Acute and chronic heart failure
Acute heart failure describes a patient who presents with sudden onset of shortness of breath and pulmonary oedema; this often is following an MI or an acute valvular problem.
Chronic heart failure is a complex syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the heart to function as a pump to support a physiological circulation. The syndrome of chronic heart failure is characterized by symptoms such as breathlessness and fatigue, and signs such as fluid retention (NICE, 2010).
Left sided or right sided heart failure
Patients with left sided heart failure will present with dyspnoea (breathlessness), coughing and expectorating white frothy sputum. Failure of the left ventricle causes reduced stroke volume, congestion in the left ventricle, left atrium and backflow in the pulmonary circulation. This increased pressure in the pulmonary circulation causes dyspnoea (‘orthopnoea at rest’), pulmonary oedema, fatigue, dizziness and confusion. Left sided heart failure commonly leads to right-sided heart failure.
Right sided heart failure can be caused by left sided heart failure, chronic lung disease, pulmonary embolism, or pulmonary stenosis. Patients with right sided heart failure have clinical indicators of venous congestion including oedematous ankles, abdominal distension, pleural and abdominal ascites, weight gain or weight loss and raised JVP. (Johnson and Rawlings- Anderson, 2007).
Systolic heart failure
Left systolic heart failure is caused by pump failure with reduced systolic function of the left ventricle. The heart’s pumping ability is indicated by reduced left ventricle ejection fraction (LVEF), resulting in reduced cardiac output.
Diastolic heart failure
Diastolic heart failure is heart failure with preserved systolic function of the left ventricle. Left ventricular filling in diastole is reduced because of increased stiffness of the heart muscle. Cardiac output may be reduced in spite of normal pump function. A consequence is increasing pressures causing pulmonary and systemic congestion. Diastolic heart failure is a common condition in the older population. (Johnson and Rawlings- Anderson, 2007)
Evidence based nursing care requires that an accurate diagnosis has been made by the medical team. The following investigations are required to establish the aetiology of the heart failure:
- 12 lead ECG to reveal ischaemia and arrhythmias.
- Chest X-ray to establish if the heart is enlarged
- Echocardiogram indicates any systolic and / or diastolic dysfunction and provides the ejection fraction percentage indicating the severity of the heart failure.
- A blood test with elevated value of a hormone, N-terminal brain natriuretic peptide (pro-BNP) is a sign of heart failure and a marker for diagnosis. The hormone is activated by the heart by increasing preload or stimulation of stretch receptors in the heart (Jakobsen et al. 2010).
The severity of heart failure is classified in function classes compiled by New York Heart Association (NYHA)|
- Class I – No limitations
- Class II – Mild heart failure. Slight limitation of physical activity. Patients are comfortable at rest. Ordinary physical activity results in fatigue, breathlessness, palpitation.
- Class III – Moderate heart failure. Marked limitation of physical activity. Comfortable at rest, less than ordinary physical activity leads to symptoms.
- Class IV – Severe heart failure. Inability to carry on any physical activity without discomfort. Symptoms are present at rest.