Issues in cardiovascular nursingDiastolic heart failure
Section snippets
Epidemiology
The Cardiovascular Health Study (CHS)9, 10 was the first large epidemiologic study (N = 4842) to examine cardiovascular disease risk in the elderly. HF was present in 425 subjects (8.8%) of the sample, whose mean age was 77 ± 5 years. This was most notable among women, in whom HF increased from 6.6% at age 65 to 69 years to 14% at age greater than 85 years. More than half (55%) of the women in the CHS exhibited a normal LVEF, and LVEF was only mildly reduced in 80% of the women.10 DHF was more
Prognosis and Hospitalizations
Among community samples, the mortality rates for patients with SHF are 10% to 15% annually, higher than the 4% to 8% observed in patients with DHF.2, 10 However, the death rate among patients with DHF is approximately four to five times higher compared with adults with normal diastolic function, indicating its serious impact.10 Short-term survival and hospital readmission rates are more favorable in younger patients with DHF (<65 years) than patients with SHF but are similar at age 75 years or
Pathophysiology of Diastolic Heart Failure
Although much less is known about DHF than SHF, the pathogenesis in most cases seems to be associated with LV diastolic impairment and is the focus of this review. However, conditions such as right-sided HF, lung disease, and pericardial and valvular heart diseases are also acknowledged to contribute to the pathologic changes associated with DHF.17, 18, 19, 20
Diastolic dysfunction is associated with delayed LV relaxation, reduced distensibility (increased diastolic pressure with no change in
Clinical Evaluation
Initially, clinical evaluation of DHF includes a medical history, physical examination, chest radiograph, serum BNP, and electrocardiogram. Symptom similarity with other medical conditions, such as asthma and chronic obstructive pulmonary disease, has increased serum BNP use in clinical settings. A detailed review of cardiac symptoms including ischemic heart disease, such as chest pain, history of angina, myocardial infarction, arrhythmias, especially tachyarrhythmias, or valvular disease,
Treatment Strategies
Although there is substantial evidence to guide therapy for patients with SHF, few trials have been conducted with patients with DHF; therefore, little is known about optimal treatment strategies for this population. The management of DHF has two major objectives: to reverse the consequences of diastolic dysfunction (eg, venous congestion and exercise intolerance) and to eliminate or reduce factors (eg, hypertension) responsible for the diastolic dysfunction.5, 8, 14, 66, 67, 68 Other important
Symptom Management
Initially, patients with DHF often have symptoms related to pulmonary congestion. Pulmonary congestion can be decreased by reducing LV volume, maintaining normal sinus rhythm (arteriovenous synchrony), and prolonging diastole (thereby decreasing heart rate and increasing coronary artery filling time). One of the most common interventions to reduce LV volume is reducing intravascular volume, either by diuretics or nonpharmacologic approaches such as fluid or sodium restriction. Other
Pharmacologic Treatment of Diastolic Heart Failure
Neurohormonal activation contributes to reduced cardiac output and exertional intolerance in patients with DHF.71 Specific therapeutic targets include reducing blood pressure; controlling hypertension, ischemia, and tachycardia; and maintaining a sinus rhythm. Beta-adrenergic receptor blockers decrease blood pressure and reduce ventricular remodeling by lowering the harmful neurohormonal and cytokine cascade. Reducing heart rate is also essential using beta-blockade to improve diastolic filling
Nonpharmacologic Management
DHF and aging both lead to a reduced exercise capacity, in part because of the loss of muscle mass (sarcopenia) and alterations in skeletal muscle blood flow and metabolism. Exercise training can in part reverse the peripheral alteration, improve functional capacity, and improve the symptoms associated with DHF and is now recommended by the American Heart Association/American College of Cardiology guidelines73, 79 and Heart Failure Society of America69 in stable patients with NYHA class I to
Multidisciplinary Management
The complex syndrome of DHF is often complicated by multiple comorbidities, advancing age, lack of resources, sensory deficits, mobility limitations, depression, nutritional concerns, social isolation, and end-of-life decisions. These factors contribute to poor outcomes, nonadherence to medical regimens, increased hospitalizations, and institutionalization. The complexity of issues surrounding many patients with DHF requires a multidisciplinary approach to ensure these issues are addressed to
Conclusions
Although there are few clinical trials to provide strong support for treatment options in DHF, the number of studies is increasing and evidence has steadily grown during the past decade, providing enthusiasm that future therapies will emerge. The most effective management is the prevention of DHF, which includes strategies aimed at aggressively treating the established risk factors, such as hypertension, diabetes, and obesity. In the meantime, nurses have an important role to play in educating
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Galectin-3 and myocardial fibrosis in nonischemic dilated cardiomyopathy
2015, International Journal of CardiologyCitation Excerpt :Neurohormonal activation and myocardial vulnerability concur to the development of cardiac fibrosis, which represents a key mechanism in the progression of adverse cardiac remodeling in patients with dilated cardiomyopathy [1,2]. Moreover, cardiac fibrosis is associated with worsening of left ventricular (LV) systolic and diastolic function [3,4], and with a poor outcome, regardless of etiology. Late gadolinium enhancement (LGE) at cardiac magnetic resonance imaging (MRI) has recently emerged as a powerful, noninvasive tool for the estimation of the extent of cardiac fibrosis in HF patients.
Heart failure: Not only reduced left ventricular ejection fraction but also reserved ejection fraction!
2013, Heart and Lung: Journal of Acute and Critical CareDiastolic Heart Failure in Women: Expanding Knowledge About Self-Care Practices
2012, Nursing for Women's HealthCitation Excerpt :To date there has been little evidence to guide clinicians concerning the diagnosis, treatment and maintenance of one type of heart failure in women—diastolic heart failure (DHF). Among individuals with heart failure, women (67 percent) more than men (42 percent) suffer from DHF (Gary & Davis, 2008; Roger et al., 2011). As compared to a healthy heart (which has an ejection fraction ranging from 55 percent to 70 percent), heart failure is classified as either systolic (ejection fraction < 40 percent) or diastolic (ejection fraction > 45 percent) or both and is characterized as a chronic and progressive condition (American Heart Association [AHA], 2012).
Cost-effectiveness of aldosterone antagonists for the treatment of post-myocardial infarction heart failure
2012, Value in HealthCitation Excerpt :The value depends crucially on the number of future patients who could benefit from further research and the time horizon over which the information would be useful. Post-MI HF accounts for approximately 20% of all HF cases [42]. The British Heart Foundation estimates that the prevalence of HF in the United Kingdom is 707,000 (393,000 men, 314,000 women) and the annual incidence of HF is estimated to be 68,000 cases (38,000 men, 30,000 women) [4].
Comorbidities and Mortality Associated With Hospitalized Heart Failure in Canada
2012, Canadian Journal of CardiologyAntifibrotic Effects of ω-3 Fatty Acids in the Heart: One Possible Treatment for Diastolic Heart Failure
2011, Trends in Cardiovascular MedicineCitation Excerpt :By 2040, this number is anticipated to increase to 1.5 million, largely because of the aging population. HF is the leading cause for hospital admissions and death among older adults, and it is the most expensive Medicare expenditure, with costs estimated to be between $30 and $40 billion annually (Aronow 2006, Gary and Davis 2008). Diastolic HF is defined as HF with preserved ejection fraction and reduced diastolic function.