Feature

Identification and Prevention

of Secondary Heart Failure:
A Case Study
Vlad Gheorghiu, MSN, NP, AGACNP-BC, PCCN-CMC
Thomas W. Barkley Jr, PhD, ACNP-BC

Heart failure, a complex clinical syndrome affecting millions of Americans, is associated with high mor-
bidity and mortality and a significant financial burden on the health care system. Recent health care reform
efforts have focused on reducing 30-day heart failure hospital readmissions, increasing the cost-effectiveness
of care provided to heart failure patients, and improving health outcomes for these patients. This case
report describes an acutely ill patient with multiple comorbidities who was not initially admitted for heart
failure but who developed acute decompensated heart failure during his hospital stay. The purpose of this
in-depth analysis is to discuss the role of bedside nurses and advanced practice nurses in managing heart
failure, describe the challenges of identifying secondary heart failure in patients with complex conditions,
and suggest methods of improving health-related outcomes to prevent hospital readmissions. (Critical Care
Nurse. 2017;37[4]:29-36)

eart failure (HF) is a chronic, progressive, and debilitating condition that affects millions

H of people in the United States and worldwide. It is estimated that more than 5.8 million Ameri-
cans and more than 23 million people worldwide are diagnosed with HF, which poses a growing
global public health problem of epidemic proportions.1 Although HF can affect many age groups, it is
especially prevalent in elderly and frail individuals.2 Certain ethnic groups are also disproportionally
affected, with a higher incidence in the black population, possibly because of higher rates of hyperten-
sion and diabetes, poor nutrition, and genetic factors.3 Despite recent medical and scientific advances,
the disease burden for HF remains high and the prognosis is poor. A diagnosis of HF is associated with
increased and recurrent hospital admissions, with a mortality rate of up to 40% within 1 year of the first
hospitalization.1 Aside from the high morbidity and mortality, HF also places an enormous financial strain
on the health care system, with an estimated $30 to $40 billion in associated annual health care costs.2
Furthermore, HF hospitalization rates in the United States have increased, and the prevalence of HF has
also increased worldwide. These trends may be due to increased awareness of heart disease, improvements
in diagnosis, increased incidence of HF, a growing population of elderly individuals, or a combination of
these and other factors.1

©2017 American Association of Critical-Care Nurses doi:https://doi.org/10.4037/ccn2017478

