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Heart Failure is a syndrome in which all disease processes that cause damage to the heart and circulatory system can lead. Once diagnosed with heart failure, death from this condition has historically tended to be certain unless another cause of passing occurs first (Young, 2021).
Worldwide about 1% to 2% of the entire population, all ages, ethnicities, and genders, currently suffer from heart failure (Schwinger, 2021). This syndrome has been the number one cause of death worldwide (Schwinger, 2021). Heart failure is common and remains the greatest cause of hospitalizations in our Medicare population (Heart Failure Society of America [HFSA], 2022). All ages can experience this condition, with one in five American adults 40 years of age or older having or going on to develop heart failure in their lifetime (Centers for Medicare & Medicaid Services [CMS], 2020). In the United States, current estimates claim that 6.5 million people over the age of 20 years have heart failure, with one large study showing 960,000 new heart failure cases diagnosed every year (HFSA, 2022).
Heart failure directly accounts for about 8.5% of all cardiovascular deaths in the United States. However, be aware that this number is undervalued. Estimates show that heart failure as a persistent prevalent comorbid condition contributes to about 36% of deaths and is listed in more than one in eight death certificates (HFSA, 2022).
In 2020, a committee selected from fourteen countries met to seek a consensus definition for what was then known as Congestive Heart Failure (CHF). The condition has been renamed as simply “Heart Failure”, with the term congestive retired into a subcategory of overall Heart Failure. Despite contentions, arguments, and intense debates, the new name, Heart Failure (HF), and a concise definition and classification system eventually emerged.
The new definition for HF is (Gibson et al., 2021; Bozkurt et al., 2021):
- Heart Failure (HF) is a clinical syndrome with symptoms and/or signs caused by a structural and/or functional cardiac abnormality.
- This syndrome is corroborated by elevated natriuretic peptide levels and/or objective evidence of pulmonary or systemic congestion.
Table 1: Classifications of Heart Failure Staging
(Gibson et al., 2021; Bozkurt et al., 2021)
- The stages of HF are revised to emphasize the presence (or absence) of symptoms fundamental in the characterization of disease progression and severity:
- Stage A – At risk for HF
- Stage B – Pre-HF
- Stage C – Symptomatic HF
- Stage D – Advanced HF
Heart failure results as the secondary condition of any disorder causing actual or functional injury to the heart.
Heart failure exists whenever our heart does not pump blood in amounts adequate to meet the metabolic needs of our brain and body. The very name echoes with the sound of doom. To the person informed that they have it, the term “heart failure” has an emotional impact often equal to being diagnosed with cancer. Half of those hearing this diagnosis being applied to them for the first time will die of complications related to this syndrome within the first five years after diagnosis, and around 22% within the first-year post-diagnosis (Virani et al., 2020). With the new HF definition and accompanying diagnostic changes, this may shift as the new HF Stages A and B focus on identifying those at risk prior to observable symptoms (Gibson et al., 2021).
Stage A of the Universal Definition focuses on risk factors, something we as health professionals talk about often. There are no observable signs of structural damage to the heart or cardiovascular system in stage A. There are, however, precursors, or things we have known to have influence to leading to heart failure that can be mitigated to prevent the diagnosis.
Risk factors for heart failure include (Bozhurt et al., 2021; HFSA, 2022; Colucci & Borlaug, 2021):
- High blood pressure (hypertension)
- Fat deposits creating blockages in the heart’s arteries (coronary artery disease)
- Heart attack (myocardial infarction)
- Damage to the heart valves or history of a heart murmur (valvular heart disease)
- Obstructive lesions in the heart or great vessels
- Heart muscle disease
- Enlargement of the heart (cardiomyopathy)
- Pericardial disease
- Heart defects at birth (congenital heart disease)
- Family history of enlarged heart (Familial cardiomyopathy)
- Excessive alcohol use
- Sleep apnea
- Severe lung disease
Where the concept of the new HF Stage A comes into play is the principle of not waiting for a catastrophe to begin treatment. When heart failure risk factors are identified, it is important to begin intervention. Risk-lowering methods include risk counseling, prescription of healthy diets, regular exercise, smoking cessation, compliance with blood pressure medications, and adequate blood sugar control (Virani et al., 2020).
