Introduction: Congestive heart failure, also known as heart failure, is a complex condition due to functional or structural cardiac disorder. As a result, there is impaired ventricular filling or ventricular ejection, where blood is pumped into the systemic space. By definition, it is the failure of the heart muscles to pump enough blood to meet the metabolic demands. With an approximate prevalence of 26 million people globally, CHF remains among the leading causes of mortality, with a high morbidity rate (Malik et al., 2021). This contributes to the high costs of healthcare globally. Several different conditions can cause heart failure, as a result, the treatment options vary depending on the etiology and the underlying conditions. However, most treatment practices are directed to treating heart failure alone, despite the etiology.
CHF is classified based on clinical manifestations and the percentage of left ventricular ejection fraction (LVEF). CHF due to dysfunction of the left ventricle is classified into heart failure with reduced ejection fraction (HFrEF), HF with preserved ejection fraction (HFpEF), and HF with mid-range ejection fraction (HFmrEF) (Malik et al., 2021). Additionally, left ventricular dysfunction could be a combination of systolic and diastolic heart failure. Even though different studies suggest a varied definition of HFrEF, most agree that it is marked by an EF of less than 40%. HFpEF is CHF with an ejection fraction of more than 50%. Finally, HFmrEF is heart failure with an EF between 40 to 50% (Malik et al., 2021).
CHF can severely impair the functional capacity of a patient while increasing their risk of mortality. Essentially, standard protocols for effective diagnosis and treatment of the condition should be established to minimize frequent hospital readmissions, enhance patient health outcomes, and improve quality of life. The management of CHF needs a collaborative approach involving patient and caregiver education, and optimal medical management to enhance cardiac contractility, and mitigate or prevent exacerbations. This paper provides a detailed discussion of evidence-based treatment approaches to CHF among adults in Memphis TN.
CHF affects about 26 million people globally. In the United States, it is among the leading causes of morbidity and mortality, with an estimate of 915,000 new cases diagnosed annually (Virani et al., 2020). This translates to an incidence of 10 in every 100 persons aged 65 years and above. A study by Virani et al. (2020), suggests that the prevalence is set to increase by roughly 50% by 2030. The study has revealed that the incidence of CHF beyond 40 years old is 1 in every 5 people, and it increases as one age. In the U.S., CHF is more common in some areas than others.
Despite the advancements in diagnosis and treatment practices over the past, CHF is still among the leading causes of mortality in Memphis TN. This is particularly associated with the high poverty rate of 28% in the area. As a lifestyle condition, studies show that poverty increases the risk of acquiring this illness, as the affected population cannot afford to live a healthy lifestyle. Notably, the expenditure associated with the treatment of CHF presents a significant burden to the government and affected families. According to Savarese and Lund (2017), in 2012, the estimated financial cost of CHF was $31 billion (£22.5 billion). This estimation was more than 10% of the cost of cardiovascular illnesses in the United States. Additionally, this cos is suggested to rise by 127% by 2030, as evidenced by trends in projections.
Trends suggest an increase in the prevalence of the condition which presents a significant problem in establishing a healthy and productive population. Therefore, this implies that it might take more time to achieve the sustainable development goal of good health and wellbeing for people of all ages. Additionally, the financial costs of CHF, associated with the management of comorbidities and recurring hospital admissions could be useful in other areas of health such as primary prevention strategies, which are cheaper and more effective in establishing a healthy population. Several studies agree that interprofessional collaboration in the management of CHF among the elderly is key to ensuring good patient outcomes, and mitigating hospital readmissions, thus minimizing expenditure on the condition.
