Congestive Heart Failure in the Older Adult
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Congestive Heart Failure in the Older Adult
Introduction
Heart failure is a complex health condition whereby the heat fails to pump enough blood required to perform body operations. Heart failure results from any medical condition that affects the ventricular filling or ejection of blood in the body (Malik et al., 2022). Some factors can lead to congestive heart failures, such as mechanical obstruction of the heart as indicated in pericardial disease, high pressure in the pulmonary or systemic circulation, lack of oxygen or inflammatory reactions in the heart muscle, and others (Momin & Lotankar, 2018). The risk of heart failure increases with age with over 10% of people aged 70 and above suffering. About 33% of men and 28% of women aged 55 and above have a higher risk of CHF (Martens & Mullens, 2018). Approximately 6.2 million people in the U.S. presented with CHF between 2013 and 2016. Therefore, CHF is a serious community health issue that needs serious attention (Malik et al., 2022). The purpose of this paper is to discuss CHF, its clinical management, and expected patient outcomes.
The Problem
Etiology and Pathophysiology of Heart Failure
Congestive heart is caused by functional and structural problems in the heart and some trigger factors. Historically, the majority of people who suffered from the disease had coronary artery disease while some had myocardial infarction. Today, diabetes and coronary artery disease have become common predisposing factors (Malik et al., 2022). Other structural problems leading to congestive heart failure are valvar heart disease, high blood pressure, myocarditis, congenital heart disease, and uncontrolled arrhythmia. Other groups of diseases associated with congenital heart failure include thyrotoxicosis, severe anemia, nutritional deficiencies, obesity, and pregnancy.
According to Malik et al. (2022), cardiac physiology often attempt to adapt through several compensatory mechanisms, during the initial stages of congestive heart failure, to maintain proper cardiac output and other body demands. Due to increased wall stress, the heart myocardium tends to compensate through eccentric remodeling, leading to the worsening of the condition, as well as the wall stress. A reduction in cardiac output causes the neuroendocrine system to release chemicals that cause vasoconstriction and increased afterload. This situation causes increased myocardial oxygen demand, which in turn leads to apoptosis (Malik et al., 2022). This incident leads to increased maladaptive mechanisms causing progressive heart failure. According to Momin & Lotankar (2018), failure of the heart to pump blood effectively causes reduced stroke volume/cardiac output. Consequently, compensatory mechanisms will attempt to increase cardiac output. If excessive, these mechanisms can worsen heart failure.
Clinical Presentation
According to Merkaš et al. (2021), signs and symptoms of heart failure are shortness of breath orthopnoea, dyspnea, paroxysmal nocturnal dyspnoea, poor stability, lack of appetite, and dizziness. Other symptoms include muscle weakness and fatigue. Patients may not show all the signs and symptoms in the early phase of congestive heart failure due to compensatory mechanisms (Merkaš et al., 2021). Auscultation and physical exam may indicate signs of abnormal pulmonary (crepitation, wheezing), the third heart sound, and cardiac cachexia, during the later stages of the illness. Martens & Mullens (2018) also identified the symptoms of congestion to include orthopnea,the third heart sound, rales, jugular venous distension, bendopnea, and pulmonary or peripheral edema. These symptoms can be used to assess congestive heart failure in patients.
The basis of diagnosis of congestive heart failure includes a physical examination by looking at the physical symptoms. Other tests such as an electrocardiogram (ECG), radiology of the heart and lungs, and ultrasound of the heart (echocardiography) (Merkaš et al., 2021). Laboratory tests such as N-terminal proB-type natriuretic peptide (NT-proBNP) or brain natriuretic peptide (BNP). Malik et al. (2022) reiterate that a comprehensive lab analysis may include iron deficiency, anemia, renal dysfunction, and others to help predict the cause of heart failure.
