| Congestive heart failure (CHF) occurs when the heart is unable to pump an adequate amount of blood to meet the metabolic demands of the body at rest or during exercise. That is, the amount of blood coming out of the heart is decreased and this leads to inadequate blood flow to the various body organs (decreased tissue perfusion). In response to decreased tissue perfusion, the body activates certain normal, compensatory mechanisms. However, these mechanisms may result in increased pressure and congestion in the vessels (hence the term congestive heart failure). Eventually, as the body uses up all its compensatory mechanisms, the heart begins to fail, and this is usually followed by increased morbidity and death.
Heart failure is not a disease itself; rather, the term denotes all of the body's responses to inadequate pumping ability of the heart. CHF may be categorized in a number of different ways. Most commonly, the classification of left or right ventricular failure is utilized. Left or right ventricular failure refers to failure of the left or right lower pumping chambers (ventricles) of the heart. Left ventricular failure typically results from high blood pressure (hypertension), decreased blood flow to the heart muscle (ischemic heart disease), or diseases of the valves within the left heart (aortic or mitral valvular disease).
Right ventricular failure may develop independently, or more commonly it may follow (and be a result of) development of left ventricular failure. Causes of right ventricular failure that develop independently of left ventricular failure include low blood flow of the right ventricle, lung diseases (chronic obstructive lung disease or COPD), inflammation of the tissue that surrounds the right ventricle (constrictive pericarditis), or diseases of the valves within the right heart (tricuspid or pulmonic valvular disease).
Risk factors for development of CHF include defects in the tissue that separates the left and right ventricles (ventricular septal defect), any disease that affects the heart muscle (cardiomyopathy), decreased oxygen-carrying capacity of the blood (anemia), over-active thyroid gland disease (thyrotoxicosis), diabetes, pregnancy, prolonged fever, blood clots in the lungs (pulmonary embolism), rheumatic fever, and abnormal heartbeat (dysrhythmia),
Almost 85% of individuals with coronary artery disease go on to develop CHF, and individuals with type II diabetes mellitus are 2 to 5 times more likely to develop CHF (Jonas; Fonarrow).Risk: Tobacco smoking, obesity, and sedentary lifestyle increase the risk of congestive heart failure. CHF is twice as common in black individuals as in whites. There is a higher incidence and prevalence of CHF in Hispanics, Native Americans, and Russians secondary to their predisposition toward hypertension and diabetes (Zevitz). Incidence and Prevalence: The number of individuals suffering from CHF in the US is currently almost 5 million, with an additional 550,000 individuals developing CHF each year (Branch; Ventura). CHF causes 300,000 deaths per year in the US (Fonarrow). The incidence of CHF increases significantly with age, and doubles with each decade of life; it affects approximately 1% of adults over 65 years of age, and 2% to 3% or more of people aged 85 years or older (Ventura). Incidence of CHF is double in individuals with a body mass index (BMI) greater than or equal to 30 kg/m²; the prevalence also increases with age, affecting 2% to 5% of individuals between 70 to 79 years of age and nearly 10% of those older than 80 (Ventura). The annual age-adjusted incidence of CHF in men is more than twice that in women (4.1 per 1,000 men and 1.6 per 1,000 women) (Adams). Worldwide it is estimated that 15 million individuals have CHF (Ventura). |
Source: Medical Disability Advisor
| History: Individuals with CHF may report a history of diabetes or chronic alcohol abuse. Those with left ventricular heart failure may complain of fatigue and activity intolerance, weakness, dizziness, brief fainting spells (syncope), shortness of breath (dyspnea), dry hacking cough, and difficulty in breathing when lying down (orthopnea). Individuals with right ventricular failure will often experience these same symptoms, and in addition, they may report swelling (edema) in the feet and legs, pain in the upper right part of the abdomen (upper right quadrant), nausea, loss of appetite (anorexia), and excessive urination at night (nocturia). Individuals with both right and left ventricular failure (bi-ventricular failure) may report all the symptoms listed above as well as the experience of awakening at night acutely short of breath (paroxysmal nocturnal dyspnea). Physical exam: The veins in the neck may be enlarged (jugular venous distention), and the arms, hands, ankles and lower back may show signs of water retention and swelling (edema). The heart rate may be high even when the individual is sitting or lying down (resting tachycardia). Abnormal heart sounds may occur (displaced apex beat; third heart sound). Using a stethoscope, popping sounds might be heard in the individual's chest when they breathe (pulmonary crackles). The abdomen may fill with fluid (ascites) and nausea, vomiting, and intestinal upset can be present. Tests: Laboratory tests that may be performed include measurement of sodium, potassium, chloride, and total electrolytes in the blood (serum electrolyte test). Other blood tests may include serum bilirubin, assessment of coagulation capabilities, albumin levels, and liver enzymes (liver function test). The amount of oxygen and carbon dioxide in the bloodstream can be measured using an arterial blood gas (ABG) analysis. A chest x-ray may show if the heart has increased in size (hypertrophied or dilated) in response to increased pressure in the heart blood vessels (vascular congestion). High frequency sound waves (ultrasound) may be used to evaluate function of the left ventricle and to obtain evidence of ventricular dilation and enlargement (hypertrophy). Electrocardiography (ECG) is used to identify changes associated with ventricular enlargement, and to detect abnormal heart rhythm (dysrhythmias), decreased blood flow to the heart (myocardial ischemia), or tissue death due to absence of blood flow to a certain region of the heart (myocardial infarction). Monitoring the heart with ECG while the individual exercises on a treadmill (cardiac stress test) may also be useful to identify cardiac abnormalities associated with congestive heart failure. |
