Congestive Heart Failure
Congestive heart failure (CHF) is a chronic progressive condition that millions of Americans struggle with every day. Heart failure (HF) describes the inability of the heart to adequately pump blood throughout the body. The result of this is fluid buildup which is where the term congestive comes into play. The fluid buildup can become not only debilitating for patients but also potentially life-threatening as patients can basically drown in their own fluids.
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There are two different kinds of HF which can have different implications for the patient’s symptoms and progression. Right sided heart failure describes the reduced force or strength of contraction of the right ventricle. The consequence of this is that blood does not get pumped through the lungs to obtain oxygen which then gets pumped by the left ventricle into the rest of the body. Left sided HF describes the left ventricle struggling to pump blood throughout the rest of the body.
Regardless of the type of HF cardiac output decreases which is defined as either decreased force of contraction by the ventricles – when it comes to HF patients. Decreased cardiac output will eventually deplete the volume of blood that reaches the kidneys.
When the volume of blood becomes lower the kidneys will activate the Renin Angiotensin Aldosterone System to retain more fluid and cause constriction of blood vessels. In addition, reduced cardiac output will ultimately lead to sympathetic nervous system stimulation which will act to increase the heart rate of the patient and cause constriction of blood vessels. Ultimately, HF patients who have progressed too far will experience increased blood pressure, fluid retention and edema.
The most important consequence of HF stems from the fact that the heart will need to work harder and harder to supply the body with enough oxygenated blood. This will increase the demand on the heart and potentially lead to damage to the heart muscles as well as conduction pathways. This can lead to abnormalities in the structure of the heart such as scarring of the conduction pathways (leading to atrial fibrillation) and growth/rounding of the left ventricle regarded as left ventricular hypertrophy.
Causes of Congestive Heart Failure
The number one risk factor for developing congestive heart failure is hypertension. High blood pressure ultimately describes the constriction of blood vessels throughout the body. When the blood vessels become overly constricted for a long time the heart will need to work harder and harder to push blood throughout the body. Eventually this can lead to structural damage of the heart as well as electrical abnormalities for the conduction pathways.
Other potential causes of HF includes structural abnormalities of the heart due to genetics, functional abnormalities of the valves in the heart, and other conditions that may have developed prior to HF such as atrial fibrillation. Heart attacks or myocardial infarctions can cause structural changes and damage to the heart leading to HF. Other disease states includes patients with coronary artery disease (CAD) or acute coronary syndrome (ACS) where the coronary arteries become narrowed or blocked with plaques reducing blood flow to the heart itself.
Patients with left sided HF may eventually develop right sided heart failure. This is because patients with left sided HF will experience a buildup of fluids in the lungs causing pulmonary hypertension (or high blood pressure in the lungs). The consequence of this is that the right ventricle will have to work harder to push the blood through the lungs – overcoming the fluid overload and hypertension. This process is described as pulmonary heart disease which can be serious and potentially fatal in time.
Some patients may develop right sided HF as a result of obstruction to the blood flow in the lungs. This can be caused by years of smoking leading to scarring of pulmonary tissues. Other causes may be patients with COPD or cystic fibrosis. Lastly, some patients may develop this kind of heart failure as a result of obstructive sleep apnea which can have different treatment modalities.
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Signs and Symptoms of Congestive Heart Failure
The classic signs and symptoms of right sided heart failure involves the buildup of fluid in the body also described as peripheral edema. This edema is sometimes described as pitting edema which describes a pit or indentation that does not go away after pressing on the swollen body part (usually the feet). Other symptoms include jugular venous distension where the jugular vein bulges. Patients may also develop abdominal growth which is also described as ascites where fluid builds up in the abdomen.
The normal signs of left sided HF includes pulmonary edema where fluids build up in the lungs. When listening to the sounds of the lungs a crackling sound also described as “rales” is observed in these patients. It is important to note that the crackles are distinctly different from rhonchi or wheezing. Patients with left sided HF may produce a blood tinged sputum that looks frothy and pink. These patients may also have trouble breathing (dyspnea) and shortness of breath while laying flat (orthopnea).
A key manifestation of heart failure regardless of the contributing side is weight gain. This is a result of fluid buildup in the body caused by the kidneys retaining too much water. Patients with HF may observe rapid weight gain – clinically significant weight gain is defined as an increase of 3 lbs in one day or > 5 lbs in 7 days. If weight suddenly increases or if symptoms described above become worse these patients should be treated immediately.