Differential Diagnoses
There are several differential diagnoses for congestive heart failure. The first differential diagnosis is a chronic obstructive pulmonary disease (COPD). The disease causes some changes in the bronchiolar structure, leading to difficulty in breathing (Güder & Störk, 2019). Although there are fundamental disparities in the pathophysiology of COPD and congestive heart failure, the clinical presentations associated with then are almost the same (Güder & Störk, 2019). Both heart failure and COPD share potential risk factors such as systemic endothelial inflammation and tobacco smoking. In both, symptoms include reduced exercise tolerance, fatigue, and shortness of breath, among others. Other differential diagnoses include pulmonary fibrosis and acute respiratory distress syndrome (ARDS) (Malik et al., 2022). Furthermore, others are pulmonary embolism (PE) and nephrotic syndrome.
Clinical Management
Majority of the approved medications for heart failure are backed up by clinical trials. Bumetanide and torsemide, as well as, furosemide are loop diuretics used to treat heart failure (Ellison & Felker, 2017). These medications bind the translocation pocket found at the extracellular surface of sodium-potassium-chloride cotransporters (NKCCs) to prevent ion transport. Bumetanide and torsemide, are other two loop diuretics that can be used to treat heart failure (Ellison & Felker, 2017). Loop diuretic medications work by increasing the excretion of sodium chloride through urine to ensure a balance between water and sodium chloride (decongestion), as well as to reduce the extracellular fluid volume in the end. Martens & Mullens, (2018) also support the use of loop diuretics to manage congestive heart failure by stating that more than 90% of patients diagnosed with acute heart failure use these drugs.
According to Bauersachs (2021), drug therapies used to treat Heart failure with reduced ejection fraction (HFrEF) require treatment with more than one drug. These drug therapies include angiotensin-converting enzyme (ACE) inhibitors, beta-blockers, mineralocorticoid receptor antagonists (MRAs), and angiotensin receptor/neprilysin inhibitors (ARNIs). These medications provide significant benefits associated with a reduction in mortality, casual hospitalization, and other symptoms of heart failure. Sodium-glucose co-transporter 2 (SGLT2) inhibitors (dapagliflozin and empagliflozin have shown significant efficacy in improving CHF (Bauersachs, 2021). Dapagliflozin or empagliflozin are now recommended for the treatment of CHF.
The European Society of Cardiology (ESC) together with the Heart Failure Association (HFA) developed a guideline for treating congestive heart failure. The 2021 ESC Guidelines for diagnosis and treatment of chronic and acute heart failure support the medications described above (McDonagh et al., 2022). This guideline recommends ACE-Is (Enalapril), beta-blockers (Carvedilol, Metoprolol CR/XL, Bisoprolol, Nebivolol), MRAs (Spironolactone, Eplerenone), SGLT2 inhibitors (Dapagliflozin, Empagliflozin), and others. These medications are used to treat chronic heart failure with reduced ejection fraction (McDonagh et al., 2022). The guideline provides other several recommendations and medications for treating congestive heart failure. Ghionzoli et al. (2021) state that some of the drug targets in heart failure treatment include the renin-angiotensin-aldosterone system, the sympathetic nervous system, and others, hence various types of medications to treat the illness. According to Momin & Lotankar (2018), Sacubitril/Valsartan and Ivabradine is FDA approved for the treatment of heart failure.
There are some other non-pharmacologic approaches to manage CHF, such as pacemakers, biventricular pacemakers, internal cardioverter defibrillators (ICD), and continuous positive airway pressure. Other approaches include aerobic/endurance training, resistance/strength training, and respiratory training (Merkaš et al., 2021). Patient education should entail how to avoid risk factors, as well as, proper management of comorbid conditions (Malik et al., 2022). Medication adherence education is essential to prevent diuretic resistance and enhance overall well-being.
Expected Patient Outcomes
Expected Treatment Outcomes
Some of the expected outcomes include significant reduction or elimination of the symptoms of heart failure comorbidities. Signs and symptoms such as fatigue, dyspnea, and fluid retention are expected to resolve. Other signs such as enlarged cardiac silhouette, edema at the lung bases, and vascular congestion should disappear in chest radiography (Malik et al., 2022). The time it takes to recover from congestive heart failure depends on the type of heart failure one has, the cause, and the type of treatment. Therefore, it is difficult to set an overall timeframe for the treatment of heart failure.
