In

By:

GALLARDO, JAY D.
BSN 4-A UI SN



Heart failure
- is an illness in which the pumping action of the heart becomes less and less powerful. When this happens, blood does not
move efficiently through the circulatory system and starts to back up, increasing the pressure in the blood vessels and
forcing fluid from the blood vessels into body tissues. Symptoms depend on which area of the body is most involved in
the reduced pumping action.
Left side -When the left side of the heart (left ventricle) starts to fail, fluid collects in the lungs (pulmonary edema).
This extra fluid in the lungs (pulmonary congestion) makes it more difficult for the airways to expand as a person
inhales. Breathing becomes more difficult and the person may feel short of breath, particularly with activity or when
lying down.
Right side -When the right side of the heart (right ventricle) starts to fail, fluid begins to collect in the feet and lower
legs. Puffy leg swelling (edema) is a sign of right heart failure, especially if the edema is pitting edema. With pitting
edema, a finger pressed on the swollen leg leaves an imprint. Non-pitting edema is not caused by heart failure.
As the right heart failure worsens, the upper legs swell and eventually the abdomen collects fluid (ascites). Weight gain
accompanies the fluid retention and is a reliable measure of how much fluid is being retained.
Congestive heart failure (CHF) is generally classified as systolic or diastolic heart failure and becomes progressively more
common with increasing age.
Systolic heart failure: This condition occurs when the pumping action of the heart is reduced or weakened. A common
clinical measurement is ejection fraction (EF). The ejection fraction is a calculation of how much blood is ejected out of
the left ventricle (stroke volume) divided by the maximum volume remaining in the left ventricle at the end of diastole, or
when the heart is relaxed after filling with blood.
Diastolic heart failure: This condition occurs when the heart can contract normally but is stiff, or less compliant, when it
is relaxing and filling with blood. The heart is unable to fill with blood properly, which produces backup into the lungs
and heart failure symptoms. Diastolic heart failure is more common in patients older than 75 years of age, especially in
patients with high blood pressure, and it is also more common in women. In diastolic heart failure, the ejection fraction is
normal or increased.
Congestive Heart Failure Causes
Weakened heart muscle (cardiomyopathy)
Damaged heart valves
Blocked blood vessels supplying the heart muscle (coronary arteries), which may lead to a heart attack (This is known
as ischemic cardiomyopathy.
Toxic exposures, such as alcohol or cocaine
Infections, commonly viruses, which for unknown reasons affect the heart in only certain individuals
High blood pressure that results in thickening of the heart muscle (left ventricular hypertrophy)
Congenital heart diseases
Certain genetic diseases involving the heart
Prolonged, serious arrhythmias
Congestive heart failure may be exacerbated by the following lifestyle habits:
Unhealthy habits, such as smoking and excessive use of alcohol
Obesity and lack of exercise
High salt intake, which may cause more fluid retention
Noncompliance with medications and other therapies


Congestive Heart Failure Risk Factors, Symptoms, and Signs
Based on a clinical study, it was determined that one in every five people will develop heart failure in his or her lifetime.
Some of the most common risk factors for heart failure include:
Age
Hypertension
Physical inactivity
Diabetes
Obesity
Smoking
Metabolic syndrome
Family history of heart failure
Enlargement of the left ventricle
Some types of valvular heart disease, including
infection
Coronary artery disease
High cholesterol and triglycerides
Excessive alcohol consumption
Infection of the heart muscle (usually viral)

Signs and Symptoms
People with congestive heart failure sometimes do not suspect a problem with their heart or have symptoms that may not
obviously be from the heart.
Early symptoms may include shortness of breath, cough, or a feeling of not being able to get a deep breath, especially
when lying down.
If a person has a known breathing problem, such as asthma, chronic obstructive pulmonary disease (COPD),
oremphysema, they may they are having an "attack" or worsening of that condition.
If a person usually does not have breathing problems, they may think they have a cold,flu, or bronchitis.
Any or several of these above conditions may coexist along with congestive heart failure.
Congestive heart failure can have the following major symptoms:
Exercise intolerance
Shortness of breath
Fluid retention and swelling
Congestive Heart Failure Stages
Once a diagnosis of heart failure is established, evaluation of heart failure is important. Providing a complete and accurate
history of symptoms is essential.