In HF patients a key lab value to evaluate are the B-type natriuretic peptides or BNP. BNP is secreted from the ventricles as they become stressed which makes BNP an important measurement to determine the severity of the patient’s condition. Below is a list of the BNP values with respect to the severity of the condition.
- ≤ 100 = normal
- ≥ 300 = mild
- ≥ 600 = moderate
- ≥ 900 = severe
HF patients will often receive an echocardiogram which can map out the extent of damage as well as functionality of both sides of the heart. A key measurement to be aware of is the left ventricular ejection fraction (fraction of blood ejected from the left ventricle) which helps to define how progressed the patient’s condition is. An ejection fraction of 55-70% is considered normal where a fraction < 40 is very bad – termed heart failure with reduced ejection fraction (HFrEF).
Another measurement that may come up on the NCLEX™ exam called hemodynamic monitoring or Swan Ganz Cath which is usually only used in severe cases. This test measures the central venous pressure (CVP) of the patient. Typical values for CVP are 2-8. When the CVP measurement comes back as higher than 8 the patients may be in critical condition and provided diuretics to reduce the fluid overload.
Test Your Knowledge
1. A patient has a history of heart failure. Which of the following statements by the patient indicates the patient may be experiencing heart failure exacerbation?
- “I’ve noticed that I’ve gained 6 lbs in one week”
- “While I sleep, I have to prop myself up with a pillow so I can breathe”
- “I haven’t noticed any swelling in my feet or hands lately”
- Options B and C are correct
- Options A and B are correct
- All options are correct
2. A 74-year-old female presents to the ER with complaints of dyspnea, persistent cough, and unable to sleep at night due to difficulty breathing. On assessment, you note crackles throughout the lung fields, respiratory rate of 25, and an oxygen saturation of 90% on room air. Which of the following lab results confirm your suspicions of heart failure?
- K+ 5.6
- BNP 820
- BUN 9
- Troponin <0.02
Pharmacology of Congestive Heart Failure
Patients with congestive heart failure will almost always be prescribed diuretics to treat their fluid overload. Diuretics work by reducing the retention of water in the body to be excreted out as urine. Diuretics can also decrease the patient’s blood pressure and alter the balance of their electrolytes as they all excrete sodium as part of its mechanism.
The most commonly used diuretics to know when treating fluid overload or edema is furosemide or bumetanide. These are loop diuretics which can drastically reduce the retention of water in the body and therefore reduce fluid in either the periphery or the lungs depending on the type of HF. Furosemide is often the first line treatment for worsening heart failure where bumetanide or torsemide are used as alternatives in some cases.
It is important to note that when furosemide or other loop diuretics are administered too quickly it can cause ototoxicity as well as nephrotoxicity (toxicity to the kidneys). These diuretics will also waste potassium potentially leading to hypokalemia. Other common kinds of diuretics to know includes thiazides such as hydrochlorothiazide or chlorthalidone which also result in potassium loss.
Patients with hypokalemia may require the use of potassium sparring diuretics to reduce the loss of potassium from the body. Examples of potassium sparing diuretics includes triamterene and amiloride. A more important class to know about that is also potassium sparring are aldosterone antagonists like spironolactone. These work by blocking aldosterone which ultimately reduces the blood pressure while not excreting potassium.
Patients who are administered large doses of diuretics should receive monitoring for changes to potassium levels as these changes can alter the electrical pathways of the heart. Patients with hyperkalemia may exhibit peaked T waves as well as ST wave elevation. Patients with high serum potassium should be instructed to avoid potassium rich foods like green leafy vegetables, melons, avocados, or bananas. Patients with hypokalemia will exhibit flat T waves and ST depression and should be instructed to increase dietary potassium. If patients need to have potassium replacement, they should receive it in an IV bag over an hour or more.
Other side effects to take note of for diuretics includes orthostatic hypotension which is low blood pressure when changing position. This can cause dizziness when standing too quickly increasing the risk of falling. These medications can also cause dehydration so patients should be counseled on adequate water intake which may vary based on their condition.
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ACE inhibitors are an essential first line therapy for patients who have HF. These medications as well as ARBs act on the kidneys to ultimately block the hypertensive effects of the RAAS system. They prevent the constriction of blood vessels, decreases retention of fluid and decreased cardiac output. Both medication types also cause increased excretion of sodium while retaining potassium.
