CHRONIC HEART
FAILURE (CHF)
2012
Jennifer Burgess
Some Facts
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Fastest rising cardiovascular condition in
Canada
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affects 1 – 2% of the population (>350,000)
1.4 million hospital days per year
Up to $2.3 billion per year
Prevalence tripled over past decade
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Increasing numbers of elderly
Improved survival rates of cardiac and other chronic
conditions
Some Facts
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Cannot be “Cured” by relieving symptoms
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Often progresses without signs or symptoms
Changes occur that lead to chronic debility
33% mortality within first year of diagnosis
50% mortality within five years
3:1 males:females
Heart Failure – What is it?
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Inability of the heart to supply sufficient blood flow to meet
the body's needs
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Results from any heart problem that impairs ability of
ventricle to fill with or eject blood
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Therefore not enough oxygen and nutrients supplied
Can lead to fluid overload
Due to low cardiac output (“Congestive” HF) or increased needs
(“high output” HF) – now referred to as Heart Failure (HF)
Can be acute or chronic (or acute on chronic)
Can be left sided, right sided, or both (L leads to R)
It is not a heart attack, or cardiac arrest
What is Heart Failure?
Causes
Congestive heart failure can be caused by
diseases that:
 cause stiffening, or weakening of, the heart
muscle e.g.. MI, HTN
 increase oxygen demand by the body tissue
beyond the capability of the heart to deliver.
Main Risk Factors
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Ischemic heart disease/MI (62%)
Smoking (16%)
Hypertension (10%)
Obesity (8%)
Diabetes (3%)
Valvular heart disease (2%, higher in elderly)
The heart
Classic
Indicators of
CHF
Shortness of Breath
Wet sounding chest due to excess
fluid in and around the lungs
Coughing
Significant swelling in lower legs
or abdomen
Fatigue
Signs And Symptoms
LEFT HEART FAILURE
RIGHT HEART FAILURE
(LOW OUTPUT/PULMONARY
CONGESTION)
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Dyspnea
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Orthopnea
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Paroxysmal nocturnal dyspnea
(PND)
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Fatigue*
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Reduced exercise tolerance*
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Cough
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Confusion (Especially in elderly)*
(SYSTEMIC VENOUS CONGESTION)
* May be earliest presentation
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Peripheral edema
Weight gain
Anorexia
Abdominal discomfort
Fatigue*
Reduced exercise tolerance*
Additional Signs & Symptoms
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RR (>20) and effort
Low blood pressure (<90mmHg)
Heart rate > 100
Lung crackles (+/- wheeze)
Elevated JVP
Heart murmur
Pleural effusion
Cyanosis (late sign)
Assessing JVP and abdominal jugular reflex
Atypical Features in Frail Elderly
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Delirium
Falls
Malnutrition
Sudden functional decline
Sleep disturbances
Nocturia or nighttime incontinence
NOTE: Dyspnea and/or crackles +/- present
Diagnosing HF
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Chest x-ray
ECG
Bloodwork, +/- BNP (cardiac vs pulmonary)
Echocardiogram
+/- angiography, nuclear imaging, MRI
Differential Diagnosis
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Heart – valvular, CAD
Renal failure with volume overload
Lung disease
Liver cirrhosis
Obesity
Deconditioning
Anemia
New York Heart Association
Classification (NYHA)
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Class l (Mild)
 No limitation of physical activity
Class ll (Mild)
 Slight limitation of physical activity
Class lll (Moderate)
 Marked limitation of physical activity
Class lV (Severe)
 Unable to carry out any physical activity without
discomfort
Medications
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ACE Inhibitors
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Ramipril, etc.
Improve hearts pumping action
Prevent disease from getting worse
S/E: decreased renal function, hypotension, dizziness, cough
Beta Blockers
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Metoprolol, etc.
Reduce heart rate and work of heart
Prevent and treat irregular heart beat
Prevent disease from getting worse
S/E: may make HF worse for first few months, bradycardia,
bronchospasm, fatigue, dizziness
Medications
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Diuretics
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Lasix, etc.
Improve symptoms by relieving fluid overload
S/E: Hypokalemia, dehydration, weakness,
muscle cramps.
Others
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ARB’s, Digoxin, Nitrates, anticoagulants,
Aspirin, etc.
Management
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Decrease sodium
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Na+ not efficiently excreted in HF
We need 500 mg/day, we consume 5-6- gm/day
Aim for 2 – 3 gm/day if stable
1 – 2 gm/day if advanced HF and fluid retention
Fluid restriction
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1.5 – 2 L/day if fluid retention, or if renal dysfunction or
hyponatremia
1 – 1.5 L/day if severe edema
Management
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Daily weight log
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when Class lll/lV or med changes
after emptying bladder, before eating, same clothes, same
scale
Report weight when 2.5 kg increase in a week, or 2 kg in
2 days
Physical activity
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Consider when stable and not fluid overloaded
Individualized – up to, but just short of, significant Sx’s
Prevention
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BP goal <140/90
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<130/80 if DM +/or chronic kiney disease
Correct anemia
Medications – proper use of recommended
meds can drastically reduce morbidity and
mortality. E.g. ACE–I use decreases death or
new HF by 29% (SOLVD Prevention study)
Acute Decompensated HF (ADHF)
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Presentation:
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Dyspnea - 89%
Crackles - 68%
Peripheral edema - 66%
SBP <90 MMHG - 3%
These residents may need immediate
hospitalization for I.V. diuretics, etc.
End of Life Care
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Consider in residents who have advanced,
persistent HF with symptoms at rest despite
optimal pharmacological and
nonpharmacological therapy:
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Three or more hospitalizations per year
Chronic poor quality of life – unable to do ADL’s
Need for IV support
Needing assistive devices for breathing etc.
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(2006 HFSA Comprehensive HF Practice Guideline)
The Good News
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We can help our residents who have Heart
Failure to have maximal quality and quantity
of life by helping them to optimally manage
their disease!
References
Aronow, W. (2004). Evidence for the Use of Beta-blockers in
Congestive Heart Failure Treatment in Older Persons.
Geriatrics & Aging. 7(2), 28-32.
Canadian Cardiovascular Society. (2009). Pocket reference card:
Is it Heart Failure and What should I do? Retrieved from:
http://www.hfcc.ca/downloads/educational_tools/pocket_card
/pocket_card.html
Canadian Heart Failure Network. (2009). Running a Heart
Failure Clinic. Retrieved from http: //www.chfn.ca/ on May
18, 2010.
References Con’t
Heart Failure Society of America. (2006). 2006 HFSA
Comprehensive Heart Failure Practice Guideline: Key
Recommendations. Retrieved from:
http://www.heartfailureguideline.org/index.cfm?id=150&s=1
Howlett, J.G., McKelvie, R.S., Arnold, J.M.O., et al. Canadian
Cardiovascular Society Consensus Conference guidelines on
heart failure, update 2009: Diagnosis and management of
right sided heart failure, myocarditis, device therapy and
recent important clinical trials. Can J Cardiol, 25(2), 85-105.
Kostuk, W. (2004). Initial Evaluation of the Older Patient with
Suspected Heart Failure. Geriatrics & Aging, 7(2), 13-16.