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Abstract
Heart failure has significant prevalence in older people: the mean average age of patients with the condition is
77. It has serious prognostic and quality of life implications for patients, as well as health service costs. Diagnosis
requires confirmatory investigations and consideration of causative processes. First-line treatment involves
education, lifestyle modification, symptom-controlling and disease-modifying medication. Further treatment may
include additional medications, cardiac devices and surgery. End of life planning is part of the care pathway.
Introduction
Time out
Causes
How many of your caseload of patients, or
the patients you have seen this week, have a
heart failure diagnosis? Using Box 1 (page 29)
list the causes, where known.
Definitions
The terminology used to describe heart failure can be
confusing and jargon is best avoided during patient
communication.
Heart muscle abnormalities are known as
cardiomyopathy and classified as dilated, hypertrophic,
restrictive, or mixed patterns. Dilated cardiomyopathy is
the most common pattern. An enlarged heart is known
as cardiomegaly.
Ventricles are the hearts main pumping chambers
and dysfunction is seen in either or both left
ventricular dysfunction or left ventricular failure and right
ventricular dysfunction or right ventricular failure. Where
both ventricles are impaired, the terms biventricular
dysfunction or biventricular failure are used. The
phrase congestive cardiac failure is sometimes used as
a synonym for biventricular failure but a patient may
have biventricular failure without overt pulmonary or
peripheral congestion. The upper chambers of the heart,
the atria, may also be impaired and/or dilated.
Specific areas of the heart muscle, the myocardium,
may be shown not to move (akinesia) on scanning, may
not move powerfully (hypokinesia) or may not move in
co-ordination with the rest of the myocardium (dyskinesia).
Heart failure can also be defined in terms of where
the impairment is in the phases of the cardiac cycle
during contraction (systole) or relaxation (diastole).
30 September 2014 | Volume 26 | Number 7
Diagnosis
Heart failure should be diagnosed using the pathway
in the European Society of Cardiology (ESC) guidelines
(McMurray et al 2012), as follows.
Clinical presentation (Table 1, pages 32-33) may
raise suspicion but is not sufficient to confirm diagnosis
because these symptoms and signs occur in other
conditions. Once diagnosis is confirmed the severity of
symptoms can be expressed using the New York Heart
Association (NYHA) classification (Box 2) (Criteria
Committee of the NYHA 1994). The NYHA classification
can also be used to monitor progress. Absence of
symptoms and signs does not exclude the heart being
dysfunctional or having structural abnormalities (ACCF/
AHA 2013). Many of the disease processes that occur
with heart failure are on a continuum and will start
before the patient has symptoms. For example, some
patients are at risk of heart failure because they are
genetically predisposed to hypertension, but for diagnosis
investigations should confirm abnormality of cardiac
structure or function.
Box 2 New York Heart Association (NYHA)
classification of heart failure
Class I No limitations to ordinary physical activity.
Class II Slight limitations to ordinary physical
activity with undue breathlessness, fatigue
or palpitations.
Class III Marked limitations to less than ordinary
physical activity with undue breathlessness,
fatigue or palpitations.
Class IV Symptoms may be present at rest and
discomfort made worse with any physical
activity.
(Criteria Committee of the NYHA 1994)
Time out
Diagnosis
Mr Smith is a new nursing home resident. His
only medical history is short-term memory
loss and high blood pressure. He has become
breathless on exertion over the past month
and his ankles have started to swell. What
is the next diagnostic step? Compare what
you have written with the answer given on
page 37.
Comorbidity
Patients with heart failure have more comorbidities
than age-matched controls, and comorbidities have
a significant effect on symptoms, hospitalisations
and prognosis (van Deursen et al 2014). Cardiac
comorbidities may cause heart failure, or sometimes
co-exist with and influence the condition, and prevalence
of cardiac comorbidities increases with age. For example,
the prevalence of atrial fibrillation doubles with each
decade of life (Cleland et al 2002). Hypertension affects
myocardium by ventricular hypertrophy and diastolic
dysfunction, which can present as heart failure with
preserved ejection fraction. Chronic valve dysfunction
NURSING OLDER PEOPLE
Management
Education and self-management Patients and carers
require education about heart failure to develop the staffpatient relationship and improve treatment concordance,
especially in older patients (Anderson et al 2005).