Types of ACE inhibitors includes lisinopril, benazepril, and quinapril. All these medications have the “pril” suffix which can help with memorization. A key side of effect of ACE inhibitors is the dry cough and potentially swelling of the tongue, mouth, or airways which can be potentially life threatening also called angioedema. As a result, if patients experience these side effects that can be transitioned to an ARB which does not cause this side effect due to a difference in its mechanism. ARB examples includes losartan, valsartan, and irbesartan which all contain the “sartan” suffix.
Key side effects for these medications includes hyperkalemia which should be monitored for (serum K+ > 5). These medications can also cause fetal toxicity which should therefore be avoided in pregnancy.
As the heart must work harder in heart failure patients the myocardial tissue becomes increasingly hypoxic (starved of oxygen) – this causes stress to the tissue leading to a variety of complications. Beta blockers are a key treatment for heart failure patients as it reduces the heart rate (negative chronotropic) and the force of contraction (negative inotropic). Reducing the force and rate of heart beats acts to minimize myocardial demand or oxygen requirements. In short, they reduce cardiac output, resistance, and workload to preserve the heart tissue.
Beta blockers should be used with caution in asthma and COPD patients as they can cause bronchoconstriction and lead to exacerbations. To reduce the risk of this side effect patients with these comorbidities should be initiated on beta-2 selective beta blockers. Examples of selective beta blockers includes metoprolol, bisoprolol, and atenolol. Non-selective beta blockers can be used in patients without COPD or asthma such as labetalol or propranolol.
Patients with diabetes should be counseled on a critical side effect where symptoms of hypoglycemia can be masked by the effects of the beta blocker. Diabetics on insulin or sulfonylureas are especially at-risk hypoglycemia. If these patients have to use a blocker then they should be advised to routinely monitor their blood glucose to reduce the risk of a hypoglycemic event.
Some key adverse effects to be aware of are increased risk of falling and orthostatic hypotension. Patients should be instructed to not change position too quickly as the heart struggles to distribute blood to the brain – leading to increased risk of feinting. Patients may also observe difficulty with exercise and physical activity. This side effect should resolve itself over time.
Heart rate should be closely monitored before and after immediately starting their therapy. Patients with a heart rate that drops below 60 bpm or systolic blood pressure below 100 should be held on the beta blocker.
Lastly it is important to note that beta blockers can worsen the symptoms of heart failure. Fluid accumulation is a key adverse effect to monitor for. These patients should be weighed daily to assess for fluid retention. Signs and symptoms of edema should also be periodically monitored.
Calcium Channel Blockers:
Calcium channel blockers (CCBs) are a common class of medication that may be used in HF patients. Overall, they work by blocking the influx of calcium into the smooth muscle surrounding blood vessels – ultimately causing dilation of blood vessels leading to lower blood pressure.
Most CCBs act only on the blood vessels utilizing this mechanism. Examples of these includes nifedipine, nicardipine, and amlodipine. These protect the heart and other organs in a similar manner to ACE inhibitors or ARBs. However, there are some CCBs that can act on the heart reducing heart rate and force of contraction. This helps reduce myocardial oxygen demand therefore protecting the heart with an additional mechanism. Examples of these CCBs are verapamil and diltiazem which can be used in patients who are not already on a beta blocker.
Common side effects for CCBs includes headaches, peripheral edema, and facial flushing. Patients on diltiazem or verapamil should routinely have their heart rate monitored. Lastly, all patients on CCBs are at an increased risk of orthostatic hypotension and falling.
Digoxin is an older medication that used to be prescribed more commonly in patients with heart failure. It is a cardiac glycoside which can be toxic in lower doses – known as a narrow therapeutic index. Therefore, its use has been reduced as alternative agents have been released on the market with a safer side effect profile. Specific patient populations may benefit from digoxin therapy as an adjunct to other treatment modalities. Digoxin is sometimes used in patients with blood flow issues leading to excessive weakness, orthostasis, and falling. Unlike beta blockers digoxin can increase the force of the contraction therefore increasing blood flow to the brain and muscles offsetting the symptoms of weakness.
Due to the narrow therapeutic index of digoxin serum levels should be monitored closely – especially within the first couple of weeks of initiation. Digoxin levels > 2 can yield side effects including vision changes, nausea, and dizziness. A very serious adverse effect to monitor is severe bradycardia (low heart rate) that can be dangerous. The risk of digoxin toxicity increases in patients with hypokalemia (< 3.5) therefore serum potassium is important to monitor. These patients should also have their serum creatinine levels measured at baseline and after starting therapy to assess kidney function. A serum creatine > 1.3 serves as a contraindication for digoxin therapy.
