Congestive Heart Failure

Incidence

Congestive Heart Failure affects an estimated 4.9 million Americans1. In the United States alone, approximately 400,000 new cases of heart failure are diagnosed annually. 

Heart Failure is the major cause or contributing factor in 250,000 deaths every year2. It is often is the end stage of cardiac disease, regardless of the underlying etiology and about half of patients diagnosed with heart failure will die within five years.

Unfortunately, according to recent estimates, only about 50 percent of the patients with heart failure receive a correct diagnosis in the early stages3.

Etiology

Initially viewed as a problem of sodium and water retention, CHF was later viewed as a problem secondary to abnormalities in the heart’s pumping ability, along with excessive peripheral vasoconstriction. Current thinking is that CHF results from an increased firing in the sympathetic nervous system, resulting in toxic effects on circulation in the heart4.

Common causes of Congestive Heart Failure

Pathophysiology

Intravascular and interstitial fluid overload resulting in shortness of breath, rales and edema may characterize heart failure.

Inadequate tissue perfusion, resulting in poor exercise tolerance and fatigue, may result. 
Cellular respiration becomes abnormal, as the impaired heart pumping ability cannot meet the body’s basic metabolic needs.

Symptoms of CHF

Diagnosis

Early detection of heart failure is essential for optimal management and prevention of further complications. The initial diagnosis may be complex, as heart failure may manifest in a range that varies from no symptoms, to cardiogenic shock and pulmonary edema. 

Physical Examination

Once heart failure is suspected the New York Heart Association (NYHA) can be utilized to assess the functional classification.

NYHA Levels of Heart Failure6

Diagnostic Testing

Clinical Manifestations

The clinical manifestations of Congestive Heart Failure may reflect impairment of the left or right ventricle.

Clues for Differentiating Between Systolic and Diastolic Dysfunction In Patients with Heart Failure7

Clues from the evaluation Systolic dysfunction Diastolic dysfunction
History 
Hypertension XX  XXX
Coronary artery disease*  XXX X
Diabetes mellitus XXX XX
Valvular heart disease* XXX --

Physical examination 

Third heart sound (S3) gallop* XXX X
Fourth heart sound (S4) gallop*  XXX
Rales  XX  XX
Jugular venous distention  XX  X
Edema  XX  X
Displaced point of maximal impulse* XX  --
Mitral regurgitation*  XXX X

Chest radiograph 

Cardiomegaly*  XXX  X
Pulmonary congestion  XXX  XXX

Electrocardiogram 

Q wave XX  X
Left ventricular hypertrophy* XXX

Echocardiogram

Decreased ejection fraction* XXX  --
Dilated left ventricle* XX  --
Left ventricle hypertrophy* XXX

NOTE: X, means suggestive; the number of Xs reflects the relative weight; -- means not suggestive.*means particularly helpful in distinguishing systolic from diastolic dysfunction in heart failure.

Therapeutic management in CHF Patients

Treatment of Diastolic or Systolic Dysfunction8

*--Diuretics are best used to treat acute congestive heart failure and as adjunctive therapy for hypertension
†--Note that the likelihood of angioedema and renal insufficiency is increased with ACE inhibitors and angiotensin-receptor blockers. Watch for late-breaking results from clinical trials on the efficacy of angiotensin-receptor blockers alone and in combination with ACE inhibitors compared with ACE inhibitors alone.
‡--The addition of milrinone is preferred in patients already receiving a beta blocker.  Suggested algorithm for the treatment of diastolic or systolic dysfunction.
ACE = angiotensin-converting enzyme
NYHA = New York Heart Association
IV = intravenous.

Non-Pharmacologic

Pharmacologic Management

Angiotensin Converting Enzyme Inhibitors (ACE inhibitors) - improve the functional status in heart failure and result in peripheral arterial and venous vasodilatation. Several large studies have indicated that ACE inhibitors improve survival among heart failure patients and may slow, or prevent the loss of heart pumping activity. This class of drugs was originally developed as treatment for hypertension9.
Examples of ACE Inhibitors

Diuretics - may be utilized to improve ventricular function. Useful for patients with hypertension.
Common diuretics

Digitalis - can assist with left ventricular systolic dysfunction and can allow for reduced diuretic medications and can prolong conduct ion in the atrial ventricular node. It is also known to increase the force of the heart' s contractions, helping to improve circulation.

Beta-Blockers - are useful with idiopathic Cardiomyopathy. In treating CHF, beta-blockers assist with a decreased heart rate and myocardial oxygen consumption resulting in improved diastolic dysfunction.

Hydralazine -A beneficial effect can be achieved when used in combination with forms of long acting nitrates. Can be beneficial with patients who cannot tolerate or have a contraindication to ACE inhibitors. Each of these medications helps relax tension in blood vessels to improve blood flow.

Surgical interventions

Revascularization - a large number of patients with heart failure have potentially reversible ischemia. The treatment goal of revascularization is to prevent further ischemia and to restore function to the non-functional heart wall segments that are viable but under-perfused. Revascularization may be appropriate in three classes of heart failure:

Risk factors associated with surgical interventions with CHF

Angioplasty - Benefits of angioplasty in patients with heart failure remain unclear. Many considerations enter into the decision to utilize Percutaneous Transluminal Coronary Angioplasty (PTCA), including underlying risk of surgery, patient preference, morbidity related to CABG and other technical factors.

