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Congestive Heart Failure: A Case Study
Approach
Cassandre Miller
Andrews University
Introduction:
RB is an 81 year old male with a history of CHF (Congestive Heart
Failure). The patient also has a history of advanced Chronic Kidney Disease
stage 3 and chronic hypotension (secondary to severe chronic heart failure).
During his admission, RB weighed 135 lbs and was 5’8”. The patient was chosen
for this study because of his family’s involvement with his care and the symptoms
the patient presents with CHF are classic for the disease. The study began on
1/4/16 and ended 1/8/15. This case study will focus on the patient’s primary
disease state of CHF.
Social History:
RB is a retired, Christian, Caucasian male that lives in a ranch style home
with his wife. He is ambulatory, still currently drives and manages his own
medications and finances. His wife cooks most of the meals for him. RB’s health
and hospital stay is covered under Medicare. His children are grown and live in
the Kettering area. His children help out when they can with household chores.
RB has a good standard of living and care at home without any immediate need
of at home health care.
Normal anatomy and physiology of applicable body functions:
Heart failure can affect either the right side of the heart or the left side of
the heart. Oftentimes it affects both sides, also called unilateral heart failure.
Congestive heart failure occurs when your heart muscle has difficulty pumping
blood. This is referred to as systolic heart failure or heart failure with reduced
ejection fraction (HFrEF). The heart may even become stiff and have difficulty
filling back up with blood. If the heart’s pumping becomes less effective blood
can enter other parts of the body. Fluid can enter the lungs (pulmonary edema),
liver, arms, legs, and gastrointestinal tract. If this occurs, it is categorized as
Congestive Heart Failure. [1]
In left sided heart failure, the left ventricle has difficulty pumping out
enough blood, which in turn can cause pulmonary edema. A prevalent symptom
of this is exhibited as shortness of breath. Unfortunately, left sided heart failure
usually precedes right sided heart failure.
Similarly, in right sided heart failure the right ventricle has difficulty
pumping blood out of the heart. Fluid buildup that can occur in this type of heart
failure usually takes place in the veins and capillaries of the body behind the right
ventricle.This can cause fluid to leak out of the capillaries which in turn builds up
inn the tissues, also known as systemic edema. This is often most noticeable in
the legs because the lower half of the body drains into the right side of the heart.
A heart’s primary function is to pump oxygen and nutrient rich blood to the
rest of the body’s tissues. In CHF, the heart continues to receive an adequate
amount of blood from the vessels, however blood is not efficiently pumped out to
the rest of the body.
The issues that can cause heart failure include but are not limited to faulty
heart valves, hypertension, cardiomyopathy (damaged heart muscle),
myocarditis, and heart arrhythmias. During hypertension, heart failure can occur
due to the heart pumping hard over a long period of time, causing the heart walls
to thicken making the heart stiff. This is one of the most common causes of
congestive heart failure.
Past Medical History:
RB has been in and out of the Kettering Medical Center throughout the
past few years for his chronic heart disease. His primary and pertinent diseases
are hypertension, cardiomyopathy, arrhythmia, hyperlipidemia, coronary artery
disease, and myocardial infarction.
The most recent visit to Kettering for his heart disease was on 6/11/15.
This visit was for a dilated ischemic cardiomyopathy. Dilated cardiomyopathy
generally occurs when the heart chambers dilate and become thinner, causing
the chambers of the heart to enlarge or bulge. When the chambers dilate, the
heart muscles don’t contract normally and over time the heart becomes weaker.
This can then turn into heart failure. [2]
RB’s history of various kinds of heart disease has led to his current
disease state of congestive heart failure. He exhibits several of the most common
causes of CHF such has cardiomyopathy, arrhythmia, coronary artery disease,
and hypertension.
Present Medical Status and Treatment :
Congestive Heart Failure affects over 5.5 million people in the United
States. Several risk factors include age, male gender, coffee consumption, low
physical activity, increased salt intake, hypertension, diabetes, obesity and lower
socio-economic status.
Unfortunately, the prognosis for most patients diagnosed with CHF is poor
with only 50% of patients surviving past 5 years. The quality of life for these
patients is poor, though some improvement can be seen in patients with just
systolic dysfunction. [1] However, there have been no major advances in therapy
for those diagnosed with congestive heart failure and reversal of the disease is
not likely.
