CHF EF Resource?
Hi All!
I am working on creating a CDI Query Guideline for CHF.
It has been explained to me that if a pt has CHF with an EF over 40% it is diastolic heart failure, and an EF under 40% is systolic heart failure.
I am trying to find a scholarly source that mentions what ejection fraction is associated with which type of heart failure to include as a resource to my guideline.
Does anyone have a resource they could share?
Thank you!
Greta
Greta Goodman
Clinical Documentation Improvement Specialist
Health Information Management
Virginia Hospital Center
1701 North George Mason Drive
Arlington, VA 22205
703-558-5336
ggoodman@virginiahospitalcenter.com
I am working on creating a CDI Query Guideline for CHF.
It has been explained to me that if a pt has CHF with an EF over 40% it is diastolic heart failure, and an EF under 40% is systolic heart failure.
I am trying to find a scholarly source that mentions what ejection fraction is associated with which type of heart failure to include as a resource to my guideline.
Does anyone have a resource they could share?
Thank you!
Greta
Greta Goodman
Clinical Documentation Improvement Specialist
Health Information Management
Virginia Hospital Center
1701 North George Mason Drive
Arlington, VA 22205
703-558-5336
ggoodman@virginiahospitalcenter.com
Comments
Systolic (pumping):
* Inability of ventricles to contract
* Abnormal Ejection Fraction
* Left ventricle is enlarged and/or thickened
* Pulmonary effusions
* Risk factors including age, previous MI
Diastolic (filling):
* Inability of Ventricles to fill
* Abnormal left ventricular filling and elevated filling
pressures
* Normal or near normal left ventricular systolic function
* Peripheral edema
* Risk factors include age, hypertension, diabetes, and obesity
Robert
Robert S. Hodges, BSN, MSN, RN, CCDS
Clinical Documentation Improvement Specialist
Aleda E. Lutz VAMC
Mail Code 136
1500 Weiss Street
Saginaw MI 48602
P: 989-497-2500 x13101
F: 989-321-4912
E: Robert.Hodges2@va.gov
"We are dealing with Veterans, not procedures; With their problems, not
ours." --General Omar Bradley
Harrison's Principles of Internal Medicine, 17th edition
Current Practice Guidelines in Primary Care 2008, Lange: Gonzales et. al
ACA/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult
Trends in Prevalence and Outcome of Heart Failure with Preserved Ejection Fraction; N Engl J Med 2006
Susan
Vicki S. Davis, RN CDS
Clinical Documentation Improvement Manager
Office (336) 586-3765
vdavis2@armc.com
"The difference between the right word and the almost right word is the difference between lightning and the lightning bug."- Samuel "Mark Twain" Clemens
Definition: "Congestive heart failure is a clinical syndrome that results from the heart's inability to pump the amount of oxygenated blood necessary to meet the metabolic requirements of the body per The Lippincott Manual of Nursing Practice, Sixth edition, page 310.
Etiologies: HF may be caused by valvular, coronary, or myocardial disease. Arrhythmias may also cause or aggravate HF. Valvular heart disease can cause obstruction or regurgitation. CAD results in ischemia and infarction by reducing myocardial blood flow. Merck, 16th Edition
High-output HF results from a persistent need for a high Cardiac Output (CO), which may eventually result in an inability of a normal heart to maintain adequate output. Conditions that may increase CO include severe anemia, beriberi, thyrotoxicosis, advanced Paget's disease, arteriovenous fistula, and persistent tachycardia. CO is high in various forms of cirrhosis, but much of the observed fluid retention is due to hepatic mechanisms.
Source: http://www.merck.com/mmpe/sec07/ch074/ch074b.html
Classifications
There are two phases to the heart's cycles. The emptying phase is known as systole. Most patients with CHF have systolic heart failure. However, there is also diastolic heart failure. Diastole is the filling phase of the cycle when the heart relaxes and allows blood to enter.
Systolic Heart Failure: Systolic heart failure occurs when the ability of the heart to contract decreases. The heart is unable to pump out adequate amounts of blood during contraction (systole). Blood coming from the lungs into the heart may back up and cause fluid leakage into the lungs causing pulmonary congestion. Treatment consists of ACE inhibitors, digoxin, diuretics and beta-blockers. (Coding Clinic 2002 4th Qtr)
In general, systolic heart failure has been thought to be associated with a reduced ejection fraction, whereas diastolic heart failure was associated with a preserved (normal) ejection fraction.
