Heart Failure

You and your partner are dispatched mid-morning for “breathing difficulties.” When you arrive at your patient’s residence, you are met at the front door by the patient’s daughter. She tells you when she stopped to check on her mother, she was having problems “catching” her breath. You find your patient sitting in a recliner in the front room. She tells you in short sentences that she is 75 years old, has high blood pressure and had a heart attack three years ago. When asked, she tells you she went to bed at her normal time and woke up at 6 a.m. short of breath. She tried resting, doing her breathing exercises and opening the window to get some fresh air. She was not getting relief when her daughter arrived to check on her. When questioned about her sleep hygiene, she tells you she normally sleeps in bed propped up with three pillows, and on really bad nights she prefers to sleep in the recliner you see her sitting in now.

Initial vital signs are heart rate of 86, temperature of 98.9° F and blood pressure of 182/90. Respirations are shallow at 24 breaths-per-minute and you hear rales bilaterally when you auscultate her chest. You note pedal edema and jugular vein distention (JVD) when you recline your patient to the semi-fowler position. Your partner retrieves her medications and you see she is taking metoprolol, furosemide, simvastatin and a baby aspirin daily. You accomplish a 3-lead and 12-lead ECG and determine your patient has atrial fibrillation. You administer oxygen, load her into your ambulance, continue to monitor her ECG, SpO₂ and EtCO2, start an IV, and administer a diuretic. Your patient remains stable during the transport. At the hospital you brief the emergency department physician and transfer care.

As the patient population ages, heart failure is going to become a common prehospital call for treatment and transport. Heart failure is associated with reduced renal excretory capacity leading to sodium and water retention; peripheral vasoconstriction and reduced cardiac output; activation of the renin-angiotensin-aldosterone and adrenergic nervous systems; increased inflammatory cytokine production; and injuries to the heart with ventricular remodeling.¹ Compensatory mechanisms activated with heart failure include increased ventricular preload, peripheral vasoconstriction to maintain vital organ perfusion, myocardial hypertrophy to reduce heart wall stress as the heart dilates, renal sodium and water retention to support cardiac preload, and initiation of the adrenergic nervous system raising heart rate and contractility.²

Uncontrolled hypertension, ischemia, arrhythmias, pneumonia, non-compliance and exacerbation of COPD are common antecedents for heart failure.^2,3 Other causal factors include diabetes,⁴ coronary artery disease, heart disease and atrial fibrillation. Additional non-cardiac precursors for heart failure include renal dysfunction, diabetes and anemia.³ Shortness of breath, fatigue and fluid retention are cardinal signs of heart failure, with dyspnea the most frequent chief complaint by patients with heart failure seeking emergency care. The presence of paroxysmal nocturnal dyspnea, orthopnea, dyspnea on exertion, pulmonary venous congestion, cardiomegaly, atrial fibrillation in a patient experiencing dyspnea, or new T-wave changes increases the likelihood your patient is experiencing heart failure. Other symptoms your patient may experience include pain, anxiety, appetite suppression, weakness, insomnia and depression.⁵ Many will be taking a combination of diuretics, angiotensin converting enzyme inhibitors, angiotensin receptor blockers, beta-blockers and digoxin.³ The presence of pneumonia, hyperinflation, wheezing, and the absence of rales, leg edema, a third heart sound or JVD decrease the likelihood of heart failure.⁵

Many patients experience worsening symptoms long before seeking medical attention.⁴ Dyspnea requires immediate attention with oxygen administration and non-invasive ventilation producing relief for most of your patients.³ The “breathlessness” your patient may describe is a non-specific symptom in heart failure relating to their ability to manage daily breathing difficulties. Feeling breathless is a part of everyday life for many heart failure patients, and most will have methods to prevent or minimize the feeling.⁶ Evidence of dyspnea causing congestion will present as JVD, peripheral edema and increased body weight. Right-heart failure should be suspected when you see peripheral edema and JVD in your patient.³

Hyponatremic patients experiencing heart failure have a poorer prognosis and more major complications than other heart failure patients. The primary types of hyponatremia are dilutional hyponatremia and depletional hyponatremia. Dilutional hyponatremia is the result of renal water retention with the increase in retained water exceeding the retained sodium level. A dehydrated patient who still has an excess of water when compared to the concentration of retained sodium will be experiencing depletional hyponatremia. Patients taking diuretics are at risk for experiencing depletional hyponatremia. Acute hyponatremia, regardless of the cause, can lead to severe neurologic deficits from brain swelling, increased intracellular pressure and cerebral hypoxia, with patients experiencing headache, nausea, vomiting, seizures and coma.⁷