Transplant - Heart transplant is the only treatment that can assist the natural course of CHF long term. Currently, the one-year survival rate is 82 percent and the three-year survival rate is 75 percent. Mortality, while waiting a donor is 12-15 percent. Sometimes, heart failure is life threatening. This usually happens when combinations of drug therapy and lifestyle changes fail to control symptoms. In these cases, heart transplant may be the only option for treatment.

Cardiomyoplasty - has been used to foster LV function by wrapping the latissimus dorsi muscle around the heart and supplying external stimulation.

Left Ventricular Assist Device – LVADs are devices that take over part, or virtually all, of the heart's pumping activity. These machines are not permanent solutions, but are frequently utilized as a bridge to transplant. LVADs are implanted in the heart and abdomen of the patient, or may be placed externally.

LVADs vary from manufacturer, but some models have an electric pump, an electronic controller the size of a Walkman. These models allow the patient the ability to move about freely, and be discharged to home to a higher quality of life. This differs sharply from the earlier models used in hospitals that had consoles the size of desks and required large hoses. Patients were unable to leave the hospital or even leave their room. These patients were often confined to an inpatient hospital stay for several months, until a heart became available for transplant. This was extremely costly, due to the long length of stay.

Newer LVADs are being used as a permanent assist device for heart failure patients, who do not qualify for a heart transplant. There are clinical trials evaluating the use of chronic implantable LVADs in patients who are ineligible for heart transplant. One trial is the REMATCH trial (Randomized Evaluation of Mechanical Assistance for the Treatment of CHF) trial being conducted at 20 heart centers throughout the country.

There are currently more than 40,000 patients who would benefit from a heart transplant, but there are only about 2,500 donor hearts available. The future for these patients may be a totally artificial heart.

Artificial heart - The future may involve a device such as the AbioMed (Abicor)10.  The AbioMed is not meant as a bridge, but is a totally implantable heart for the end-stage patient. The cost of the implantation and the first year's follow-up is estimated around $120,000.

Dor procedure - Areas of the hypofunctioning myocardium are cut out and the remainder of the heart, which is relatively normal, is oversewn. A prospective trial looking at the efficacy of this procedure is being organized.

Related Conditions

Acute pulmonary edema occurs with acute heart failure as a result of onset of pulmonary venous hypertension11.

Common treatment protocol for pulmonary edema include

Myocardial infarction

Renal failure

Prognosis in heart failure patients

Prognosis for heart failure patients will depend on related effects of the disease, cardiac exercise ability, age, overall health and comorbidities and left ventricular blood output levels. Early diagnosis is key to favorable prognosis. An estimated 50 percent survive five years after the initial diagnosis.

Cost Implications

Case Management Considerations

Effective case management is an important factor in decreasing acute care hospitalizations and it allows the patient a higher quality of life by remaining in his home environment. To achieve the goal of decreased hospitalizations, an effective case manager will educate the patient on his disease process and in how to effectively manage his disease through lifestyle changes.

There are many programs available to allow the patient to effectively manage his disease process, which include disease management programs, clinic settings, and home health care programs that specialize in management programs for CHF patients.

An effective disease management program includes the following components:

Heart Failure Clinic - Hospitals are establishing outpatient CHF clinics and provide expert care for high-risk patients.

Home Health Cardiac Specialists - Home care intervention programs offer experienced cardiac trained home nurses

Telemanagement home programs -

Cardiac rehab programs -

Community based Case Managers -

CHF Subacute Care

Offers a bridge from acute care to the home and lowers the financial impact of an acute care admission.


1- Heart and Stroke Statistical Update. Dallas American Health Association, 1997.

2,3- Heart Failure: Evaluation and care of patients with left ventricular systolic dysfunction. Rockville, MD: US Dept of Health and Human Services, Public Health Service, Agency for Health Care Policy & Research, AHCPR Duplication No. 94-0612

4- Essentials of the Diagnosis of Heart Failure, American Family Physician March 2000.Fadi ShamSham, MD & Judith Mitchell, MD

5- Zema, M.J.,Masters AP, Margouleff D. Dyspnea: The Heart or the Lungs? Differentiation at Bedside by use of the Simple Valsalva Maneuver, Chest.1984;85:59-64

6- Clues for Differentiation between systolic and diastolic dysfunction. Young, J.B. Assessment of Heart Failure;In:Braunwald E Atlas of Heart Disease. Vol 4, Philadelphia, Current Medicine, 1995:7.1-7.2

7- Clues for Differentiation between systolic and diastolic dysfunction. Young, J.B. Assessment of Heart Failure;In:Braunwald E Atlas of Heart Disease. Vol 4, Philadelphia, Current Medicine, 1995:7.1-7.2

8- NYHA. www.aafp.org/2000301/319.html

9- Doses of ACE inhibitors indicated for heart failure, Aetna US Healthcare Healthy Outlook Program, Vol.2, Chapter II, section 4.2 January 1996

10- General and Interventional Therapies for Heart Failure: Robert C. Bourge, MD (Chair)/Medscape/Treatment update. 1999

11- Aetna U.S Healthcare TM Healthy Outlook Program, volume 2,Chapter II, section 6.6

12- Lifestyle Advantage Program from Highmarlk and the Dean Ornish Program to reverse heart disease,Highmark Blue Cross Blue Shield or Western Pennsylvania