CONTINUING EDUCATION plastic drugs, such as anthracyclines, and when these agents are used, they are given with dexrazoxane, an iron-chelating agent to decrease the risk of HF.6,13 8. Additional causes of heart failure include tachycardia, myocarditis and other inflammations of the cardiac muscle, iron overload, amyloidosis, sarcoidosis, and stress.6
Assessment Clinical assessment of HF begins with an in-depth history and physical exam.2,6 It is important to identify cardiac and noncardiac conditions and behaviors that might contribute to the development of HF. Family history can indicate if the condition is familial; volume status and vital signs should be noted.2,6 These factors will assist with staging and targeting appropriate treatment options. Important items to include in support of HF staging include history of alcohol or drug use, orthostatic blood pressure changes, weight and height, body mass calculation, depression screening and education, and obstructive sleep apnea screening.2,6 Signs and symptoms of HF (Figure 5) resulting from excess fluid include dyspnea, orthopnea, edema, abdominal pain due to hepatic congestion, and abdominal distention.2,6,10 Reduction in cardiac output may lead to fatigue and weakness. 2,6,10 Other positive findings associated with vital signs, blood pressure, and pulse are resting sinus tachycardia and narrow pulse pressure, as decreased cardiac output is suggested when pulse pressure is below 25 mmHg. 6 Appearance can also help in diagnosis; diaphoresis seen as cool, pale, and sometimes cyanotic extremities suggests poor perfusion and oxygenation.6 Additional findings include jugular venous distention, pulmonary congestion manifested by rales, displaced precordial impulse, and S3 gallop. Hepatomegaly, splenomegaly and scrotal edema as well as peripheral edema and pulsus alternations, manifested as weak and strong beats are also indicative of severe left ventricular failure.6 Figure 5: Symptoms of Heart Failure10 SYMPTOMS OF HEART FAILURE
The symptoms of heart failure include: • Shortness of breath • Chronic coughing or wheezing • Build-up of fluid (edema) • Fatigue or feeling lightheaded • Nausea or lack of appetite • Confusion or impaired thinking • High heart rate People who experience more than one should be evaluated. Initial testing to rule out other issues should include: • A12 lead-EKG; • Complete blood count (CBC) to check for anemia or infection;6 • Serum electrolytes with calcium and magnesium; • BUN, creatinine, and liver function tests (LFT) to identify electrolyte imbalance; liver and/or renal disease.6 • Lipid profile, fasting blood sugar (FBS), and thyroid stimu-
lating hormone (TSH) are also helpful.6 • B-type natriuretic peptide (BNP) or N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels support a diagnosis of HF and establish prognosis.6,9 Hospital admission levels of BNP or NT-proBNP can assist with discharge prognosis. If the values diminish, patients are thought to have a better prognosis.9 BNP levels below100pg/mL are negative predictors for HF; most with HF have values above 400pg/ mL.9 (Note that severe renal impairment may interfere with interpretation of these values. )9 It is also important to remember that BNP is a substrate for neprilysin, so it can elevate BNP levels but not NT-pro BNP levels. Patients treated with sacubitril/valsartan (ARNI), a neprilysin inhibitor, should have NT-pro BNP levels followed instead of BNP levels.6,8,9 Also of note: beta-blocker initiation can precipitate a transient uptick in levels.9 • Troponin I or T in patients presenting with acutely decompensated HF; 6 • Chest X-ray to evaluate heart size, shape, and pulmonary congestion at lung base;6 and • Echocardiogram to establish left ventricular ejection fraction and exercise testing.6 Natriuretic peptide biomarker screening and early intervention may prevent HF. Treating comorbidities and coordination of care are essential to improve overall outcomes.
T E S T YO U R K N O W L E D G E Q U E ST I O N # 1:
What are the symptoms of HF?
Guideline Directed Medical Therapy Guideline directed medical therapy (GDMT) for HF is based on the 2013 ACC/AHA Guideline for the Management of Heart Failure and the 2016 and 2017 ACC/AHA focused updates, which combine lifestyle modifications and medications for best outcomes,6,8,9 and the ACC/AHA Stages of HF and NYHA Functional Classifications (Figure 3).6,7 The 2016 European Committee Guidelines for the Diagnosis and Treatment of Acute and Chronic Heart Failure is also a good source.11 Nonpharmacological interventions should be initiated and include: • Education to promote self-care; • Sodium restricted diet; and • Identification of sleep disorders with a formal sleep assessment (if NYHA class I-IV HF) to differentiate type of sleep apnea.6,9 In patients with CV disease and obstructive sleep apnea, continuous positive airway pressure (CPAP) may help with sleep quality and daytime sleepiness. In patients with NYHA class I-IV and central sleep apnea, adaptive servo-ventilaInnovatix | innovatix.com 21