Best practices in congestive heart failure management and diagnosis

Best Practices in the Management of Congestive Heart Failure

In recent years, diagnostic testing and treatments for cardiovascular diseases have improved survival rates and the quality of life for many patients, with the sole exception of congestive heart failure (CHF), which has experienced increases in both prevalence and incidence (Rahnavard & Nodeh, 2014). Moreover, today, coronary heart diseases in general and CHF in particular are among the leading causes of mortality in the United States, and the World Health Organization (WHO) projects that by 2020, cardiovascular diseases and major depression will become the two leading contributors to the global burden of disease (Ai & Bruce, 2010). While the precise causes of these increases remain under investigation, a great deal has been learned concerning the pathophysiological and clinical presentation of the condition, as well as its typical progression trajectory (Ai & Bruce, 2010). The availability of effective diagnostic testing has also facilitated the clinical management of CHF, but the disease continues to have an enormous impact on patients and their families that requires ongoing multidisciplinary support. Taken together, these factors combine to make CHF an especially challenging disease for management to achieve optimal clinical outcomes. To this end, this paper reviews the relevant peer-reviewed and scholarly literature concerning CHF to identify best practices in the foregoing areas, together with a specific case study of a 63-year-old retired Vietnam veteran suffering from the condition.

Analysis of Congestive Heart Failure

Pathophysiology

Congestive heart failure refers to the human heart's diminished ability to adequately satisfy the body's metabolic demands (Tilney, 2010). Typically, this diminished ability develops over time and can involve the right (i.e., venous congestion) or left side (i.e., cardiogenic pulmonary edema) of the heart individual or collectively (Tilney, 2010). There are two fundamental types of heart failure: (a) systolic and (b) diastolic (Tilney, 2010). The former condition occurs with the heart loses its ability to adequately pump blood through the circulatory system while the latter is most commonly caused by ischemic heart disease (Tilney, 2010). Some of the other etiologies of systolic heart failure are set forth in Table 1 below.

Table 1

Etiologies of Congestive Heart Failure

Systolic Heart Failure

Diastolic Heart Failure

Ischemic Heart Disease s/p MI

Hypertension

Coronary artery Disease

Infiltrative Cardiomyopathy

Hypertension

Coronary Artery Disease

Fluid overload (and fluid retention)

Diabetes Mellitus

Cardiac Dysrhythmias

Left ventricular hypertrophy

Renal Disease

Chronic heart valve stenosis

Valvular Disease (i.e. regurgitation, chordae tendonae rupture)

Source: Adapted from Tilney, 2010

Clinical presentation

The clinical presentation of patients with CHF includes a number of different types of symptoms, the majority of which are non-specific (Watson, Gibbs & Lip, 2010). Typically, patients with CHF will present complaining of fatigue, a lack of endurance for physical activities, swollen ankles, and dyspnea, the most common complaint (Watson et al., 2010). In addition, many patients present with respiratory distress, including wheezing and bronchospasm (Watson et al., 2010). It is important to note, though, that the accurate diagnosis of CHF based on clinical presentation symptoms is isolation of other diagnostic testing may not be possible in certain groups, most especially obese individuals, women and the elderly (Watson et al., 2010).

Symptoms

Congestive heart failure is characterized by the following symptoms:

Dyspnea;

Orthopnea;

Paroxysmal nocturnal dyspnea;

Reduced exercise tolerance;

Lethargy;

Fatigue;

Nocturnal cough;

Wheeze;

Ankle swelling; and,

Anorexia (Watson et al., 2010, p. 238).

Disease progression trajectory

Among the several chronic conditions that comprise the group of cardiovascular diseases, CHF is the only disease whose incidence and prevalence rates have both increased significantly in recent years (Rahnavard & Nodeh, 2014). The disease's progression trajectory includes atrial fibrillation, malignant ventricular arrhythmias, strokes and embolisms (Watson et al., 2010). As Watson and his associates stress, "As [CHF] is progressive, the importance of early treatment, in an attempt to prevent progression to more severe disease, cannot be overemphasized" (2010, p. 237). Indeed, the morbidity and mortality for all types of CHF remain high, and even mild to moderate cases have a 20%-30% 1-year mortality rate which increases to 50% in severe cases (Watson et al., 2010).

