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After reading the article you should be able to:

1. Identify signs and symptoms of systolic dysfunction.
2. Discuss nursing and medical management for a patient with systolic dysfunction.
3. Develop a plan of care for a patient with systolic dysfunction.

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By SHERILYN A. SERDAHL, RN, MS, CNP

SHERILYN SERDAHL is a nurse practitioner with University of Minnesota Physicians, Fairview, MN. The author has no financial relationships to disclose. EDITOR: Kathleen A. Moore, RN, BS.

The effective management of systolic dysfunction includes medication, lifestyle changes, and comprehensive patient education.

Heart failure affects an estimated 5 million Americans, accounting for nearly a million hospitalizations each year.^1,2 In addition, almost 500,000 new cases are diagnosed yearly.^1,2 In the United States, the most common causes of heart failure are coronary artery disease and uncontrolled hypertension.

The diagnosis of heart failure is a clinical one, distinguished by a constellation of signs and symptoms caused by either systolic or diastolic dysfunction, or both. Here, we'll review heart failure caused by systolic dysfunction, so that you'll be equipped to recognize its manifestations and ready to help your patients manage their disease.

What happens when the heart fails

In heart failure caused by systolic dysfunction, the left ventricular myocardium is weakened, often enlarged, and the ventricles are unable to pump blood efficiently enough to meet the body's demands. Stroke volume, the amount of blood ejected from the ventricles with each contraction, is reduced. The blood that's not expelled remains in the ventricles during relaxation, or diastole, and this can lead to pulmonary congestion.^3,4

Initially, when cardiac output drops, compensatory neurohormonal mechanisms ensure that perfusion to vital organs remains adequate. Heart rate rises to increase cardiac output, and ventricles enlarge—hypertrophy—allowing more blood to be ejected with each contraction. With these adaptive mechanisms in effect, the individual experiences few or no symptoms in the short term. However, these compensatory responses require higher energy expenditure and increase the workload of the heart. Damage may continue for years—undetected. When adaptive mechanisms eventually fail, symptoms appear, indicating that the disease has progressed.

The most common presenting signs of heart failure are fatigue and shortness of breath, or dyspnea. Fatigue in the presence of heart failure is often a sign of low cardiac output.^1,2 Dyspnea is the result of pulmonary congestion and an indication of fluid overload.

Dyspnea that occurs when the person lies down but lessens when he or she sits up or stands is called orthopnea. Lying flat increases venous blood return to the heart, which may precipitate pulmonary edema—and hence, shortness of breath. Patients with orthopnea frequently sleep with their upper body propped up on pillows. Shortness of breath that occurs several hours after falling asleep and is eased by sitting upright is called paroxysmal nocturnal dyspnea (PND), and is a sign of severe heart failure.^1,2

The fluid overload of heart failure may become evident as edema—usually in depen dent areas such as ankles or feet—or as overall weight gain. Fluid may also accumulate in the liver and manifest as ascites and/or hepatomegaly, and in severe cases, cause jaundice. A patient with gastrointestinal congestion from heart failure may report abdominal pain, bloating, or nausea.^1,2

The all-important patient history

A thorough history is invaluable to the diagnosis and work-up of heart failure. Ask if the patient experiences shortness of breath or fatigue, and what and how much activity causes it. Document your findings using objective language. For example, write: "John Doe is able to walk two blocks before stopping because of shortness of breath." Note whether the patient has to sleep on multiple pillows, and whether he or she wakes up at night with breathing difficulty.

Also ask if the patient has gained any weight recently, and if so, how much and over what period of time. A gain of two pounds in 24 hours or five pounds in one week can indicate increased fluid retention. Ask if he or she has experienced swelling of the ankles, feet, or legs, or if shoe size or width has recently increased—a clue that this condition may exist.

Since coronary artery disease is one of the leading causes of heart failure, screen for angina. Choose your words carefully, however, because not all patients with angina describe it as "pain." Instead, they may report a feeling of "heaviness" or "discomfort."

To evaluate angina, ask if the sensation is present at rest or only with activity, and whether it subsides with rest. Also inquire about risk factors for coronary artery disease, including hypertension, hyperlipidemia, smoking, obesity, diabetes, physical inactivity, and family history of heart disease. Furthermore, diabetics do not typically experience anginal-type pain, so they may require more detailed evaluation and frequent monitoring.⁵

As part of the physical exam, assess respiratory rate and pattern. Auscultate the lungs, noting any crackles or other adventitious sounds. Examine the patient's lower extremities, checking for pitting edema, uneven hair distribution, wounds, prolonged capillary refill time, and diminished or absent pedal pulses. Be aware, however, that peripheral edema is a nonspecific indicator of systolic dysfunction. It can occur with diastolic dysfunction and with a multitude of other conditions as well.