Specific education should address individual adaptation
to the condition, warning signs and what to do in acute
situations. Education empowers patients and increases
successful self-management. For example, some patients
may be given discretion over the dose of their diuretic or
be given monitoring parameters for rapid weight gain.
Lifestyle modification Certain behaviours help the heart
to function either efficiently or inefficiently. For example,
excess alcohol depresses myocardial cell function
and causes dilated cardiomyopathy and arrhythmias.
In smokers, as well as endothelial wall effects, the
immediate release of nicotine contracts arteries,
increasing the risk of ischaemia (Lanza et al 2011).
Obesity and being sedentary adversely affect resting
heart rate and increase cardiac demands. Anaemia
increases cardiac workload (Levick 2009).
Conversely, exercise has significantly positive effects
on symptoms and left ventricular function (Piepoli et al
2004). Good control of comorbid conditions such as
diabetes, hypercholesterolaemia and kidney disease
improves cardiac outcomes. Patients with heart failure
who are hospitalised for another condition have longer
stays and worse outcomes than matched populations
without heart failure (Ahluwalia et al 2012).
How patients can be supported to achieve these
outcomes is outside the scope of this article but is
covered comprehensively in nursing texts, for example,
Nicholson (2007).
Now do time out 3.
3
Time out
Medications
List the first-line medications used to
treat heart failure. Reflect on how you
would explain to patients how these drugs
work. Remember that some patients will
need a simpler and some a more detailed
explanation.
Symptoms
Breathlessness
Peripheral oedema
Orthopnoea (shortness of
breath on lying flat)
Loss of appetite
Bloated feeling
Confusion
Palpitations
Paroxysmal nocturnal
dyspnoea (PND) (sudden
difficulty breathing at
night)
Nocturnal cough
Sleep disorders
Fatigue
Reduced exercise
capacity
Signs
Tachypnoea
Tachycardia
Abnormal pulse
Heart murmurs
Wheezing
Lung crepitation
Weight changes
Hepatomegaly
Tissue wasting
Note: Clinical presentation will depend on the patients acuteness, severity of heart failure
and particular pattern of disease. Patients can therefore have some, or even none, of the
above signs and symptoms.
Disease-modifying drugs
Initial dose
Full dose
Indication
Bisoprolol
5mg BD or 10mg OD
Carvedilol
25mg or 50mg BD
depending on weight
Nebivolol
1.25mg OD
10mg OD
Beta blockers
2.5mg BD
20mg BD
Lisinopril
2.5mg OD
35mg OD
Ramipril
2.5mg OD
5mg BD
Perindopril
2mg OD
8mg OD
4mg OD
32mg OD
Valsartan
40mg BD
160mg BD
Losartan
50mg OD
150mg OD
25mg OD
50mg OD
Eplerenone
25mg OD
50mg OD
20-40mg
Up to 240mg
Bumetanide
0.5-1mg
Up to 5mg
Bendroflumethiazide
2.5mg
10mg
Metolazone*
2.5mg
10mg
Indapamide
2.5mg
5mg
Ivabradine
2.5mg
10mg
Digoxin
62.5mcg OD
250mcg OD
Thiazide diuretics
As either a milder alterative to a loop diuretic or an addition
to a loop diuretic to produce synergistic action.
Hydralazine and
isosorbide dinitrate
*Note: Metolazone is no longer manufactured in the UK but supplies are still being used up at the time of writing.
Criteria
CRT-D
Patients with CRT-P indication who also meet the ICD criteria or who
have LVEF <30%.
