- Written By: Pete Tilney DO, EMT-P, Albany Medical Center, Albany New York
- Edited By: Lorraine Thibodeau, Albany Medical Center, Albany, New York
- Last Updated: 2008
Case: Shortness of Breath
It is 5 a.m. The EMS radio crackles announcing the arrival of a 78-year old male being transported to the Emergency Department with the chief complaint of shortness of breath. When the ambulance arrives, the paramedic tells the receiving team that this gentleman has a history of coronary artery disease and a history of several previous episodes of respiratory distress that have required hospitalization.
The EMS team reports that when they arrived to the patient’s house, the patient was sitting on the edge of the bed and was in moderate respiratory distress with the ability to say on three to four words at a time between his respirations. They immediately placed him on a non-rebreather mask. A peripheral IV was attempted enroute to the hospital. During transport, his respiratory status did not improve with the application of the oxygen. The paramedics opted to place the patient on non-invasive ventilation or Bi-pap.
When he arrived in the ED, his vital signs were the following: Pulse 100, Respiratory rate: 32 Blood pressure of 154/92 and oxygen saturations were 91% on 100% oxygen. He was still in moderate respiratory distress despite the paramedic’s intervention. He was seated in a tri-pod position and using his accessory muscles to breath. On his exam, it was noted that he had audible rales bilaterally, elevated jugular venous distention and edematous lower extremities. (Figure 1. Lower extremity edema).
What is the next step?
- At the end of this module, the reader will be able to:
- Explain common pathophysiology of congestive heart failure.
- Identify the signs and symptoms of acute decompensated heart failure.
- Describe the initial treatment of acute heart failure in the Emergency Department.
- Describe the long-term prognosis of patient’s with this disease.
Congestive heart failure (CHF) is a common diagnosis that is evaluated and treated in Emergency Departments daily. Approximately four to five million Americans are afflicted with this condition resulting in more than one million admissions to hospitals annually.
With the increasing age of the North American population, the number of heart failure hospitalizations has increased almost 150% in the last 20 years accounting for approximately 20% of all admissions in patients 65 years and older that occur annually. Each year an additional 500,000 patients are diagnosed with heart failure.
Because of the overwhelming nature of this disease, acute decompensated congestive heart failure is the leading diagnosis of patients older than 65 who are admitted to the hospital annually. 75-80% of the patients admitted with this diagnosis are evaluated, treated, and brought into the hospital through the Emergency Department. Since it is such a common diagnosis in this setting, a solid foundation of knowledge relating to this topic is essential for the emergency medicine provider.
Heart failure (HF), also known as congestive heart failure (CHF), is a broad definition that describes the hearts inability to meet the metabolic demands of the body. It is a condition that can afflict the heart insidiously over time or acutely depending on the etiology. There are many different types of heart failure, which can either affect the left or right side of the heart individually or can affect both sides simultaneously. In order to adequately treat HF, it is imperative to determine the etiology of the insult and what portions of the heart are afflicted.
In simple terms, etiology of heart failure can be broken down into two types: systolic and diastolic heart failure. Systolic failure is the hearts inability to pump the blood forward in the circulatory system. It is essentially has lost the “squeeze.” Diastolic heart failure occurs due the fact that the muscles of the heart are unable to relax adequately and allow the heart to fill appropriately.
Systolic failure can occur for a variety of reasons, however, the most common etiology of systolic HF is due to ischemic heart disease. When the heart is injured during a myocardial infarction, the damaged muscle is unable to pump blood as efficiently as it did prior to the event. This results in a decreased ejection fraction (normal is 55-75%). Depending on which part of the myocardium that is affected, this can lead to cardiogenic pulmonary edema (left sided failure) or venous congestion (right sided) failure. Other etiologies of systolic heart failure are noted in Table 1.
Diastolic heart failure occurs due to the myocardium’s inability to relax and the loss of this organ’s elasticity. There are a variety of factors that lead to this typically chronic syndrome including untreated hypertension, cardiomyopathies, valve pathology, and coronary artery disease. In these patients, the ejection fraction or heart’s ability to pump is preserved (Table 1).
Etiologies of Congestive Heart Failure (Table 1)
|Systolic Heart Failure||Diastolic Heart Failure|
|Ischemic Heart Disease s/p MI||Hypertension|
|Coronary artery Disease||Infiltrative Cardiomyopathy|
|Hypertension||Coronary Artery Disease|
|Fluid overload (and fluid retention)||Diabetes Mellitus|
|Cardiac Dysrhythmias||Left ventricular hypertrophy|
|Renal Disease||Chronic heart valve stenosis|
|Valvular Disease (i.e. regurgitation, chordae tendonae rupture)|
Despite the fact that congestive heart failure is relatively common disease, 10-20% of patients who present to the ED are misdiagnosed. This makes it imperative for the ED provider to complete a thorough history and physical exam. The most common complaint that patients will offer is that of dyspnea. In patients with chronic symptoms, they will report increasing exercise intolerance and symptoms relating to fluid overload. Patients routinely will report episodes of orthopnea (positional shortness of breath), paroxysmal nocturnal dyspnea (waking in the middle of the night with respiratory distress). They may also report a history of weight gain due to fluid retention. If the etiology of the HF is related to cardiac ischemia, chest pain and accompanying signs of symptoms classically elicited with cardiac disease may be present as well.
