, Jula A, et al, for the National Institute for Health and Welfare-THL - Helsinki - Finland. Salt intake and the risk of heart failure [abstract 1192]. Presented at: European Society of Cardiology 2017 Congress; August 27, 2017; Barcelona, Spain. Eur Heart J. Aug 2017. 38 (suppl 1):240. [Full Text].
Davenport L. High salt intake linked to increased heart-failure risk. Medscape News from WebMD. August 28, 2017. Available at http://www.medscape.com/viewarticle/884824. Accessed: September 1, 2017.
Lam CS, Lyass A, Kraigher-Krainer E, et al. Cardiac dysfunction and noncardiac dysfunction as precursors of heart failure with reduced and preserved ejection fraction in the community. Circulation. 2011 Jul 5. 124 (1):24-30. [Medline].
Ho KK, Anderson KM, Kannel WB, Grossman W, Levy D. Survival after the onset of congestive heart failure in Framingham Heart Study subjects. Circulation. 1993 Jul. 88 (1):107-15. [Medline].
Halley CM, Houghtaling PL, Khalil MK, Thomas JD, Jaber WA. Mortality rate in patients with diastolic dysfunction and normal systolic function. Arch Intern Med. 2011 Jun 27. 171 (12):1082-7. [Medline].
Murphy RT, Starling RC. Genetics and cardiomyopathy: where are we now?. Cleve Clin J Med. 2005 Jun. 72 (6):465-6, 469-70, 472-3 passim. [Medline].
Benjamin EJ, Blaha MJ, Chiuve SE, et al, for the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics-2017 update: a report from the American Heart Association. Circulation. 2017 Mar 7. 135 (10):e146-e603. [Medline]. [Full Text].
Ni H, Xu J. Recent trends in heart failure-related mortality: United States, 2000–2014. Centers for Disease Control and Prevention. December 31, 2015. Available at http://www.cdc.gov/nchs/data/databriefs/db231.htm. Accessed: January 5, 2016.
Brauser D. CDC: Heart-failure–related mortality rate climbs after decade-long decrease. Heartwire from Medscape. January 4, 2016. Available at http://www.medscape.com/viewarticle/856704. Accessed: January 5, 2016.
Chen J, Normand SL, Wang Y, Krumholz HM. National and regional trends in heart failure hospitalization and mortality rates for Medicare beneficiaries, 1998-2008. JAMA. 2011 Oct 19. 306 (15):1669-78. [Medline].
Kolte D, Abbott JD, Aronow HD. Interventional therapies for heart failure in older adults. Heart Fail Clin. 2017 Jul. 13 (3):535-70. [Medline].
Dharmarajan K, Rich MW. Epidemiology, pathophysiology, and prognosis of heart failure in older adults. Heart Fail Clin. 2017 Jul. 13(3):417-26. [Medline].
Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009 Apr 2. 360 (14):1418-28. [Medline].
Stewart S, Wilkinson D, Hansen C, et al. Predominance of heart failure in the Heart of Soweto Study cohort: emerging challenges for urban African communities. Circulation. 2008 Dec 2. 118 (23):2360-7. [Medline].
Damasceno A, Cotter G, Dzudie A, Sliwa K, Mayosi BM. Heart failure in Sub-Saharan Africa: time for action. J Am Coll Cardiol. 2007 Oct 23. 50 (17):1688-93. [Medline].
Mbewu A, Mbanya JC. Cardiovascular diseases. In: Jamison DT, Feachem RG, Makgoba MW, et al, eds. Disease and mortality in Sub-Saharan Africa. 2nd ed. Washington, DC: World Bank Publications; 2006. 305-28.
Dries DL, Exner DV, Domanski MJ, Greenberg B, Stevenson LW. The prognostic implications of renal insufficiency in asymptomatic and symptomatic patients with left ventricular systolic dysfunction. J Am Coll Cardiol. 2000 Mar 1. 35 (3):681-9. [Medline].
Fonarow GC, Adams KF Jr, Abraham WT, Yancy CW, Boscardin WJ, ADHERE Scientific Advisory Committee, et al. Risk stratification for in-hospital mortality in acutely decompensated heart failure: classification and regression tree analysis. JAMA. 2005 Feb 2. 293 (5):572-80. [Medline].
Levy D, Kenchaiah S, Larson MG, et al. Long-term trends in the incidence of and survival with heart failure. N Engl J Med. 2002 Oct 31. 347 (18):1397-402. [Medline].
Lucas C, Johnson W, Hamilton MA, et al. Freedom from congestion predicts good survival despite previous class IV symptoms of heart failure. Am Heart J. 2000 Dec. 140 (6):840-7. [Medline].