To assess whether the expected outcomes are achieved, the doctor may focus on several clinical symptoms such as orthopnea, bendopnea, dyspnea, rales, jugular venous distention, pulmonary or peripheral edema, and the third heart sound, which all point to congestion (Martens & Mullens, 2018). Auxiliary tests are normally necessary to detect heart failure. The standard for assessing congestion recovery is the right heart catheterization and direct measurements of right atrial and pulmonary capillary wedge pressure using a pulmonary artery catheter (Martens & Mullens, 2018). Echocardiography provides a comprehensive non-invasive evaluation of cardiac hemodynamics. Furthermore, natriuretic peptides (NPs) are useful in assessing cardiac filling pressures.
When the Management Stop Management and a Plan of Transfer
Since congestive heart failure cannot be cured in most cases, the treatment can be stopped when the symptoms have disappeared. The patient should remain on medications, as well as practice healthy lifestyle changes to manage the condition. According to Martens & Mullens (2018), the volume overload is completely resolved when the patient achieves hemoconcentration during AHF treatment. However, the patient may be transferred to a cardiologist because for further treatment when having a bad prognosis. A cardiologist is preferred because they are doctors who are trained to detect and treat complicated cardiovascular diseases.
Conclusion
Congestive heart failure causes detrimental health impacts to the patient. It is caused by any medical condition that affects the ventricular filling or ejection of blood in the body. Symptoms of this disorder include shortness of breath including orthopnoea, dyspnea, paroxysmal nocturnal dyspnoea, poor stability, and lack of appetite, dizziness, and others. Differential diagnoses include COPD, pulmonary fibrosis, and acute respiratory. Drugs include ACE-Is, beta-blockers, MRAs, and SGLT2 inhibitors. Better outcomes are expected with these drugs.
References
Bauersachs, J. (2021). Heart failure drug treatment: the fantastic four. European Heart Journal, 42(6), 681-683. https://doi.org/10.1093/eurheartj/ehaa1012
Ellison, D. H., & Felker, G. M. (2017). Diuretic treatment in heart failure. New England Journal of Medicine, 377(20), 1964-1975. https://doi.org/10.1056/NEJMra1703100
Ghionzoli, N., Gentile, F., Del Franco, A. M., Castiglione, V., Aimo, A., Giannoni, A., & Vergaro, G. (2021). Current and emerging drug targets in heart failure treatment. Heart failure reviews 1-18. https://doi.org/10.1007/s10741-021-10137-2
Güder, G., & Störk, S. (2019). COPD and heart failure: differential diagnosis and comorbidity. Herz, 44(6), 502-508. https://doi.org/10.1007/s00059-019-4814-7
Malik, A., Brito, D., Vaqar, S., & Chhabra, L., (2022). Congestive Heart Failure. In StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK430873/
Momin, A. J., & Lotankar, A. R. (2018). Congestive Heart Failure: Current Treatment and Therapies under Realm of Research. ADVANCES IN PHARMACOLOGY AND PHARMACY, 6(2), 57-64. https://doi.org/10.13189/app.2018.060204
Merkaš, I. S., Slišković, A. M., & Lakušić, N. (2021). Current concept in the diagnosis, treatment and rehabilitation of patients with congestive heart failure. World Journal of Cardiology, 13(7), 183. https://doi.org/10.4330/wjc.v13.i7.183
Martens, P., & Mullens, W. (2018). How to tackle congestion in acute heart failure. The Korean Journal of Internal Medicine, 33(3), 462. https://doi.org/10.3904/kjim.2017.355
McDonagh, T. A., Metra, M., Adamo, M., Gardner, R. S., Baumbach, A., & Waltenberger, J. (2022). 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: Developed by the Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). With the special contribution of the Heart Failure Association (HFA) of the ESC. European Journal of Heart Failure, 24(1), 4-131. https://doi.org/10.1093/eurheartj/ehab368