Stage A: High risk for developing heart failure
o Patient has one or more risk factors for developing heart failure.
Stage B: Asymptomatic heart failure
o This stage includes patients who have an enlarged or dysfunctional left ventricle from any cause, but are
asymptomatic.
Stage C: Symptomatic heart failure
o Patient experiences heart failure symptoms -- shortness of breath, fatigue, inability to exercise, etc.
Stage D: Refractory end-stage heart failure
o Patient has heart failure symptoms at rest in spite of medical treatment.
o Cardiac transplantation, mechanical devices, more aggressive medical therapy, or end-of-life care may be necessary.


Congestive Heart Failure Diagnosis Procedures
Chest X-ray: This is very helpful in identifying the buildup of fluid in the lungs. Also, the heart usually enlarges in
congestive heart failure, and this may be visible on the X-ray film.
An electrocardiogram (ECG, EKG) is a painless test that measures the electrical activity (rhythm) of the heart. The
ECG can reveal several different heart problems that can cause heart failure, including heart attacks, rhythm disorders,
long-standing strain on the heart from high blood pressure, and certain valve problems.
Blood tests: People may have blood drawn for lab tests.
Low blood cell counts (anemia) may cause symptoms much like congestive heart failure or contribute to the condition.
Sodium, potassium, magnesium, and other electrolyte levels may be abnormal, especially if the person has been treated
with diuretics and/or has kidney disease.
B-type natriuretic peptide (BNP) can be measured. This is a hormone produced at higher levels by the failing heart
muscle. This is a good screening test; the levels of this hormone generally increase as the severity of heart failure
worsens.
Echocardiogram (ECG, EKG): This is a type of ultrasound that shows the beating of the heart and the various cardiac
structures. It is one of the most important tests for diagnosing and following patients with heart failure over time.
An echocardiogram can be useful in determining the cause of heart failure (such as problems with the muscle, valves,
or pericardium) and it provides an accurate measurement of the left ventricle's ejection fraction, an important measure
of the heart's pumping function.
In multiple-gated acquisition scanning (MUGA scan), a small amount of a mildly radioactive dye is injected into a vein
and travels to the heart. As the heart pumps, pictures are taken. The pumping performance of the left and right
ventricles can then be determined from these pictures.
Stress testing: A treadmill or medication (nonwalking) stress test is used to help evaluate the cause or causes of heart
failure, in particular, regarding coronary artery disease. This test is frequently combined with nuclear imaging or
echocardiography to improve accuracy. Stress testing is commonly performed and is a cornerstone of diagnostic
cardiology.
MRI (Magnetic resonance imaging):
Magnetic fields are used to provide images of the structure of the heart and its ability to pump blood to the body.
If used with a special MRI contrast agent (gadolinium), it can provide information about inflammation, injury, and
blood flow to the heart.
Cardiac catheterization (cath): During this procedure, a small tube is inserted into and artery in the leg or arm. The
catheter is moved to the heart to measure pressures inside the heart and to put contrast into the coronary arteries to look
for blockages.
Although this test is invasive, it is common and considered the gold standard for diagnosing coronary artery disease
as well as for measuring various pressures in the heart and diagnosing certain disorders of the heart valves.
Medical Treatment
Congestive Heart Failure Diet and Lifestyle Changes
Congestive heart failure is a serious medical condition that requires professional medical help, but even some simple
treatments at home may help reduce congestive heart failure symptoms.
Once diagnosed and under the care of a qualified medical professional, patients can and should do several things at
home to increase their comfort and reduce the chance of the condition getting worse.
In fact, the more active role patients take in managing heart failure, the more likely they are to do well.
Making the lifestyle changes described here will make a real difference. Not only will patients feel better, but they will
increase their chances of a longer, healthier life.
Treat swelling with the following measures:
Elevate the feet and legs if they are swollen.
Eat a reduced-salt diet.
Weigh in every morning before breakfast and record it in a diary that can be shown to a health care provider.