www.ccnonline.org CriticalCareNurse Vol 37, No. 4, AUGUST 2017 29

Downloaded from http://ccn.aacnjournals.org/ by AACN on September 14, 2018
Etiology and Associated Risk Factors
Heart failure can best be described as a clinical syn-
drome with symptoms related to impaired myocardial
ventricular function. It most commonly manifests as
vascular congestion in the pulmonary and systemic
circulation and produces symptoms of circulatory
insufficiency.4 Most symptoms of HF can be classified
as secondary to either vascular congestion or target
organ hypoperfusion.4
The etiology of HF is multifactorial and is also associ-
ated with both modifiable and nonmodifiable risk fac-
tors. Such risk factors include hypertension, coronary
artery disease, diabetes, arrhythmias, congenital heart
defects, previous history of myocardial infarction, and
cardiomyopathy.1 Modifiable risk factors, such as ciga-
rette smoking, obesity, and hyperlipidemia, as well as
socioeconomic status, may also contribute to the devel-
opment of HF.1
Health Care Reform for Improving
HF Outcomes
Heart failure is recognized as the leading cause of
hospital admissions and readmissions in patients older
than 65 years and is a leading cause of death among
those hospitalized.5 Because HF is one of the most
reported and costly cardiovascular diagnoses for Medi-
care, the Hospital Readmission Reduction Program
plans to use 30-day readmission rates to reduce reim-
bursement for underperforming health care facilities
by 1% in 2013, 2% in 2014, and 3% in 2015.5 Various qual-
ity improvement initiatives have been implemented to
contain these growing health care costs.
Team-based interdisciplinary efforts among nurses,
health care practitioners, social workers, and case man-
agement professionals focus on providing self-care
Authors
Vlad Gheorghiu is a graduate student in the Adult-Gerontology
Acute Care Nurse Practitioner Program at the School of Nursing at
California State University, Los Angeles, California.
Thomas W. Barkley Jr is coordinator of the Adult-Gerontology Acute
Care Nurse Practitioner Program and director of nurse practitioner
programs at the School of Nursing at California State University,
Los Angeles, California.
Corresponding author: Vlad Gheorghiu, MSN, NP, AGACNP-BC, PCCN-CMC, 5505 Greenbush
Avenue, Sherman Oaks, CA 91401 (email: vlgheo@gmail.com).
To purchase electronic or print reprints, contact the American Association of Critical-
Care Nurses, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 899-1712 or
(949) 362-2050 (ext 532); fax, (949) 362-2049; email, reprints@aacn.org.
30 CriticalCareNurse Vol 37, No. 4, AUGUST 2017
Downloaded from http://ccn.aacnjournals.org/ by AACN on September 14, 2018
education to HF patients on admission, as well as improv-
ing discharge planning, transition of care, and follow-up.
For example, a study of an evidence-based quality improve-
ment initiative in a Florida hospital has shown that pro-
viding patients with the education and tools that they
need to manage their disease and maintaining telephone
follow-up after discharge can reduce readmission rates.6
Indeed, one of the most challenging areas of quality
improvement remains to motivate patients to efficiently
manage their condition at home, an environment over
which practitioners have no control.
Cost-effectiveness can be improved by reducing the
length of stay, a factor that affects health care funding
and reimbursement. With bundled payment systems,
health care providers receive a fixed payment for all ser-
vices provided in a single episode of care, thus providing
an incentive to deliver high-quality care more efficiently
in addition to containing health care costs.7 Although
the results of some studies have suggested that increased
readmission rates are related to a decreased length of stay,
current research indicates that readmission is more closely
related to factors such as quality of care and case sever-
ity. Therefore, a 1-day reduction in the length of stay is
not associated with a higher rehospitalization rate.8
Furthermore, in a study by Chen et al, the overall HF
length of stay declined from 2000 to 2009 among older
patients but did not significantly decrease in black men
and younger patients.9
Purpose
The purpose of this case study is to explore possible
strategies by which nurses and clinicians can identify
secondary HF in hospitalized patients and implement
early measures to prevent progression to acute decom-
pensated heart failure (ADHF), thus improving patient
outcomes and decreasing health care costs. The increase
in the overall rate of HF hospitalizations has been greater
in patients with an additional diagnosis of ADHF than
in those with noncardiac conditions as the primary
diagnosis.10 Therefore, nurses must be able to identify
patients who are not admitted with a primary diagnosis
of HF but may have potential HF or are at high risk of
developing secondary HF. Various comorbidities, such
as diabetes mellitus and renal failure, may also contrib-
ute to the development and exacerbation of HF.11 The
following case study introduces a patient with complex
disease who was not initially admitted for HF but who,
www.ccnonline.org
during the course of hospitalization, developed second-
ary HF with preserved ejection fraction (EF), which rap-
idly progressed to ADHF.
Case Study
A 90-year-old Spanish-speaking man was brought
by his family to the emergency department (ED) with a
