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All you need to know about … heart failure

An estimated 900,000 people in the UK currently live with heart failure and this number is set to increase. Jillian Riley reviews some important issues in prompt diagnosis and effective management

Jillian Riley
MSc BA(Hons) RN RM
Head of Postgraduate Education for Nurses and Allied Health Professionals
Department of Education
Royal Brompton Hospital
London

Heart failure is now well recognised as a common and progressive condition associated with frequent hospital admissions and a poor prognosis. Patients with heart failure experience breathlessness, oedema and tiredness, all of which reduce their mobility and quality of life. Although heart failure cannot be cured, its symptoms can be alleviated, deterioration prevented and patients and their families can learn to live with the condition.
Patients with heart failure require careful monitoring to detect signs and symptoms of clinical deterioration, education and support for self-care. There is evidence to suggest that following a heart failure hospital admission patients are at highest risk of a further hospitalisation within the subsequent three months.(1) This has influenced clinical guidelines, which suggest that vigilant follow-up should be provided during this period with the first follow-up visit taking place within the first 10 days of discharge.(2) Many hospitals and primary care trusts in the UK have responded by employing heart failure nurse specialists who are ideally placed to provide this care. Equipped with specialist knowledge and experience they are in a key position to offer advice, education and support to the patient and their family, to detect early signs of clinical deterioration and liaise with the multidisciplinary team when the condition deteriorates. For patients at the endstage of the disease, palliative care may be necessary with specialist nursing care to control symptoms and manage death. This article will review the more common causes of heart failure and some of the nursing interventions that may assist symptom management and improve quality of life.
Heart failure is not uncommon and its incidence increases with age. With an increasingly elderly population in the UK and with more people surviving a myocardial infarction it is not surprising that both the incidence and prevalence is rising. In the UK the mean age of a person with heart failure is 75 years while a recent European survey showed that approximately 26% of the heart failure population are over 80 years old.(3) Considering this elderly age group heart failure commonly sits alongside other comorbidities, which increase the complexity of managing it from both a health professional and patient perspective (see Box 1).

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Definition
Heart failure may result from various types of cardiac dysfunction. Traditionally the term was used to describe left ventricular dysfunction. More recently it is acknowledged that heart failure can be associated with preserved systolic function. This is found in about 50% of people with heart failure and is more common among the elderly. However, whether of systolic dysfunction or not, heart failure occurs when the heart is unable to pump sufficient oxygenated blood to meet the body's requirements. The patient presents with breathlessness, fatigue and ankle swelling.
Although the list of possible causes of heart failure is long, the more common ones can be divided into the following three main groups:

  • Damage to the ventricular muscle of the heart may result in insufficient blood pumped out and a consequent fall in cardiac output. This may arise following myocardial infarction (the predominant cause in the UK), coronary heart disease or dilated cardiomyopathy.
  • Excessive cardiac workload develops when the body has an increased demand for oxygen and nutrients, and so cardiac output increases. Common causes include hypertension, severe anaemia or thyrotoxicosis.
  • Alteration to ventricular filling that may result from a tachycardia such as atrial fibrillation or poor diastolic relaxation.

Regardless of cause, the heart starts to fail and cardiac output falls. The body activates a neurohormonal response to restore cardiac output in the short term. However, over time this becomes harmful; activation of the renin-angiotensin-aldosterone system (RAAS) leads to the retention of sodium and water, which initially improves cardiac output, but eventually results in pulmonary or peripheral oedema; sympathetic nervous system (SNS) activation increases the heart rate and blood pressure, but also increases the work of the heart. The symptoms of heart failure develop therefore from the failing heart muscle (myocardium) and this overexpression of compensatory neurohormones.

Patient assessment
Three commonly occurring signs and symptoms are suggestive of heart failure:

  • Breathlessness.
  • Fatigue.
  • Peripheral oedema.

Findings from the clinical assessment vary depending upon which side of the heart is failing. Patients with impaired left ventricular function (left-sided heart failure) experience shortness of breath from a build-up of fluid in their lungs. With impaired right ventricular function (right-sided heart failure) the build-up of fluid leads to venous congestion and oedema of the peripheries, gastrointestinal tract and liver (ascites). In most patients left-sided heart failure develops initially and is followed by right-sided heart failure. However, in an acute episode the patient is likely to rapidly develop both left- and right-sided failure and present with pulmonary oedema and swollen ankles.
The symptoms of heart failure are frequently grouped into the New York Heart Association classification system. These categories describe the findings from the clinical assessment and any limitations placed upon the person. They provide a useful assessment tool for assessing disease severity and can monitor response to treatment (see Table 1).

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Although a good clinical assessment and history taking can raise the suspicion of heart failure, the diagnosis should be confirmed to ensure appropriate management is commenced as soon as possible. The following investigations are useful:

  • A 12-lead ECG to detect arrhythmias such as atrial fibrillation, atrial flutter and premature ventricular beats. Myocardial ischaemia or previous infarction may also be detected and raise the suspicion of heart failure. An ECG cannot be used to provide a definitive diagnosis, but in the presence of heart failure the ECG is unlikely to be normal.
  • B-type natriuretic peptide (BNP), a hormone secreted in response to fluid overload, can be detected from a simple blood test. If levels are raised this is suggestive of heart failure and warrants further investigation.
  • Chest X-ray may be useful to identify if breathlessness is due to pulmonary congestion or to detect lung pathologies.
  • An echocardiogram (echo) can confirm a diagnosis of heart failure. This noninvasive procedure is predominately, although not always, carried out in secondary care. Wherever performed it should be interpreted by a specialist familiar with determining the function of the ventricles, the dimensions of the heart chambers and at identifying structural abnormalities. An echo can therefore confirm that the patient has heart failure, identify a probable cause and indicate its severity.