Usual treatment of heart disease, if caught early includes several lifestyle
changes including cessation of smoking, heart healthy eating, physical activity,
and maintaining a healthy weight. Medicine can help manage some symptoms.
However, surgical intervention may be required for more severe cases of heart
failure.
The nutrition-based approach of treating heart failure may include diets
such as the TLC diet or the DASH diet. Both of these diets include guidelines
such as drinking low fat or fat free dairy, eating fish high in Omega 3’s twice a
week, and consuming more fruits, vegetables and whole grains. These diets also
include parameters on reducing sodium to 1500-2000mg a day as well as limiting
Saturated fat to less than 5-7% of your daily caloric intake.
Moderate physical activity of at least 2 hours and 30 minutes per week
can significantly reduce a person’s risk of heart disease, or reverse early signs of
heart disease. Studies have shown that physical activity lowers blood pressure
and LDL cholesterol while increasing HDL cholesterol.
Physical activity along with following a heart healthy diet can assist a
person in losing weight. A BMI less than 25 is considered “healthy” and
significantly reduces the risk and progression of heart failure. A weight loss of
just 3-5% can lower triglycerides, blood glucose, risk of type 2 diabetes, and can
improve blood pressure.
Medications that aid in treating heart disease include Ace Inhibitors,
aldosterone antagonists, angiotensin receptor blockers, beta blockers, digoxin,
diuretics, and Isosorbide dinitrate/hydralazine hydrochloride. Ace Inhibitors and
angiotensin receptor blockers lower blood pressure and may reduce the risk of
future heart attacks. Aldosterone antagonists assist the body in secreting excess
sodium through the urine as waste. This also lowers the blood volume that
pumps through the heart, so it doesn’t have to work as hard. Digoxin makes the
heart beat stronger so it can pump more blood to the body’s tissues and organs.
Diuretics may be used for patients with CHF that are experiencing edema by
removing excess fluid through the urine. Isosorbide dinitrate/hydralazine
hydrochloride relaxes your blood vessels, allowing the blood to move fluidly
without extra effort from the heart. These medications may be prescribed by a
physician but do not cure heart failure, they only alleviate the symptoms and may
reduce the risk of heart attack.
Cessation of smoking has shown to greatly reduce the risk of heart failure. The
smoking of tobacco products causes an inflammatory response in the
cardiovascular system and damages endothelial cells. These damaged cells can
cause vasoconstriction which directly effects how well the blood moves the blood
vessels and can lead to dyslipidemia. Continued smoking also causes chronic
inflammation to the endothelial cells, which then can damage the heart.
Persistent smoking after a myocardial infarction has shown to greatly increase
the re-occurrence of an infarction and mortality. [3]
If a patient has severe heart failure, medication, diet, exercise and weight
loss may not be enough to treat them. Sometimes a surgical intervention is
necessary. For patients with irregular heartbeats or an arrhythmia, a physician
may implant an ICD (implantable cardioverter defibrillator.) It is placed in the
abdomen and if the heartbeat becomes irregular, it may shock it by using an
electrical pulse to correct it. Another implantable device called at Left Ventricle
Assist Device (LVAD) can be used as a mechanical pump. This device assists
the heart with pumping blood to the rest of the body. It can be used as a long
term treatment or while awaiting surgery or a heart transplant. A heart transplant
is usually performed as a life saving treatment when all other treatments have
failed. The patient is usually young and otherwise healthy. [4]
RB entered Kettering hospital with increasing shortness of breath, which
worsened with minimal exertion. The physician attributed this to orthopnea and
nocturnal dyspnea (difficult or uncomfortable breathing usually waking a person
at night). The patient recently stopped one of his blood pressure medications per
his primary care physician due to low blood pressure. Orthopnea and dyspnea is
usually associate with left ventricle heart failure. Both are relieved by sitting in an
upright position. [5]
The etiology of heart failure include as previously stated include faulty
heart valves, hypertension, cardiomyopathy, myocarditis, heart arrhythmias, and
diabetes. The patient has exhibited several of these symptoms in his past
medical history. Cardiomyopathy (weakened heart) can cause heart failure and is
usually due to genetics or a viral infection, though the direct causes may be
unclear. Cardiomyopathy is the thickening or scarring of the heart tissue. Again,
the causes of this are unknown but may be inherited. [6] Some research
suggests that it may be caused by prolonged hypertension.