chief concern of bilateral lower-extremity itching, swell-
ing, and redness for several days before admission. His
medical history included coronary artery disease, coro-
nary artery bypass grafting, moderate aortic stenosis,
right bundle branch block, hypertension, vancomycin-
resistant enterococcal and methicillin-resistant staphylo-
coccal colonization, type 2 diabetes mellitus, chronic
lower back pain, pneumonia, prostate cancer, depres-
sion, and dementia. The patient was initially diagnosed
with sepsis related to lower-extremity cellulitis. He was
also diagnosed with acute renal failure secondary to
dehydration. The attending physician’s initial note, as
well as the subsequent progress notes, made no mention
of HF in the assessment section.
The patient’s vital signs in the ED were temperature,
39.0°C; blood pressure, 142/80 mm Hg; heart rate, 104/
min; and respiratory rate, 26 breaths/min. Notable base-
line blood laboratory values were sodium, 145 mEq/L;
potassium, 5.3 mEq/L; blood urea nitrogen, 37 mg/
dL; creatinine, 2.5 mg/dL; white blood cell count, 14 000/
μL; hemoglobin, 10.8 g/dL; and platelets, 125/μL. Follow-
ing stabilization in the ED, the patient was transferred
to a critical care telemetry/surgical unit under progres-
sive care unit (PCU) status, which included closer
observation, more frequent assessments, and monitor-
ing of vital signs.
Upon arrival at the surgical unit, the patient received
an indwelling urinary catheter for accurate measurement
of fluid output. An initial chest radiograph showed no
pulmonary vascular congestion, cardiomegaly, or other
abnormalities. Of note, an echocardiogram obtained 1
year before had revealed moderate aortic stenosis, mild
mitral regurgitation, and an EF of 65%. A broad-spectrum
intravenous (IV) antibiotic regimen of piperacillin-
tazobactam and vancomycin was initiated pending blood
culture results. The patient was given IV normal saline
because of presumed sepsis and dehydration, but it
should be noted that no baseline B-type natriuretic
peptide (BNP) assay was obtained. The patient was
subsequently transferred to a medical telemetry unit,
www.ccnonline.org
Downloaded from http://ccn.aacnjournals.org/ by AACN on September 14, 2018
also under PCU monitoring, to free the surgical bed. The
indwelling urinary catheter was removed before transfer,
so we were no longer able to strictly monitor urine output
because of the patient’s frequent episodes of incontinence.
Upon transfer to the telemetry unit, the patient was
initially hypertensive, with a blood pressure of 189/102
mm Hg. He received 10 mg of IV hydralazine as needed
when his systolic blood pressure (SBP) was greater than
160 mm Hg. The hydralazine lowered his SBP to around
150 mm Hg for only a brief time after administration.
The patient also began to receive his home regimen of
antihypertensive medications: carvedilol, 6.25 mg twice
daily; isosorbide dinitrate, 20 mg 3 times daily; irbesar-
tan, 150 mg daily; hydralazine, 25 mg 4 times daily; and
amlodipine, 10 mg daily. The patient’s BNP levels ranged
from 411 to 458 pg/mL; BNP levels reached 458 pg/mL
on 2 consecutive days, indicating potential fluid overload.
Four days after the patient was transferred from the
surgical unit, he was noted to be progressively more
lethargic. His blood pressure became increasingly more
difficult to control, with the SBP frequently elevated
above 180 mm Hg despite multiple doses of hydralazine
and the titration of scheduled blood pressure medica-
tions. He also
had respira- Heart failure should be considered
tory distress as a differential diagnosis in acutely
with increas- ill patients with multiple cardiac risk
ing oxygen factors and comorbidities.
demand and
was given oxygen via a simple face mask at 10 L/min.
The attending physician discontinued the hydralazine
and instead ordered minoxidil 5 mg by mouth, with the
first dose to be administered immediately, for hyperten-
sive urgency refractory to the current medication regimen.
Before the first dose of minoxidil was administered,
however, the rapid response team was called to evaluate
the patient’s progressive shortness of breath and blood
oxygen saturation of 90% despite receiving 100% oxygen
via a nonrebreather mask. A chest radiograph showed
diffuse bilateral infiltrates and pulmonary vascular con-
gestion consistent with flash pulmonary edema. The
patient received an IV dose of 40 mg furosemide. Arte-
rial blood gas values were also obtained, and the patient
subsequently received bilevel positive airway pressure
for acute respiratory distress. The patient was then trans-
ferred to a respiratory intensive care unit (ICU) for fur-
ther management of ADHF and acute respiratory failure.
CriticalCareNurse Vol 37, No. 4, AUGUST 2017 31
 In the ICU, bilevel positive airway pressure treatment
continued and the patient was given an IV bumetanide
infusion for aggressive diuresis. A Foley catheter was rein-
serted so urine output could be monitored. The patient
received diuresis to reach a fluid balance of -2048 mL
during his stay in the ICU. Upon arrival in the ICU, the
patient’s BNP level was 1151 pg/mL. An echocardiogram
showed moderate aortic stenosis, moderate mitral regur-
gitation, moderate pulmonary hypertension, and an EF
of 74%. The
Patients can quickly progress to acutely cardiology
decompensated heart failure if early team diag-
signs and symptoms of heart failure are nosed the
not identified in a timely manner. patient with
