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CHF pathway starter

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Michelle DuBridge

on 3 April 2013

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Transcript of CHF pathway starter

Navigating Heart Failure Congestive
Heart Failure What is Heart Failure? Heart Failure occurs when the heart is unable to
pump blood to adequately meet the needs of the
body's tissues and support the physiological system.
. In some cases, the heart can't fill with enough blood. In other cases, the heart can't pump blood to the rest of the body with enough force. Some people have both problems. CHF by the Numbers approximately 550,000 new cases each year
The number of patients with heart failure is expected to increase 2-3 times over the 10 years
Heart Failure is responsible for 290,000 death
each year
The 5 year mortality rate for those diagnosed
with heart failure is 45% Systolic Heart Failure A "pumping problem"
The Heart muscle itself loses the ability to pump and contract efficiently
Poor ability to contract leads to a decreased ejection fraction value Diastolic Heart Failure A "filling problem"
Heart muscle becomes too stiff to allow for optimal filling
Diastolic heart failure leads to edema and disruption of capillary osmotic pressure Left Sided vs. Right Sided Failure Left-Sided Failure Right ventricle continues to pump
Fluid backs up into the lungs
Pulmonary congestion causes pulmonary edema
orthopnea -difficulty breathing especially when lying flat
patient may breath better when lying use additional pillows for support CHF
Signs and Symptoms Signs and Symptoms
Short of breath - Red Flag when continues for 2-3 weeks and increases at night.
Paroxysmal Nocturnal Dyspnea
Orthopnea - need 2 or more pillows to sleep - Red Flag
Increased heart rate
Fatigue - Red Flag lasting longer than 2-3 weeks
Edema in feet, ankles, legs - Red Flag
Bloating/ weight gain - due to fluid retention
Criteria: 2-3 lbs in 2 days or 5 pounds in 1 week
Red Flag
Frequent cough/wheezing - usually unproductive
Red Flag greater than 3 weeks without being ill
Dry/ hacking cough while lying down
Frequent nocturnal urination - Red Flag when greater than 2 times a night
Confused/ impaired thinking - Red Flag
Exercise intolerance due to fatigue or shortness of breath with exertion
Red Flag = a new, different, atypical, unusual, or unexplained symptom Chief Complaint: Increased Fatigue Risk Factors:
High Blood Pressure - Your heart works harder than it has to if your blood pressure is elevated
Coronary Artery Disease - narrowed arteries may limit your heart's supply of oxygen-rich blood resulting in weakened heart muscle.
Heart Attack - damage to your heart muscle from an MI may mean that your heart can no longer pump efficiently
Irregular Heart Beats - these abnormal rhythms can create extra work for you heart, weakening the muscle
Congenital Heart Defects - structural heart defects can lead to heart failure
Sleep Apnea - the inability to breathe properly at night results in low blood oxygen levels and increased risk of abnormal heart rhythms. Both of these problems can weaken the heart.
Kidney Conditions - these can contribute to heart failure because it can lead to high blood pressure and fluid retention.
