Congestive Heart Failure

Definition
a complex clinical syndrome that results from structural or functional impairment
of ventricular filling or ejection of blood, which in turn leads to the cardinal clinical
symptoms of dyspnea and fatigue and signs of HF, namely edema and rales.
Because many patients present without signs or symptoms of volume overload, the
term “heart failure” is preferred over the older term “congestive heart failure.”

the historical terms “systolic” and “diastolic” HF have been abandoned, and HF patients are now
broadly categorized into HF with a reduced Ejection Fraction (HFrEF; formerly systolic failure) or HF
with a preserved Ejection Fraction (HRpEF; formerly diastolic failure).
Causes of Heart Failure
Right Sided HF Left Sided HF (usually systolic)

• Left sided HF • Ischemic heart disease

• Chronic Liver Disease • Long standing HTN
• Cor-Pulmonale • Dilated Cardiomyopathy
• (also associated with Duchenne’s,
Becker’s, and limb-girdle muscular
Precipitating Factors dystrophies)
➢ Myocardial Ischemia/Infarction
➢ Intercurrent illness (infections)
➢ Arrythmias
➢ Inappropriate reduction of cardio therapy
➢ Drugs ( -ve ionotrops like Beta blockers ) (Fluid retaining like NSAIDS, CCS)
➢ Anemia
➢ Pregnancy
➢ Thyrotoxicosis
 Symptomatology
• The cardinal symptoms of HF are fatigue and shortness of breath.
• In the early stages of HF, dyspnea is observed only during exertion; however, as the disease
progresses, dyspnea occurs with less strenuous activity, and it ultimately may occur even at rest.
• The most important mechanism is pulmonary congestion with accumulation of interstitial or intra-
alveolar fluid, which activates juxtacapillary J receptors, which in turn stimulate the rapid, shallow
breathing characteristic
of cardiac dyspnea
• ORTHOPNEA Orthopnea, which is defined as dyspnea occurring in the recumbent position, is usually a
later manifestation of HF than is exertional dyspnea. It results from redistribution of fluid from the
splanchnic circulation and lower extremities into the central circulation during recumbency, with a
resultant increase in pulmonary capillary pressure.
• Bendopnea – SOB felt when leaning forward.
• Nocturnal cough is a common manifestation of this process.
• PAROXYSMAL NOCTURNAL DYSPNEA (PND)
• CHEYNE-STOKES RESPIRATION Also referred to as periodic respiration
or cyclic respiration, Cheyne-Stokes respiration is present in 40% of
patients with advanced HF and usually is associated with low cardiac
output.
• Patients with HF also may present with gastrointestinal symptoms.
Anorexia, nausea, and early satiety associated with abdominal pain and
fullness are common complaints and may be related to edema of the
bowel wall and/or a congested liver. Congestion of the liver and
stretching of its capsule may lead to right upper quadrant pain.
• Cerebral symptoms such as confusion, disorientation,
and sleep and mood disturbances may be observed in patients with
severe HF, particularly elderly patients with cerebral arteriosclerosis
and reduced cerebral perfusion.
• Nocturia is common in HF and may contribute to insomnia.
• Crackles (rales)—Pulmonary crackles are abnormal breath sounds that
were formerly referred to as rales. Crackles are heard during inspiration
due to alveolar opening in the presence of pulmonary edema and are
considered a hallmark sign (although nonspecific) of CHF.
 Musculoskeletal Issues
• The skeletal muscle of persons with heart failure appears to be markedly
impaired in the areas of strength, endurance, mitochondrial function, and energy
production.
• These impairments of skeletal muscle have been hypothesized to be due to
marked neurohumoral activation associated with heart failure, deconditioning
associated with heart failure, or the presence of a myopathic process that is not
limited to only cardiac muscle, but to all muscles.
• skeletal muscle fatigue in patients with CHF is associated with intracellular
acidosis and phosphocreatinine depletion, which if prolonged may predispose to
myopathic processes.

In conclusion, The cause of the muscle fatigue is multifactorial, including a

decrease in peripheral blood flow, changes within the peripheral vascular beds,
peripheral vasoconstriction, atrophy of muscle fibers, and increased utilization of
anaerobic metabolism for energy production.
Clinical Evaluation and Assessment

1. appearance of the patient, orientation, cyanosis? Clubbing? Edema?