Avoid the following:
Not taking prescribed medications
Smoking (in all forms)
Alcohol (up to one drink per day is usually fine, unless prone to excessive intake/alcoholism)
Excessive emotional stress and/ordepression (seek professional help)
Patients with congestive heart failure should know the following information that may apply to their disease:
Keep walking or doing some form of aerobic exercise. Join a cardiac rehabilitation program (this program can monitor
a person's exercise capacity).
People with diabetes must control their blood sugar level every day.
People with high blood pressure should measure it regularly, and make sure they know the value, (systolic pressure
should be below 140 mm Hg in everyone and even below 130 in many individuals).
Congestive Heart Failure Medications
People with heart failure usually take several different medications that work in different ways to lessen heart failure
symptoms, to prevent worsening of the underlying disease, and to prolong life.
Diuretics (water pills): The buildup of fluid is usually treated with a diuretic.
Diuretics cause the kidneys to remove excess salt and accompanying water from the bloodstream, thereby reducing the
amount of blood volume in circulation. With a lower volume of blood, the heart does not have to work so hard.
The end result is an improvement in the ability to breathe (clear out water in the lungs) and a lessening of the swelling
in the lower body.
Diuretics commonly used in heart failure
include furosemide (Lasix), bumetanide(Bumex), hydrochlorothiazide (HCTZ),spironolactone (Aldactone), eplerenone
Digoxin (Lanoxin): Digoxin is a mild inotrope and, in some cases, is beneficial as an add-on therapy to ACE inhibitors
and beta-blockers.
Digoxin can reduce heart failure symptoms and hospitalizations, but it does not prolong life.
Digoxin is mainly used as an antiarrhythmic to control the rate of the heart in atrial fibrillation and flutter. In contrast,
excessive digoxin in the blood can cause life-threatening arrhythmias.
Vasodilators: These medications enlarge the small arteries or arterioles, which relieve the systolic workload of the left
ventricle. Therefore, the heart has to work less to pump blood through the arteries.
ACE inhibitors are the most widely used vasodilators for congestive heart failure. They block the production of
angiotensin II, which is abnormally high in congestive heart failure. Angiotensin II causes vasoconstriction with
increased workload on the left ventricle, and it is directly toxic to the left ventricle at excessive levels.
Some common examples of ACE inhibitors
are captopril (Capoten),enalapril (Vasotec), lisinopril (Zestril/Prinivil), benazepril (Lotensin),quinapril (Accupril)
Angiotensin II receptor blockers (ARBs) work by preventing the effect of angiotensin II at the tissue level. Include
candesartan (Atacand), irbesartan (Avapro), olmesartan (Benicar), losartan(Cozaar), valsartan (Diovan), telmisartan (M
icardis), and eprosartan (Teveten). These medications are usually prescribed for people who cannot take ACE
inhibitors because of side effects.
ACE inhibitors and ARBs may cause the body to retain potassium, but this is generally only a problem in people with
significant kidney disease, or in people who are also taking a potassium-sparing diuretic, such as triamterene or
spironolactone. Potassium levels can be monitored with lab testing.
Calcium channel blockers (CCBs) are arterial vasodilators that are not used for treatment of heart failure because
clinical trials have proven no specific benefit. However, calcium channel blockers are useful for lowering blood
pressure. Some CCBs include diltiazem (Cardizem), verapamil(Calan, Isoptin), nifedipine (Procardia, Adalat),
and amlodipine (Norvasc).
Nitrates are venous vasodilators that include isosorbide mononitrate (Imdur) and isosorbide dinitrate (Isordil). They are
commonly used in combination with an arterial vasodilator, such as hydralazine .
Nitroglycerin is a nitrate preparation that is administered to treat acute chest pain, or angina.
Beta-blockers: These drugs slow down the heart rate, lower blood pressure, and have a direct effect on the heart muscle
to lessen the workload of the heart. Specific beta-blockers, such as carvedilol (Coreg) and long-acting metoprolol (Toprol
XL), have been shown to decrease symptoms, hospitalization due to congestive heart failure, and deaths.
Inotropes: IV inotropes are stimulants, such as dobutamine and milrinone, which increase the pumping ability of the
heart. These are used as a temporary support of a very weak left ventricle that is not responding to standard congestive
heart failure therapy. Commonly used inotropes are dobutamine (Dobutex) and milrinone (Primacor).
