Congestive Heart Failure Management for an Elderly Veteran

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). Differentiation of Congestive Heart Failure from Normal Development Given the debilitating effects of CHF, it is not surprising that the condition can place enormous physical and psychological demands on the patient and family, but the extent of these adverse effects is widely believed to be highly related to the individual characteristics of the patient and family unit (Rahnavard & Nodeh, 2014).

The research to date indicates that the impact on the quality of life for younger patients (65 years) counterparts (Rahnavard & Nodeh, 2014). In addition, studies have shown that women in general tend to experience more severe effects on quality of life indicators, especially psychological aspects, compared to men (Rahnavard & Nodeh, 2014). Finally, patients' economic status will also have an effect on their quality of life and functioning ability (Rahnavard & Nodeh, 2014).

It is important to note, though, that the adverse effects of CHF have consistently been shown to have a more severe impact on quality of life overall compared to other chronic diseases (Rahnavard & Nodeh, 2014).

Therefore, the key concepts that must be shared with the patient and family to achieve optimal clinical outcomes include the need for patients with CHF to receive education from a registered nurse based on established risk factors taken from the predictive index elements and/or prior discharge plan failures together with planned transitions to home-based care or other post-discharge care resources (Carpenter & Short, 2015). There is also abundant evidence that supports the use of an interdisciplinary team for management CHF cases (Carpenter & Short, 2015).

Although every patient's needs are unique, the key personnel that should be included in such an interdisciplinary team include a cardiologist, nurse practitioner, dietitian and occupational rehabilitation specialist, as appropriate (Carpenter & Short, 2015). As noted above, though, economic status can have an enormous effect on the ability of patients and their families to provide optimal home-based or other post-discharge care (Rahnavard & Nodeh, 2014).

Therefore, an informed, individualized, patient-centered clinical management approach is required in order to identify potential barriers to optimal disease management and outcomes and appropriate strategies developed to overcome these barriers, such as referrals to community-based resources and follow-up visits to ensure patient adherence to medication regimens (Rahnavard & Nodeh, 2014). 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.