2. specific signs and symptoms of cardiac and cardiovascular diseases
3. feel of the pulse,
4. resting systolic and diastolic blood pressures,
5. systolic and diastolic blood pressures’ response to a variety of perturbations,
6. heart sounds via auscultation, S3? ( is normal in children, young adults & pregnancy)
7. Chest x-ray
8. direct and indirect measurements of cardiac and cardiovascular function,
9. exercise and functional abilities via exercise testing, and
10. outcome measures and quality of life of patients with known or suspected cardiac
disorders.
 Evaluation of Symptoms
• Before proceeding with exercise, it is important to check for signs and symptoms of left-sided pump failure at rest.
Patients with pump failure at rest should not be exercised, and they should be tested only in a safe, well-equipped
setting with appropriate medical backup.
• The therapist should listen to the heart sounds with a stethoscope, at rest and immediately following exercise.
• the presence of an S3 heart sound very low-pitched sound, heard best with the bell of the stethoscope placed
lightly on the chest wall over the apex of the heart.
• The lungs should be auscultated for the presence of crackles.
• popping sounds that are heard primarily during inspiration. Unlike pulmonary crackles, they do not clear with a
cough.
• Crackles, like the S3 heart sound, can be absent at rest but come on during exercise, indicating that the workload is
too strenuous and producing transient pump fail.
• The therapist’s clinical response is similar to that of arrhythmia and ischemia: Mark the onset of these signs by
noting the workload, HR, and BP, and then stop exercise and adjust the exercise regimen accordingly.
• POSTIONING
• It is important to avoid placement of a patient in supine during recovery; this will increase the volume of blood
that the heart has to pump out and exacerbate the patient’s symptoms.
• Rather, the patient’s upper chest and head can be propped up with pillows, or the head of the bed can be
cranked up, or the patient can be seated in a chair.
Dyspnea
• An easy method for documenting
the level of dyspnea is to count the
numbers of words that the patient
is able to speak per breath.
• Scale is used as a parameter for
Exercise intensities corresponding
to a perceived
• exertion level between 12 and 14
(Borg 6–20 scale) have been shown
to be well-tolerated and associated
with favorable training responses in
patients with CHF

RPE = Rate of perceived exertion

Chest x-ray
Chest x-ray findings include
• Pleural effusions,
• cardiomegaly (enlargement of the cardiac silhouette),
• Kerley B lines (horizontal lines in the periphery of the
lower posterior lung fields),
• upper lobe pulmonary venous congestion and
• interstitial edema.

mnemonic to remember these principles is ABCDE:

•A - alveolar edema (bat wing opacities)

•B - Kerley B lines
•C - cardiomegaly
•D - dilated upper lobe vessels
•E - pleural effusion
Management
• Core components of cardiac rehabilitation in chronic heart failure
• Baseline clinical assessment and risk stratification
• Treatment of causative factors of heart failure (hypertension, coronary artery disease, atrial
fibrillation, and valvular heart disease) and correction of precipitating causes (non-compliance with
drugs, use of non-steroidal anti-inflammatory drugs and cyclooxygenases-2 inhibitors, nasal
decongestants, infections, pulmonary emboli, dietary indiscretion, inactivity, hyperthyroidism)
• Optimal pharmacological therapy directed by national and international guidelines
• Management of HF-related diseases and competing comorbidities
• Implementation of a continuing program on physical activity and exercise training
• Counseling and education: lifestyle, dietary recommendations, coping strategies, medications, self-
monitoring, prognosis
• Psychological support
• Planning of continuum of care thorough an efficient, organized linkage between hospital and
community
1. Progressive worsening of exercise tolerance or dyspnea at rest or on
exertion over previous 3–5 days
Phases of Cardiac rehabilitation
Phase I: Clinical phase
This phase begins in the inpatient setting soon after a cardiovascular event or completion of an intervention. It begins by
assessing the patient's physical ability and motivation to tolerate rehabilitation. Therapists and nurses may start by
guiding patients through non-strenuous exercises in the bed or at the bedside, focusing on a range of motion and limiting
hospital deconditioning. The rehabilitation team may also focus on activities of daily living (ADLs) and educate the patient
on avoiding excessive stress. Patients are encouraged to remain relatively rested until completion of treatment of
comorbid conditions, or post-operative complications. The rehabilitation team assesses patient needs such as assistive
devices, patient and family education, as well as discharge planning.