A variety of physical findings will occur with patients who present with CHF. In patients who present with respiratory distress, a thorough lung exam must be completed. Adventitious lung sounds may be heard through all fields. Typically, those patients with acute HF will have rales in dependent portions of the lungs; however, it is also very typical to have patients in HF who present with diffuse wheezing and bronchospasm. It is important to remember that all wheezing is not asthma. When evaluating the heart, additional heart sounds may be auscultated as well. An S3 on exam can be indicative of fluid overload, while a S4 heart sound is associated with diastolic heart failure with stiff, non-pliable ventricles. Heart sounds may often be difficult to ascertain due to persistent tachycardia with which many acutely decompensated heart failure patients present.
Other signs of heart failure can be manifested in different portions of the body. These signs are indicative of both fluid overload and the heart’s inability to pump adequately. Most commonly, providers may see elevated venous congestion which is manifested in neck vein distention, elevated hepatojugular reflux, and hepatomegaly. With additional fluid accumulation, the lower extremities must be evaluated for pedal edema and signs of venous stasis (i.e. discoloration of the skin).
There is a segment of the population with this disease, however, who may simply present with respiratory distress only. In these cases, further diagnostic evaluation in the Emergency Department is required.
Most common signs and symptoms of congestive Heart Failure based upon the Framingham Criteria (Table 2)
|Signs of HF||Symptoms of HF|
|Rales and or wheezing||Dyspnea on exertion|
|Jugular venous distension||Orthopnea|
|Bilateral lower extremity edema||Paroxsysmal nocturnal dyspnea|
|Lower extremity venous stasis||S3 or S4 gallops|
|Hepatomegaly/ hepatojugular reflex||Hemoptysis with blood tinged sputum|
After eliciting a detailed history and completing a physical exam, clinical diagnostics must be completed. An electrocardiogram (EKG) is routinely evaluated to determine whether there is evidence of cardiac ischemia that has occurred in the past or is currently the etiology of the patient’s heart failure. Myocardial ischemia and subsequent infarction is the leading cause of systolic heart failure (Figure 2. EKG demonstrating an ST-elevation myocardial infarction or STEMI). Additionally, cardiac enzymes including creatinine kinase (CK), creatinine kinase myocardial band (CK-MB), and troponin are completed. Electrolytes including sodium, potassium are assessed. Renal function is evaluated with BUN and creatinine to determine whether there is a component of renal failure, which may be the cause or may be additionally exacerbating the fluid retention and subsequent overload. A routine complete blood count is recommended as well to determine if anemia or thrombocytopenia may be contributing to the presentation.
In the last several years, the use of a B-type natriuretic peptide (BNP) has become a standard of care in determining whether the etiology of the patient’s respiratory distress is secondary to heart failure. BNP is released as a response to increased ventricular wall stress. Patients whose respiratory distress is secondary to HF will have elevated level of BNP greater than 500 pg/ml.
The last diagnostic used routinely in the Emergency Department is the chest x-ray. Not only can it be used to determine the presence of pulmonary congestion and subsequent edema, it can also be used to evaluate for the presence of cardiomegaly. Other radiographic findings on the chest film can be indicative of heart failure can include pleural effusions and Kerley B lines. (Figure 3. Chest x-ray demonstrating pulmonary edema). The use of diagnostic imaging, EKG, and labs should augment and solidify the provider’s diagnosis.
The initial management of acute decompensated heart failure in the Emergency Department begins with the standard ABC’s of airway, breathing, and circulation. Similar to other patients with respiratory distress, supplemental oxygen should be initiated as soon as possible. In patients with moderate or severe respiratory distress, the application of non-invasive ventilation (CPAP or BiPAP) has been the only therapy used in management of HF that has consistently demonstrated decreased morbidity and mortality. Typically these patients are tachypneic, hypoxic and demonstrate other signs of respiratory distress and impending respiratory failure. The administration of positive pressure ventilation has reduced the need for endotracheal intubation and mechanical ventilation in a significant portion of the population with this disease.
Medication therapy for heart failure has also been altered in the last decade with less emphasis on aggressive diuretic monotherapy. Currently, the recommendations for management of acutely decompensated heart failure focus on the use of nitrates to decrease pre-load, myocardial oxygen consumption and systemic vascular resistance. The net result increases cardiac output and allows the heart to pump blood more efficiently through the vasculature. Using nitroglycerin and occasionally nitroprusside, healthcare providers must continually reassess for evidence of expected side effects including headaches and hypotension.
Loop diuretics including lasix and bumex were once considered mainstays of therapy for this population. These medications have now been relegated to second tier adjuncts. If there is clinical evidence of fluid overload with increased jugular venous distention and other clinical findings, these medications are indicated. It is imperative to note, that many patients presenting with heart failure are, in fact, euvolemic and will become hypotensive with diuretic therapy.
There is a small sub-segment of the HF population who present not only with signs and symptoms of decompensated heart failure, but are also noted be hypotensive with cardiogenic shock. It is imperative that these patients be treated aggressively and efficiently. They may require inotropic medications including Levophed, dopamine and other peripheral vasoconstrictors (i.e. neosynephrine) to support their blood pressures. While on these medications, vital signs and evidence of end organ perfusion must be monitored carefully. If, despite these medications, there is evidence of progressive hemodynamic collapse, mechanical circulatory support including intra-aortic balloon pumps (IABP) and ventricular assist devices (VAD) may be utilized as temporary therapy.
As noted in the initial section of this overview, there is a significant population who suffer from the effects of heart failure. It is an insidious disease that affects a large portion of the geriatric population. Conservative management and persistent monitoring of patients can limit the rapid progression of this disease. However, it is important to note that despite technological advances in therapeutic strategies, the overall long term mortality with this condition remains high. On average, once diagnosed, most patients succumb to their illness within five years. As Emergency physicians, our role is to remain vigilant and treat these patients aggressively and limit further progression of this disease.
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