Background Information
Congestive heart failure or chronic heart failure “is a condition that reflects the impairment of the pumping action of the left ventricle of the heart” (Maisttison, 2005, p.23). As a result, blood flow from the left ventricle of the heart into the aorta and into the peripheral aortic circulation is reduced. In addition, failure to eject blood from the left ventricle leads to increased back pressure in pulmonary circulation, with reduced blood flow through the lungs and oozing of fluid.
This pandemic affects close to 15 million people globally, and approximately 4 million US residents (Topol, 2006). A recent report by The American Heart Association indicated that by 2003, close to 5 million people had congestive heart failure in the US, and in that year, this disease caused 57,200 deaths (Topol, 2006). Ten incidences of heart failure are reported in every 1, 000 individuals aged 65 years and above in the US (Topol, 2006). Topol (2006, p.1331) argues that “despite declining mortality rates for cardiovascular disease in the US, hospitalizations for heart failure have increased substantially. Hospital discharges for congestive heart failure in the United States rose from 399,000 to 1, 093, 000, in 2003, which represents a 174% increase” (Topol, 2006, p. 1331). It should be noted that most of the criteria for diagnosing congestive heart failure are not standardized; hence population estimates may underestimate the extent of the heart failure. Measurements used in population-based studies and cardiovascular drug research rely on composite signs, symptoms, and diagnostic findings. In addition, a recent cohort study in Scotland comprising of 2, 000 participants aged 25-74 years indicated 1.5% of the participants were symptomatic while 1.4% were asymptomatic. According to the study, prevalence rates increase with age (Topol, 2006, p. 1331).
Heart failure may arise from several underlying processes such as myocardial infarction, which causes significant localized damage to the ventricular wall, or longstanding high blood pressure. Other risk factors include inadequately controlled cardiomyopathies such as Chagas disease, which reduces heart muscle cell function, or valvular disease like a chronic rheumatic heart attack which causes valvular obstruction or regurgitation of blood flow back into the left ventricle. Compensatory physiologic changes can maintain adequate left ventricular function, even when the underlying disease progresses. For example, if an ACE inhibitor is given, peripheral arterial resistance is reduced thus enhancing blood flow in the heart. Once heart failure develops, its manifestations are the same regardless of its cause. However, in the case of coronary heart attack, as in acute myocardial infarction, the onset of heart failure may be very sudden. Chronic heart failure may persist after an acute onset and partial recovery, or progressive ventricular decomposition may occur over weeks, months or years. Fatigue and shortness of breath on minimal exertion are the main clinical indications of congestive heart failure. Treatment may improve function and prolong life for several years, but progressive decomposition or other complications result in death in a large proportion of cases. Congestive heart failure is a worldwide pandemic. People need to be knowledgeable about the causes, effects, and management of congestive heart failure because its prevalence is high and anyone is at risk of developing this condition, and its causes are multifactorial in nature.
Case Presentation
Mr. Brown who is 57 years old has been referred by his cardiologist to the University of Maryland’s cardiology department for a heart transplant. “Here I sit at the heart center on a follow-up consultation, listening to my cardiologist told me that he is referring me to the University of Maryland’s cardiology department for a heart transplant and I’m saying to myself, what rock have I been hiding under, because at no time has anyone mentioned a heart transplant to me. But, in the same breath, he has told me that, I have a snowball chance in hell of getting a transplant, because “I look too good, I’m fit and I do not have any artery blockage” which is the minimum requirement to get a heart transplant. So, I thought, if that’s the case, why to bother. The cardiologist said my heart condition is serious and I need to get on the heart transplant list because the new echocardiogram just performed on me shows my heart has deteriorated since the hospital stay four weeks ago to an EF (Ejection Function) reading of 14%. My last word to the doctor before I left; I said doc., it’s going to be a pretty cold day in hell for me before I have a transplant, you can schedule it with the University of Maryland, but I want to think about it” (Maisttison, 2009, p. 4). This is representative of most patients when faced with such overwhelming situations.
