🌊Heart Failure: This heart can’t swim.

Understanding Acute Heart Failure (HF)

Acute heart failure typically begins with progressively increasing dyspnea on exertion (DOE, or difficulty breathing with activity). According to the UK National Heart Failure Audit, approximately 80% of patients admitted for their first hospitalization with acute or decompensated HF experience shortness of breath (SOB) during at least moderate exercise. This incidence tends to decrease with subsequent hospitalizations.

According to the National Heart Failure Audit for England and Wales (2008–2009), 30% of patients were breathless at rest upon admission, while 43% had peripheral edema . This suggests that while shortness of breath is a common symptom, the prevalence may be lower than initially thought.​

(Note: this may be a difficult read for some, as you will have to translate it from British.)

Common Symptoms Accompanying Dyspnea:

• Edema (swelling)

• Fatigue

• Loss of appetite

• Weight fluctuations

Assessing Signs and Symptoms Across Systems

Respiratory

• Respiratory Rate: Note any increase or irregularities.

• Severity of Dyspnea: Assess how limiting symptoms are.

• SOB/Dyspnea on Exertion (DOE): Evaluate the patient's breathing effort.

• Orthopnea: Screen patient's tolerance for lying flat.

• Oxygen Saturation: Monitor for hypoxia.

• Progression Timeline: Document how quickly symptoms have advanced.

Hemodynamic

• Blood Pressure: Track trends and stability.

Cardiac Rhythm

• Screen for heart rhythm irregularities:

  • Patient history of arrhythmias.

  • Symptoms such as palpitations, dizziness, or fainting.

Cardiac Output

• Peripheral Perfusion: Check for diminished pulses, cool extremities.

• Urine Output: Monitor for decreased renal perfusion.

• Mental Status: Look for confusion or decreased cognitive function.

Signs of Congestion

• Pulmonary Rales: Listen for crackles indicating fluid accumulation.

• Peripheral Edema: Check for swelling in extremities.

• Jugular Venous Pressure (JVP): Assess for elevated pressure indicating fluid overload.

Anxiety

Often overlooked, anxiety significantly impacts heart failure management. Include assessment and management strategies.

Diagnostic Testing Recommendations

• Echocardiography: Assesses heart structure and function, including ejection fraction.

• Electrocardiogram (ECG): Detects arrhythmias, ischemia, and other cardiac abnormalities.

• Chest X-ray: Identifies pulmonary congestion and cardiomegaly.

• Cardiac MRI: Provides detailed images of heart tissue and function.

• Hemogram (Complete Blood Count): Checks for anemia or infection.

• Nuclear Blood Study: Assesses ventricular function and blood flow.

• Basic Metabolic Panel (BMP): Evaluates renal function and electrolyte balance.

• Troponin Levels: Determines cardiac muscle damage.

• NT-proBNP: Measures severity of heart failure.

  • NT-proBNP levels are used to aid in the diagnosis of heart failure. A level below 300 pg/mL can effectively rule out heart failure in the emergency setting . In outpatient settings, levels below 125 pg/mL make a diagnosis of heart failure less likely .

Types of Heart Failure

• Heart Failure with Reduced Ejection Fraction (HFrEF): Ejection fraction ≤40%.

• Heart Failure with Preserved Ejection Fraction (HFpEF): Ejection fraction ≥50%.

• Heart Failure with Mid-Range Ejection Fraction (HFmrEF): Ejection fraction 41–49%.

Management Strategies

• Lifestyle Modifications: Dietary changes, exercise, and fluid restriction.

• Pharmacological Treatments: ACE inhibitors, beta-blockers, diuretics, and newer agents like SGLT2 inhibitors.

• Device Therapy: Implantable cardioverter-defibrillators (ICDs) and cardiac resynchronization therapy (CRT) for selected patients.

Fluid Restriction Conversions

(Note: there is some controversy on the effectiveness of fluid restrictions in the management of heart failure. Dietary sodium restriction may be more important.)

2000mL = 67.6 oz = 8.5 cups

1800mL = 60.9 oz = 7.6 cups

1600mL = 54.1 oz = 6.8 cups

1500mL = 50.7 oz = 6.3 cups

1400mL = 47.3 oz = 5.9 cups

1200mL = 40.6 oz = 5.1 cups

1100mL = 37.2 oz = 4.6 cups

1000mL = 33.8 oz = 4.2 cups

Compression Stockings

10 -15 mmHg “Soft” - OTC; no Rx needed

15-20 mmHg “Soft” - OTC; no Rx needed

20-30 mmHg “Medium” - Rx needed

30-40 mmHg “Hard” - Rx needed

Patients can get these at:

• Aspirus Home Medical

• Pink Ribbon in Wausau

HF Education Sites

Recommended HF websites for patient education:

• HFSA: Heart Failure Society of America

• NIH StatPearls on Heart Failure

• American Heart Association: Heart Failure

• National Heart, Lung, and Blood Institute: Heart Failure