acute exac-
erbation of HF with preserved EF. A repeat chest radio-
graph obtained 4 days after ICU admission again showed
findings consistent with pulmonary edema. The patient
was eventually transitioned from the bumetanide infu-
sion to daily doses of IV diuretics. He was also weaned
off bilevel positive airway pressure treatment and began
receiving supplemental oxygen via nasal cannula. Fol-
lowing a 4-day stay in the ICU, the patient was trans-
ferred to a specialized HF unit, again under PCU status
for close observation.
Upon transfer to the HF unit, the patient’s BNP
level was 630 pg/mL, a significant improvement from
the level in the ICU. A repeat chest radiograph also showed
significant improvement in his pulmonary vascular
congestion. The patient demonstrated progressively
improved mentation and activity tolerance. His blood
pressure also subsequently stabilized, ranging from
150/40 to 100/30 mm Hg. Per institutional protocol
to prevent HF readmission, the patient and his family
received education regarding HF self-management at
home. This education, provided by nursing staff, a
clinical dietician, and a clinical pharmacist, included
information regarding daily weight monitoring, fluid
and sodium restrictions, medication adherence, and
signs and symptoms of exacerbation that should be
reported to his primary care provider. A follow-up appoint-
ment was also made with the cardiologist before discharge.
Discussion
Important aspects of HF management are recogni-
tion of risk factors and early signs and symptoms, cor-
relation of assessment findings with laboratory data,
32 CriticalCareNurse Vol 37, No. 4, AUGUST 2017
Downloaded from http://ccn.aacnjournals.org/ by AACN on September 14, 2018
and differentiation of HF from other conditions with
similar symptoms. Our patient had multiple cardiac
risk factors for HF, including hypertension, moderate
aortic stenosis, coronary artery disease, and a history
of coronary artery bypass grafting.12 All these factors
may contribute to myocardial dysfunction and precipi-
tate secondary HF. One of the most important risk fac-
tors to note is the patient’s poorly controlled hypertension,
which may increase left ventricular afterload and left
ventricular diastolic pressures, resulting in reduced
stroke volume. These effects are estimated to increase
the risk of HF 3-fold compared with normotensive
patients.2 Furthermore, arterial hypertension is a com-
mon comorbidity in ADHF, and hypertension may be a
prognostic indicator of the development of HF before
clinical manifestations occur.13 Therefore, early manage-
ment of hypertension in high-risk patients is important
for reducing morbidity and mortality.13
Although our patient was receiving various routine
antihypertensive medications at gradually increasing
dosages, his blood pressure was not adequately con-
trolled for several days. The requirement of frequent
doses of IV hydralazine for short-term blood pressure
control may have warranted more aggressive optimiza-
tion of medical therapy early in the course of care.
Current management guidelines emphasize the use of
angiotensin-converting enzyme inhibitors or angioten-
sin receptor blockers as first-line agents in managing
hypertension in HF. These medications are followed by
`-blockers and mineralocorticoid receptor antagonists.13
For hypertension refractory to these therapies, a loop or
thiazide diuretic and a dihydropyridine calcium channel
blocker (such as amlodipine) may be added as third and
fourth steps, respectively, to maintain a target blood
pressure of 130/80 mm Hg or to titrate to the lowest
level that can be tolerated without adverse effects.13
Adding a diuretic or aldosterone antagonist and maxi-
mizing the dosages of the existing medications may
have been appropriate interventions for this patient.
It should also be noted that using the antihypertensive
agent minoxidil in patients with HF can have potentially
serious adverse effects, such as pulmonary edema, fluid
retention, and angina. Therefore, minoxidil is usually
used as a last resort for a hypertensive crisis refractory
to other agents.14 Consultation with the clinical phar-
macist regarding a more appropriate medication regi-
men may have been warranted.
www.ccnonline.org
 Nurses must be able to recognize data that indicate
fluid overload and be able to assess conditions that could
potentially cause such findings. Although the patient’s
initial presentation included lower-extremity swelling
and erythema indicative of cellulitis, these findings
may also be associated with venous stasis dermatitis
in patients with chronic HF. Lower-extremity edema is a
classic indicator of fluid overload in patients with HF.4
Also, the patient continued to have persistent bilateral
lower-extremity edema throughout his hospital stay.
This finding may have also warranted further suspicion
for the development of HF, especially given the patient’s
multiple cardiac risk factors.
Laboratory data and imaging studies should be cor-
related with assessment findings. An echocardiogram
performed before admission revealed a normal EF, so
an echocardiogram was not repeated until the patient
was found to have ADHF. Although the 2013 American
College of Cardiology Foundation/American Heart
Association guidelines recommend echocardiography
as the tool of choice in evaluating left ventricular EF,
an echocardiogram showing a normal EF does not rule
out HF with preserved EF, which may present with an