The new Stage B of the Universal Definition focuses on pre “traditional” heart failure, when you hear the horn of a train (Stage B), and you are already standing on train tracks (Stage A), you do not really need to see the train barreling toward you to realize you are at risk. So, let us stop, look, and listen to our clients while using some hard-earned discernment.
When there is a known structural injury to the heart or vascular system, cardiac pumping efficiency may be reduced. Reduced cardiac output, or stroke volume, will lead to heart changes (called remodeling) that create the visible signs of heart failure we currently await before beginning a diagnostic process, let alone treatment (Virani et al., 2020).
So, when structural cardiac damage or compromise is suspected or expected, look at the cardiac outflow. Ejection fraction measurement is key. Studies have already shown that most clients who compromise Stage B pre-heart failure, will already have an ejection fraction of 40% or less (Cannizzaro, 2021). Remember that Stage B still shows no visible sign of heart failure, yet.
The Ejection Fraction (EF), often referred to as “stroke volume,” measures the strength of each heart muscle contraction (Fogoros, 2021; Mayo Clinic, 2021). It is a comparison of how much blood volume was in the heart ventricle (either the left ventricle or the right ventricle) compared with how much blood remains after one complete heartbeat. Essentially, it is all about how efficient the heart pumps. The ejection fraction is provided as a percentage and indicates the percentage of blood pushed out into the circulation of the body (Fogoros, 2021; Mayo Clinic, 2021). If your Left Ventricle (LV) pushed half of the blood out, you would have a LVEF of 50%, sometimes written in a decimal format, so 0.5.
Ejection fraction percentage levels include (Fogoros, 2021; Mayo Clinic, 2021):
- Normal ejection fractions run between 50 and 70%.
- Ejection fractions higher than 75% are too strong and may be a disease process known as hypertrophic cardiomyopathy.
- An ejection fraction between 41 and 49% is a borderline health issue yet does not always show developing heart failure. It does reflect heart damage, however, and should be acted on.
- An ejection fraction of 40% or below is compelling evidence of impending or present heart failure.
It is important to note that left ventricle ejection fraction (LVEF) is what cardiologists look at most often. The right is important as well, yet if ejection fraction is referred to without specifying the right ventricle (RVEF) then it is LVEF that is being discussed.
Ejection fraction is measured in several ways (Fogoros, 2021; Mayo Clinic, 2021):
- This is the most often used and noninvasive way to study heart function with sound, now how cool is that!
- MUGA scan:
- Multigated acquisition (MUGA) scan is also noninvasive and is thought to be the most accurate and reproducible means of measuring EF.
- CT scan:
- Computed tomography scans are a medical imaging technique used in radiology to obtain detailed internal images of the body noninvasively.
- Cardiac Catheterization:
- This involves inserting a catheter into the blood vessels in the groin, wrist, neck, or arm as a means of direct heart flow readings.
- Nuclear Stress Test:
- This test uses a small amount of radioactive material (tracer) and an imaging machine to create pictures showing the blood flow of the heart.
The new classification of HF includes the specificity of left ventricular ejection fraction (LVEF) (Gibson et al., 2021; Bozkurt et al., 2021). See Table 2.
Table 2: Heart Failure & Ejection Fraction
(Gibson et al., 2021; Bozkurt et al., 2021)
|HF with reduced ejection fraction (HFrEF)||→||Symptomatic HF with LVEF ≤ 40%|
|HF with mildly reduced ejection fraction (HFmrEF)||→||Symptomatic HF with LVEF 41-49% (previously referred to as HF with mid-range ejection fraction)|
|HF with preserved ejection fraction (HFpEF)||→||Symptomatic HF with LVEF ≥ 50% (formerly known as diastolic failure)|
|HF with improved ejection fraction (HFimpEF*)||→||This is a new classification which is distinctly defined as symptomatic HF with a baseline LVEF ≤ 40%, a ≥10-point increase from baseline LVEF, and subsequent second measurement of LVEF > 40%|
It is also important to note that the international consensus panel determined that Heart Failure physicians and specialists will now be known as “Heart Function Specialists” from this point forward (Gibson et al., 2021; Bozkurt et al., 2021).