The average age for a heart failure patient is 75 years old and more than half are women. Women with impaired systolic left ventricular function are more likely than men to have a history of hypertension and atrial arrhythmias, and present with severe hypertension dependent edema, jugular venous distention and a third heart sound occurring in early diastole.³ More women are dying from cardiovascular disease than of breast or uterine cancer, with more women than men over 79 years of age experiencing heart failure. And thyroid disease is present in many of the women experiencing acute decompensated heart failure.⁸

Older pregnant women,⁸ women who have had five or more pregnancies,⁹ women pregnant with twins, pregnant women taking tocolytics to suppress premature labor, pregnant women living at the poverty level and women of African descent who are pregnant have a higher risk of heart failure with impaired systolic function during the last month of pregnancy to five months post-partum. Of those women in these categories diagnosed with heart failure, half will recover normal systolic function within six months, while 1 in 5 may require heart transplantation.⁸

Loop diuretics are the cornerstone of therapy and symptom relief. The administration of a loop diuretic after confirming heart failure will often result in rapid symptomatic improvement.³ Given as a bolus in the prehospital environment, continuous infusion is better for diuretic-resistant patients receiving combined therapy with a vasodilator and digoxin. Vasodilators are used to lower ventricular filling pressures and systemic vascular resistance. Positive inotropic agents are used to increase cardiac output. Ventricular dysfunction is treated with an angiotensin converting enzyme inhibitor. Beta-blockers are normally used to treat systolic heart failure and previous myocardial infarctions with left ventricular dysfunction.² Aldosterone-blocking agents are used to treat patients with right-heart failure and liver congestion. Nitroglycerin is given to reduce left ventricular filling pressure and to treat patients with coronary artery disease or acute coronary syndrome complicated by heart failure. Dobutamine improves hemodynamics in patients with low blood pressures and signs of organ hypoperfusion not responding to other therapies. Digoxin improves hemodynamics without activating neurohormones or negatively affecting heart rate, blood pressure or renal function, and can be used alone or in combination with vasoactive agents and ACE inhibitors.²

To summarize, heart failure is the result of any structural or functional deficit impairing the ability of the heart to meet the systemic metabolic demands. Initial management should be based on your patient’s clinical presentation. Treat the immediate life-threatening conditions, stabilize the patient and confirm heart failure based on medical history, signs and symptoms. Ask the patient if they have already been diagnosed with heart failure, have coronary artery disease or had a previous myocardial infarction. Assess for paroxysmal nocturnal dyspnea, orthopnea and dyspnea on exertion. Listen for extra heart sounds, rales, wheezing and murmurs. Look for pedal edema and use the ECG to determine if your patient has atrial fibrillation or any electrophysiological abnormalities. Your goals for managing heart failure are symptom alleviation, protecting and preserving the myocardium and renal function, avoiding hypotension or increases in heart rate, reducing excess extracellular fluid, improving hemodynamics, and maintaining perfusion to vital organs.³

Accurately identifying heart failure in acute cases, performing early interventions to relieve respiratory distress, and confirming the absence of pneumonia or infection prior to the administration of a diuretic will improve your patient’s chances for survival.^1,3

References

1. Dobson T, Jensen JL, Karim S, Travers AH. Correlation of paramedic administration of furosemide with emergency physician diagnosis of congestive heart failure. Journal of Emergency Primary Health Care, 2009; 7(3).
2. Krum H, Abraham WT. Heart failure. Lancet, 2009; 373: 941–55.
3. Gheorghiade M, Pang PS. Acute heart failure syndromes. Journal of the American College of Cardiology, 2009; 53(7).
4. Lett D, Petrie DA, Ackroyd-Stolarz S. Accuracy of prehospital assessment of acute pulmonary edema, Abstract. CJEM, 2000; 3(2): 142.
5. Wang CS, Fitzgerald JM, Schulzer M, Mak E, Ayas NT. Does this dyspneic patient in the emergency department have congestive heart failure? JAMA, 2005 Oct; 294(15).
6. Edmonds PM, Rogers A, Addington-Hall JM, McCoy A, Coats AJS, Gibbs JSR. Patient descriptions of breathlessness in heart failure. International Journal of Cardiology, 2005 Jan; 98(11): 61–66.
7. Shafazand M, Patel H, Ekman I, Swedberg K, Schaufelberger M. Patients with worsening chronic heart failure who present to a hospital emergency department require hospital care. BMC Research Notes, 2012; 5: 132.
8. Hsich EM, Pina IL. Heart failure in women. Journal of the American College of Cardiology, 2009; 54(6).
9. U.S. National Laboratory of Medicine, National Institutes of Health. Birth, 2005 Mar; 32(1): 45–59.

Robert E. Sippel, Major, USAF (Ret.), MS, MAEd, NRP,FP-C is an assistant professor and clinical instructor in the Emergency Health Science Department at the University of Texas Health Science Center, San Antonio, TX, and a civilian training officer with the San Antonio Fire Department’s EMS division.