Pathophysiology of Heart Failure - Essay Example

Pathopharmacology s Pathophysiology of Heart Failure Heart failure (HF) is a clinical syndrome that occurs when the heart’s capacity to provide the body with enough blood to sustain its requirements or to adequately take in returning inflows is compromised due to any functional or structural impairment (Mann, 2010). There are different types of heart failure namely systolic heart failure that is described as the inability of the heart to contract in order to maintain adequate blood volume to support the essential organs. On the other hand, diastolic heart failure is considered as heart failure with an impaired ability for the heart to relax effectively (Robinson & Bristrow, 2008). There are left-ventricular, right-ventricular, acute, and chronic heart failures. An estimated 70 percent of the patient populations have been found to have systolic heart failure (Mann, 2010). Additionally, the most common etiology of the systolic heart failure is ischemic heart disease. The pure diastolic heart failure may be caused by hypertension, ischemic heart disease, and both hypertrophic and restrictive cardiomyopathies. Clinical manifestation of heart failure include weight gain, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, peripheral edema, JVD, tachycardia, hepatosplenomegaly, ascites, fatigue, weakness, nausea, poor appetite, renal hypoperfusion, and chachexia. Neurohormonal responses to heart failure are adaptive at first, and then become deleterious when they are sustained. Modern treatment of heart failure is based on neurohormonal modulation. (Steimle, 2007) Clinical guidelines vs. standard of practice for heart failure Management of heart failure is a very complex issue that is why heart failure care needs to be delivered in a multi-professional manner. Although the standard of practise of managing heart failure has some consensus among healthcare providers, I based my heart failure disease management on the clinical guidelines that I developed at my organization. Using the clinical guidelines I was able to identify, summarize, and evaluate the highest quality evidence and most current data about prevention, diagnose, prognoses, and provide therapy including medications and cost-effectiveness. Using my clinical guidelines that I developed in the place I worked, I noted that there are four stages in the heart failure development namely stage A, B, C, and D. According to McDonagh et al. (2011), those patients who are in stage A and B usually do not have heart failure. However, they have risk factors that predispose them towards heart failure development. Patients in stage C comprise of those people with current or past symptoms of heart failure that is associated with underlying structural heart disease. Patients in stage D have refractory heart failure. These patients can be treated by hydralazine, atrial fibrillation and sinus rhythm, cardiac resynchronization therapy, and hospitalizing the patient. After treatment, I ensured that there was follow-up care. In our case the patients were enrolled to a follow-up program in our health facilities. We also offered post-charge follow-up care in order to assist the HF patients avoid exacerbation. Patient education was done once the patients visited the facility, through print and electronic media. I also made use of social media to educate the patients. I also ensured that there was improved the financial cost containment without necessarily sacrificing quality or patient satisfaction. Besides, our health facility had improved quality care, improved access to care and improved patient self-management. I believed I had fulfilled my responsibilities once the patient’s symptoms were resolved. In relation to the clinical guidelines, I monitored patients who have underlying disorders, for instance, hypertension and coronary artery disease recognizing patients in whom untimely treatment for heart failure may be useful. The patients are adviced to practice regularly and avoid habits such as smoking and excessive drinking. The most common cause of heart failure is coronary artery disease (King, Kingery, & Casey, 2012). An estimated 5.05 million individuals in the US have heart failure and about half of those who develop HF die within 5 years of diagnosis. In my state, heart disease kills 11 Americans daily. In my state I established that HF is more common in men as compared to women aged between 40 and 75 years of age, even though amongst persons aged over 70, both sexes are affected equally. HF costs my state about $55 million annually including the cost of health care services, missed work days, and medications to treat HF. My clinical guideline outlined that the disease management that smoking cessation, avoiding excessive intake of cocaine and alcohol, low-fat diet, and regular exercise reduces the incidences of HF. In addition, device placement and pharmacologic therapy assist in preventing disease progression and complications like sudden cardiac death. On the other hand, in relation to the standard practice of managing heart failure, the cardinal manifestations of heart failure are fatigue and dyspenea that may limit tolerance to exercises and fluid retention, thus leading peripheral and pulmonary edema. In relation to treatment, patients are determined in the course of their disease and provided treatment at each stage of their illness. Stage A: control of systolic and diastolic hypertension Stage B: treatment of lipid disorder Stage C: avoiding behaviour that may increase chances HF, control of ventricular rate in patients that have supravetricular teachyarrhythmias, treatment of typhoid, and periodic evaluation of HF’s signs and symptoms. Stage D: patients require specialized treatment strategies such as continuous inotropic infusions mechanical circulatory support, hospice care, or cardiac transplantation. Class 