Diagnostic testing

Following the completion of comprehensive physical examination and detailed medical history, diagnostic testing for CHF typically includes one or more of the following tests:

An electrocardiogram (EKG) is used to assess whether cardiac ischemia is the current etiology of the patient's condition;

Cardiac enzymes including creatinine kinase (CK), creatinine kinase myocardial band (CK-MB), and troponin;

Assessment of electrolytes (including sodium and potassium);

Evaluation of renal function is evaluated with BUN and creatinine to determine the extent, if any, of renal failure;

A routine complete blood count is used in many cases to determine whether anemia or thrombocytopenia are complicating factors;

Evaluation to determine if the B-type natriuretic peptide (BNP) is elevated which can help determine to extent, if any, to which the etiology of the patient's respiratory distress is secondary to heart failure;

A chest x-ray to determine the presence of pulmonary congestion, subsequent edema, the presence of cardiomegaly, pleural effusions and Kerley B lines (Tilney, 2010, p. 5).

Clinical management

Appropriate and timely clinical management of CHF can help improve survival rates, but the majority of patients suffering from CHF remains misdiagnosed or receives inappropriate treatments (Watson et al., 2010). In fact, a recent study by Carpenter and Short (2015) found that, "Patients with a diagnosis of congestive heart failure had a 30- day readmission rate of 26.9%, the highest of all diagnostic categories reported. The estimated annual cost to Medicare of unplanned readmissions was $17.4 billion in 2004" (p. 255). In those cases where the etiology of CHF implicates systolic dysfunction, survival rates can be minimally improved by administering angiotensin converting enzyme inhibitors (Watson et al., 2010).

Case Presentation

The individual of interest is "Mr. Johnson," a married, 63-year-old male, 100% service-connected disabled Vietnam veteran who retired from the U.S. Army in 1977 who has no other family members living. The patient was transported to a local community hospital by ambulance complaining on an inability of "catch his breath" due to the distance to the nearest available Department of Veterans Affairs (VA) medical facility. The patient reports a series of previous similar episodes, some of which required inpatient care in a VA medical center. Upon arrival at the emergency room, the patient's vital signs were as follow: (a) respiration rate -- 34; pulse -- 105; BP 160/100; oxygen saturation 89% on 100% oxygen.

The physical examination of Mr. Johnson identified the following symptoms:

Edema in his ankles;

Labored breathing while sitting;

Shortness of breath when supine;

A reduced tolerance for physical activities;

Lethargy;

Nocturnal coughing; and,

Wheezing.

Assessment of the Problem

In some cases, the symptoms of CHF resemble and overlap certain mental health or other respiratory-related conditions that should be ruled out (Rahnavard & Nodeh, 2014). In addition, bacterial and viral pneumonia as well as stroke should be ruled out (Rounds & Rappaport, 2010). A complete physical examination and medical history should be completed together with the foregoing diagnostic testing regimens (Tilney, 2010; Watson et al., 2010). Based on the results of these findings, an appropriate management plan can be formulated as described below.

Management Plan Synthesis

Following the administration of the diagnostic testing protocols described above, including an EKG and chest x-ray, Mr. Johnson and his wife should receive patient education concerning his post-discharge needs, including any limitations on his physical activities, nutritional needs, and community-based resources (especially those available through the VA) (Muller & Early, 2014). Although Mr. Johnson receives monthly disability compensation from the VA, he has no applied for aid and attendance assistance and he should be encouraged to apply at his earliest opportunity to obtain in-home nursing assistance as required to help management his CHF symptoms (Muller & Early, 2014). In addition, Mr. Johnson had delayed application for Social Security payments until his 65th birthday in order to attain the maximum rate, and he has not applied for a Social Security disability rating. Therefore, the patient should be encouraged to consult his local Social Security office to determine the feasibility of earlier application for Social Security benefits as well as disability status to provide him and his wife with the financial means to improve their quality of life while undergoing treatment for his CHF condition (Muller & Early, 2014).

Finally, follow-up visits should be scheduled to ensure Mr. Johnson's adherence to his medication regimen. For instance, a recent analysis of a cohort of 135,000 individuals with CHF, hypertension, diabetes, or dyslipidemia over a 3-year period determined that adherence rates ranged from 34 to 51%, with nonadherence rates being highest for CHF (Roebuck et al. 2011). Likewise, other researchers have also determined that full compliance rates by CHF patients can dramatically reduce readmission rates and the corresponding costs of their health care as well as improving clinical outcomes (Hough, 2013).