The target population for this research article is the elderly, aged 65 and above, living in Memphis TN. In the United States, CHF is among the leading causes of mortality and morbidity. There are approximately 915,000 new cases of CHF diagnosed annually among the geriatric population (Virani et al., 2020). At 40 years, the incidence of CHF is 1 in every 5 people, beyond that, it increases with age. In fact, the incidence of CHF at 65 years old is 1%, and this figure doubles every following decade, both 80- and 20-year olds have the same risk, 20%, of acquiring CHF (Butrous & Hummel, 2016). CHF is among the leading causes of mortality in Memphis TN, Shelby county, with the highest mortality rates recorded in those above 85 years. Also, statistics indicate that CHF affects more men than women. According to a study by Khan et al. (2020), certain populations with arrhythmias, structural and functional heart defects, high body mass indexes, and diabetes are at an increased risk of getting CHF. Poor lifestyle choices are also associated with CHF. Despite the high mortality rates, there has been a significant in deaths, which could be associated with decreased tobacco use, and significant advances in treatment practices (Malik et al., 2021).
The geriatric population has been significantly underrepresented in clinical trials. This is due to comorbidities, impaired cognitive functions, and frailty, which present challenges in assessing and managing them (Butrous & Himmel, 2016). However, several studies suggest that medical and device treatment based on standard protocols can be effective in the management of CHF. Ultimately, there will be a significant improvement in patient outcomes and the quality of life in those diagnosed with CHF.
Significance of the Topic
The findings of this research article will have a significant impact on the financial expenditure on CHF, as well as the patient outcomes. One of the economic goals of a nation is establishing a healthy and productive population that will positively contribute to improving the country’s economy. Additionally, it aligns with the sustainable development goal of achieving good health and wellbeing for people of all ages. The federal government, in conjunction with the major treatment centers, can establish cost-effective treatment strategies that will ensure good patient outcomes and reduced rates of hospital readmissions thereby cutting the additional expenditure on CHF. Having established the existing gap in clinical trials involving the elderly population, these findings will be useful in enhancing the existing information regarding evidence-based treatment practices for CHF. As such, both students and researchers can benefit by expanding their knowledge and conducting further investigations based on the existing information.
Treatment practices for CHF
The aim of the treatment and management of chronic CHF is to mitigate deaths and coexisting conditions associated with the illness lower hospitalizations, improve quality of life and symptom management (Virani et al, 2020). It’s essential to consider multiple indicated agents in pharmacologic therapy rather than a single agent. This is because the combined effects of multiple therapies are more effective than monotherapy agents.
The primary combined therapy for HFrEF entails a beta-blocker, diuretics, a renin-angiotensin system inhibitor, for example, angiotensin receptor neprilysin inhibitor (ARNI), an angiotensin-converting enzyme (ACE) inhibitor, or angiotensin II receptor blockers (ARB) (Malik et al, 2021). Combined nitrate and hydralazine can be used where ACE, ARB, and ARNI are contraindicated. Also, a combination of nitrate and hydralazine is recommended to reduce morbidity and mortality in Africa American population with symptomatic HFrEF. Studies indicate combined therapy of ARB-ARNI significantly HF hospitalizations and cardiovascular deaths compared to ACE inhibitors (Malik et al, 2021).
Mineralocorticoid receptor antagonists, for example, eplerenone or spironolactone are recommended in patients with an LVEF of less than or equal to 35% and NYHA functional class II TO IV (Malik et al, 2021). Likewise, they are recommended in patients with HF after MI and an LVEF of less than 40%. However, the medication is not beneficial in patients with current myocardial infaction and a low EF with no asymptomatic HF.
Recommended guidelines established by the AHA/ACC state that ivabradine should be used in patients with regular symptomatic HF and an EF of equal to or less than 35% in sinus rhythm (Malik et al, 2021). There is selective inhibition of the funny current (I-F) in the sinoatrial node when ivabradine is used. Regardless of better-blocker therapy, the resting heart rate should be more than 70 b/mins.
Vericiguat stimulates the intracellular receptor for endogenic NO known to be a potent vasodilator (Malik et al, 2021). FDA approved vericiguat to lower the risk of HF hospital readmissions, deaths, and deterioration in those with chronic CHF and EF of less than 45% (Virani et al, 2020). Additionally, digoxin can be recommended in symptomatic patients with sinus rhythm but studies have limited evidence on the role.