Phase II: Outpatient cardiac rehab

Once a patient is stable and cleared by cardiology, outpatient cardiac rehabilitation may begin. Phase II typically lasts
three to six weeks though some may last up to up to twelve weeks. Initially, patients have an assessment with a focus on
identifying limitations in physical function, restrictions of participation secondary to comorbidities, and limitations to
activities. A more rigorous patient-centered therapy plan is designed, comprising three modalities: information/advice,
tailored training program, and a relaxation program. The treatment phase intends to promote independence and lifestyle
changes to prepare patients to return to their lives at home.

Phase III: Post-cardiac rehab. Maintenance

This phase involves more independence and self-monitoring. Phase III centers on increasing flexibility, strengthening,
and aerobic conditioning.
 Exercise prescription for cardiac patients
I. Mode - Utilize large muscle groups , Aerobic exercise training includes walking, jogging, running, swimming and stationary bicycling or any
combination of these activities.
II. Frequency -
I. Individuals with a less than 3-MET capacity should engage in multiple short sessions each day.
II. Individuals with a 3- to 5-MET capacity should engage in 1-2 sessions per day.
III. Individuals a greater than 5-MET capacity should engage in 3-5 sessions per week.
III. Duration - Patients usually need to allow 30-60 minutes for each session, which includes a warm-up of at least 10 minutes upto 12 weeks.
IV. Intensity – 40%–85% of functional capacity (VO2max), corresponding to 55%–90% of maximal heart rate.
I. The intensity prescribed according to:
I. Target heart rate (training heart rate) which determined according to Karvonen formula as following: Target heart rate = Resting
heart rate + 60%-80 %( Maximum heart rate –resting heart rate) Maximum heart rate = 220- age.
II. Based on the results of the exercise stress test (prescribed in METs)
N.B. One MET (metabolic equivalent) is the amount of oxygen consumed by the myocardium each minute is about 3.5 ml. O2 /Kg of
body weight/ minute.
V. Resistance Training -- is traditionally prescribed based on the individual’s measured or estimated maximal strength or the “one-repetition
maximum.” General strength prescription in cardiac patients involves 30%–40% of the 1 RM for upper body exercises and 40%–50% of the 1 RM for
lower body exercises. Exercises are performed for 12 to 15 repetitions per set, performed two to three times each week.
Exercise session consists of
• Warming-up: Applied for about 5 - 10 minutes in the form of light calisthenics and muscular
stretching are performed to:
• 1- Avoid muscle injury
• 2-Prepare cardiopulmonary system to exercise.
• 3-Reduce incidence of arrhythmias.
• Aerobic exercise: Applied for about 40 minutes in the form of walking, jogging and bicycling.
• Cooling down: Applied for 10 minutes in the same form of the applied aerobic exercises used during
training. 75 The cool-down period is very important to:
• 1- Prevent ventricular arrhythmias.
• 2-Prevent pooling down of blood in lower limbs.
Patient Education
1. Symptom Recognition and Response- Being able to recognize their specific cardiac symptoms and to
know how to respond is a key component in patient education.
2. Reduce sodium intake (improve dietary habits)
3. Walk daily.
4. Sleep 6 to 8 hours every night.
5. Wait at least 1 hour after meals before exercising.
6. Avoid extremes in weather: In the winter, exercise during the warmer parts of the day; in the
summer, exercise in the early morning or evening.
7. Avoid vigorous arm and shoulder activities, especially overhead arm activity (arm activity requires
more energy than leg activity).
8. Avoid lifting heavy weights or objects (isometric exercise).
9. If you have chest pain, dizziness, excessive fatigue, unusual palpitation or shortness of breath stop
what you are doing and Call your physician.
10. Take your medications as ordered.
11. Don't exercise if you have an acute illness.