Also assess apical rate and heart sounds. Tachycardia may indicate that the heart is compensating for a drop in cardiac output. An S₃ heart sound, or ventricular gallop, is a specific indicator of systolic dysfunction. It's low-pitched and occurs during diastole, after S₂.¹ Because life-threatening arrhythmias can occur in patients with heart failure, be sure to assess heart rhythm, noting any abnormalities. Ask if the patient has ever experienced light-headedness or sudden fainting spells.

You can also estimate the size of the heart by locating the point of maximal impulse (PMI), which is normally palpated at the left fifth intercostal space at the midclavicular line; the pulsation you'll feel is the contraction of the left ventricle. As the heart enlarges and dilates, the PMI becomes weaker and is displaced laterally, in which case you'll note the pulsation below the fifth intercostal space, lateral to midclavicular line.

Observe the jugular veins for distention, a sign of vascular congestion. Jugular venous pressure greater than 4 cm from the sternal notch suggests fluid overload or right-sided heart failure.¹

Confusion in an elderly patient may be a sign of heart failure, so be sure to note it. As cardiac output falls, perfusion to vital organs is compromised. Hypoperfusion of the brain can lead to changes in mental status.

A closer look at the failing heart

Heart failure is a clinical diagnosis made after a detailed history and physical and confirmed with the appropriate testing.^3,4 Some of these tests will also help determine disease severity.

An echocardiogram is the most useful and sensitive noninvasive test for detecting heart failure. It enables the examiner to look at heart wall motion and chamber size, to evaluate valve function, and to determine ejection fraction (EF), which is the percentage of blood pumped out of the left ventricle with each heartbeat. An ejection fraction less than 40% indicates systolic dysfunction.^1,2

Cardiac catheterization, or coronary angiography, is the gold standard for evaluating heart function. It allows for direct visualization of blood flow through the coronary arteries, and for measurement of EF and heart pressures. It is, however, invasive.

Another test used in the diagnosis and management of heart failure is brain natriuretic peptide (BNP). This blood test measures the level of a protein that's released in response to the stretching of cells in the myocardium. A level greater than 500 pg/ml can be an indicator of heart failure in patients with other signs and symptoms.^1,2 If the BNP level is less than 100, heart failure is unlikely.^1,2

Other tests that are ordered as part of the work-up for heart failure include: chest X-ray, which may reveal a hypertrophied heart and pulmonary congestion; EKG, which might show a bundle branch block, or left axis deviation, an indicator of left ventricular hypertrophy,^1,2 and blood tests such as serum creatinine, electrolytes, and liver enzymes, which are helpful in evaluating hepatic and renal function before and during drug treatment.

Common treatment options

The treatment depends on the cause; therefore, determining the cause is very important. If heart failure is due to valvular heart disease, a heart valve replacement can be done. If it's due to coronary artery disease or hypertension, the goal is to slow the progression of heart failure. Furthermore, because systolic and diastolic heart failure result from different mechanisms, the two require distinctly different treatment. The medications commonly used to treat systolic dysfunction are discussed in the table.

Arrhythmias and sudden cardiac death are potential sequelae to heart failure; therefore, it's not surprising that the use of interventional devices in the treatment of heart failure is rapidly evolving. Implantable cardioverter defibrillators, for example, are recommended for the prevention of life-threatening ventricular arrhythmias in heart failure patients with ischemic or nonischemic cardiomyopathy, EF of 35% or less, and New York Heart Association (NYHA) class II or III functional status.⁶ (The classes of heart failure are discussed).

A complementary set of guidelines was established by the American College of Cardiology (ACC) together with the American Heart Association (AHA). These ACC/AHA Guidelines offer a way to evaluate and manage chronic heart failure by classifying symptoms into Stages A through D. (The stages are described in detail in the box at the left.) They range from Stage A for individuals at risk for heart failure through Stage D for those with advanced heart failure symptoms at rest requiring intervention in the acute care setting.⁷ This classification system is intended to complement but not replace the NYHA functional classification, which primarily gauges the severity of symptoms in patients who are in Stage C or D.