MacIntyre K, Capewell S, Stewart S, et al. Evidence of improving prognosis in heart failure: trends in case fatality in 66 547 patients hospitalized between 1986 and 1995. Circulation. 2000 Sep 5. 102 (10):1126-31. [Medline].
Ketchum ES, Levy WC. Establishing prognosis in heart failure: a multimarker approach. Prog Cardiovasc Dis. 2011 Sep-Oct. 54 (2):86-96. [Medline].
van Diepen S, Bakal JA, McAlister FA, Ezekowitz JA. Mortality and readmission of patients with heart failure, atrial fibrillation, or coronary artery disease undergoing noncardiac surgery: an analysis of 38 047 patients. Circulation. 2011 Jul 19. 124 (3):289-96. [Medline].
Bursi F, McNallan SM, Redfield MM, et al. Pulmonary pressures and death in heart failure: a community study. J Am Coll Cardiol. 2012 Jan 17. 59 (3):222-31. [Medline]. [Full Text].
Ho JE, Liu C, Lyass A, et al. Galectin-3, a marker of cardiac fibrosis, predicts incident heart failure in the community. J Am Coll Cardiol. 2012 Oct 2. 60 (14):1249-56. [Medline].
Dunlay SM, Eveleth JM, Shah ND, McNallan SM, Roger VL. Medication adherence among community-dwelling patients with heart failure. Mayo Clin Proc. 2011 Apr. 86 (4):273-81. [Medline]. [Full Text].
DeWalt DA, Schillinger D, Ruo B, et al. Multisite randomized trial of a single-session versus multisession literacy-sensitive self-care intervention for patients with heart failure. Circulation. 2012 Jun 12. 125 (23):2854-62. [Medline].
Lainscak M, Cleland JG, Lenzen MJ, Follath F, Komajda M, Swedberg K. International variations in the treatment and co-morbidity of left ventricular systolic dysfunction: data from the EuroHeart Failure Survey. Eur J Heart Fail. 2007 Mar. 9 (3):292-9. [Medline].
Panjrath G, Ahmed A. Diagnosis and management of heart failure in older adults. Heart Fail Clin. 2017 Jul. 13 (3):427-44. [Medline].
Stevenson LW, Perloff JK. The limited reliability of physical signs for estimating hemodynamics in chronic heart failure. JAMA. 1989 Feb 10. 261 (6):884-8. [Medline].
Steinhart B, Thorpe KE, Bayoumi AM, Moe G, Januzzi JL Jr, Mazer CD. Improving the diagnosis of acute heart failure using a validated prediction model. J Am Coll Cardiol. 2009 Oct 13. 54 (16):1515-21. [Medline].
[Guideline] Yancy CW, Jessup M, Bozkurt B, et al. 2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. Circulation. 2017 Aug 8. 136(6):e137-e161. [Medline]. [Full Text].
Rich MW, McSherry F, Williford WO, Yusuf S, for the Digitalis Investigation Group. Effect of age on mortality, hospitalizations and response to digoxin in patients with heart failure: the DIG study. J Am Coll Cardiol. 2001 Sep. 38 (3):806-13. [Medline].
[Guideline] Yancy CW, Jessup M, Bozkurt B, et al, for the Writing Committee Members. 2016 ACC/AHA/HFSA focused update on new pharmacological therapy for heart failure: an update of the 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. Circulation. 2016 Sep 27. 134 (13):e282-93. [Medline]. [Full Text].
Badve SV, Roberts MA, Hawley CM, et al. Effects of beta-adrenergic antagonists in patients with chronic kidney disease: a systematic review and meta-analysis. J Am Coll Cardiol. 2011 Sep 6. 58 (11):1152-61. [Medline].
Maisel AS, Krishnaswamy P, Nowak RM, et al, for the Breathing Not Properly Multinational Study Investigators. Rapid measurement of B-type natriuretic peptide in the emergency diagnosis of heart failure. N Engl J Med. 2002 Jul 18. 347 (3):161-7. [Medline].
Januzzi JL Jr, Camargo CA, Anwaruddin S, et al. The N-terminal pro-BNP investigation of dyspnea in the emergency department (PRIDE) study. Am J Cardiol. 2005 Apr 15. 95 (8):948-54. [Medline].
Wang CS, FitzGerald JM, Schulzer M, Mak E, Ayas NT. Does this dyspneic patient in the emergency department have congestive heart failure?. JAMA. 2005 Oct 19. 294 (15):1944-56. [Medline].
Maisel AS, McCord J, Nowak RM, et al, for the Breathing Not Properly Multinational Study Investigators. Bedside B-Type natriuretic peptide in the emergency diagnosis of heart failure with reduced or preserved ejection fraction. Results from the Breathing Not Properly Multinational Study. J Am Coll Cardiol. 2003 Jun 4. 41 (11):2010-7. [Medline].