Congestive Heart Failure Interventions
Other treatment or procedures may be offered, depending on the underlying cause of the heart failure.
Angioplasty: This is an alternative to coronary bypass surgery for some people whose heart failure is caused by coronary
artery disease and may be compounded by heart damage or a previous heart attack. Angioplasty is performed to treat
narrowing or blockage of a coronary artery that supplies the left ventricle with blood. The narrowing or blockage is
caused by cholesterol deposits.
Pacemaker: This device controls the rate of the heartbeat. A pacemaker may keep the heart from going too slow,
increasing heart rate when the heart is not increasing enough with activity. It also helps sustain regular rates when the
heart is not beating in a coordinated way. Or, the pacemaker performs some combination of these.
A pacemaker is an electrode on the tip of a wire, usually implanted inside the heart by an electrophysiologist or
specialized cardiologist in the cardiac cath lab. This wire goes to the right ventricle, frequently with a second wire to
the right atrium (dual chamber pacemaker).
Implantable Cardioverter Defibrillator (ICD): This device returns the heart to a normal rhythm by pacing or delivering
an electrical shock, with a life-threatening arrhythmia.
ICDs are indicated for ischemic or nonischemic cardiomyopathy patients with slight or marked physical limitations and
low left ventricular ejection fractions (<30% to 35%), since these patients are at higher risk for serious ventricular
arrhythmias. In these circumstances, an ICD may be implanted as part of a pacemaker device. This defibrillator can
detect and electrically shock a life-threatening arrhythmia back to normal.
Temporary Cardiac Support: An intra-aortic balloon pump is used as a temporary support of left ventricle function,
such as in a large heart attack, waiting for the heart to recover
Congestive Heart Failure Surgery and Follow-up
Surgery can repair some underlying causes of heart failure, such as blockage of the coronary arteries, a valve problem, a
congenital heart defect, or thickened pericardium. For patients with severe coronary artery disease, coronary artery bypass
graft (CABG) surgery can be conducted to circumvent blockages in vessels and ensure that the heart muscle maintains its
blood supply. Valve replacement surgery can also be performed to repair malfunctioning heart valves. However, once the
heart's ability to pump blood is severely, permanently, and irreversibly impaired, no surgery can repair the damage. The
only alternative is a heart transplant.
Left ventricle assist device (LVAD): This device is surgically implanted to mechanically bypass the left ventricle. It can
be used as a bridge to transplant until a heart transplant is available.
Total artificial heart (TAH): For patients with severe, end-stage heart failure.
These devices are most commonly used as a temporary bridge to heart transplantation, but can be used as destination
therapy in patients who are not eligible for a transplant and have a high chance of mortality within 30 days.
Congestive Heart Failure Prevention and Prognosis
Some examples of illnesses or lifestyle choices that can lead to congestive heart failure are as follows:
Coronary heart disease (coronary artery disease),
including heart attack
Uncontrolled high blood pressure (hypertension)
Uncontrolled high cholesterol
Diabetes
Congenital heart disease
Infection
Damage to the heart valves
Alcoholism
Smoking
If a person has congestive heart failure, they are at increased risk of developing pneumonia. They probably should receive
both the pneumonia vaccination and annual flu shots. Patients should ask their primary health care provider to be sure.
Prognosis
Heart failure is a major health problem that comes with the aging of America. Today, many more people are surviving
heart attacks and other heart diseases. Enduring these heart conditions allows them many more years of quality life, but
can eventually lead to the development of heart failure.
In recent years, more effective medications have been developed that improve the outlook of heart failure. Medications
are the mainstay of therapy with congestive heart failure.
New and sophisticated treatments are allowing people to live longer. These results are proven by clinical trials in which
patients volunteer to take new therapies under strict ethical and scientific monitoring.
Pacemakers and implantable defibrillators have improved and now offer the ability to control rare, but life-threatening,
disturbances of heart rhythm in some people.
Some people may even benefit from sophisticated treatments such as heart transplants and newer forms of temporary
mechanical hearts and LVADs.