1 recommended treatment for Stage A HF patients who have a high chance of contracting left-ventricular dysfunction are classified as follows: for the control of systolic and diastolic hypertension in line with recommended practice; treatment of lipid disorders; abstinence from high-risk behavior patterns such as smoking, drug and alcohol abuse; control of heart palpitations especially for patients with supraventricular tachyarrhythmias; treatment of thyroid disorders; consistent and regular monitoring of the signs and symptoms of heart failure. The second level of treatment would include the administration of Angiotensin Converting Enzyme Inhibitors (ACEIs) or Angiotensin II receptor blockers (ARBs). These interventions are important in reducing the chances of contracting HF for predisposed patients; those that have a strong family history for atherosclerotic vascular disease, diabetes mellitus, or hypertension with attendant risk factors for cardiovascular disease. According to Deswall and Mann (2006), use of ARBs in HF patients significantly reduces mortality and morbidity rates. For asymptomatic Stage B patients (left-ventricular dysfunction), vulnerability can be reduced using therapies that diminish the risk of procuring additional injury, remodeling process, and progression of the disease. Stage B patients do not display symptoms of HF but have suffered acute myocardial infarction or left-ventricular dysfunction and are, therefore, at great risk of suffering heart failure. For acute MI patients, the administration of a fibrinolytic agent or percutaneous coronary intervention significantly reduces their chances of developing heart failure. The administration of a beta-blocker together with ACEIs or ARBs reduces the chances of death or reinfarction for patients who have suffered acute myocardial infarction or have a strong family history, especially if they have a history of heart failure, if given within days after the ischemic occurrence. Life expectancy and outcomes for a patient who has well managed CHF Effective management of HF translates to significant reduction of morbidity and mortality rates, with Class 1 interventions for Stage A patients (behavior-change intervention strategies, treatment for lipid disorders, and monitoring of palpitation rates) leading to significant gains in reducing progression rates for high risk and predisposed patients (Robinson & Bristrow, 2006). According to Robinson and Bristrow (2006), the use of beta-blockers in particular had a significant contributory effect on the reduction of deaths and hospitalization from clinical heart failure with both rates coming down by an average of 30%. Class 1 interventions lead to reduction of hospitalization and disease progression, while Class 2 interventions contribute to reduced risk of additional injury and remodeling for HF patients. However, therapy with digoxin might be initiated at any time in order to reduce symptoms and improve exercise tolerance, as well as diuretic therapy. In relation follow-up care, the patients take medications as prescribed by the doctor, having regular appointments with doctor, regular exercise, and avoiding salt consumption. Those people who properly manage the disease have a higher life expectancy, frequent access to quality care, and have an array of treatment options. This reduces the severity of the heart disease and increases the life expectancy. Furthermore, it helps to keep the heart stronger, improve symptoms, reduce the risk of worsening symptoms, and it allows you to live a long quality life. Patients who have well managed HF usually have the ability to access to emergency care, thus having reduced signs and symptom, in addition to leading an improved life. This implies that there increased use of emergency departments by managed care patients. They also access to quality treatment for their HF condition. Therefore, this means that they have the money to go to hospital when need arises, and that the hospital – complete with competent doctors and nurses as well as equipment – is readily available within the locality of the patient. Improved quality of patient care reduces the length of stay and treatment cost for the heart failure patients. Adequate financial resources are, therefore, a critical factor in care provision for HF patients. With regard to Medicare/Medicaid, this ensures that one is guaranteed access to heath care services. Heart failure is the world’s leading most cause of hospitalization in adults. There are various factors that are related to unmanaged care of heart failure patients. Inaccessibility to quality health care for the unmanaged patients significantly increases length of hospitalization and treatment cost. Due to the high cost of treating the disease, most unmanaged patients can not afford emergency care services and quality treatment. As a consequence, they have high mortality rate and reduced life expectancy. I our health facility, I noted the cost-implications of providing effective interventions for patients. Some of the most common scenarios for poorly managed HF cases arise from lack of money to purchase equipment and pay personnel. For the unmanaged HF patients, since Medicare covers all the necessary medical care in any hospital or doctor in the nation, the absence of this service could mean improper management of the disease which could even lead to death. This is because it is very essential to enhance the access and quality to palliative care for any heart failure patients who are in the later stages of heart failure. The characteristics of patients with unmanaged heart failure include emotional and psychological stress, physical problems including high blood pressure, high risk of heart disease, low life expectancy, extended length of stay in hospitals, and increased documentation of left ventricular dysfunction. Comparing the disparity of management