Heart failure is a growing public health problem and is now the most common cause of hospitalizations in the U.S. among patients 65 years and older. The increasing prevalence of heart failure in the population is most likely secondary to the aging of the population, increased risk factors, better outcomes for acute coronary syndrome survivors, and a reduction in mortality from other chronic conditions. Healthcare providers should be familiar with the pathophysiology, presentation, and treatment of heart failure because of the morbidity, mortality, and projected increased prevalence of the condition.
Heart failure (HF) is a clinical syndrome and constellation of symptoms secondary to impaired cardiac function. There are numerous etiologies for impaired heart function. The causative factors for heart failure are generally divided into either structural or functional categories. Patients who suffer from heart failure can also be classified based on the stage or degree of heart failure and symptoms, including episodes of acute exacerbation and pulmonary edema heart failure can be divided into two broad categories. HFpEF (heart failure with preserved ejection fraction) and HFrEF (heart failure with reduced ejection fraction). The incidence of HFpEF increases with age. The majority of cases of heart failure in the elderly is due to HFpEF.
Acute decompensated heart failure (ADHF) is a common and potentially fatal cause of cardiac dysfunction that can present with acute respiratory distress. In ADHF, pulmonary edema and the rapid accumulation of fluid within the interstitial and alveolar spaces leads to significant dyspnea and respiratory decompensation. There are many different causes of pulmonary edema, though cardiogenic pulmonary edema is usually a result of acutely elevated cardiac filling pressures.
Risk Factors and Etiology of Heart Failure
There are many causes of heart failure and the most common of which is coronary artery disease in the United States. The importance of identifying the risk factors for heart failure is that heart failure is preventable. In recognition of the preventable nature of the condition, the American College of Cardiology and the American Heart Association have modified their classification schemes so that patients currently without any structural abnormalities are identified early and treated appropriately. Treatment of systolic and diastolic hypertension concurrently in alignment with contemporary guidelines reduces the risk of heart failure by approximately 50%.
Risk Factors for Heart Failure 
Acute heart failure is the worsening of heart failure symptoms to the point that the patient requires intensification of therapy and intravenous treatment. Acute heart failure can be dramatic and rapid in onset, such as flash pulmonary edema or more gradual with the worsening of symptoms over time until a critical point of decompensation is reached. For those with a history of pre-existing heart failure, there is often a clear trigger for decompensation.
Heart Failure is a major public health problem and is now the most common cause of hospitalization in the US among patients 65 years and older, and approximately 915000 new cases of heart failure are diagnosed each year in the United States. The increasing prevalence of heart failure is most likely secondary to the aging of the population, increased risk factors, better outcomes for acute coronary syndrome survivors, and a reduction in mortality secondary to improved management of chronic conditions. Incidence rates for heart failure increase with age for both sexes.
The lifetime risk of developing heart failure for those over age 40 years residing in the U.S. is 20%. The risk and incidence of heart failure continue to increase from 20 per 1000 people age 60 to 65 years to over 80 per 1000 people over age 80. There are also differences in risk for heart failure based on the population, with African Americans having the highest risk and greater five-year mortality for heart failure than the white population in the U.S. The European Society of Cardiology states that the prevalence of heart failure is 1 to 2% and rises to greater than 10% in the over 70 population.
Heart Failure Statistics 
Acute Heart Failure
While consensus guidelines tend to use the term heart failure to refer to those with established chronic disease, acute heart failure is defined as a more rapid onset of signs and symptoms or the gradual worsening of chronic symptoms that necessitate intravenous treatment. Acute heart failure exacerbation that requires hospitalization tends to occur in the more elderly population mean age of 79 years old with a slightly higher preponderance of women affected than men. Data from the UK National Heart Failure Audit shows mortality rates of approximately 10% during the index admission, 30-day post-discharge mortality of 6.5% and 1-year mortality of 30%.
Different cardiovascular or metabolic abnormalities can cause heart failure, but in most patients, the clinical symptoms are secondary to left ventricular dysfunction. In cases caused by left ventricular dysfunction, the ejection fraction may be preserved or compromised. The ejection fraction is important because most clinical trials select patients based on the percentage of ejection fraction and use the data on ejection fraction to help guide therapy. In contrast, pulmonary edema associated with acute decompensated heart failure is secondary to dysregulation of pulmonary fluid homeostasis and the forces that balance fluid movement into the alveolar space.
Heart failure is mainly a clinical diagnosis. It is essential to consider the following during the history and physical.
1. The presentation of heart failure may vary based on each patient. If the patient has a history of heart failure in the past, ask them if this is the same presentation as when they had previous episodes of heart failure or an acute decompensation.
2. Consider non-cardiac and other causes for the patient's symptoms. It is important to ensure that there is a broad differential diagnosis and to avoid anchoring bias, premature closer, and diagnostic inertia.
3. Heart failure symptoms:
The physical examination should include the following:
Classification is one of the key determinates of how to evaluate and treat heart failure. When a patient is in acute or decompensated heart failure, our focus is on expeditious identification and treatment of life threats. When evaluating chronic heart failure, different classification schemes are available. The classification scheme used to categorize the type and degree of heart failure is based on the presentation and will affect the treatment and prognosis of the condition. Heart failure classification schemes are generally based on one of the following:
All heart failure patients should also be classified based on the ACCF/American Heart Association stages of heart failure, a New York Heart Association functional classification.