Left Ventricle hypertrophy affects systolic and diastolic blood pressure,
causing hypertension. The heart wall then begins to thicken to compensate and
minimize wall stress. The ejection fraction (EF) declines, subsequently causing
dilated cardiac failure. [7] RB unfortunately presented with all of the concerns
mentioned above including cardiomyopathy and diabetes.
Diabetic heart disease is a type of heart disease that develops in people
with type 2 diabetes. It is usually caused by chronic inflammation. Studies show
that heart disease is more prevalent in those with uncontrolled diabetes. RB was
in control of his diabetes with blood glucose levels consistently under 120, thus
suggesting that his diabetes may not be contributing to his current disease state.
Pertinent laboratory findings and interpretation :
Labs
Normal Values
Patient’s values
Interpretation
1/04/16
4.1 gm/dL
Albumin
3.5-5.2 gm/dL
Creatinine
Males: 0.7 to 1.3
mg/dL
1.89 mg/dL
BUN
6-20 mg/dL
52
Na
135 to 145 mEq/L
134 mEq/L
K
3.7 to 5.2 mEq/L.
5.4 mEq/L
Within normal
limits. Low levels
may indicate
malnutrition,
nephritic
syndrome or
inflammation.
Elevated levels
may indicate
dehydration. Not a
good indicator of
nutritional status
because it is
effected by many
factors.
Slightly elevated.
Elevated levels
may indicate
kidney disfunction,
reduced blood
flow, dehydration,
breakdown of
muscle, and
possibly
hypertension.
Elevated levels.
May indicate CHF,
heart attack,
kidney disease, or
dehydration
Slightly
decreased. May
be lower than
normal due to use
of diuretics, too
much
vasopressin, or
dehydration.
Slightly elevated.
May indicate red
blood cell
destruction,
certain medicines
elevate K, kidney
Glucose
74-106 mg/dL
fasting
150 mg/dL
post prandial
should be under
125 mg/dL
failure, tissue
damage
Elevated.
Indicates
diabetes. Elevated
levels can also
occur due to
trauma such as
stroke or heart
attack. Steroids
may also elevate
blood glucose
levels.
[9]
Home Medications:
Medicatio Indications
n
Aspirin
Magnesiu
m oxide
omeprazol
e
Pain, and
reduces risk
of heart
attack,
angina
Heart burn,
indigestion
Food/Drug
Interactions
Possible
Common Side
Effects
None known
interactions
Stomach pain,
ulcers (from
prolonged use),
vomiting,
nausea
Cramping and
diarrhea
Take all other
medications at least
2 hours before or
after. warfarin
(Coumadin), aspirin,
diuretics, medicine
for ulcers, ranitidine,
and vitamins.
Used to
Ampicillin;
treat GERD, anticoagulants such
H.pylori
as warfarin
infection
(Coumadin);
benzodiazepines
such as diazepam
(Valium); digoxin;
diuretics; iron
supplements;
methotrexate and
other prescription
Constipation,
gas, nausea,
vomiting,
headaches
Observabl
e effects
on patient
if
applicable
No
observable
effects
No
observable
effects
No
observable
effects
Simvastati
n
Sotalol
antifungal or antiyeast medications
Heart
Antifungal
disease and medications,
high
vitamins, nutritional
cholesterol
supplements, and
herbal supplements,
other cholesterol
lowering
medications, blood
thinners, grapefruit
juice
Tachycardia Take magnesium
, arrhythmia antacids 2 hours
before or after this
medication, be
careful when taking
vitamins or over the
counter medications
for colds, flu,
migraines/headache
s
Constipation,
stomach pain,
nausea,
headache,
forgetfulness,
confusion
No
observable
effects
Dizziness,
lightheadedness
, excessive
tiredness,
constipation,
diarrhea, upset
stomach,
muscle aches
The patient
did exhibit
excessive
tiredness.
His wife
also stated
that he
rarely
moved
from his
chair in the
family
room.
[10]
Treatment:
During his admission, RB was already post CABG (Coronary artery
bypass graft.) This type of procedure allows blood to flow more effectively to the
heart. It is usually performed during severe coronary heart disease where plaque
builds up over time in the coronary arteries, decreasing or blocking blood flow to
the heart. Oftentimes, the plaque can rupture, forming a blood clot, which can in
turn cause a heart attack. During a CABG an unblocked, or healthy artery is
grafted to the blocked, unhealthy artery. The new grafted artery bypasses the
unhealthy one, allowing oxygen and blood to travel to the heart. This type of
surgical intervention is a common one to help combat Congestive Heart Failure.