The new Stage B is the time to correct the functional damage that tends to build and develop into classic heart failure (Gibson et al., 2021; Bozkurt et al., 2021). Methods of intervention at this point include beta blockers for hypertension, cardiac catheterization to correct blockage of an artery, or even a replacement of a bad heart valve that a patient has been living with.
Stage C of the Universal Definition is where traditional thinking about heart failure begins. You can visibly see that something is wrong, audibly you can hear the shortness of breath, tactilely you can feel edema in the ankles, and the client reports feelings of fatigue and shortness of breath. Using these clues, you can discern that heart and/or circulatory issues exist.
As mentioned above in the initial definition of heart failure, heart failure is a clinical syndrome. A clinical syndrome is a recognizable cluster of signs and symptoms (Bozkurt et al., 2021). For the clinical syndrome of heart failure to be diagnosed, the presence of at least some of the following cardinal symptoms of heart failure are required (Bozkurt et al., 2021):
- Fluid retention/edema
- Activity intolerance
- Exercise limitation
Now that we have reviewed the general symptoms of heart failure, review the following case study to begin to apply what you have learned in this first course within the Heart Failure Series.
Agnes Miller is a 47-year-old female with a mixed Pacific Islander and West African black heritage. She is an active, working person who has complained to her husband about not feeling well for months. She had gone to an urgent care two weeks previously with a persistent cough that would not go away and shortness of breath on exertion. At that time, she was started on a general antibiotic. She now follows up with her family practitioner, who she has not visited in the last two years; her husband goes with her. Her stated purpose is to get another cycle of antibiotics as she still has a cough and shortness of breath.
Upon questioning, it is revealed that she continues to smoke three packs a day. Early last year, she experienced a prolonged bout of the flu, characterized by severe abdominal gas pains that kept her in bed for over a week. Since then, she has been feeling fatigued and having intermittent episodes of difficulty concentrating at work where she is a high-level actuary for an international insurance provider. Her job consists of desk and paperwork, with little physical activity, and includes missed meals and late work nights.
Physical exam reveals faint right lower lung field crackles, a blood pressure of 190/120, pulse of 110, respiration of 22, and tympanic temperature of 99.7. She is hesitant about lying flat on her back, complaining of "snoring troubles" at home when she rests in this position. Ankle edema is present under heavy support stockings. By palpation, her liver is enlarged, and a positive hepatojugular response is present.
Due to the physical exam findings and Mrs. Miller’s report, the initial impression is that of Stage C – symptomatic Heart Failure and not an infectious process requiring antibiotics. However, that will be ruled out by laboratory testing.
The initial plan is to inform Mrs. and Mr. Miller that there may be more going on than another course of antibiotics will resolve, and gain their cooperation in further diagnostic testing, starting with an echocardiogram to determine LVEF, a chest x-ray, and laboratory testing.
Mrs. Miller’s reported symptoms fall directly in line with developing and possibly advanced heart failure of the congestive type. In women, Myocardial Infarctions are often manifested as dyspnea with or without abdominal pain and discomfort, instead of left arm pain as is more typical in men. Her heritage and lifestyle, as she reports, also fall in line with an increased risk for cardiac disease. Right-sided diastolic heart failure or HFpEF, where the pulmonary vascular pressures are high, often manifests with night coughs and crackles in the lung fields due to the presence of fluid in the lungs forced out of the vascular beds by pressure. The increase in overall blood pressure and pulse may be a compensatory mechanism by which the body is trying to deal with the heart failure forced on it by ischemic heart changes post-myocardial infarction. The high respiratory rate may also be a compensation for vascular changes and overall lack of blood oxygenation.
Should diagnostic testing confirm the suspicion of Stage D - Advanced Heart Failure, immediate targeted treatment will need to be started. Due to the potentially advanced state of the condition, as it manifests, the Millers will be faced with hard choices as far as lifestyle changes and therapeutic options.