Nitroglycerin is a staple treatment used in patients who have experienced an MI to reverse the symptoms of angina (chest pain) and reduce the risk of having a serious cardiac event. It works by causing dilation of the blood vessels particularly around the heart including the coronary arteries – thereby improving blood flow to the heart. It therefore decreases vascular resistance, increase preload, and increases afterload.
There are several different formulations of nitroglycerin – the one used in post-MI patients are the sublingual tablets used to for heart attacks. Other formulations includes nitroprusside, isosorbide, hydralazine, and minoxidil. Isosorbide and hydralazine may be used daily as a maintenance therapy for patients experiencing frequent/chronic chest pain. Minoxidil can sometimes be used in patients with severe heart failure.
A key serious side effect of these medications is severe hypotension which can be life threatening. If the systolic blood pressure falls below 90 mmHg or if it decreases by 30 mmHg the medication should be halted. Signs and symptoms of severe hypotension includes lack of coordination or dizziness. Less serious side effects includes headaches and facial redness or flushing. Orthostatic hypotension and falling is also a problem with nitroglycerin use so patients should be counseled on not changing position too quickly.
Patients who are prescribed nitroglycerin should never be on Viagra (sildenafil) or Cialis (tadalafil) or “afil” drugs that are used for erectile dysfunction. When these medications are used with nitrates it can lead to severe hypotension and become life-threatening. Alternative treatments for erectile dysfunction should be pursued in these patients.
Milrinone is a positive inotropic medication (increase contractile force) which is generally reserved as a last line therapy for HF patients. Usually this is used in palliative care to improve their quality of life due to poor blood flow issues. The main side effects of this medication are headaches, tachycardia, and arrythmia. Close monitoring of heart rate should be a key monitoring parameter for these patients.
Test Your Knowledge
3. These drugs are used as first-line treatment of heart failure. They work by allowing more blood to flow to the heart which decreases the workload of the heart and allows the kidneys to secrete sodium. However, some patients can develop a nagging cough with these types of drugs. This description describes.
- ACE inhibitors
Patients with HF should be closely monitored for side effects and efficacy of therapy. Therapeutic interventions for HF should result in reduced HR and resolution of edema symptoms. Patients should be weighed daily to assess for fluid retention. When transferring patients to other units or floors they should be evaluated for worsening conditions. Periodically checking lung sounds for worsening crackles is also imperative to assess for pulmonary edema.
Heart failure patients should be counseled on a variety of lifestyle interventions that are essential to reduce their risk of morbidity and mortality. Sodium restriction is a key intervention for these patients as sodium draws water into the body and leads to swelling and edema. Specifically, they should strive to consume < 2 grams of sodium every day. They should be instructed to avoid fried foods, canned foods, and packaged foods. They should also be advised to be careful before taking over the counter medications as they can contain sodium. Examples of medications that may include sodium are acetaminophen, antacids, cold or flu medications, and NSAIDs including aspirin. Careful consultations with the provider or pharmacists should be made before starting new OTC medications.
Fluid restriction is another key consultation to conduct in HF patients. They should be advised to reduce fluid intake by < 2 liters of fluid every day. Excess fluid can increase blood pressure as well as exacerbate HF symptoms such as edema. Daily weighing of HF patients is critical to assess for fluid overload symptoms. If they gain 2-3 lbs in 1 day or 5 lbs in 7 days, they may be developing severe edema and should be treated appropriately.
When edema symptoms are present these patients should be administered intravenous furosemide as well as morphine to reduce fluid retention and decrease myocardial oxygen demand. They should have their head raised in bed by a 45-degree angle to reduce the swelling in the lungs. These patients may also benefit from oxygen administration especially if they are having trouble breathing.
Patients with HF should be advised to not have sex until cleared by a physician. They should be able to climb 2 flights of stairs without experiencing shortness of breath. This is important to counsel on as sex can cause a lot of stress on the heart and potentially trigger a heart attack.
Lastly patients who are not mobile should be provided ted hose which are elastic stockings used to reduce pooling of blood. These should be removed daily to allow for cleaning and assess edema. TED hose are critical to use in patients who are not ambulating as they can reduce the risk of a clot forming leading to other serious embolic events.
Heart failure is a life-threatening and life changing disease that affects millions of Americans every year. It can be challenging for these patients to deal with the consequences of their condition as well as side effects from the medications they are getting put on. These patients will often require a lot of care and monitoring to treat their condition and improve their quality of life. This is why having a strong understanding of HF is crucial when preparing for the NCLEX™ exam.