Primary prevention
Symptomatic heart failure with an LVEF <35% despite three months of
optimised medical therapy and the patient is expected to survive for more
than a year with good functional status.
Secondary prevention
Evidence of ventricular arrhythmia leading to haemodynamic instability
and the patient is expected to survive for more than a year with good
functional status.
*Device therapy indications are based on the evidence from trial populations but there are areas which are uncertain or where trial data are
lacking or limited, such as in patients with atrial fibrillation, right bundle branch block and those with a conventional pacemaker indication who
also have reduced LV function. Therefore, precise practice may vary between clinicians.
4
Time out
Optimising treatment
Referring to the patients you noted for time
out 1, add the heart failure drugs they are
prescribed to the list. Are they all on optimal
treatment? If not, is there a documented
reason why not in their records?
Advanced treatments
Cardiac devices Symptomatic patients on optimised
medication might benefit from biventricular pacing, also
known as cardiac resynchronisation therapy (CRT-P).
Criteria for CRT-P are listed in Box 3. A third wire paces
the left ventricle and the device co-ordinates electrical
stimulation of the heart and can improve symptoms and
quality of life significantly. However, around one quarter
of patients who seem suitable for CRT-P do not respond
(Fox et al 2005).
Half of heart failure patients die of arrhythmia.
Ventricular arrhythmia survival is improved with
an implantable cardioverter defibrillator (ICD).
The device can be a stand-alone ICD or with CRT
pacemaker functions (CRT-D). Criteria for ICDs are
listed in Box 3.
Devices are inserted under local anaesthetic
and there are no age restrictions. In patients with
terminal diagnosis, unlikely to survive a year, it is
NURSING OLDER PEOPLE
End of life
Heart failure causes death through either terminal
pump failure or arrhythmia. Some people die within
months of diagnosis and others survive years, but there
comes a phase when every patient is at the end of life
(Box 4). Recognising end of life is important to plan
changing care needs. Palliative care planning should take
place as for any dying patient, with emphasis on symptom
control. Non-essential medication can be discontinued,
although neurohormonal drugs and diuretics may be
controlling symptoms and stopping them could make some
patients feel worse.
NURSING OLDER PEOPLE
5
Time out
Best practice
Reflect on one patient with heart failure who
you have cared for. Did his or her diagnosis,
treatment and progression fit with best
practice guidelines? What systems were in
place to ensure the patient received optimal
care? If you are unsure, consult the ESC
guidelines (McMurray et al 2012).
Conclusion
Understanding and being able to manage heart failure
is important for patients quantity and quality of life,
regardless of age. It is also important for health service
costs. Heart failure is most common in older adults and
it is expected that the average age of patients will rise.
Nurses have a crucial role in the care of patients but
a multidisciplinary approach is mandatory, including
partnership with older adult services.
Suggested answer to time out 2
A screening test such as brain natriuretic peptide blood
test or ECG. It is possible he has heart failure with the
September 2014 | Volume 26 | Number 7 37
Reflective account
Now that you have completed reading the
article you might like to write a reflective
account. Guidelines to help you are on
page 39.
References
Adam A, Nicholson C, Owens L (2008)
Alcoholic dilated cardiomyopathy. Nursing
Standard. 22, 38, 42-47.
Ahluwalia S, Gross C, Chaudhry S et al
(2012) Impact of comorbidity on mortality
among older persons with advanced heart
failure. Journal of General Internal Medicine.
27, 5, 513-519.
American College of Cardiology Foundation/
American Heart Association (2013) Guideline
for the management of heart failure. A
Report of the American College of Cardiology
Foundation/American Heart Association Task
Force on practice guidelines. Circulation.
https://circ.ahajournals.org/content/128/16/
e240.extract (Last accessed: August 8 2014.)
Anderson C, Deepak B, Amoateng-Adjepong Y
et al (2005) Benefits of comprehensive inpatient
education and discharge planning combined
with outpatient support in elderly patients
with congestive heart failure. Congestive Heart
Failure. 11, 6, 315-321.
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