Other: Diabetes medications, alcohol abuse, viruses, age, physical inactivity, uncontrolled diabetes, obesity, smoking, family history Review of Symptoms
General Health
Unexplained Weight Change
Mentation/Cognition Change
Cardio/Peripheral Vascular System
Peripheral Edema
Pulmonary System
Clubbing of Nails
Urinary System
Increased Frequency at Night Right-Sided Failure Left ventricle continues to pump
Results in fluid back-up in the capillaries of the body
Excess fluid accumulation under the skin and in the sacral area, legs, ankles, abdomen
In severe cases, may result in hepatomegaly
Most common cause is left-sided failure Tests Electrocardiography no specific EKG is indicative of heart failure, but atrial and ventricular arrhythmias are common
atrial fibrillation is present in 25% of patients with cardiomyopathy
prognosis is worse patients with atrial fibrillation, atrial or ventricular tachycardia, or LBBB Atrial Fibrillation will show an irregular irregular
rhythm with P-waves and T-waves replaced by
fibrilatory waves. Atrial Tachycardia - Presents with a regular rhythm. The T-wave is usually hidden in the preceding P-wave sometimes called a T-P wave. The heart rate is greater than 100 bpm. Ventricular Tachycardia
and Ectopic Beats Ventricular Tachycardia - Wide QRS > 0.14s and has a bizzare configuration. The rhythm is regular with a rate between 100-250 bpm. Left Bundle Branch Block LBBB: QRS duration greater than or equal to 0.12 seconds. Q waves absent in leads V5 and V6 and R waves may be notched or slurred. Deep, wide S wave in V1-3. Chest Radiography Two principal features of the chest radiograph are useful in the evaluation of patients with congestive heart failure: (1) the size and shape of the cardiac silhouette, and (2) edema at the lung bases. To measure: Cardiomegaly is usually manifested by the presence of an increased cardiothoracic ratio (greater than 0.50) on a posteroanterior view. To find the cardiothoracic ratio look at a chest radio graph in the PA view and draw a vertical line from the start of the thoracic cavity down to the level of the diaphragm. (1/3 of the cardiac outline should be on the right hand side and 2/3 should be on the left.) Find the maximum extension of the right hand side and left hand side to the vertical line in the middle. The addition of these two numbers is the transverse diameter of the heart. Make another horizontal measurement of the maximum width of the thoracic cavity. Add the R and L max extension measurements together and divide by the max width of the thoracic cavity measurement to get your cardio thoracic ratio. Anything greater than 0.50 is indicative of cardiomegaly. However, patients with predominantly diastolic dysfunction may have normal heart size, one of the distinguishing markers of diastolic versus systolic dysfunction. Right ventricular enlargement is suggested by the loss of free space between the cardiac silhouette and the sternum on a lateral view. Pic 1: Heart size is normal, pulmonary vessels are sharply marinated and that they are normal in caliber, costophrenic angles are sharp, no Kerley B lines. Pic 2: Heart has increased in size, in the upper lobes there is vascular redistribution or encephalization, which is distension of the pulmonary veins due to the increased left sides pressures, there are blunted costophrenic angles, presents of Kerley B lines, which is indicative of thickened interlobular septa due to edema. The pulmonary vasculature is blurred due to interstitial pulmonary edema. Kerley B lines are horizontal that start from pleura and travel towards the hilum, max of 2 cm in length and 2 mm in diameter. Mostly visible in the costophrenic angles. Become smaller as they move towards the hilum. Echocardiography Transthoracic two-dimensional echocardiography with Doppler flow studies is highly recommended for all patients with heart failure. This test helps in the assessment of left ventricular size, mass and function. The velocity of blood flow can be determined through echo.

The ejection fraction can be calculated by several methods, including visual estimation, which has good correlation with ejection fractions obtained by angiography or radionuclide cineangiography.

EF = Diastolic Volume – End Systolic Volume/End Diastolic Volume Left: an echocardiogram of a normal heart: the left ventricle (LV) is clear and full of blood.
Right: an echocardiogram with a thickened left ventricle wall, indicating hypertrophy, which is a sign of heart failure. Stress Echocardiogram A stress echocardiogram combines an echocardiogram with a stress test to observe how the heart muscle performs when it is stressed and has to work harder. Some people have no symptoms of heart failure when they are resting, so a stress echocardiogram is performed during exercise (on a treadmill or stationary bike) or with special medication (Dobutamine) if you are unable to exercise. It is then compared with the echocardiogram of your heart at rest. Differential
Diagnosis Other Diseases to Consider Lab Values Conditions that Mimic CHF Kidney Disease - both would show signs of loss of appetite, nausea, fatigue, and edema
Liver disease - both would show signs of nausea, vomiting, and fatigue
Profound Anemia - fatigue, shortness of breath, chest pain, fast or irritable heartbeat
Abnormal thyroid function - both would present with fatigue, poor appetite, weight gain, decrease in cognitive function
Lung disease - both would show present with shortness of breath, cough, chest pain
Abnormal retention of salt and water - weight gain and edema
Effects of different medications - weight gain, edema, fatigue, poor appetite, nausea Based on the large amount of diseases that present similarly to CHF, it is important to use lab values, diagnostic tests, and diagnostic imaging to accurately diagnosis a patient. Testing Considerations Rank of Order of Tests
1. Chest Radiography
Costs - $350
Radiation Considerations - Yes, Low Exposure 0.1 mSv
2. Echocardiogram
Costs - $400
Radiation Considerations - none
Contraindications - none
3. EKG
Costs - $1,450
Radiation Considerations - none
Contraindications - none
4. Stress Echocardiogram
Costs - $4,300
Radiation Considerations - none
Contraindications - Several Physical Therapy
Considerations Evidence-Based Considerations The Effect of Physical Training
in Chronic Heart Failure • Patients with heart failure generally have reduced exercise quality, and two of the main symptoms in heart failure are exercise intolerance and fatigue.