This course covered the new universal definition of heart failure, the risk factors for heart failure, a review of ejection fraction and how it is used in the staging of heart failure, the new staging classifications for levels of heart failure, and the symptoms of heart failure. For more information regarding a comparison of left vs. right-sided heart failure, acute heart failure, sudden cardiac death, and the treatment of heart failure, please continue forth within the heart failure series to Heart Failure Series:Part 2- Types of Heart Failure.
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Implicit Bias Statement
CEUFast, Inc. is committed to furthering diversity, equity, and inclusion (DEI). While reflecting on this course content, CEUFast, Inc. would like you to consider your individual perspective and question your own biases. Remember, implicit bias is a form of bias that impacts our practice as healthcare professionals. Implicit bias occurs when we have automatic prejudices, judgments, and/or a general attitude towards a person or a group of people based on associated stereotypes we have formed over time. These automatic thoughts occur without our conscious knowledge and without our intentional desire to discriminate. The concern with implicit bias is that this can impact our actions and decisions with our workplace leadership, colleagues, and even our patients. While it is our universal goal to treat everyone equally, our implicit biases can influence our interactions, assessments, communication, prioritization, and decision-making concerning patients, which can ultimately adversely impact health outcomes. It is important to keep this in mind in order to intentionally work to self-identify our own risk areas where our implicit biases might influence our behaviors. Together, we can cease perpetuating stereotypes and remind each other to remain mindful to help avoid reacting according to biases that are contrary to our conscious beliefs and values.
- Bozkurt, B., Coats, A., Tsutsui, H., Abdelhamid, M., Adamopoulos, S., Albert, N., Anker, S., Atherton, J., Böhm, M,. Butler, J., Drazner, M., Felker, M., Filippatos, G., Fonarow, G., Fiuzat, M., Gomez-Meza, J., Heidenreich, P., Imamura., T., Januzzi, J.,… Zieroth, S. (2021). Universal definition and classification of heart failure. Journal of Cardiac Failure. 27(4). Visit Source.
- Cannizzaro, T. (2021). The Four Stages of Heart Failure. Heart Failure. Retrieved February 20, 2022. Visit Source.
- Centers for Medicare & Medicaid Services. (CMS). (2020). Heart Failure Disparities in Medicare Fee-For-Service. CMS Data Snapshot. CMS Office of Minority Health. Retrieved February 19, 2022. Visit Source.
- Colucci, W., & Borlaug, B. (2021). Heart Failure: Clinical Manifestations and Diagnosis in adults. UpToDate. Retrieved February 20, 2022. Visit Source.
- Fogoros, R. (2021). What is Ejection Fraction? Verywell Health. Retrieved February 20, 2022. Visit Source.
- Gibson, G., Blumer, V., Mentz, J., & Lala, A. (2021). Universal definition and classification of heart failure: A step in the right direction from failure to function. American College of Cardiology. Retrieved February 20, 2022, Visit Source.
- Heart Failure Society of America. (HFSA). (2022). Heart Failure Facts & Information. Heart Failure Society of America. Retrieved February 19, 2022. Visit Source.
- Mayo Clinic. (2021). Nuclear Stress Test. Retrieved February 21, 2022. Visit Source.
- Schwinger, R. (2021). Pathophysiology of Heart Failure. Visit Source.
- Thaker, R., Pink, K., Garapati, S., Zarandi, D., Shah, P., Ramasubbu, K., & Mehta, P. (2022). Identify early and involve everyone: Interdisciplinary comprehensive care pathway developed for inpatient management and transitions of care for heart failure patients reported using SQUIRE 2.0 guidelines. Cureus. 14(1): e21123. Visit Source.
- Virani, S., Alonso, A., Aparicio, H., Benjamin, E., Bittencourt, M., Callaway, C., Carson, Chamberlain, A., Cheng, S., Delling, F., Elkind, M., Evenson, K., Ferguson, J., Gupta, D., Khan, S., Kissela, B., Knutson, K., Lee, C., Lewis, T.,… & Tsao., C. (2021). Heart disease and stroke statistics: 2021 update. A report from the American Heart Association. Circulation. Visit Source.
- Young, B. (2021). What's the Outlook for Congestive Heart Failure? Healthline. Retrieved March 7, 2022. Visit Source.