Januzzi JL, van Kimmenade R, Lainchbury J, et al. NT-proBNP testing for diagnosis and short-term prognosis in acute destabilized heart failure: an international pooled analysis of 1256 patients: the International Collaborative of NT-proBNP Study. Eur Heart J. 2006 Feb. 27 (3):330-7. [Medline].
Maeda K, Tsutamoto T, Wada A, Hisanaga T, Kinoshita M. Plasma brain natriuretic peptide as a biochemical marker of high left ventricular end-diastolic pressure in patients with symptomatic left ventricular dysfunction. Am Heart J. 1998 May. 135 (5 Pt 1):825-32. [Medline].
Fisher C, Berry C, Blue L, Morton JJ, McMurray J. N-terminal pro B type natriuretic peptide, but not the new putative cardiac hormone relaxin, predicts prognosis in patients with chronic heart failure. Heart. 2003 Aug. 89 (8):879-81. [Medline]. [Full Text].
Hall C, Rouleau JL, Moye L, et al. N-terminal proatrial natriuretic factor. An independent predictor of long-term prognosis after myocardial infarction. Circulation. 1994 May. 89 (5):1934-42. [Medline].
Andersson B, Hall C. N-terminal proatrial natriuretic peptide and prognosis in patients with heart failure and preserved systolic function. J Card Fail. 2000 Sep. 6 (3):208-13. [Medline].
Chen HH, Burnett JC. Natriuretic peptides in the pathophysiology of congestive heart failure. Curr Cardiol Rep. 2000 May. 2 (3):198-205. [Medline].
Cheng V, Kazanagra R, Garcia A, et al. A rapid bedside test for B-type peptide predicts treatment outcomes in patients admitted for decompensated heart failure: a pilot study. J Am Coll Cardiol. 2001 Feb. 37 (2):386-91. [Medline].
Cowie MR, Struthers AD, Wood DA, et al. Value of natriuretic peptides in assessment of patients with possible new heart failure in primary care. Lancet. 1997 Nov 8. 350 (9088):1349-53. [Medline].
Dao Q, Krishnaswamy P, Kazanegra R, et al. Utility of B-type natriuretic peptide in the diagnosis of congestive heart failure in an urgent-care setting. J Am Coll Cardiol. 2001 Feb. 37 (2):379-85. [Medline].
Maeda K, Tsutamoto T, Wada A, Hisanaga T, Kinoshita M. Plasma brain natriuretic peptide as a biochemical marker of high left ventricular end-diastolic pressure in patients with symptomatic left ventricular dysfunction. Am Heart J. 1998 May. 135 (5 pt 1):825-32. [Medline].
Maisel AS, Koon J, Hope J, et al. A rapid bedside test for brain natriuretic peptide accurately predicts cardiac function in patients referred for echocardiography. Am Heart J. 2001. 141:374-9.
Masson S, Vago T, Baldi G, et al. Comparative measurement of N-terminal pro-brain natriuretic peptide and brain natriuretic peptide in ambulatory patients with heart failure. Clin Chem Lab Med. 2002 Aug. 40 (8):761-3. [Medline].
Song BG, Jeon ES, Kim YH, et al. Correlation between levels of N-terminal pro-B-type natriuretic peptide and degrees of heart failure. Korean J Intern Med. 2005 Mar. 20 (1):26-32. [Medline].
Hobbs FD, Davis RC, Roalfe AK, Hare R, Davies MK, Kenkre JE. Reliability of N-terminal pro-brain natriuretic peptide assay in diagnosis of heart failure: cohort study in representative and high risk community populations. BMJ. 2002 Jun 22. 324 (7352):1498. [Medline]. [Full Text].
Redfield MM, Rodeheffer RJ, Jacobsen SJ, Mahoney DW, Bailey KR, Burnett JC Jr. Plasma brain natriuretic peptide concentration: impact of age and gender. J Am Coll Cardiol. 2002 Sep 4. 40 (5):976-82. [Medline].
St Peter JV, Hartley GG, Murakami MM, Apple FS. B-type natriuretic peptide (BNP) and N-terminal pro-BNP in obese patients without heart failure: relationship to body mass index and gastric bypass surgery. Clin Chem. 2006 Apr. 52 (4):680-5. [Medline].
Rivera M, Cortes R, Salvador A, et al. Obese subjects with heart failure have lower N-terminal pro-brain natriuretic peptide plasma levels irrespective of aetiology. Eur J Heart Fail. 2005 Dec. 7 (7):1168-70. [Medline].