EF greater than 50%.15 Furthermore, an echocardiogram
is useful for determining worsening myocardial function,
regurgitant or stenotic valve defects, pulmonary vascular
abnormalities, and left ventricular size and wall thick-
ness, as well as changes in clinical status and response
to treatment.4,12,15 Differentiating HF with preserved EF
from other comorbid conditions with similar symptoms
remains a challenge; it is primarily a diagnosis of exclu-
sion. Differential diagnoses for HF with preserved EF
include pulmonary disease, obesity, high-output cardiac
diseases (eg, anemia), thyrotoxicosis, valvular disease,
and pericardial disease.16
The administration of maintenance IV fluids may
also contribute to the development of secondary HF.
Many patients who are hospitalized for HF and treated
with diuretics also receive variable amounts of IV fluids
early in the course of hospitalization.17 The administra-
tion of IV fluids in an acutely ill patient with sepsis and
acute kidney injury may be reasonable according to the
early goal-directed guidelines for sepsis. However, fluids
may need to be discontinued early in a patient with car-
diac disease once hemodynamic stability is achieved.
Because nurses play an important part in patient moni-
toring, maintenance IV fluids should be discontinued
www.ccnonline.org
Downloaded from http://ccn.aacnjournals.org/ by AACN on September 14, 2018
before symptoms of fluid overload (such as pedal
edema, respiratory distress, and adventitious breath
sounds) develop.
Our patient’s BNP measurements before the develop-
ment of ADHF were elevated; however, no further action
was taken. Although elevated BNP and N-terminal-proBNP
levels reflect volume changes in HF, these values also
reflect other important aspects of cardiac physiology,
such as right and left ventricular size and function, dia-
stolic function, valvular heart disease, ventricular filling
pressures, and coronary ischemia.18 Studies have also
found that elevated N-terminal-proBNP levels on admis-
sion are a strong predictor of mortality in patients with
HF and can be used as a screening tool for cardiac risk
stratification.19 Serial BNP levels can also be used to
stratify cardiac risk and aid treatment decisions.18,19
However, BNP levels may be falsely elevated in patients
with renal dysfunction, sepsis, acute coronary syndromes,
and pulmonary embolism and may be falsely decreased
in patients with conditions such as obesity and preg-
nancy.18 Even though BNP levels are important when
evaluating patients with fluid overload, values should
be taken in context with clinical status and physical
assessment findings.
Given our patient’s multiple cardiac risk factors, assess-
ment findings, and laboratory studies indicative of fluid
overload, repeat
chest radiographs Institutional heart failure bundles
could have been can improve patient care delivery
used to evaluate and improve patient outcomes
for pulmonary after discharge.
edema and to dif-
ferentiate HF from respiratory conditions.4,16 A chest
radiograph, taken in context with a physical assessment
findings, can identify pleural effusion, pulmonary infil-
trates, cardiomegaly, and pericardial effusion.13
In addition to assessment findings, laboratory data,
and imaging studies, daily monitoring of weight and
measurement of fluid intake and output are key to man-
agement.20,21 Our patient’s indwelling urinary catheter
was removed early in the course of care, although he
remained immobile and had frequent episodes of uri-
nary incontinence. In such cases, accurate assessment
of volume status may pose a challenge. Alternative means
of monitoring, such as a bed scale to measure weight
daily and a condom catheter to measure urinary output,
may be considered. Although the accuracy of these means
CriticalCareNurse Vol 37, No. 4, AUGUST 2017 33
of monitoring may be variable, assessment of fluid status
should always be taken in context with changes in the
patient’s clinical status, physical assessment findings,
signs and symptoms, and objective and subjective data.22
Other issues that can affect patient care and satisfac-
tion include psychosocial dynamics, which can affect
diagnostic decisions and the care provided. Our patient’s
children were all highly educated but expressed a great
deal of anxiety during the course of his stay, requiring a
family meeting with the unit manager and medical team.
Studies have shown that unmet needs of family members
can negatively affect their satisfaction with care, infor-
mation, and decision-making. Higher education levels
of family members are also related to decreased levels
of satisfaction with care.23 Interventions should there-
fore be directed toward identifying and addressing fam-
ily needs, improving consistency in communication
with multiple family members, and setting boundaries
for requests that may negatively affect patient safety
and the quality of care.
Implications for Practice
Various conditions, such as systemic infection, hyper-
tension, and arrhythmias, can cause hemodynamic stress
in patients with compromised myocardial function that
may rapidly progress to ADHF.21 Nurses and clinicians
working with critically ill patients must be able to iden-
tify precipitating factors for secondary HF, recognize early
physical assessment and diagnostic findings indicative of
HF, and identify patients at risk for developing HF. Addi-
tionally, when patients with complex conditions are trans-
