Heart failure

This article focuses on chronic heart failure and provides an outline of the main features of this illness. 

Heart failure is an increasingly common problem mainly as a result of a growing elderly population. Nurses are ideally placed to recognise, investigate and manage patients with this problematic condition. 

Heart failure is a complex syndrome where the ability of the heart to maintain the circulation of blood is reduced due to a problem with either the structure or the function of the heart’s ventricles.

This causes symptoms including breathlessness, retention of fluid and fatigue; and signs that include crepitations at the bases of the lungs, and oedema usually worst in the legs.

Terminology

Acute heart failure: This is the name given to a new presentation of heart failure or a deterioration or ‘decompensation’ in a person with existing chronic heart failure.

Chronic heart failure: There is no agreed definition of the timescale of chronic heart failure, although stable heart failure is a term used to describe a person with treated heart failure and symptoms that are unchanged for at least a month.¹ The New York Heart Association (NYHA) has produced a classification of heart failure based on severity of symptoms and limitation of physical activity.² This useful guide is set out below. 

• Class I – no limitation of physical activity. Ordinary physical activity does not cause undue fatigue, breathlessness or palpitations.
• Class II – slight limitation of physical activity. Comfortable at rest but ordinary physical activity results in undue breathlessness, fatigue or palpitations.
• Class III – marked limitation of physical activity. Comfortable at rest but less than ordinary physical activity results in undue breathlessness, fatigue or palpitations.
• Class IV – unable to carry out any physical activity without discomfort. Symptoms at rest can be present. If any physical activity is undertaken discomfort is increased.

Ireland

Heart failure is a common health problem in the developed world. In Ireland, the prevalence of heart failure is estimated to be about 

• One in 50 people 65-74 years of age

• One in 10 people 75-84 years of age

• Just over one in seven people 85 years of age or older

• The average age at first diagnosis is 76 years of age.

Approximately 10,000 new cases are diagnosed annually in Ireland. This means that heart failure is more common than some cancers and represents a significant disease burden.³

Causes of chronic heart failure

There are many different causes of heart failure. The most common are due to problems of the muscle of the ventricle wall. Most common of all is coronary artery disease, followed by hypertension. There are other less common causes including: cardiomyopathies, pregnancy, valvular heart disease (for example aortic stenosis), arrhythmias (for example atrial fibrillation and other tachyarrhythmias), thyrotoxicosis and obesity. It is important to note that some prescription medications can worsen heart failure. These drugs include non-steroidal anti-inflammatory drugs (NSAIDs), beta-blockers and calcium-channel blockers.

Prognosis

Sadly, about 50% of people with heart failure die within five years of diagnosis.⁴ In the UK one study found that the six-month mortality rate for people with heart failure was 14%.⁵ It is recognised that many of these people have frequent admissions and re-admissions to hospital. Indeed, it has been reported that approximately 40% of people admitted to hospital with heart failure die or are re-admitted within one year.⁶

The difficulty is that heart failure often has an unpredictable course. Stable periods are often interrupted by episodic acute destabilisation. There are some indicators that can point towards a poor prognosis. These include, increasing age (particularly over the age of 85), being over or underweight, having other conditions (such as atrial fibrillation, chronic kidney disease, chronic obstructive pulmonary disease (COPD), depression and diabetes mellitus). 

In addition, heart failure caused by ischaemic heart disease has a much poorer outlook. In particular, those who have heart failure and a history of myocardial infarction are at a much higher risk of sudden death. 

Taking a history

When suspecting that someone has possible heart failure you should ask them the following:

• Do they feel breathless – on exertion, at rest, on lying flat (orthopnoea), nocturnal cough, or waking from sleep (paroxysmal nocturnal dyspnoea)?

• Do they have problems with fluid retention (ankle swelling, bloated feeling, abdominal swelling or abnormal weight gain)?

• Do they feel abnormally tired and have a reduced ability to move around?

• Do they feel light-headed or have they had episodes of unexplained fainting or collapsing?

If you think that someone might have heart failure you should ask about possible risk factors: For example, do they have a history of coronary artery disease including a previous history of myocardial infarction, hypertension, atrial fibrillation or diabetes mellitus? Are they taking prescription medications? Do they have a family history of heart failure or sudden cardiac death under the age of 40 years?

Examination

If this is a person with possible heart failure they need to be examined. You should check the following:

• Check pulse, looking for a tachycardia (heart rate over 100 beats per minute) and pulse rhythm. Carry out a chest examination, looking for a laterally displaced apex beat, heart murmurs, and third or fourth heart sounds (gallop rhythm)

• Listen to the chest for respiratory signs such as tachypnoea, basal crepitations and pleural effusions

• Take blood pressure, to rule out a problem with hypertension

• Carry out a neck examination to rule out raised jugular venous pressure

• Perform an abdominal examination to exclude an enlarged liver (due to engorgement) or ascites

• Examine for dependent oedema, particularly in the legs and sacrum, or the scrotum in men. 

Best management

Some people who are very ill with heart failure will need immediate hospital care. For example, if the person has severe symptoms seek immediate specialist advice. For pregnant women (or women who have given birth within six months) with suspected heart failure seek immediate specialist advice. Those with heart failure due to heart valve disease or a previous myocardial infarction should be referred for specialist assessment. 