The figure below shows in greater detail how a CABG works:
[8]
RB’s heart failure is also being treated with physical therapy and diet
intervention. Heart Healthy diet teaching was performed to the patient and his
family. Both verbalized understanding of limiting sodium to 1500mg-2000mg.
Literature was also provided at the time to further assist with the patient’s diet
education. Physical therapy is also often used in conjunction with diet to help
strengthen the heart. RB was fairly non-compliant with his therapies and tended
to complain through most sessions.
Medical Nutrition Therapy:
Nutrition History:
RB’s wife normally cooked for him on a regular basis. In the past they
followed a strict low sodium, diabetic diet. However due to recent taste changes,
feelings of early satiety, and loss of appetite, they have been less restrictive of
his diet though they still do not add any salt to foods. The patient lost several
pounds and his wife was concerned so she began making him whatever he
would eat.
The patient did not generally eat three meals a day, and would usually
skip breakfast or only consume coffee and a piece of fruit. His wife reported that
they usually eat at the dinner table together, though since he has not been
feeling well, sometimes he takes meals in front of the TV.
Analysis of previous diet (24 hr recall) with calculations:
Protein
Carbs
Fat
Sodium
Calories
0g
0g
0g
0 mg
9 kcal
1g
27 g
0g
1 mg
105 kcal
0g
19 g
0g
1 mg
72 kcal
0
0
0
0
2 kcal
8g
18 g
6g
1612 mg
152 kcal
20 g
96 g
11 g
1474 mg
575 kcal
First Meal:
10:00am
Coffee (5
cups)
1 medium
banana
Snack:
12:00pm
1 medium
apple
Coffee (1
cup)
Second
Meal:
2:00pm
Campbells
chicken
noodle
soup (1
can)
Third Meal:
6:30pm
Spaghetti
with meat
sauce (1 ½
cups
spaghetti
noodles, 1
cup sauce)
TOTALS:
29 g
160 g
17 g
3088 mg
915 kcal
Patient’s estimated nutritional needs:
Calories per kg
Protein gms per kg
Fluid needs if
25-30
1.2-1.4
applicable
73-85 grams protein
Not applicable
1530-1836 calories
Based on current weight of 61.2 kg (87% of ideal body weight.)
Based on the heart healthy eating guidelines and the nutrition prescription
(estimated needs), the patient is not getting the nutrients he needs at home, nor
is he following the sodium guidelines of under 1500mg-2000mg. The patient
needs double the amount of calories and more than triple the amount of protein.
RB also needs to cut his sodium in half by eating more fresh foods and limiting
canned soups and sauces.
Nutrition related problems, including prescribed diet:
During the patient’s admission, he was placed on a heart healthy diet with
a 1500 mL fluid restriction. This diet limited the amount of sodium and saturated
fat as well as the amount of fluid per meal. Sodium can cause fluid to build up in
a person’s body, particularly someone with CHF. If sodium and fluid are not
limited, fluid may accumulate behind the heart, making it more difficult to pump
oxygen rich blood to the rest of the body.
Due to the patient’s home diet differing greatly from his hospital prescribed
diet, he was not very accepting of it. At home he ate sodium filled soup and
drank several cups of coffee throughout the day. Limiting sodium and fluid were
not diet modifications that RB was used to. However, that being said, the patient
and his family were willing to try a low sodium, fluid restricted diet once he was
discharged. They both verbalized their desire to try anything to help him heal
and get better.
The patient was found to be moderately malnourished due to loss of
appetite. The patient stated that it was due to taste changes and early satiety. It
may be speculated that the early satiety could be due to fluid accumulation in the
abdomen and trunk from advanced CHF. Oftentimes, fluid accumulation in the
trunk leaves very little room for food in the stomach. When a person eats, they
may feel full after a small meal. If this is occurring, small frequent meals may be
recommended to get as much nutrition as possible.
Taste changes or distorted taste are a common complaint during heart
failure and heart disease. The cause of taste changes during heart disease is
unknown. Some medications may be to blame. Scientists are working on finding
out why some medications and disease may have a harmful effect on a person’s
sense of smell and taste so they can possibly restore these senses to those who
have lost it.
