After decades of uncontrolled hypertension, Ms. Griffin was diagnosed with left-sided heart failure. Although her heart failure was diagnosed eight years ago, she is currently in nursing care and cannot move from the bed or wheelchair because angina and dyspnea episodes often occur even during periods of rest. Over the past 2 years, she has been losing weight and is currently at 93 pounds, which is a 58 percent reduction compared to her previous weight of 160 pounds, so a percutaneous esophageal gastronomy (PEG) tube was inserted in her.
According to the New York Heart Association (NYHA) functional classification system, Ms. Griffin has a class IV stage heart failure, which is considered a severe case of heart failure because she cannot engage in any physical activity and symptoms of dyspnea and angina are present even while she is resting. However, it is important to mention that the NYHA described their own functional assessment only as a subjective estimate of the patient’s condition by the physician (Raphael et al., 2007). Nevertheless, that limitation applies only to classes II and III because they rely only on the patients’ subjective evaluations of their physical capacity, so there is no mistake in evaluating Ms. Griffin’s case as a stage IV heart failure.
The significant weight loss accompanying her heart failure suggests that she has a higher mortality rate than patients who maintain their weight. According to a study by Pocock et al. (2008), chronic heart failure patients who lose 5% or more weight over the course of six months have a 50% mortality risk than patients who keep their weight consistent. Weight loss is more common in elderly patients and patients with severe heart failure according to the NYHA classification, which is consistent with Ms. Griffin’s case. However, her rate of weight loss also suggests that she may suffer from cachexia, which is a possible outcome in heart failure patients and results in tissue wasting that affects muscle, bone, and fat tissue (Pocock et al., 2008). In order to confirm that suspicion, it is important to assess her neurohormones, anemia markers, and inflammatory cytokine levels.
In treating Ms. Griffin, it is important to consider that acute weight gain may also contribute to increasing short-term risks for mortality. For example, if she gains 2 pounds immediately, which indicates an approximate 2% gain, her short-term mortality risk will increase by 6.8% (Pocock et al., 2008). However, there is no long-term mortality risk associated with acute weight gain. That can be explained by the possible presence of edema that account for the acute weight gain and may place the patients’ life at risk.
Even though Ms. Griffin was diagnosed with left-sided heart failure, she displays symptoms of both-sided heart failure. That is not uncommon because right-sided heart failure follows left-sided failure. In both diastolic and systolic failure, the left ventricle loses its ability to relax or contract, which results in increased fluid pressure. That pressure is transferred to the lungs and results in significant damage to the right side of the heart (American Heart Association [AHA], 2012a).
Because the left-sided heart failure was the primary cause of Ms. Griffin’s condition, her ejection fraction is significantly reduced from the normal range of 55 – 60 percent to 19%. The ejection fraction is used to measure how much blood is pumped out with each heart beat by the left ventricle, and any measurement under 40% indicates heart failure (AHA, 2013). Because Ms. Griffin’s case is severe, she has a very low ejection fraction.
Measuring ejection fraction with an echocardiogram, cardiac catherization, and other tests is only one possible indicator of heart failure. The most common tests for diagnosing heart failure include a physical examination, blood test, X-ray, electrocardiogram (ECG), Multiple-gated acquisition scanning (MUGA), exercise stress test, echocardiogram, and cardiac catherization.
Physical examination is the first step because it requires an assessment of the patient’s medical history, lifestyle habits, weight, blood pressure, and the assessment of the heart and lungs with a stethoscope. The blood test in determining heart failure measures the levels of creatine, albumin, sodium, and potassium. Abnormal levels of those substances indicate liver or kidney strain, which may result from heart failure (AHA, 2012b). However, a blood test alone is not enough to directly determine the presence of heart failure.
Chest X-rays can show congestion in the lungs or enlargement in the heart. The ECG can measure abnormal heart rhythms, left ventricle thickness, and previous heart failures. Echocardiography produces images that can explain the heart muscle thickness and the ejection fraction. The exercise stress test alone cannot diagnose heart failure, but it can be used to determine acceptable activity levels and classify the severity of the patients’ heart failure. Cardiac catherization requires a fluid injection that is visible by the X-ray test, and the images obtained show whether the coronary arteries are blocked, and how those blockages weaken or damage parts of the heart. Finally, the MUGA scan determines the level of function of heart chambers, and determines which part was damaged because of the heart attack.
There is a variety of pharmacological interventions available to patients with heart failure, but they all depend on the individual circumstances of each patient. For example, the focus of clinical trials shifted from reducing mortality to improving survival rates, relieving symptoms, and reducing hospitalization (McMurray et al., 2012). The first line of treatment in heart failure consists of angiotensin-converting enzyme (ACE) inhibitors and beta-blockers because they decrease fluid retention and alleviate symptoms associated with reduced ejection fraction (McMurray et al., 2012). Other potential choices are ivabradine or digoxin for reducing heart rate and balancing the heart beat rhythm.