Mr. Brown had experienced breathing problems the previous month and he went for a check-up at a local hospital. Upon conducting a blood test and an ejection fraction test, laboratory reports indicated that he had tested positive for congestive heart failure. Mr. Brown was admitted and the physician conducted a number of additional tests, which included an echocardiogram test, stress test, and a nuclear test and they all confirmed that Mr. Brown had Congestive heart failure. The doctors at the hospital were determined to find out the etiology of this condition, so they ran differential tests. The doctors conducted an ejection function (EF) test and the results indicated that Mr. Brown had an EF of 27%. The other tests showed that Mr. Brown did not have any artery blockages and everything else about his heart is okay. After examining his clinical history, the doctors concluded that Mr. Brown’s heart failure was caused by a viral infection. Mr. Brown had recently recovered from flu he got from one of his grandchildren. This indicates the importance of educating adults about the dangers which can be caused by viral infections such as flu.
Discussion
As mentioned earlier, heart failure has multifactorial causes. Congestive heart failure or chronic heart failure is a condition that reflects the impairment of the pumping action of the left ventricle of the heart (Maisttison, 2005, p.23). Congestive heart failure may be acute or chronic. In this case, Brown’s condition was acute. Generally, impairment of the left ventricle can be caused by many factors including myocardial infarction, which causes significant localized damage to the ventricular wall, longstanding high blood pressure, or inadequately controlled cardiomyopathies such as Chagas disease, which reduces heart muscle cell function due to severe inflammatory reactions, or valvular disease like chronic rheumatic heart disease which causes valvular obstruction or regurgitation of blood flow back into the left ventricle. Having recovered from flu just a few weeks earlier, the impairment of the pumping action of the left ventricle in Mr. Brown’s heart was caused by the viral infection.
The infection degraded Mr. Browns’ heart muscle in the left ventricle leading to the impairment. During Mr. Brown’s clinical examination, the doctors had to conduct differential studies in order to rule out the other causes. In this case, EF, which is a measure of the amount of blood the heart ejects or pumps with each contraction, was measured. The previous test indicated that Mr. Brown had an EF of 27%. However, his EF had dropped to 14%, which reflected a drastic fall in Mr. Brown’s heart performance. An EF of 14% is an extremely low score and calls for immediate action. Thus, Mr. Brown’s condition is a perfect example of an acute case of congestive heart failure. Most cases of congestive heart failure are chronic.
Management and Outcome
A number of medications are available for the treatment of congestive heart failure. Neurohormonal blocking agents are the main forms of medications used in the management of congestive heart failure. Examples include Angiotensin-converting enzyme inhibitors, Angiotensin receptor blockers, and aldosterone antagonists. Other treatment regimes involve the use of diuretics and vasodilators. Angiotensin-converting enzyme inhibitors, inhibit the activation of the Angiotensin-converting enzyme, which plays a key role in the rennin Angiotensin system. ACE often leads to vasoconstriction. Thus, ACE inhibitors prevent the development of hypertension which is a risk factor for heart failure. Angiotensin blockers prevent the activation of Angiotensin receptors thus preventing the development of vasoconstriction. Aldosterone antagonists counter the action of aldosterone because this hormone often leads to hypertension. On the other hand, diuretics enhance the elimination of water while vasodilators reduce high blood pressure by eliminating vasoconstriction. In addition, a heart transplant is often recommended when medication has failed or in cases where a timely action is required. Mr. Brown’s case required a timely intervention. In this case, the doctors recommended that Mr. Brown should undergo a heart transplant immediately owing to the emergency of his case. Heart transplants are complex medical procedures and they depend on the availability of a donor. The donated heart must be compatible with the recipient’s immune system. After the transplant, the patient has to be monitored to evaluate the progress of the patient’s condition.
Conclusion
Congestive heart failure is a major and growing public health problem. This increase is only partly explained by the aging of the population. In addition, most studies have concentrated on chronic heart failure. Mr. Brown’s case indicates the need to also focus on acute heart failure. Identifying and preventing the well-recognized illnesses that cause congestive heart failure, including hypertension and coronary heart disease, and myocardial infections should be the guiding principle. Aggressive implementation of evidence-based management of risk factors for coronary heart disease and myocardial infections should be at the core of congestive heart failure prevention.
References
Maisttison, L. (2005). Kissed by Death: Congestive Heart Failure. London: Lulu Press.
Topol, Eric. (2006). The Topol Solution: Textbook of Cardiovascular Medicine. New York: Lippincott Williams & Wilkins.