o Improvements in exercise capacity are often delayed for weeks or even months.
• The results of this study were used to decided whether CHF patients should attend cardiac rehabilitation programs
• 2 groups: control and training group
• Initial measurements consisted of cardiopulmonary exercise test on ergometer bicycle, 6 min walk test, MMT, dynamic spirometry, ANP/BNP levels in plasma, 2-D echo, and a QOL questionnaire
• Training group attended OP-supervised physical training 2x/wk for 5 months.
o Each session consisted of 10 min warm up, breathing exercises, free non-resistance arm and leg movements, 15 min pedaling on bicycle, 20 mins of circuit resistance training with free weights/rubber tubing, a 5 min cool down, and a stretch.
• Work load on bike 50% of peak work load from initial test.
• Resistance in circuit training was 20-25% of 1RM (some at 35-40% 1RM)(resistance held constant)
o BP, pulse, O2 Sats, dyspnea, exertion, and body weight measured/reported each session
• Control group continued their previous level of physical activity: varied from little physical activity up to taking a daily walk outdoors.
• Exercise time, and work load on bicycle improved significantly in training group, highly significant improvement in 6 min walk test.
• 1 year after study, 5 from control group rehospitalized while 2 from training group rehospitalized; the 2 from the training group did not go back to hospital due to a worsening heart, while the 5 from the control group did.
• For a PT, it is seen that supervised exercise training can be of value and can improve exercise intolerance and fatigue in a CHF patient. A Meta-Analysis of the Effect of
Exercise Training on LV Remodeling
in Heart Failure Patients • Objective was to determine the effect of exercise training and type of exercise (aerobic vs. strength vs. combined training)on left ventricular remodeling in HF
• Cardinal feature in CHF is progressive chamber dilation and deterioration in pump function resulting from increased hemodynamic load and nonhormonal stress (LV Remodeling→associated with increased morbidity/mortality)
• Exercise training now recommended by number of international scientific organizations for patients with mild to moderate HF symptoms.
• This review indicates that aerobic exercise training reverses ventricular remodeling in clinically stable individuals with CHF. The favorable changes in LV volumes and ejection fractions associated with aerobic training were supplementary to pharmacologic benefits.
• An unexpected finding was that strength training was not associated with demonstrable benefit in LV remodeling.
• According to this meta-analysis, the PT should focus more on aerobic exercise when treating CHF patients.
o Most studies used a cycle ergometer 2-5 days/wk at around 50-65% peak VO2 around 25-50 mins.
• Most studies used patients with mild to moderate CHF. Effects of Exercise Training on Cardiac Performance, Exercise Capacity and Quality of Life in Patients with Heart Failure: A Meta-Analysis • Despite major advances in pharmacologic treatment of CHF, a large number of patients will still suffer from dyspnea, fatigue, diminished exercise capacity and poor quality of life.
• To date, there is a consensus about the positive effect of exercise training on peak oxygen consumption (peak VO2) and mortality in patients with CHF.
• Exercise training usually consisted of aerobic activities, sometimes combined with calisthenics and ball games. Resistance training alone was performed in only three studies.
• Exercise training in stable with mild to moderate ACHF, results in statistically significant improvements in max HR, max CO, peak VO2, anaerobic threshold, 6-MWD and HQRL.