In Ms. Griffin’s case, an interdisciplinary intervention is required that will consist of nurses, pharmacists, physical therapists, psychologists, dietitians, and cardiologists, but a surgeon may also be required if the cardiologists considers a complex invasive procedure is necessary. The treatment is not differentiated between young and elderly patients, but elderly patients require more care regarding decision-making to prevent unwanted medicine interactions and complications in comorbid disorders.
For Ms. Griffin, ACE inhibitors and beta-blockers should be the first choice of treatment because her heart failure is characterized by reduced ejection fraction. In addition, beta-blockers were found effective in managing angina while ACE inhibitors should regulate her blood pressure. If the angina symptoms are a significant hazard the cardiologist and surgeon may decide to perform a percutaneous or surgical revascularization or a coronary artery bypass surgery (McMurray et al., 2012).
Ms. Griffin also has cachexia, judging by her significant weight reduction, so appetite stimulants or anabolic agents should be considered to help hear increase weight slowly. Although it is possible for the dietitian to include certain supplements, none have proven significantly beneficial in heart failure patients, so it might be best to avoid them to reduce interference risks with medication (McMurray et al., 2012). The emphasis should be on improving her nutrition because she is not capable for exercise therapy given her severe condition. For example, the Dietary Approaches to Stop Hypertension (DASH) diet could prove useful because it was designed to regulate hypertension and is beneficial to all individuals with cardiovascular conditions (Azadbakht et al., 2011).
The presence of dyspnea also suggests that she could suffer from chronic obstructive pulmonary disease (COPD). Spyrometry or a chest X-ray should be used to determine whether the patient suffers from COPD. If that is the case, beta-blockers could prove beneficial. However, beta-blockers are not recommended in cases of asthma, so a selective beta-1 adrenoceptor antagonist may be preferred in her condition (McMurray et al., 2012). Physical therapy should not be used extensively in her condition, but the goal of physical therapy should be keeping the joints functional. If the patient shows progress, the new goal will be improving her aerobic functions to restore her mobility as much as possible.
Other components of treatment should include frequent assessments, patient education, family education, and providing psychosocial support. Nurses can assess Ms. Griffin’s physical and mental status, which includes monitoring tests results, educating her about her disorder and expected outcomes from interventions, assessing her pulse, and monitoring her blood pressure. Although the nurses should also provide psychosocial support, the psychologist is responsible for providing support by improving her motivation and reducing potential symptoms of anxiety or other behavioral and emotional issues.
Decision-making, patient education, psychosocial support, and monitoring the patient’s condition are shared responsibilities for all members of the interdisciplinary team, but the roles can be assigned within the team to prevent role confusion. The planned interventions should also be discussed with Ms. Griffin to include her in the decision-making process and allow her to state her needs. Finally, the follow-up care requires staying in contact with the patient by phone or home visits. The role of follow-up care is monitoring her condition frequently and altering her treatment if necessary.
References
American Heart Association. (2012a). Types of heart failure. Retrieved from http://www.heart.org/HEARTORG/Conditions/HeartFailure/AboutHeartFailure/Types-of-Heart-Failure_UCM_306323_Article.jsp
American Heart Association. (2012b). Common tests for heart failure. Retrieved from http://www.heart.org/HEARTORG/Conditions/HeartFailure/SymptomsDiagnosisofHeartFailure/Common-Tests-for-Heart-Failure_UCM_306334_Article.jsp
American Heart Association. (2013). Ejection fraction heart failure measurement. Retrieved from http://www.heart.org/HEARTORG/Conditions/HeartFailure/ SymptomsDiagnosisofHeartFailure/Ejection-Fraction-Heart-Failure-Measurement_UCM_306339_Article.jsp
Azadbakht, L., Fard, N. R. P., Karimi, M., Baghaei, M. H., Surkan, P. J., Rahimi, M., & Willett, W. C. (2011). Effects of the Dietary Approaches to Stop Hypertension (DASH) eating plan on cardiovascular risks among type 2 diabetic patients: A randomized crossover clinical trial. Diabetes Care, 34(1), 55-57.
McMurray, J. J., Adamopoulos, S., Anker, S. D., Auricchio, A., Böhm, M., Dickstein, K., & Lamin, H. A. B. (2012). ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012 The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. European Heart Journal, 33(14), 1787-1847.
Pocock, S. J., McMurray, J. J., Dobson, J., Yusuf, S., Granger, C. B., Michelson, E. L., & Swedberg, K. B. (2008). Weight loss and mortality risk in patients with chronic heart failure in the candesartan in heart failure: assessment of reduction in mortality and morbidity (CHARM) programme. European heart journal, 29(21), 2641-2650.
Raphael, C., Briscoe, C., Davies, J., Whinnett, Z. I., Manisty, C., Sutton, R., & Francis, D. P. (2007). Limitations of the New York Heart Association functional classification system and self-reported walking distances in chronic heart failure. Heart, 93(4), 476-482.