ACCF/AHA Stages of Heart Failure
The ACC/AHA stages of heart failure are defined by the risk of heart failure, the presence of active heart failure, and whether structural heart disease is present. In general, the higher the classification, the greater the treatment and interventions that the patient may require.
NYHA Functional Classification of Heart Failure
The NYHA classification is a functional classification of heart failure and based upon how much the patients' symptoms limit their physical activity and to what degree physical activity can cause the person to become symptomatic. The grading scale is from I up to the most severe of grade IV where the patient is unable to carry on physical activity and has symptoms at rest.
Testing for heart failure patients should be focused on the patient's symptoms, clinical suspicion, and the current and any pre-existing or current stage of heart failure. The ordering of multiple routine tests should be avoided in all heart failure patients. Basic tests that should merit consideration for all patients evaluated for heart failure are the following:
Other tests that may be considered based on severity and classification of patient condition are:
For further information on the recommendations for evaluating heart failure, please see the American Heart Association and New York Heart Association classification based heart failure guidelines.
Treatment of Acute Decompensated Heart Failure and Pulmonary Edema
The focus of treatment for patients in heart failure is dependent on the severity of the symptoms and the stage of heart failure. When patients are in acute decompensated heart failure or flash pulmonary edema, the most important focus for therapeutic interventions is the enhancement of hemodynamic status through reduction of vascular congestion and improving preload, afterload, and myocardial contractility.
In flash pulmonary edema, where there is a rapid onset of heart failure, the initial management, and treatment goals are very similar to acute decompensated heart failure. Treatment options for acute decompensated heart failure and flash pulmonary edema are as follows:
While acute decompensated heart failure and flash pulmonary edema can be dramatic and require intensive care and aggressive therapy, the main focus of heart failure management is on helping prevent the progression of the disease and mitigate episodes of acute exacerbation. The American Heart Association and the New York Heart Association stages of heart failure are what medical practitioners often use to guide the evidence-based treatment of heart failure. Treatment of early stages of chronic heart failure usually focuses on risk factor modification, and as the disease process progresses, it starts to include more aggressive interventions.
For further information on the medical management of chronic heart failure, please refer to the American Heart Association and New York Heart Association guidelines.
Advanced Treatment Strategies for End-Stage Congestive Heart Failure
For select patients with end-stage heart failure, which are refractory to other treatment strategies, the option of mechanical circulatory support and cardiac transplantation should be considered. Mechanical circulatory support, as for example, a left ventricular assist device, is often used as a bridge therapy until a heart transplant is available. In certain situations, mechanical circulatory support is utilized as destination therapy.
For patients who are not candidates for mechanical circulatory support or cardiac transplantation, palliative care, and continuous inotropic support should be a consideration and discussed with the patient.
When patients present in acute decompensated heart failure or flash pulmonary edema, there are many different diagnoses to consider, based on the risk factors for heart failure alone. It is also important to consider other potentially life-threatening causes of heart failure.
The diagnosis of heart failure alone can be associated with a mortality rate greater than many cancers. Despite advances made in heart failure treatments, the prognosis of the condition worsens over time, resulting in frequent hospital admissions and premature death. One recent study showed that patients recently diagnosed with new-onset heart failure had a mortality rate of 20.2% at one year and 52.6% at five years. The one and five-year mortality rates also increase significantly based on patient age. Another study showed that the one and five-year mortality for patients at 60-year-old is 7.4%, and 24.4% and for patients at 80-year-olds is 19.5% and 54.4%. The mortality rates were similar when evaluated across different cardiac ejection fractions.
The prognosis is worse for heart failure patients who are hospitalized. Heart failure patients commonly require repeat hospitalizations and develop an intolerance for standard treatments as the disease progresses. Data from U.S. Medicare beneficiaries hospitalized during 2006 showed 30-day and 1-year mortality rates post admission of 10.8% and 30.7,% respectively. Mortality outcomes at one year also demonstrate a clear relationship with age and increase from 22% at 65 years old to 42.7% for patients age 85 years and older.
Effective treatment of comorbidities and risk factor reduction can decrease the chance of developing heart failure. Patient education should be focused on ensuring compliance with prescribed evidence-based treatments.
The treatment of heart failure and acute decompensated heart failure is challenging despite the use of maximal evidence-based therapy based on the stage of heart failure. Given the limited effect that current treatment strategies have on the progression of heart failure, it is important to identify ways to maximize patient outcomes and quality of care by the interprofessional team.
Patients at potential risk for heart failure based on comorbidities or other identified risk factors should receive appropriate evidence-based preventative counseling and treatments. When appropriate, the primary care providers who may be the most involved in the management of the patients' risk factors should consult other specialists, including cardiologists, endocrinologists, pharmacists, cardiology nurses, and nutritionists, to ensure that they are providing the best advice and treatment for their patients. Nurses monitor patients, provide education, and collaborate with the physicians and the rest of the team to improve outcomes. Pharmacists review medications, inform patients and their families about side effects and monitor compliance.
Given the propensity of heart failure patients to require re-current admissions, often because of non-heart failure related conditions, the collaboration between inpatient and outpatient services can be of benefit in the continuity of care and helping promote improved outcomes.
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