Managing heart failure requires lifestyle changes

In addition to utilizing drug therapy and/or interventional devices, most patients with heart failure will need to make lifestyle changes. Since coronary artery disease and hypertension can cause or contribute to heart failure, patient teaching should also address these conditions and their risk factors.

Remind smokers that they face a significantly greater risk of heart attack than individuals who've never smoked, and encourage them to stop. If a patient is ready to quit, help implement an appropriate plan. Success is more likely when pharmacotherapy, such as nicotine replacement, is used.⁸

Teach patients that even a small decrease in dietary sodium—say, from 10 to 5 grams a day—can significantly decrease blood pressure.⁹ Tell them to watch their intake of sodium and to refrain from adding salt to their food. Make sure they know how to look for the sodium content of food on package labels. The ACC and AHA recommend that people with heart failure limit their daily sodium intake to 2 to 3 grams.¹⁰ If hyperkalemia is a concern, patients should avoid salt substitutes, since they're often high in potassium.

Instruct patients to weigh themselves and record their weight daily, and to report a weight gain that could signify fluid retention. Most patients with heart failure won't need to restrict their fluid intake, but they should avoid drinking excessive amounts. Candidates for fluid restriction include patients with severe heart failure, extreme edema, or hyponatremia. Sucking on hard candy or mints may help abate thirst.

Make sure patients know that nonsteroidal anti-inflammatory drugs (NSAIDs) can decrease the effectiveness of certain antihypertensive drugs and can lead to fluid retention^7,11 Advise them to check with their physician before using NSAIDs. Patients who take aspirin for coronary artery disease, however, should continue to do so.⁷

Some research suggests a link between social alcohol use and decreased left ventricular function. Because the role of alcohol in heart failure is unclear, encourage patients who drink to do so sparingly, perhaps limiting themselves to one drink per day. Patients with severe heart failure and those with alcoholic cardiomyopathy should not drink alcohol at all.¹⁰

Supervised exercise decreases symptoms and increases function and quality of life in people with heart failure. Encourage patients with newly diagnosed heart failure to participate in a cardiac rehabilitation program once symptoms have stabilized. Participation in cardiac rehab decreases mortality and hospitalization rates in heart failure patients.¹²

Addressing the more sensitive issues

The need for intimacy continues throughout the life span, and sexuality is part of intimacy. Reassure patients and their partners that sexual activity is safe in all but the most severely decompensated individuals. Those who can climb two flights of stairs without symptoms should be able to tolerate sexual intercourse,¹³ but should do so at a level that's safe and comfortable. Inform patients with cardiac defibrillators that the device may fire during intercourse, in response to an elevated heart rate or an arrhythmia; if that happens, their partners may feel a tingling but will not be harmed.¹³

Dealing with a chronic, debilitating disease often leads to anxiety and depression. Encourage patients and their loved ones to discuss their fears and concerns openly. As heart failure progresses, treatment may become less effective and symptoms more burdensome, at which point palliative care may be necessary. Specialists in palliative care are experts at managing pain, shortness of breath, and anorexia, and at helping patients and families explore theethical and legal implications of end-of-life care. In the meantime, urge families to review the patient's advanced directives regularly to be sure they reflect his or her current wishes. Suggest that they keep a copy in a designated place in the home.

Heart failure is a chronic, progressive disease with an uncertain prognosis. Still, there's a lot we can offer patients with respect to treatment, symptom management, and lifestyle modification. In all of these areas, the nurse's role is vital.

REFERENCES

1. Braunwald, E. (2005). Approach to the patient with cardiovascular disease. In. D. L. Kasper, E. Braunwald, et al. (Eds.), Harrison's principles of internal medicine (16th ed., pp. 1301–1304). New York: McGraw-Hill.

2. Braunwald, E. (2005). Normal and abnormal myocardial function. In. D. L. Kasper, E. Braunwald, et al. (Eds.), Harrison's principles of internal medicine (16th ed., pp. 1358–1367). New York: McGraw-Hill.

3. Rodgers, J. M., & Reeder, S. R. (2001). Managing heart failure: Part 1. Critical Care, 31(11), 1.

4. Rodgers, J. M., & Reeder, S. R. (2001). Managing heart failure: Part 2. Critical Care, 31(12), 1.

5. Tabibiazar, R., & Edelman, S. V. (2003). Silent ischemia in people with diabetes: A condition that must be heard. Clin Diabetes, 21, 5. http://clinical.diabetesjournals.org/cgi/content/full/21/1/5.