ferred among multiple hospital units, nurses should be
familiar with the course of hospitalization to avoid miss-
ing critical data and prevent fragmentation of care.
Because some nurses who do not routinely encounter
patients with cardiac disease may have knowledge deficits,
a comprehensive educational intervention with continued
reinforcement may prove useful in increasing knowledge
of HF management principles, even among experienced
acute care nurses.24 Such an intervention may also
improve the delivery of HF patient education. Some
nurses may have significant knowledge deficits related to
teaching HF self-management, such as assessing fluid and
blood pressure, modifying the diet, managing symptoms,
and recognizing early signs of HF exacerbation.24
Studies have also found that many patients who pres-
ent with ADHF delay seeking care for various reasons,
34 CriticalCareNurse Vol 37, No. 4, AUGUST 2017
Downloaded from http://ccn.aacnjournals.org/ by AACN on September 14, 2018
one of the most important being the patient’s ability to
effectively manage the condition at home.25 Patients
often have difficulty recognizing early signs and symp-
toms of their condition or may show a lack of self-care
behaviors, leading to delays in care and unplanned read-
missions.26 Symptoms of HF often occur together rather
than in isolation.27 Therefore, nurses should have the
knowledge necessary to provide patient self-care educa-
tion on HF topics that range from admission to discharge.
Although many modalities exist for managing HF,
nurses should develop realistic goals, including advanced-
care planning, with patients and families. Only a fraction
of HF patients with high mortality risk receive palliative
care services, which suggests the need to integrate the
option of palliative care into the plan of care as early as
at the time of diagnosis.28 This is an aspect of care that
may need to be considered, especially in high-risk geriat-
ric patients with advanced disease.
Health care organizations should develop protocols
that identify admitted patients with potential and active
HF on the basis of physical assessment findings sugges-
tive of fluid overload, elevated biomarkers, left ventricu-
lar hypertrophy or reduced left ventricular EF, multiple
cardiac risk factors, and preexisting comorbidities. Inter-
ventions such as daily weight measurement, strict fluid
intake and output monitoring, and interdisciplinary
education should be incorporated into the plan of care
for all such patients. HF should be considered as a dif-
ferential diagnosis along the continuum of care in any
patient with an extensive history of cardiac problems.11
Risk stratification for HF should start with American
Heart Association stage A, defined as having a high risk
for HF without structural heart disease in the presence
of multiple risk factors, such as hypertension, coronary
artery disease, diabetes, obesity, and metabolic syn-
drome.20 Interventions typically focus on goal-directed
medical therapy for symptom management and control
of fluid overload with diuretics and restriction of fluid
and sodium intake.20 More recently, however, studies
have found that aggressive fluid and sodium restriction
has shown no benefit in weight loss or clinical stability,
results in increased thirst, and may actually be detrimen-
tal in ADHF.29 Therefore, this area requires further
research to optimize treatment.
Although numerous other disease processes, such
as systemic infection and renal failure, may confound
the early identification of HF, screening modalities in
www.ccnonline.org
high-risk patients may be able to identify symptoms
of myocardial dysfunction. Two possible strategies for
identifying asymptomatic HF are prescreening with
plasma BNP levels and stratifying risk on the basis of
factors such as age, left ventricular hypertrophy, cardio-
megaly, heart rate, blood pressure, vital capacity, and
the presence of hypertension, diabetes, valvular disease,
or previous myocardial infarction.30
Conclusion
Heart failure is a complex, chronic, debilitating con-
dition associated with high morbidity and mortality, a
detrimental impact on quality of life, and a high finan-
cial burden on the health care system. Efforts in health
care reform have focused on improving the quality of
care for HF patients, cost containment, and prevention
of unplanned hospital readmissions.
Nurses and health care providers must be able to
consider all findings, including patient history, physical
assessment findings, imaging, and laboratory studies, to
identify secondary HF in acutely ill patients, even when
HF is not a primary diagnosis. Guideline-directed medi-
cal therapy, management of comorbid conditions and
precipitating risk factors, and health promotion and
self-care education should be incorporated in the plan
of care, starting with admission and reinforced along
the continuum of care.
Hospital-established protocols for identifying poten-
tial and active HF are effective for improving outcomes
in high-risk patients. Additionally, comprehensive edu-
cation programs for nurses and other health care pro-
viders may be necessary to narrow the knowledge gaps
regarding HF management and to improve the delivery
of self-care education to patients. &&1
Financial Disclosures
None reported.
Now that you’ve read the article, create or contribute to an online discussion about
this topic using eLetters. Just visit www.ccnonline.org and select the article you want