• For the PT, it is important to realize that patients with CHF are generally older. It is possible that many will experience exercise limitation as a result of coexisting diseases such as neurological disorders, lung diseases, muscle skeletal abnormalities or orthopedic problems.
o In addition, it is also not clear whether training has the same effect in older patients than in younger patients (above and below the age of 65)
o This meta-analysis shows that further research is required, especially in elder patients and in those with more severe CHF, as most of the studies analyze patients with mild to moderate CHF. Efficacy of Inspiratory Muscle Training in
Chronic Heart Failure Patients:
A Systematic Review and Meta-Analysis Authors: Neil A. Smart, Francesco Giallauria, Gudrun Dieberg Results showed that the 148 participants that received IMT showed vast improvements in peak VO2; 6-Minute Walk Distance; Minnesota Living with Heart Failure Questionnaire; Maximum Inspiratory Pressure- PImax; and VE/VCO2 slope. Diagnostic Imaging Chest X-ray - Pneumonia will show a lack of air space, opacity which reveals consolidation
CT Scan - used if chest X-ray is unclear; look for consolidation and ground-glass opacity Diagnostic Imaging Chest X-ray - will show opacification of the collapsed lung lobe, mediastinal shift toward the side of collapse, elevation of ipsilateral and compensatory hyperlucency of the remaining lobes Diagnostic Imaging EKG - look for ST segment elevation Case Study 1 Oprah who is a 58 y/o female came into the clinic via direct access. Her chief complaint was feeling palpitations and ‘butterflies’ in her chest when walking with her friend Gayle last night. She also reported feeling run down the past few weeks and unable to make it through her workday without having to rest more frequently than usual. Oprah is very active and healthy woman. She has never had any past history of these symptoms. If you have 3 questions for Oprah
what would they be?
(Health Related) Additional Patient Report “I have not noticed any swelling in any parts of my body. I am able to sleep during the night without issues. I just feel the shortness of breath when I am physically active, such as walking up the stairs. I have not seen anyone about this because I just thought I was getting old. The heart palpitation is what scared me. I have had a cough for three weeks but it is not productive.” Physical Exam
Reveals No pitting edema was noted
No change in weight
BP was 110/90 at rest
HR was 70 bpm with a regular rhythm at rest
Chest Auscultation: abnormal S3 sound over the apex of her heart at rest
Faint rales and crackling were heard during inspiration at rest.

Since we didn’t hear any abnormalities while Oprah was at rest we wanted to see her active. So we referred her to a physician who ordered her to have a stress test. Diagnostic Imaging Stress Test Stress test revealed prolonged QT intervals with several PVCs with increasing intensity. At peak exercise Oprah had a 5-beat run of ventricular tachycardia. Her stress test lasted 5:34 minutes with a peak heart rate of 160 bpm. The patient reported increased shortness of breath and feeling extremely fatigued at peak work. Chest Radiography PA View Lateral View Demonstrates the increased diameter of the pulmonary vessels and the hazy contours. Echocardiogram Echocardiogram reveals:
1) Atrial and Ventricular Dilation
2) Ejection Fraction calculated to be 28%
Anything less than 35% is considered abnormal PT Plan of Care Treatment Session Aerobic Warm-Up:
Mode = Eliptical
Time = 10 minutes
Intensity = 50% HR Reserve Resistance Training:
Mode = Free Weights, Machines
Leg Press, Hamstring Curls, Body Weight Squats, DB Bench Press, and Tricep Kickbacks
Intensity = 40% of 1RM
Sets and Reps = 2 sets of 12 repetitions Patient Education
How to take pulse rate and recognize rhythm changes
When to terminate activity
Reminder to take blood pressure with automated cuff Triage Considerations:
It is important to monitor the patient's vitals throughout the treatment session. Respiratory rate, heart rate and rhythm, and blood pressure should be taken throughout the treatment session. Stop Treatment if:
Drop in blood pressure occurs with physical activity
Increase or decrease of 25 beats per minute occurs
Patient reports feeling dizzy or lightheaded
Abnormal heart rhythm is measured Home Exercise
Program Aerobic Conditioning
Mode: Cycle or treadmill
Intensity: 60% of HR reserve or 11-14 on Borg Scale
Frequency 4 times per week
Duration: 30-40 minutes
Resistance Training
Exercises: Body Weight Squats, Calf Raises, Step-Ups, Shoulder Press, Tricep Kicbacks
Frequency: 3 times per week