Source: Medical Disability Advisor
| Individuals with CHF typically receive several different medications to treat their condition. Most commonly, drugs to prevent formation of angiotensin II (angiotensin converting enzyme, or ACE inhibitors), to reduce hypertension (adrenergic antagonists or beta-blockers), to increase urine output (diuretics), to increase the strength of the heart (inotropic medications), to relax the blood vessels (vasodilators), and to prevent abnormal heart rhythm (antidysrhythmics) are used. Also, individuals are commonly put on a diet that contains very little salt (sodium). Telemedicine monitoring of blood pressure, temperature, pulse oximetry, and ECG tracings with nursing telephonic support may be used. New noninvasive treatments of enhanced external counterpulsation (EECP) utilize the ECG-coordinated sequenced inflation of pressure cuffs on the thighs and lower legs to improve heart blood flow. Rarely, with end-stage patients who are usually hospitalized, devices that assist the heart in pumping blood (mechanical circulatory support devices) may be implanted into arteries or into the heart itself (left ventricular assist devices, LVADs). Mechanical counterpulsation devices such as the intra-aortic balloon pump (IABP) can be inserted into the aorta to improve blood flow to the heart and help decrease up to 20% of the heart's workload. Any other surgical treatment for CHF is usually reserved for individuals in end-stage disease who cannot be treated using drug therapy only. The main surgical option is replacement of the diseased heart with the heart of a donor (cardiac transplantation). |
Source: Medical Disability Advisor
| Congestive heart failure is most often a progressive and deteriorating condition. The outlook may depend upon the age of the individual, severity of the failure, and the underlying cause for the condition. There is an increased risk of sudden death, and overall, 50% of individuals die within 5 years of diagnosis (Branch). Other sources reveal that the average survival time following diagnosis is 3.2 years for men and 5.4 years for women (Grossman). Drug treatment may decrease the mortality rate by approximately 20%. Implantation of mechanical circulatory support devices provide only temporary support for individuals who are waiting for a donor heart to become available so they may undergo cardiac transplantation. Following cardiac transplantation, the percentage of individuals that survive 1, 5, and 10 years after surgery are 85%, 67%, and 40%, respectively. |
Source: Medical Disability Advisor
| Early incorporation of a physical rehabilitation program for CHF may increase survival time. Individuals with the diagnosis of CHF should attend outpatient physical and occupational therapy at a clinic specializing in cardiac rehabilitation. Cardiac rehabilitation centers offer ECG monitoring of all participants during exercise sessions.
Individuals learn to self-monitor their pulse and rate the amount of energy they expend by utilizing a rating of perceived exertion scale. Individuals use their pulse and this scale to stay within safe exercise parameters predetermined by their physicians. Individuals also learn to monitor their weight daily to determine if they are gaining fluid, and are instructed to inform their physicians if more than 2 pounds are gained over a period of 24 to 48 hours.
Individuals attend physical therapy to learn basic conditioning and stretching exercises. Initial activities may include limited walking, range of motion, and treadmill exercises. Eventually, more aerobic exercise including frequent walks, walk-jog, biking, and arm ergometer exercises may be encouraged. Eventually, exercise may become more strenuous with a goal of attaining 75% to 85% of maximum intensity while walking, jogging, biking, swimming, performing calisthenics, and/or weight training.
Occupational therapy addresses any fatigue or shortness of breath that may occur during activities of daily living. Individuals learn to utilize adaptive equipment to decrease the energy expended, as excessive arm activity is more taxing on the heart and can lead to fatigue. Therapists also teach energy conservation techniques where activities of daily living (ADLs) are broken into smaller components that make tasks more manageable. |
Source: Medical Disability Advisor
| Possible complications of congestive heart failure include difficulty in breathing when lying down (orthopnea), abnormal (cyclic) breathing (Cheyne-Stokes respiration), fluid in the lungs (pulmonary edema), decreased oxygen supply to the brain (cerebral hypoxia), fatigue and muscular weakness, and water accumulation (congestion) in various body organs. |
Source: Medical Disability Advisor
| Work activities may be continued and encouraged to the extent that the individual's symptoms allow them to perform their duties. Modifications and/or restrictions may be required with work duties that require medium to heavy physical activity. In this situation, it may be necessary for the individual to return to work at a completely different level, job function, or activity. In work settings that are primarily sedentary, materials and supplies should be organized nearby and restroom facilities should be easily accessible. Ergonomic seating with the ability to raise the legs may be needed. It may be necessary to limit walking distances that are required to function at work. There should be easy access to the work area and facilities such as parking, elevators, and lunch or break areas. Alternating physical activities with rest periods may be necessary. Shortened work hours or work weeks may be necessary; however, this will vary according to the severity of the individual's symptoms. |
Source: Medical Disability Advisor
| If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case. Regarding diagnosis:
- Has individual had a history of underlying heart conditions or precipitating events that are known to contribute to congestive heart failure?