to comment on. In the full-text or PDF view of the article, click “Responses” in the
middle column and then “Submit a response.”
See also
To learn more about caring for patients with heart failure, read
“Prehospital Delay, Precipitants of Admission, and Length of Stay
in Patients With Exacerbation of Heart Failure” by Wu et al in the
American Journal of Critical Care, January 2017;26:62-69. Available
at www.ajcconline.org.
www.ccnonline.org
Downloaded from http://ccn.aacnjournals.org/ by AACN on September 14, 2018
References
1. Liu L, Eisen HJ. Epidemiology of heart failure and scope of the problem.
Cardiol Clin. 2014;32(1):1-8.
2. Thottan MR, May C, Hunter WJ, Mancuso P. Heart failure with preserved
left ventricular function: a case study-based overview. Nurse Pract. 2013;
38(5):14-19.
3. Cuyjet AB, Akinboboye O. Acute heart failure in the African American
patient. J Card Fail. 2014;20(7):533-540.
4. Patel RB, Secemsky EA. Clinical features of heart failure and acute coro-
nary syndromes. Clin Lab Med. 2014;34(1):15-30.
5. Stamp KD, Machado MA, Allen NA. Transitional care programs improve
outcomes for heart failure patients: an integrative review. J Cardiovasc
Nurs. 2014;29(2):140-154.
6. Simpson M. A quality improvement plan to improve 30-day readmissions
of heart failure patients. J Nurs Care Qual. 2014;29(3):280-286.
7. Hines PA, Yu K, Randall M. Preventing heart failure readmissions: is your
organization prepared? Nurs Econ. 2010;28(2):74-85.
8. Unruh MA, Trivedi AN, Grabowski DC, Mor V. Does reducing length of
stay increase rehospitalization of Medicare fee-for-service beneficiaries dis-
charged to skilled nursing facilities? J Am Geriatr Soc. 2014;61(9):1443-1448.
9. Chen J, Dharmarajan K, Wang Y, Krumholz HM. National trends in heart
failure hospital stay rates, 2001 to 2009. J Am Coll Cardiol. 2013;61(10):
1078-1088.
10. Fang J, Mensah GA, Croft JB, Keenan NL. Heart failure-related hospital-
ization in the U.S., 1979 to 2004. J Am Coll Cardiol. 2008;52(6):428-434.
11. Giamouzis G, Kalogeropoulos A, Georgiopoulou V, et al. Hospitaliza-
tion epidemic in patients with heart failure: risk factors, risk prediction,
knowledge gaps, and future directions. J Card Fail. 2011;17(1):54-75.
12. Patarroyo-Aponte M, Colvin-Adams M. Evaluation of patients with heart
failure. Cardiol Clin. 2014;32(1):47-62.
13. Díez J. Arterial hypertension in patients with heart failure. Heart Fail
Clin. 2014;10(2):233-242.
14. Cohn JN, McInnes GT, Shepherd AM. Direct-acting vasodilators. J Clin
Hypertens (Greenwich). 2011;13(9):690-692.
15. Bowers MT. Managing patients with heart failure. J Nurse Pract. 2013;
9(10):634-642.
16. Rose-Jones LJ, Rommel JJ, Chang PP. Heart failure with preserved ejection
fraction: an ongoing enigma. Cardiol Clin. 2014;32(1):151-161.
17. Bikdeli B, Strait KM, Dharmarajan K, et al. Intravenous fluids in acute
decompensated heart failure. JACC Heart Fail. 2015;3(2):127-133.
18. Januzzi JL, Troughton R. Are serial BNP measurements useful in heart
failure management? Serial natriuretic peptide measurements are useful
in heart failure management. Circulation. 2013;127(4):500-507.
19. Golcuk Y, Golcuk B, Velibey Y, et al. Predictive cutoff point of admission
N-terminal pro-B-type natriuretic peptide testing in the ED for prognosis
of patients with acute heart failure. Am J Emerg Med. 2013;31(8):1191-1195.
20. King J, Fellin R, Barkley TW Jr. Heart failure. In: Barkley TW Jr, Myers
CM, eds. Practice Considerations for Adult-Gerontology Acute Care Nurse
Practitioners. 2nd ed. West Hollywood, CA: Barkley & Associates;
2015:222-246.
21. Pauly DF. Managing acute decompensated heart failure. Cardiol Clin.
2014;32(1):145-149.
22. Paul S, Hice A. Role of the acute care nurse in managing patients with heart
failure using evidence-based care. Crit Care Nurs Q. 2014;37(4):357-376.
22. Khalaila R. Patients’ family satisfaction with needs met at the medical
intensive care unit. J Adv Nurs. 2013;69(5):1172-1182.
24. Mahramus T, Penoyer DA, Frewin S, Chamberlein L, Sole ML. Assess-
ment of an educational intervention on nurses’ knowledge and retention
of heart failure self-care principles and the Teach Back method. Heart
Lung. 2014;43(3):204-212.
25. Darling C, Saczynski JS, McManus DD, Lessard D, Spencer FA, Goldberg
RJ. Delayed hospital presentation in acute decompensated heart failure:
clinical and patient reported factors. Heart Lung. 2013;42(4):281-286.
26. Colandrea M, Murphy-Gustavson J. Patient care heart failure model: the
hospitalization to home plan of care. Home Healthc Nurse. 2012;30(6):337-344.
27. Moser DK, Lee KS, Wu JR, et al. Identification of symptom clusters
among patients with heart failure: an international observational study.
Int J Nurs Stud. 2014;51(10):1366-1372.
28. Greener DT, Quill T, Amir O, Szydlowski J, Gramling RE. Palliative care
referral among patients hospitalized with advanced heart failure. J Palliat
Med. 2014;17(10):1115-1120.
29. Aliti GB, Rabelo ER, Clausell N, Rohde LE, Biolo A, Beck-da-Silva L. Aggres-
sive fluid and sodium restriction in acute dec ompensated heart fail-
ure: a randomized clinical trial. JAMA Intern Med. 2013;173(12):1058-1064.
30. Mills GD, Chambers CV. Effective strategies to improve the management
of heart failure. Prim Care. 2012;39(2):393-413.
CriticalCareNurse Vol 37, No. 4, AUGUST 2017 35
 CCN Fast Facts CriticalCareNurse
The journal for high acuity, progressive, and critical care nursing