A consideration that should be made for RB, is the use of nutritional
supplements. During his admission, a mighty shake was sent once per day. Due
to his fluid restriction and increased protein needs, a single mighty shake was the
only acceptable supplementation at this point. However, once his fluid and
sodium intake is controlled, Boost Plus may be appropriate for additional calories
and protein.
Prognosis:
The patient’s prognosis at the end of the study was difficult to determine
based on the patient’s motivation. He was non-compliant with his physical
therapy. He also expressed a dislike for the heart healthy diet. However, his
family’s motivation was strong. His wife performs all of the cooking and shopping
for food and stated that she was planning on changing the way she cooked
entirely. The patient may not have much control over what he eats if his wife is
purchasing and preparing all his meals. However, if RB does not continue with
his physical therapy, he may not improve physically and it is possible that he may
end up in the hospital again within the year.
Summary & Conclusion:
During this case study I learned that there are several contributing factors to
Congestive Heart Failure such as diabetes and hereditary conditions. I was most
surprised to find that it isn’t entirely related to diet and exercise status, while that
is certainly an important part. It makes me wonder if a person has a strong
family history of heart disease, by exercising and eating right epigenetics
possibly could play a role in reversing this genetic predisposition.
I also learned how prolonged hypertension actually can contribute to CHF
by causing scar tissue to build up in the heart muscle, causing the heart muscle
to stiffen. I was unaware that this was one of the main issues with hypertension.
I previously believed that hypertension made the heart beat so hard it would
eventually give out or the arteries would end up being overloaded that they would
rupture.
In conclusion, I now understand how important diet and exercise are in
improving the outcome of someone with heart failure and how much of a role diet
and exercise play in preventing it. While, sometimes genetics do play a role in
heart disease, limiting sodium early on if you have a strong family history of heart
disease can also help prevent heart failure.
Bibliography
1)
Butler, Javed “Primary Prevention of Heart Failure, Primary Prevention of Heart Failure.”
International Scholarly Research Notices, International Scholarly Research Notices 2012,
2012 (August 16, 2012): e982417. doi:10.5402/2012/982417, 10.5402/2012/982417.
2)
“Dilated Cardiomyopathy (DCM).” American Heart Association, August 6, 2015.
http://www.heart.org/HEARTORG/Conditions/More/Cardiomyopathy/DilatedCardiomyopathy-DCM_UCM_444187_Article.jsp#.VpvjWfFdNmA.
3)
Eisenberg, Mark J., Sonia M. Grandi, André Gervais, Jennifer O’Loughlin, Gilles Paradis,
Stéphane Rinfret, Nizal Sarrafzadegan, et al. “Bupropion for Smoking Cessation in
Patients Hospitalized With Acute Myocardial InfarctionA Randomized, Placebo-Controlled
Trial.” Journal of the American College of Cardiology 61, no. 5 (February 5, 2013): 524–
32. doi:10.1016/j.jacc.2012.08.1030.
4)
“How Is Heart Failure Treated? - NHLBI, NIH.” National Institute of Health: National Heart,
Lung, and Blood Institute, November 6, 2015. http://www.nhlbi.nih.gov/health/healthtopics/topics/hf/treatment#Medicines.
5)
Mukerji, Vaskar. “Dyspnea, Orthopnea, and Paroxysmal Nocturnal Dyspnea.” In Clinical
Methods: The History, Physical, and Laboratory Examinations, edited by H. Kenneth
Walker, W. Dallas Hall, and J. Willis Hurst, 3rd ed. Boston: Butterworths, 1990.
http://www.ncbi.nlm.nih.gov/books/NBK213/.
6)
“What Is Cardiomyopathy? - NHLBI, NIH.” Accessed January 17, 2016.
http://www.nhlbi.nih.gov/health/health-topics/topics/cm.
7)
Drazner, Mark H. “The Progression of Hypertensive Heart Disease.” Circulation 123, no. 3
(January 25, 2011): 327–34. doi:10.1161/CIRCULATIONAHA.108.845792.
8)
“What Is Coronary Artery Bypass Grafting? - NHLBI, NIH.” Accessed January 24, 2016.
http://www.nhlbi.nih.gov/health/health-topics/topics/cabg.
9)
“Laboratory Tests.” Text. Accessed January 24, 2016.
https://www.nlm.nih.gov/medlineplus/laboratorytests.html.
10)
“Drugs, Herbs and Supplements: MedlinePlus.” Accessed January 24, 2016.
https://www.nlm.nih.gov/medlineplus/druginformation.html.