strategies for CHF nationally and internationally The strategies for managing the disease were similar both nationally and internationally. Both strategies are proactive, multidisciplinary and systematic approach to health care delivery of HF patients including incorporating all members with HF, supports the provider-patient relationship and plan of care, optimizes patient care through prevention and proactive interventions based on evidence-based guidelines, incorporating patient self-management, and continuously evaluating the health status of the HF patients. On both national and international level, there is following up for the in-patients who have no complications. Expert analysis of the patient’s data on the risks and benefits of these practices improves the care quality of care and the patient’s outcomes. Lastly, the heart failure patients are usually provided with information on how to manage their condition, as well as the existence of a variety of community supports so that the patients, once discharged, they can continue with their recovery. However, on national scale, especially on a community level, there exist numerous factors that are suitable for treating and managing patients with heart disease. These factors comprise of the following; the easy availability and accessibility of diagnostic equipment and expert diagnosticians, the proficiency of interventional surgeons and cardiologists, and most notably, the wishes of well-informed patients. HF treatments on national scale provide self-management that includes support groups and behavior modification. Contrarily, disparities HF and related risk factors remain pervasive. Hospitalizations for CHF are highest in the southeastern United States. It was also noted that life expectancy remains higher in women as compared to men, in addition to being higher in whites than blacks by more that five years. CHF mortality in all ages tends to be highest in blacks. Patients, families and populations Heart failure disease has been found to have significant effect on the patients, families and the population in general, both economically and psychologically. According to Dunbar et al. (2009), the heart failure patients that do not have a family, live alone, or socially isolated are increasingly susceptible to poor self-care. As a result, they ought to receive focused attention. The population and family members are usually engaged in symptom evaluation, response and interpretation thus changing the process of experienced by the patient. Higher levels of distress have been linked to discordance between patient and family members (Grey, Knafl, & McCorkle, 2006). Besides, isolation leads to depression. The family members and population are obliged to provide financial support to those HF patients who can not afford. When they can not afford the required, this leads to increased caregiver and patient depression. Astedt-Kurki et al. (2004) argues that the caregiver factors, for example, self-efficacy for the role as heart failure caregiver and the abilities to solve problems affects the self-care and patient out-comes. Additionally, due family and population economic and emotional support have resulted to enhanced outcomes and reduced the patient hospital readmission in other serious and chronic illnesses. Behavior and change management In relation to behavior and change management in heart failure patients, suitable management of chronic heart failure and its symptoms and signs needs a significant amount of participation by the patients themselves. Some of the behavioral changes that reduce the disease progression, as well minimizing the signs and symptoms are considered to be essential as the medications that have actually been prescribed for the treatment of heart failure. The most difficult lifestyle changes consist of the following: weight loss, smoking cessation and restriction of dietary sodium (Paul & Sneed, 2004). Studies have shown that complex multi-component intervention that included a wide range of behavior change techniques resulted to improved adherence to HF medication Costs After being diagnosed with HF, one will require a lifelong treatment of the disease. Consequently, whether in private practice or academic medicine, profit or a non-profit institution, the treatment of heart failure is a regarded as a business (Bogaev, 2010, p.557). This is because treatment is available for heart failure, even though it can not be cured. The approximated direct and indirect cost of treating HF patients in the US was more than $37 billion in 2009. Nonetheless, more that 25% of the HF patients are readmitted within thirty days of discharge. For these patients who are readmitted during this time length, Medicare does not refund the hospital. Therefore, the cost burden is transferred to the healthcare facility (Bogaev, 2010). The cost of managing HF is driven by the care costs as an inpatient in terms of hospitalization (Ross et al., 2010). Averagely, the hospital stay for heart failure patients is 6 days, while the rate of rehospitalization during the six months after discharge is as high as 50 percent. This may be due to fluid overload, angina (chest pain) or heart attack and irregular heart rhythms. This puts a significant health and financial burden on the patients, the society and their families. Best practises promotion Since the goal of treatment is to enhance symptoms and signs, as well as reducing hospital admissions, I will ensure that I offer diuretic therapy to the HF patients in order to reduce fluid overload. As cited by (Steimle, 2007), I will ensure that optimal treatment of heart failure takes into consideration correct diagnosis, suitable use of medication, recognition of potentially reversible causes, and patient education on self-care. I will also promote that all HF patients be reviewed regularly, even though those patients on optimal doses