For those with heart failure who do not need immediate specialist advice the following tests are recommended:

• Arrange a 12-lead ECG, this will help establish the diagnosis, exclude arrhythmias and can also help give an indication of the severity of the heart failure

• A chest x-ray, this will help establish the diagnosis and exclude other chest causes for breathlessness, such as pneumonia

• Blood tests such as urea and electrolytes, estimated glomerular filtration rate (eGFR), full blood count, thyroid function tests, liver function tests, HbA1c, and fasting lipids. These tests will help exclude other causes for breathlessness such as anaemia and also help in managing risk factors in people with heart failure

• Beta-type natriuretic peptide levels (BNP) – this blood test can provide a clear diagnosis of heart failure and also a measurement of heart failure severity

• Lung function tests (peak flow and/or spirometry) can help exclude other causes of breathlessness such as COPD

• Echocardiogram – this is the gold standard investigation for the diagnosis and confirmation of heart failure. It can also establish the difference between reduced ejection fraction and preserved ejection fraction types of heart failure. 

Other diagnosis

There are many reasons for people to have symptoms similar to those of heart failure. The diagnosis is therefore difficult, particularly when people have a combination of illnesses. The main differential diagnoses for people who are breathless are: respiratory causes such as COPD, asthma, pulmonary embolism, and lung cancer.

Conditions that can cause water retention include problems with dependent oedema, for example from prolonged inactivity or venous insufficiency and medications such as calcium-channel blockers and NSAIDs. There are other less common problems which can cause oedema these include; nephrotic syndrome, low albumin levels, tumour in the pelvis, severe anaemia and thyroid disease. 

The overriding concern for people with heart failure is to manage symptoms and any underlying causes of their problem. In particular you should review the person’s medication and if appropriate reduce or stop any drugs that may cause or worsen heart failure, such NSAIDs. 

Treatments 

If symptoms are sufficiently severe, those with heart failure should start a loop diuretic such as:

• Furosemide 20-40mg daily

• Bumetanide 0.5-1mg daily

• Torasemide 5-10mg daily.

For those who have been found to have reduced ejection fraction heart failure, they should also have an angiotensin-converting enzyme (ACE) inhibitor and a beta-blocker licensed to treat heart failure.

You should explain that the aim of treatment is to improve symptoms, prevent worsening of symptoms, and increase survival, and that symptoms should improve within a few weeks to a few months.

If the person still has troublesome symptoms (NYHA classification II-IV) despite optimal treatment with an ACE-inhibitor and beta-blocker, they should be referred to cardiology for specialist management. 

Further measures

It might be appropriate for those with heart failure to have an antiplatelet and a statin medication. Particularly for people who have or are at risk of having atherosclerotic arterial disease, including coronary heart disease. 

People with heart failure should also be screened for depression and anxiety, which are very common in people with heart failure. 

It is also recommended that the person is offered referral to an exercise-based group rehabilitation programme. Ensure the person is offered an annual influenza vaccine and a once-only pneumococcal vaccination. 

You should also give general information about heart failure and its management and offer a discussion regarding advance care planning and advance decisions, if appropriate. These issues should be considered at an early stage of the disease. 

You should advise the person about reporting symptoms of worsening heart failure, including increasing breathlessness, fatigue, ankle or abdominal swelling, and rapid weight gain.

It can be helpful to advise the person to monitor their weight at home to detect fluid retention of worsening heart failure, if practical. Advise what to do if there is a sudden and sustained weight gain, eg. more than 2kg in three days. Options include seeking medical advice, increasing the diuretic dose, reducing fluid intake, or a combination of actions. You should also offer smoking cessation, if this is relevant.

You can explain that people with stable heart failure can undertake normal sexual activity that does not provoke undue symptoms.

It can also be helpful to provide sources of information and support, including helplines, support groups or web links such as:

• Irish Heart Foundation – Living well with heart failure: www.irishheart.ie/media/pub/patient_booklets/living_with_heart_failure.pdf 

• European Society of Cardiology – Heart failure matters: www.heartfailurematters.org

References

1. European Society of Cardiology. Acute and Chronic Heart Failure ESC Clinical Practice Guidelines. 2012. Available from: http://www.escardio.org/Guidelines-&-Education/Clinical-Practice-Guidelines/Acute-and-Chronic-Heart-Failure
2. American Heart Association. Classification of Functional Capacity and Objective Assessment. 1994. Available from: http://my.americanheart.org/professional/StatementsGuidelines/ByPublicationDate/PreviousYears/Classification-of-Functional-Capacity-and-Objective-Assessment_UCM_423811_Article.jsp#.VpdjcGp1Sxs
3. National Medicines Information Centre.  18(3). 2012. Available from: http://www.stjames.ie/GPsHealthcareProfessionals/Newsletters/NMICBulletins/NMICBulletins2012/heart%20failure%202012.pdf
4. American College of Cardiology and American Heart Association Guideline for the Management of Heart Failure. Journal of the American College of Cardiology 2013 Oct. 62 (16):147-239. Available from: http://content.onlinejacc.org/article.aspx?articleID=1695825
5. Improving survival in the 6 months after diagnosis of heart failure in the past decade: population-based data from the UK. Heart. 2009 Nov. 95(22):1851-6. Doi: 10.1136/hrt.2008.156034. Abstract available from: http://www.ncbi.nlm.nih.gov/pubmed/19587390
6. European Society of Cardiology. Guidelines for the diagnosis and treatment of acute and chronic heart failure. European Health Journal. 2008. 29: 2388-2442. Available from: http://eurheartj.oxfordjournals.org/content/ehj/29/19/2388.full.pdf