Another important step in assessing heart failure is to identify comorbid conditions that may have either exacerbated the heart failure or may complicate routine heart failure management.
 
Treatment
The aims of treatment include an improvement in quality of life as well as improving survival. Treatment options fall into two main categories: pharmacological and nonpharmacological.
Medication has played an enormous role in improving the outcome for people with heart failure through reducing symptoms, increasing exercise tolerance and enhancing quality of life. Yet nonadherence to drug therapy has been cited as a common cause for hospitalisation in as many as 30% of situations.(6) Optimising the use of medication is important and includes simple strategies such as ensuring the patient has a full understanding of their medication and an easy-to-follow regimen. When the drug regimen is complex, a dossette box may be useful. Nurses have a key role to play in heart failure medication; ensuring patients understand their medication, careful uptitration to provide optimised dosages through evidence-based protocols and regular blood tests to detect medication side-effects.
Treatment of heart failure does not rely exclusively upon these pharmacological interventions and exercise and diet are also important components of care. Regular, moderate exercise, such as walking, will help the body use its blood supply more efficiently as well as create a sense of wellbeing. Useful advice includes encouraging regular exercise of about 30 minutes at least three times a week. However, concurrent medical problems such as chronic airways disease or arthritis may limit exercise tolerance and patients may require more specialist advice.
Effective education and support will encourage both the patient and their families to actively manage the illness. This should include not only the common symptoms of heart failure, but also how these can be minimised. However, this should be tailored to the individual and include lifestyle changes and guidelines for the management of the medication regimen. For example, although diuretics are frequently prescribed to be taken in the morning and early afternoon, they may be taken at a time that will not interfere with any social activities. A variety of educational strategies are useful to enhance recall. Printed information that provides both general heart failure advice and leaves room for the nurse to detail patient-specific information may be useful. There are already several leaflets available within the UK providing this, and the British Heart Foundation may be a useful starting point (see Resources). As nonadherence to medication is common, it is good practice to offer advice and support with medication at every opportunity.

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Self-care
People with heart failure should be advised to weigh themselves daily and preferably in the morning, immediately after going to the toilet, and before breakfast or dressing. Diaries are useful to encourage recording of daily weight. An increase in weight, especially if associated with increased breathlessness, oedema, persistent coughing or coughing loose white sputum is an indicator of fluid retention, while a loss of weight may indicate overdiuresis. Many patients, if given written guidelines and parameters, learn to alter their diuretic dose according to these findings. Simple advice such as increasing the dose of furosemide by 40 mg (one extra tablet) for a weight increase over 1 kg over two consecutive days is useful.
Ongoing support is necessary and regular contact either through clinic visits, telephone contact or home visits will ensure that patients are effectively monitoring and managing their condition. In the UK this is predominately facilitated through nurse-managed disease management strategies, and there is much evidence for their benefit.(7) More recently interest in facilitating self-care and enabling the early detection of clinical deterioration through home telemonitoring has developed. Telemonitoring systems are easy to use and involve patients in monitoring their weight, blood pressure, oxygen saturation and symptoms of dyspnoea daily. This information is then transmitted via the normal telephone line to a base station where it is reviewed. If clinically important change is identified, the nurse then uses standard protocols to offer advice or suggest further review through a clinic or home visit.(8) It is hoped that this novel technology will facilitate self-care while providing the patient with help and advice when required.

Conclusion
Heart failure is an important healthcare concern in the UK. Over the past decade significant developments have improved the management of heart failure. However, there is still much that can be done. The nurse, working as part of a multidisciplinary team, has an important role to play in educating the patient and their family on the disease process, its symptoms and management, enhancing self-care abilities and ensuring support is given when needed.

References

  1. Cowie MR, Fox KF, Wood DA, et al. Hospitalization of patients with heart failure. Eur Heart J 2002;23:877-85.
  2. Swedberg K, Cleland J, Dargie H, Drexler H, Follath F, Komajda M, et al. Guidelines for the diagnosis and treatment of chronic heart failure: executive summary (update 2005): The task force for the diagnosis and treatment of chronic heart failure of the European Society of Cardiology. Eur Heart J 2005;26(11):1115-40.
  3. Komajda M, Hanon O, Hochadel M, et al. Management of octogenarians hospitalised for heart failure in Euro Heart failure survey I. Eur Heart J 2004;28:1310-8.
  4. British Heart Foundation Statistics. Available from: http://www.heartstats.org
  5. NICE. Chronic heart failure. National clinical guidance for diagnosis and management in primary and secondary care. London: NICE; 2003. Available from: http://www.nice.org.uk/nicemedia/pdf/Full_HF_Guideline.pdf
  6. Tsuyuki RT, McKelvie RS, Arnold JM, et al. Acute precipitants of congestive heart failure exacerbations. Arch Intern Med 2001;161:2337-42.
  7. Stewart S, Blue L. Improving outcomes in chronic heart failure. London: BMJ Publishing; 2004.
  8. Riley J. The HOME-HF heart failure study. Br J Cardiac Nurs 2007;2:356.

Resources
National Institute for Health and Clinical Excellence
W: www.nice.org.uk
Chronic heart failure. National clinical guidance for
diagnosis and management in primary and secondary care. London: NICE; 2003. Available from: http://www.nice.org.uk/nicemedia/pdf/Full_HF_Guideline.pdf
British Heart Foundation
W: www.bhf.org.uk