of medicines require six monthly review. Implementation plan Some of the strategies that I will use to implement best practices for managing the selected disease include: 1. Trans-Theoretical Y Model; Effective management of HF patients requires the intermarriage of finance and quality issues using the Trans-Theoretical Y Model. As cited by Sieck (2006), I will make use of the trans-theoretical Y model to show how medical facilities can maximize clinical outcomes per dollar spent. She argues that stratification of care from the point of entry to discharge and the application of total quality management (TQM) practices at each of the tiers of care maximize quality at each point while minimizing the cost of treatment. Quality enhancement depends on point-of-care testing for HF patients combined with patient-centered quality management efforts. The overall effect is quality care offered at least cost. Sieck (2006) points out that one study of the practical applications of the Y Model at a hospital showed improved clinical outcomes with up to 30% reduction in HF rehospitalization cases as well as morbidity and mortality rates. Her solution to the prevalent challenge of reducing the load of HF patients on bed-capacity by moving them to outpatient units while at the same time ensuring quality care for them, offers the best method of merging quality with economic considerations. This works by ensuring that patient testing and care for HF is moved to entry points rather than locating them at observation units. Not all HF patients require bed hospitalization and relocating testing and care to entry points improves care while at the same time ensuring that the hospital saves the money it would have used in admitting the patient to hospital wards (Sieck, 2006). 2. Relocation of testing and care from OU to points-of-entry Another strategy that I will use to properly manage HF is the relocation of testing and care for HF patients at points-of-entry rather than at the observation units. Most HF patients have no use for OU or hospital beds. This will reduce crowding and save money spent in observing patients who would have otherwise been attended to and discharged. 3. Improving HF treatment facilities and add qualified personnel This is an accessibility issue that compromises the quality of care, not just for my hospital but for the wider community in the state and the country. There will be more qualified personnel with the capability to offer care to patients at home who have been discharged and recuperating. I will advocate for an increment in the number of personnel and the quality of equipment at the hospital. 4. Increased use of behavior-change education strategies to manage morbidity rates Behavior-change communication provides the best means with which the society can stem the rising morbidity rates of heart disease. I will liaise with the relevant authorities to educate the community on proper exercise, diet, and early testing and care. Such education shall be targeted at school-age children. Evaluation Strategies Relocation of testing and care from OU to points-of-entry. I will rate the success of this method by measuring the hospitalization rates for HF patients, number of deaths, and increased life span for patients. With regard to improving facilities and add personnel; objective-based approach and total quality management methods will be used to continually monitor and evaluate how this is implemented in the hospital. This will assist in ensuring that the correct decision is obtained when adding personnel and improving facilities. In relation to increased use of behavior-change education strategies to manage morbidity rates, I will use content analysis to evaluate this method. This is because declining hospitalization, morbidity, and mortality rates will translate to improving testing and care for HF patients through the new methods of care. Reference List Astedt-Kurki P, Lehti, K., Tarkka M., T., Paavilainen, E. 2004. Determinants of perceived health in families of patients with heart disease. J Adv Nurs.48(5):115–123. Bogaev, R. (2010). Cost Considerations in the Treatment of Heart Failure. Tex Heart Inst J. , 37 (5), 557- 558. Deswal, A., & Mann, D. L. (2006). Angiotensin Receptor Blockers in the Treatment of Heart Failure. In A. M. Feldman, Ed, Heart Failure Pharmacological Management (pp. 44-56). Malden, MA: Blackwell Publishing. Dunbar, S., Clark, P., Quinn, C., Gary, R., & Kaslow, N. (2009). Family Influences on Heart Failure Self-care and Outcomes. J Cardiovasc Nurs. , 23 (3), 258-265. Grey M, Knafl K., & McCorkle R. 2006. A framework for the study of self- and family management of chronic conditions. Nurs Outlook. 54(5):278–286. King, M., Kingery, J., & Casey, B. (2012). Diagnosis and Evaluation of Heart Failure. Am Fam Physician , 15 (85), 1161-1168. Mann, D. L. (2010). Heart Failure: A Companion to Braunwald’s Heart Disease. New York: Elsevier Health Sciences. McDonagh, T., Blue, L., Clark, A., Dahlstrom, U., Ekman, I., Lainscak, M., et al. (2011). Standards for delivering heart failure care. European Journal of Heart Failure , 13, 235-241. Paul, S., & Sneed, N. W. (2004). Strategies for behavior change in patients with heart failure. Am J Crit Care , 13 (4), 305-313. Robinson, F., & Bristrow, M. R. (2008). Beta Blockers. In A. M. Feldman. Ed, Heart Failure Pharmacological Management (pp. 44-56). Malden, MA: Blackwell Publishing. Ross JS, Chen J, Lin Z, Bueno H, Curtis JP, Keenan PS, et al. 2010. Recent national trends in readmission rates after heart failure hospitalization. Circ Heart Fail, 3(1):97–103. Sieck, S. (2006). The Process and Economics of Heart Failure. In W. F. Peacock, Ed., Short Stay Management of Heart Failure (pp. 39-53). Philadelphia, PA: Lippincott, Williams and Wilkins. Steimle, A. (2007). Clinical Evidence Review: Best Practice Heart Failure. Perm J. , 11 (2), 55-64. Read More