6. Beyerbach, D. M. "Implantable cardioverter-defibrillators." (2006). www.emedicine.com/med/topic3386.htm (10 May 2008).

7. Hunt, S. A., Baker, D. W., et al. (2005). ACC/AHA Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation, 112, e154.

8. Okuyemi, K. S., Nollen, N. L., and Ahluwalia, J. S. (2006). Interventions to facilitate smoking cessation. Am Fam Physician, 74(2), 262.

9. He, F. J., Markandu, N. D., & MacGregor, G. A. (2005). Modest salt reduction lowers blood pressure in isolated systolic hypertension and combined hypertension. Circulation, 46(1), 66.

10. Kopecky, S., Festin, R., et al. "Health care guidelines: Heart failure in adults." 2007. www.icsi.org/heart_failure_2/heart_failure_in_adults_.html (1 Aug. 2007).

11. Huerta, C., Varas-Lorenzo, C., et al. (2006). Non-steroidal anti-inflammatory drugs and risk of first hospital admission for heart failure in the general population. Heart, 92(11), 1610.

12. Mears, S. (2006). The importance of exercise training in patients with chronic heart failure. Nurs Stand, 20(31), 41.

13. Steinke, E. E. (2005). Intimacy needs and chronic illness: Strategies for sexual counseling and self-management. J Gerontol Nurs, 31(5), 40.

Classifying heart failure

Once heart failure is diagnosed, its severity is determined using the New York Heart Association (NYHA) Classification of Functional Capacity, summarized below:

Class I: Heart has identifiable structural changes, but individual's physical activity is not limited. Able to perform activities that require 10 metabolic equivalents (METs)* of oxygen consumption.

Class II: Physical activity slightly limited, but individual comfortable and asymptomatic at rest. Able to perform 5 or 6 METs of activity.

Class III: Indicates increased severity of heart failure. Minimal physical activity causes fatigue, palpitations, shortness of breath, or angina. Able to perform 3.6 to 4.2 METs of activity.

Class IV: Debilitating symptoms. Individual unable to carry out any physical activity without discomfort. Angina, shortness of breath, fatigue, and palpitations may occur at rest. Symptoms increase with activity. Able to perform 2 METs of activity.

*An MET is a measure of physical activity intensity; 1 MET equals energy (oxygen) used by the body as it sits quietly.

Source: Braunwald, E. (2005). Approach to the patient with cardiovascular disease. In. D. L. Kasper, E. Braunwald, et al. (Eds.), Harrison's principles of internal medicine (16th ed., pp. 1301–1304). New York: McGraw-Hill.

Treating systolic dysfunction

The three main classes of drugs for treating systolic dysfunction are listed below. Other drugs may be indicated for specific patients and classes of heart failure, including, for example, digoxin (Lanoxin), the diuretic spironolactone (Aldactone), nitrates, such as nitroglycerin, plus hydralazine.

Click here to view full-size graphic

Sources: 1. Hunt, S. A., Baker, D. W., et al. (2001). ACC/AHA Guidelines for Evaluation and Management of Chronic Heart Failure in the Adult, Executive Summary: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation, 104, 2996. 2. Hunt, S. A., Baker, D. W., et al. (2005). ACC/AHA Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation, 112, e154. 3. Kopecky, S., Festin, R., et al. "Health care guidelines: Heart failure in adults." 2007. www.icsi.org/heart_failure_2/heart_failure_in_adults_.html (1 Aug. 2007).

ACC/AHA 2005 Guidelines

Stage A: Patients at high risk for HF due to presence of HTN, diabetes, obesity.
Treatment is to control these conditions.

Stage B: Patients with left ventricular hypertrophy and/or history of MI but no symptoms.
Treatment is to stop the progression. Might use pharmacological agents.

Stage C: Patients with symptoms.
Treatment is more aggressive.
Diuretics, ACE inhibitors, beta blockers.
Modify fluid and dietary intake.
Biventricular pacing.

Stage D: Patients with advanced HF symptoms at rest requiring intervention in the acute care setting.
Treatment includes aggressive therapies used in Stage C and possibly heart transplant or left ventricular assist device.

Source: Hunt, S. A., Baker, D. W., et al. (2005). ACC/AHA Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation, 112, e154.