An implantable cardioverter-defibrillator (ICD) is recommended for the prevention of cardiac death, especially in patients with CHF having an LVEF of less than or equal to 35% while on goal-directed medical therapy (Malik et al, 2021). Also, the guidelines recommend adequate medical therapy for patients with HYHA functional class II and an EF of less than or equal to 30%.
Patients with HFrEF and an NYHA functional class of II to IV with an LVEF less than or equal to 35% and QRS duration of more than 150 ms are recommended to use Cardiac Resynchronization therapy (CRP) with biventricular pacing. Studies have shown harm in using CRT in patients with a QRS of less than 30 ms (Virani et al, 2020). European Society of Cardiology (ESC) advocates CRT for patients with non-left bundle branch block (LBBB) morphology who meet the criteria for CRT.
Intravenous vasodilator therapy and intravenous inotropes should be considered in patients having refractory HF (Virani et al, 2020). However, AHA/ACC 2013 and 2017 guidelines restrict this intervention to manage symptoms in patients suffering end-stage who are disease resistant to standard medical therapy.
Heart transplantation should be considered in patients with progressive Heart Failure or those with acute or severe refractory Heart Failure (Malik et al, 2021). Furthermore, it is essential to address the probable risk factors that exacerbate CHF once a diagnosis is made. Some drugs such as calcium channel blockers except Vasoselective, nonsteroidal anti-inflammatory drugs (NSAIDSs), and most antiarrhythmic drugs should be shunned from being used by CHF patients.
Impact on nursing practice
One of the effective strategies for preventing morbidity and mortality associated with CHF is the reduction of possible triggers and extensive treatment of comorbidities. Other than medical treatment, patients require adequate guidance on self-monitoring on the clinical manifestations of CHF and living a healthy lifestyle through physical activity, and cessation of smoking and alcohol intake. These strategies are effective in delaying the progression of the disease in those already diagnosed with it and preventing the development of the condition in those who are at a high risk of acquiring it (Malik et al., 2021). Patient health education is highly recommended to facilitate self-care monitoring activities and compliance to the treatment regimen.
The American Heart Association recommends close patient supervision, including close supervision of patient and the family through home-based visits, teleconferencing, and/or remote monitoring to prevent adverse patient outcomes and promoted delayed disease progression (Malik et al., 2021). Family nurse practitioners are particularly significant in the follow-up procedures and ensuring drug compliance among these patients. The FNPs should ensure the caregivers have sufficient knowledge, particularly of dietary recommendations of CHF patients. Their dietary sodium should be restricted to 2 to 3g/day, and fluids restricted to 2L/day if they have hyponatremia, and fluid overload despite being on medical therapy. It is through FNPs that patients can have frequent in-depth education and evaluation to ascertain adherence to recommended guidelines for optimal health outcomes.
To conclude, CHF is highly prevalent among the elderly. The prevalence doubles every decade after the age of 65 years, making the elderly population at a high risk of contracting the illness. Certain characteristics of the elderly including impaired cognitive functions, existing comorbidities, and frailty make it difficult to include them in clinical trials. However, despite their underrepresentation in the randomized clinical trials, the recommended guidelines, made up of pharmacological and nonpharmacological therapies, for the treatment of CHF are effective for both the young and elderly populations. The treatments include diuretics, angiotensin-converting enzyme inhibitors (ACEs), angiotensin II receptor blockers (ARBs). Mineralocorticoids, ivabradine, and digoxin. The use of medical devices such as implantable cardioverter-defibrillator (ICD) and cardiac resynchronization therapy (CRT) has also demonstrated significant efficacy in the treatment of CHF. In totality, interprofessional collaboration is necessary for improved patient outcomes, minimum hospital readmissions, enhanced quality of life, and increased life expectancy.
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