Sets and Reps: 2 sets of 10 repetitions Other: Patient is told to monitor HR during exercise with a heart rate monitor. If the patient feels any chest palpitations, she is told to stop exercise and if palpitations persist to seek medical attention. Oprah should monitor her blood pressure each day with an automated cuff. From wet read, cardiomegaly observed - transthoracic ratio greater than 0.50 ABC's
A - Alignment
B - Bone Outline and Density
C - Cartilage - Outline, Joint Space and Loose Bodies In significant studies of exercise echocardiography (> 100 patients), the sensitivity and specificity range from 74–97% and 64–86%, respectively. Significant studies (> 100 patients) of dobutamine stress echocardiography show a range for sensitivity of between 61–95%, while that for specificity ranged from 51–95% Stress echocardiography
Thomas H Marwick
Heart. 2003 January; 89(1): 113–118. A normal ECG can help to rule out the diagnosis of heart failure, but the presence of any abnormality does not help to rule in the diagnosis of heart failure high sensitivity but only moderate specificity):
Sensitivity: 0.89
Specificity: 0.56 Mant, J., Doust, J., Roalfe, A. et al. (2009) Systematic review and individual patient data meta-analysis of diagnosis of heart failure, with modelling of implications of different diagnostic strategies in primary care. 13(32), 1-207. Chest X-ray was moderately specific but insensitive (an abnormal chest X-ray is moderately helpful for ruling the diagnosis in, but a normal chest X-ray cannot rule out the diagnosis):
Sensitivity: 0.68
Specificity: 0.83 Mant, J., Doust, J., Roalfe, A. et al. (2009) Systematic review and individual patient data meta-analysis of diagnosis of heart failure, with modelling of implications of different diagnostic strategies in primary care. 13(32), 1-207. Sensitivity: 80%
Specificity: 88% Mant, J., Doust, J., Roalfe, A. et al. (2009) Systematic review and individual patient data meta-analysis of diagnosis of heart failure, with modelling of implications of different diagnostic strategies in primary care. 13(32), 1-207. Other Possible Diagnostic Tests 1) Angiography
2) MRI
3) CT Scan
4) Nuclear Medicine Imaging This radiograph reveals air space change illustrated by radioopacity involving the right middle and lower zones and the left lower zone. Pneumonia: CT scan obtained at level of main bronchi reveals consolidation in right upper lobe. The left upper lobe also has localized areas of ground-glass attenuation in addition to consolidation. CHF CT scan reveals cardiomegaly. Extensive consolidation is not observed compared to pneumonia. The chest X-ray depicts atelectasis of the right lung demonstrated by the loss of volume on the right, pronounced shift of the mediastinum to the right, and overexpansion of the left lung. EKG indicating left ventricular dysfunction consistent with CHF. Remember that no EKG is diagnostic of heart failure but certain EKG abnormalities including the LBBB pictured here may be present in CHF. Additional diagnostic images should be ordered to diagnose CHF. ST Segment Elevation consistent with an MI Contraindications Contraindications to Stress Testing:
Recent MI within the past 7 days
Symptoms of Left Ventricular Failure at rest
Severe ventricular outflow tract obstruction
Blood Pressure > 220/120 mmHg
Recent Pulmonary Embolism, Infarction, or DVT
Known Hypokalemia
Active endocarditis, myocarditis, or pericarditis Contraindications to Dobutamine Stress Challenge
Suspected or known severe bronchospasm
Sick sinus syndrome without pacemaker
2nd or 3rd degree AV block without pacemaker
Systolic BP < 90 mmHg Case Study 2 You are assigned a 75 y.o. male patient whose primary diagnosis is CHF stage 4 on his chart… how do you think he will present? This is how he actually presented:

Marco's wife brought him to the hospital because she was concerned. While he was laying down to go to sleep, Marco began to breathe rapid, shallow breaths. She gave him his O2 tank from home, but when his symptoms did not improve, she brought him to the ER. Marco can’t seem to catch his breath and is extremely fatigued. He has said that it feels like his heart is jumping out of his chest and is painful. He reports coughing. PMH is positive for kidney failure, CHF, UTI, Fx elbow due to a fall (5 yrs ago), GERD, and hypertension. What pathologies should you consider based on the patient's presentation? CHF, pneumonia, AMI, atelectasis Before looking at the chart, you think of the tests that should be ordered. What do you think the results would be? X-ray: cardiomegaly (cardiothoracic ratio 82%), kerly b lines, distended vasculature in the upper lobes and blurred costophrenic angle.
