The diagnosis of heart failure is often determined by a careful history and physical examination and characteristic chestradiograph findings. The measurement of serum brain natriuretic peptide and echocardiography have substantially improved the accuracy of diagnosis.
Therapy for CHF is directed at restoring normal cardiopulmonary physiology and reducing the hyperadrenergic state. The cornerstone of treatment is a combination of an angiotensin-converting-enzyme inhibitor and slow titration of a blocker.
Patients with CHF are prone to pulmonary complications, including obstructive sleep apnea, pulmonary edema, and pleural effusions. Continuous positive airway pressure and noninvasive positive-pressure ventilation benefit patients in CHF exacerbations. NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail.
This translates to 9. Age is a major determinant of HF. Regardless of the cause or the definition used to classify patients with heart failure HF , the prevalence of HF increases steeply with age. According to the American Heart Association, heart failure is still the primary cause of hospitalization in the elderly population and accounts for 8. International statistics regarding the epidemiology of HF are similar to those of the United States.
The incidence increases dramatically with age, and metabolic risk factors along with a sedentary lifestyle are major risk factors. Ischemic cardiomyopathy, along with hypertension, is a major cause of HF in developing countries. The theoretical cause of this is thought to be due to the higher prevalence of tuberculous, pericardial disease, and lung disease.
There is a lack of robust data to verify these claims. The adaptive mechanisms that may be adequate to maintain the overall contractile performance of the heart at relatively normal levels become maladaptive when trying to sustain adequate cardiac performance. In the initial stages of congestive heart failure, cardiac physiology attempts to adapt via several compensatory mechanisms to maintain cardiac output and meet the systemic demands. These include the Frank-Starling mechanism, changes in myocyte regeneration, myocardial hypertrophy, and myocardial hypercontractility.
With increased wall stress, the myocardium attempts to compensate via eccentric remodeling, which further worsens the loading conditions and wall stress.
A decrease in cardiac output stimulates the neuroendocrine system with a release of epinephrine, norepinephrine, endothelin-1 ET-1 , and vasopressin. They cause vasoconstriction leading to increased afterload. There is an increase in cyclic adenosine monophosphate cAMP , which causes an increase in cytosolic calcium in the myocytes.
This increases myocardial contractility and further prevents myocardial relaxation. An increase in afterload and myocardial contractility with impaired myocardial relaxation leads to increased myocardial oxygen demand. This paradoxical need for increased cardiac output to meet myocardial demand eventually leads to myocardial cell death and apoptosis. As apoptosis continues, a decrease in cardiac output with increased demand leads to a perpetuating cycle of increased neurohumoral stimulation and maladaptive hemodynamic and myocardial responses.
A decrease in cardiac output also stimulates the renin-angiotensin-aldosterone system RAAS , leading to increased salt and water retention, along with increased vasoconstriction.
This further fuels the maladaptive mechanisms in the heart and cause progressive heart failure. In addition to this, the RAAS system releases angiotensin II, which has been shown to increase myocardial cellular hypertrophy and interstitial fibrosis. This maladaptive function of angiotensin II has been shown to increase myocardial remodeling.
In HFpEF, there is a decrease in myocardial relaxation and an increase in the stiffness of the ventricle due to an increase in ventricular afterload. This perpetuates a similar maladaptive hemodynamic compensation and leads to progressive heart failure. The most commonly reported symptom is shortness of breath.
Further qualification of this symptom is essential to help elucidate potential causes of heart failure and to determine the plan of care for the patient. Shortness of breath must further be classified to determine if it is related to exertion, positional changes orthopnea , and whether it is acute or chronic.
Other commonly reported symptoms of HF include chest pain, palpitations, anorexia, and fatigue. Some patients may present with a recumbent cough which may be due to orthopnea. Physical examination of patients with heart failure requires a comprehensive assessment. The general appearance of patients with severe, chronic heart failure or those with acutely decompensated heart failure will include anxiety, diaphoresis, and poor nutritional status.
The classical finding of pulmonary rales translates to heart failure of moderate to severe intensity. Wheezing may be present in acute decompensated heart failure. As the severity of pulmonary congestion increases, frothy and blood-tinged sputum may be seen. It is important to note that the absence of rales does not exclude pulmonary congestion. Jugular venous distention is another classical finding which must be assessed in all patients with HF.
A paradoxical increase in jugular venous distention with respiration Kussmaul sign may be seen. Peripheral edema is present in severe heart failure and will be seen if a substantial degree of volume overload is present. Cardiac findings in patients with HF include S3 gallop, pulsus alternans, and accentuation of P2. An S3 gallop is the most significant and early finding associated with HF.
The commonly used Framingham Diagnostic Criteria for Heart Failure requires the presence of 2 major criteria or 1 major and 2 minor criteria to make the diagnosis of heart failure.
This diagnostic tool is highly sensitive for the diagnosis of heart failure but has a relatively low specificity. The Framingham Diagnostic criteria are as follows:. It has an estimated prevalence of 26 million people worldwide and contributes to increased healthcare costs worldwide. Multiple different diseases can cause heart failure. The etiology of heart failure varies the treatment plan to some degree; however, most of the treatment recommendations are based on the presence of heart failure alone, regardless of the cause.
HF is classified under the Diagnosis-Related Group DRG , which is a statistical system of classifying possible diagnoses into more than 20 major body systems and subdividing them into roughly groups for the purpose of Medicare reimbursement. Factors used to determine the DRG payment amount include the involved diagnosis, as well as the hospital resources necessary to treat the condition.