Identification and Prevention of

Secondary Heart Failure: A Case Study

eart failure (HF), a complex clinical syndrome diagnostic findings indicative of HF, and identify

H affecting millions of Americans, is associated

with high morbidity and mortality and a signif-
icant financial burden on the health care system. Recent
patients at risk for developing HF.
• When patients with complex conditions are trans-
ferred among multiple hospital units, nurses should
health care reform efforts have focused on reducing 30-day
be familiar with the course of hospitalization to
heart failure hospital readmissions, increasing the cost-
avoid missing critical data and prevent fragmenta-
effectiveness of care provided to heart failure patients,
tion of care.
and improving health outcomes for these patients.
• Because some nurses who do not routinely encounter
• Important aspects of HF management are recogni-
patients with cardiac disease may have knowledge
tion of risk factors and early signs and symptoms,
deficits, a comprehensive educational intervention
correlation of assessment findings with laboratory
with continued reinforcement over a period may
data, and differentiation of HF from other condi-
prove useful.
tions with similar symptoms.
• Patients often have difficulty recognizing early
• Current management guidelines emphasize the use
signs and symptoms of their condition or may
of angiotensin-converting enzyme inhibitors or
show a lack of self-care behaviors. Therefore,
angiotensin receptor blockers as first-line agents in
nurses should have the knowledge necessary to
managing hypertension in HF.
provide patient self-care education on topics
• Nurses must be able to recognize data that indicate that range from admission to discharge.
fluid overload and be able to assess conditions that
• Only a fraction of HF patients with high mortal-
could potentially cause such findings.
ity risk receive palliative care services, which is an
• Because nurses play an important part in patient aspect of care that may need to be considered,
monitoring, maintenance intravenous fluids especially in high-risk geriatric patients with
should be discontinued before symptoms of fluid advanced disease.
overload (such as pedal edema, respiratory dis-
• Although numerous other disease processes, such
tress, and adventitious breath sounds) develop.
as systemic infection and renal failure, may con-
• Nurses working with critically ill patients must be found the early identification of HF, screening modali-
able to identify precipitating factors for secondary ties in high-risk patients may be able to identify
HF, recognize early physical assessment and symptoms of myocardial dysfunction. &&1

Gheorghiu V, Barkley TW Jr. Identification and prevention of secondary heart failure: a case study. Critical Care Nurse. 2017;37(4):29-36.

36 CriticalCareNurse Vol 37, No. 4, AUGUST 2017 www.ccnonline.org

Downloaded from http://ccn.aacnjournals.org/ by AACN on September 14, 2018

Identification and Prevention of Secondary Heart Failure: A Case Study
Vlad Gheorghiu and Thomas W. Barkley, Jr
Crit Care Nurse 2017;37 29-35 10.4037/ccn2017478
©2017 American Association of Critical-Care Nurses
Published online http://ccn.aacnjournals.org/
Personal use only. For copyright permission information:
http://ccn.aacnjournals.org/cgi/external_ref?link_type=PERMISSIONDIRECT

Subscription Information
http://ccn.aacnjournals.org/subscriptions/
Information for authors
http://ccn.aacnjournals.org/misc/ifora.xhtml

Submit a manuscript
http://www.editorialmanager.com/ccn

Email alerts
http://ccn.aacnjournals.org/subscriptions/etoc.xhtml

Critical Care Nurse is an official peer-reviewed journal of the American Association of Critical-Care Nurses (AACN) published
bimonthly by AACN, 101 Columbia, Aliso Viejo, CA 92656. Telephone: (800) 899-1712, (949) 362-2050, ext. 532. Fax: (949)
362-2049. Copyright ©2016 by AACN. All rights reserved.

Downloaded from http://ccn.aacnjournals.org/ by AACN on September 14, 2018