-
Did individual present with symptoms and clinical findings consistent with the diagnosis of congestive heart failure?
-
Is the condition new or is individual presenting with worsening symptoms, associated with the progression of the heart failure?
-
If the diagnosis or cause was uncertain, were additional diagnostic tests done to rule out other possible conditions?
-
Would individual benefit from consultation with a specialist (cardiologist, cardiac surgeon)?
Regarding treatment:
- Was any underlying cause addressed in the treatment plan?
-
Did the treatment provide appropriate medications to maximize heart function and minimize symptoms?
-
Is individual participating in a cardiac rehabilitation program?
-
Did the severity of the heart failure warrant intervention with cardiac assist devices?
-
Was individual considered for cardiac transplantation?
Regarding prognosis:
- Based on individual's age, severity of heart failure and treatment, what is the expected outcome?
-
Did individual participate in a cardiac rehabilitation program as recommended? If not, are there obvious barriers to participation (insurance limits, transportation, motivation)?
-
Does individual have any pre-existing conditions that could impact ability to recover? Are these pre-existing conditions being addressed in the treatment plan?
-
Did individual suffer any associated complications that would influence length of disability and prognosis? If so, has adequate time elapsed for recovery?
|
Source: Medical Disability Advisor
| Adams, K. F. "New Epidemiologic Perspectives Concerning Mild-to-Moderate Heart Failure." American Journal of Medicine 110 7A (2001): 6S-13S. MD Consult. 7 May. 2001. Elsevier, Inc. 30 Oct. 2004 <http://home.mdconsult.com/das/journal/view/42051340-4/N/11852161?sid=290087838&source=MI>.Branch, Kelley R., William E. Chavey, and John M. Nicklas. "Management of Congestive Heart Failure Due to Systolic Dysfunction An Evidence-Based Approach for the Primary Care Physician." Clinics in Family Practice 3 4 (2001): MD Consult. Dec. 2001. Elsevier, Inc. 30 Oct. 2004 <http://home.mdconsult.com>. Fonarow, G. C. "Managing the Patient with Diabetes Mellitus and Heart Failure: Issues and Considerations." American Journal of Medicine 116 5A (2004): 76S-88S. MD Consult. 8 Mar. 2004. Elsevier, Inc. 30 Oct. 2004 <http://home.mdconsult.com/das/journal/view/42051340-4/N/14539147?sid=290087838&source=MI>. Grossman, Shamai, and David F.M. Brown. "Congestive Heart Failure and Pulmonary Edema." eMedicine. Eds. William Chiang, et al. 20 Sep. 2004. Medscape. 30 Oct. 2004 <http://emedicine.com/emerg/topic108.htm>. Jonas, Bruce S. "Coronary Heart Disease, Smoking and Hypertension are the Greatest Risk Factors for Congestive Heart Failure." Evidence-based Cardiovascular Medicine 5 3 (2001): MD Consult. Sep. 2001. Elsevier, Inc. 30 Oct. 2004 <http://home.mdconsult.com>. Ventura, H. O., and M. R. Mehra. "The Growing Burden of Heart Failure: The 'Syndemic' is Reaching Latin America." American Heart Journal 147 3 (2004): 386-389. MD Consult. 1 Mar. 2004. Elsevier, Inc. 30 Oct. 2004 <http://home.mdconsult.com/das/journal/view/42051340-4/N/14430368?sid=290087838&source=MI>. Zevitz, Michael E. "Heart Failure." eMedicine. Eds. George A. Stouffer, et al. 1 Sep. 2004. Medscape. 30 Oct. 2004 <http://emedicine.com/med/topic3552.htm>. |
Source: Medical Disability Advisor
| Feedback |
| Send us comments, suggestions, corrections, or anything you would like us to hear. If you are not logged in, you must
include your email address, in order for us to respond. We cannot, unfortunately, respond to every comment.
If you are seeking medical advice, please contact your physician. Thank you! |
Send this comment to:
Sales
Customer Support
Content Development
|
|
| |
|
|
|
|
|
This publication is designed to provide accurate and authoritative information in
regard to the subject matter covered. It is published with the understanding that
the author, editors, and publisher are not engaged in rendering medical, legal,
accounting or other professional service. If medical, legal, or other expert assistance
is required, the service of a competent professional should be sought. We are unable to respond to requests for advice.
Any Sales inquiries should include an email address or other means of
communication.
|