The DRG codes for HF are categorized based on the severity, associated co-morbid conditions and reflect the level of utilization of hospital resources along with the payment reimbursement [ ]. GLOS determines the payment or reimbursement the hospital will receive for providing the care for the assigned period of stay.
LOS length of stay defines the actual period for which the patient remained in the hospital and is usually more than GLOS [ ].
Each DRG has been assigned a weight, which is used to adjust for the fact that different types of patients consume different resources and have different costs. The diseases that require more resources have been assigned a higher weight than those that require fewer resources. Weights are updated annually to reflect the changes in medical practice patterns, the use of hospital resources, diagnostic and procedural definitions and DRG assignment criteria.
Physicians must be very specific when documenting the type of heart failure that has been diagnosed during hospital admission or a previous episode of care to get credit for a higher severity of illness and the corresponding payment increase [ 51 ]. For example, instead of documenting acute heart failure, based on the signs and symptoms, documentation should include the precise type of heart failure, such as acute systolic heart failure, or acute on chronic systolic heart failure, or acute diastolic heart failure, or possible chronic systolic heart failure, etc.
Secondary diagnosis should also be as precise as possible. Heart failure indeed is a complex disease and so far has been a major cause of morbidity and mortality in developing and developed countries. A standardized medical therapy has been successful in the early stages of HF. Advanced stages of HF require frequent hospitalization due to the presence of severe HF and or associated co-morbid conditions, which require strict implementation of an appropriately individualized multidisciplinary approach and quality measures to reduce re-admissions.
While pharmacological management has a limited role in advanced cases of HF, novel therapeutic agents, such as regenerative and gene therapy, are in the developmental stages and need further refinement before their approval for the treatment of HF. Despite the appropriate measures, hospitalization in HF as a DRG has been a great challenge, especially since the adoption of the financial penalty program for excessive readmissions related to HF. In addition to the appropriate management of cases, healthcare professionals also need to provide precise and complete medical codes for procedures and diagnosis to help hospitals to receive the maximum reimbursement for the services provided to such patients.
National Center for Biotechnology Information , U. Journal List J Clin Med v. J Clin Med. Published online Jun Arati A. Inamdar 2. Ajinkya C. Inamdar 2 Ansicht Scidel Inc. Salvatore De Rosa, Academic Editor. Author information Article notes Copyright and License information Disclaimer.
Received Mar 10; Accepted Jun This article has been cited by other articles in PMC. Abstract Despite the advancement in medicine, management of heart failure HF , which usually presents as a disease syndrome, has been a challenge to healthcare providers.
Keywords: biomarker, heart failure, ICD 10, readmission, utilization. Introduction 1. Background Heart failure HF is a clinical syndrome caused by structural and functional defects in myocardium resulting in impairment of ventricular filling or the ejection of blood. Classification of HFs Heart failure can be classified as predominantly left ventricular, right ventricular or biventricular based on the location of the deficit. Class II: HF causes slight limitations to physical activity; the patients are comfortable at rest, but ordinary physical activity results in HF symptoms.
Class III: HF causes marked limitations of physical activity; the patients are comfortable at rest, but less than ordinary activity causes symptoms of HF. Diagnosis of HF The evaluation for HF is performed using various parameters: physical examination to determine the presence of clinical symptoms and signs, blood tests, including complete blood count, urinalysis, complete metabolic profile for levels of serum electrolytes including calcium and magnesium , blood urea nitrogen, serum creatinine, glucose, fasting lipid profile, liver function tests and thyroid-stimulating hormone.
Table 1 The specific biomarkers expressed in heart failure HF patients as they correlate to the underlying mechanism of the pathogenesis for HF could be utilized for the diagnosis and prognosis of HF. Open in a separate window. High NYHA functional class Reduced left ventricular ejection fraction Third heart sound Increased pulmonary artery capillary wedge pressure Reduced cardiac index Diabetes mellitus Reduced sodium concentration Raised plasma catecholamine and natriuretic peptide concentrations.
Management of Heart Failure The major goals of treatment in heart failure are 1 to improve prognosis and reduce mortality and 2 to alleviate symptoms and reduce morbidity by reversing or slowing the cardiac and peripheral dysfunction.
Anticoagulants, if applicable, to decrease the risk of thromboembolism. Readmission Readmission is defined as a subsequent hospital admission within 30 days following an original admission or index stay.
Several studies have been performed to determine the causes for the day readmission [ 8 , 48 , 49 , 50 ], and some of the major causes include: 1. Quality Improvement Strategies for HF We have achieved great success in the optimization of pharmacological therapy along with the relative increase in the availability of better healthcare options.
Patient education: patient education about HF and strategies for its treatment. Figure 1. Standard and Novel Therapies for HF 8. Role of Cardiac Rejuvenation Therapy in the Management of HF Current medical management for heart failure only alleviates symptoms, delays deterioration and prolongs life modestly. Utilization and Medical Coding In addition to having the knowledge of the pathophysiology of the HF and its management with the help of established and novel therapies, it is important for a physician to understand how to document the therapy so as to satisfy the reimbursement requirements.
Conclusions Heart failure indeed is a complex disease and so far has been a major cause of morbidity and mortality in developing and developed countries. Author Contributions A. Conflicts of Interest The authors declare no conflict of interest.
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