Echo: Ejection fraction of 15%
Blood tests: BNP is 1000 pg/mL, Troponin 55 mg/L, Hemoglobin 5 g/dL, BUN 93 mg/dL, and creatinine 8.5 mg/dL
Vitals: BP 164/106, RR 25 breaths per min, HR is 120 bmp at rest, rhythm felt thready and irregularly irregular. Test Results Knowing that he has stage 4 CHF what do you think he would be able to do in PT? PT considerations:
-Patient may be confined to bed or wheelchair
-Activity may cause or worsen severe symptoms (since symptoms are present at rest)
-Comparison of 6-minute walk test (if the patient is even able to perform the test at this stage)
-Every patient, every time
-Watch for decrease in HR (of 10-25 bpm) or decrease in blood pressure (since an increase in blood pressure is expected with activity)
-Increase in respiration rate greater than 40 respirations/minute
-RPE increasing above 14/20 (moderate exertion); also note what the RPE is before activity
– may not be able to endure the session very long
-Presentation of V Tach, A Fib, V Fib PT Considerations with a Ventricular Assist Device If a ventricular assist device is being used, other considerations apply:
-sternal precautions for up to 12 weeks s/p
-Patient should begin ambulation within 3-5 days post-op
-6-minute walk test should be administered within 6-8 days post-op
-Patient should progress to stair ambulation within 12-14 days post-op PT Plan of Care (with VAD):
(Trying to maximize functional independence and safety before d/c OR to maximize independence and endurance while in the hospital)
-interval ambulation (9-11 days post-op)
-treadmill walking program (12-14 days post-op) using modified treadmill ramp protocol
-cycling (3 weeks post-op)
– begin with 50 watts-exercise should be progressed by 5 minutes each week for a total of 50 minutes of exercise 4-5 times per week by post-op week 6 What is a Ventricular Assist Device? A ventricular assist device (VAD) is a mechanical pump that supports heart function and blood flow in people who are in heart failure. The device pumps blood from either lower chamber of the heart to the body and vital organs, just as a healthy heart would. Haykowsky, M. J., Liang, Y., Pechter, D., Jones, L., McAlister, F. A., Clark, A. M., A Meta-Analysis of the Effect of Exercise Training on Left Ventricular Remodeling in Heart Failure Patients: The Benefit Depends on the Type of Training Performed. (2007) Jonsdottir, S., Andersen, K. K., Sigurosson, A. F., Sigurosson, S. B. (2006). The Effect of Physical Training in Chronic Heart Failure. Van Tol, B., Huijsmans, R. J., Kroon, D. W., Schothorst, M., Kwakkel, G. (2006). Effects of Exercise Training on Cardiac Performance, Exercise Capacity and Quality of Life in Patients with Heart Failure: A Meta-Analysis A conclusion that physical therapists can take from this study is that inspiratory muscle training can show improvements in CHF patients’ cardio-respiratory fitness capacity and their quality of life and may provide an alternative for more severely de-conditioned CHF patients who may need to gradually transition into conventional exercise therapy. check data Knowledge is the POWER we need to guide our elders in this difficult to manage chronic illness.
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