CONGESTIVE HEART FAILURE

Overview Congestive heart failure is defined as the state in which the heart is unable to pump blood at a rate adequate for satisfying the requirements of the tissues with function parameters remaining within normal limits usually accompanied by effort intolerance, fluid retention, and reduced longevity (Denolin, 1983, p. 445). Currently, congestive heart failure or heart failure, continues to be a major public health problem worldwide. It is the leading cause of morbidity and mortality in most developed countries. According to the American Heart Association (2001), approximately 5 million patients have heart failure and nearly 550,000 new patients are diagnosed each year. In addition, nearly 300,000 patients die from heart failure yearly.

ANATOMY AND PHYSIOLOGY

The heart has two atria (right atrium and left atrium) that make up the upper chambers of the heart, and two ventricles (left ventricle and right ventricle) that make up the lower chambers of the heart. The ventricles are muscular chambers that pump blood when the muscles contract. The contraction of the ventricle muscles is called systole. Many diseases can impair the pumping action of the ventricles. For example, the muscles of the ventricles can be weakened by heart attacks, infections (myocarditis) or toxins (alcohol, some chemotherapy agents). The diminished pumping ability of the ventricles due to muscle weakening is called systolic dysfunction. After each ventricular contraction (systole) the ventricle muscles need to relax to allow blood from the atria to fill the ventricles. This relaxation of the ventricles is called diastole. Diseases such as hemochromatosis (iron overload) or amyloidosis can cause stiffening of the heart muscle and impair the ventricles' capacity to relax and fill; this is referred to as diastolic dysfunction. The most common cause of this is longstanding high blood pressure resulting in a thickened (hypertrophied) heart. Additionally, in some patients, although the pumping action and filling capacity of the heart may be normal, abnormally high oxygen demand by the body's tissues (for example, with hyperthyroidism or anemia) may make it difficult for the heart to supply an adequate blood flow (called high output heart failure).

PATHOPHYSIOLOGY

HISTORY OF PRESENT ILLNESS A 63-year-old male presents to the emergency room complaining of breathlessness for the past three days. Cardiac history is positive for a myocardial infarction three years ago followed by four-vessel coronary artery bypass surgery. The patient has been asymptomatic since surgery with no complaints of chest pain. Over the last three months PTA, the patient notes onset of shortness of breath while unloading groceries, walking stairs, and other strenuous ADLs. Two weeks ago, he was unable to complete his daily one-mile walk at the high school track. He noted swelling in his feet and ankles. Four days PTA he woke at 2am short of breath and had to sleep in his recliner the rest of the night. He has been unable to lay flat in bed at night since then and has slept on 3 pillows. Yesterday, he became breathless walking from one room to another. He presents today with extreme shortness of breath. He denies chest pain.

PAST MEDICAL HISTORY MI in 1990, CABG 4 vessel in 1996. Vague history og hypercholesteremia. Surgical history also positive for inguinal hernia repair 15 years previous. CURRENT MEDICATIONS None ALLERGIES NKDA HABITS Walks one mile daily until one week PTA. Smoked 1ppd until 1997, 30 pack/year history. ETOHnone. Works 8-12 hours/day in grocery store. FAMILY HISTORY Father died at 60 sudden death of unknown cause, no CAD documented. Mother A&W at 80 with DJD only. Sister died at 58 with AMI. No other siblings. 2 children, A&W. SOCIAL HISTORY Owns and manages own grocery store. Lives with wife in own home. PHYSICAL EXAMINATION BP- 108/52 P- 140, irreg. R- 30 and labored Temp- 99 F Ht: 58 Wt: 210 lbs General: Breathless, moderately obese male in acute distress sitting upright complaining I am going to die. Please help me.

HEENT: Normocephalic. Eyes, ears and throat normal. Neck: Distended neck veins with visible cannon waves, JVD to 12cm. Carotids without bruits. Chest: Scattered rhonchi throughout, rales bilateral one third lower bases. Cough is productive and frothy. Heart: Tachycardia and irreg. Grade 3/6 systolic murmur at LSB, S3 gallop noted. Abd: Liver palpable three centimeters below right costal margin. HJR+, Non-tender to palpation, +Bowel sounds 4 quadrants. Genitalia: Exam deferred. Extremities: 4+ pitting edema of lower extremities to the knees. Nail beds minimally cyanotic, no clubbing. Pulses intact. Neurologic: Anxious with feeling of impending doom. No localized or sensory deficits. Mental status intact. INITIAL LABORATORY DATA Na- 130, K- 3.8, HCO3- 20, BUN- 18, Cr- 1.0. ABGs on room air: pH- 7.30, PaO2- 55, PaCO2- 28. ECG: Left bundle branch block. Atrial fibrillation with ventricular rate of 140. CXR: Cardiomegaly with diffuse pulmonary infiltrate consistent with pulmonary edema.