Source: http://www.umm.edu/patiented/articles/what_congestive_heart_failure_000013_1.htm
Systolic dysfunction is the most common type of heart failure, accounting for 60-70% of heart failure patients. This form of failure results from a loss of intrinsic contractility and is generally associated with a dilated ventricle. A decrease in stroke volume coupled to an increase in ventricular end-diastolic volume leads to a significant reduction in ejection fraction (EF). Normally, EF is greater than 55%. In severe systolic dysfunction, the EF may be less than 20%. An example of systolic dysfunction is dilated cardiomyopathy (DCM), which can result from known or unknown diseases that impair ventricular function.
Source: http://cvpharmacology.com/clinical topics/heart failure-3.htm
Diastolic Dysfunction: A newly recognized condition that can influence ventricular performance and may lead to pulmonary venous congestion without significant declines in ventricular systolic performance. The impediment to diastolic filling results from fibrosis and scarring (or infiltration) of the ventricle. May be seen with various forms of myocardial hypertrophy or ischemia due to CAD. Diastolic heart failure occurs when the heart has a problem relaxing between contractions (diastole) to allow enough blood to enter the ventricles. The heart cannot fill with sufficient blood because the heart muscle is stiff and unable to relax. This may lead to fluid accumulation, especially in the legs, ankles and feet. Some patients may also have lung congestion. The treatment depends on the underlying cause. Beta blockers and calcium channel blockers are often used when diastolic dysfunction is due to ischemia or hypertension (Coding Clinic 2002 4th Qtr)
This type of ventricular failure is related to impaired ventricular filling caused by hypertrophied (less compliant) ventricles or by impaired ventricular relaxation. Hypertrophy can result from chronic hypertension or aortic valve stenosis . Some patients may have a genetic defect that causes hypertrophic cardiomyopathy (HCM). Diastolic dysfunction can also occur due to a stiffening of the ventricular wall (restrictive cardiomyopathy) caused by fibrosis. These patients will often have normal or near normal ejection fractions. Diastolic dysfunction results in large increases in ventricular end-diastolic pressure, which can lead to pulmonary edema. Despite a large end-diastolic pressure, the end-diastolic volume may actually be reduced because of the decreased ventricular compliance
Source: http://cvpharmacology.com/clinical topics/heart failure-3.htm
The major causes of diastolic dysfunction include:
* chronic hypertension
* hypertrophic cardiomyopathy
* aortic stenosis
* coronary artery disease
* restrictive cardiomyopathy (a rare condition in which the heart muscle is infiltrated, and made stiff, by abnormal cells, protein, or scar tissue. The most common cause of restrictive cardiomyopathy is amyloidosis, a disease in which protein-like substance is deposited within the body's tissues. Other causes include sarcoidosis and hemochromatosis.)
* aging (Whether age alone causes stiffening of the ventricles, or whether such stiffening is related to "subclinical hypertension" or some other definable medical condition, is not yet worked out)
Echocardiography plays a critical diagnostic role in patients with heart failure, in part because the physical examination, electrocardiogram, and chest radiograph do not provide information that distinguishes diastolic from systolic heart failure. The documentation of a normal or near-normal left ventricular ejection fraction (e.g., >40 percent to 50 percent) is necessary for the diagnosis of diastolic heart failure.
Guidelines from the American College of Cardiology and the American Heart Association suggest "the diagnosis of diastolic heart failure is generally based on the finding of typical symptoms and signs of heart failure in a patient who is shown to have a normal left ventricular ejection fraction and no valvular abnormalities on echocardiography."
Available data indicate that brain natriuretic peptide levels are not as high in diastolic heart failure
as they are in systolic heart failure. The diagnosis of diastolic heart failure can be made on the basis of left ventricular hypertrophy, clinical evidence of heart failure, and a normal ejection fraction, as well as Doppler findings that are consistent with diastolic dysfunction and elevated filling pressures. The initial treatment of diastolic heart failure should be directed at reducing the congestive state (with the use of diuretics). Long-term goals are to control congestion and to eliminate or reduce the factors, including hypertension, tachycardia, and ischemia, that confer a predisposition to diastolic dysfunction.
Source: http://www.temple.edu/imreports/ReadingList/Card-Diastolic-heartfailureNEJM2004.pdf
DHF cannot usually be distinguished from SHF by patient history, physical exam, x-ray, and EKG alone. Diagnosis requires an estimate of LV size and EF . These measurements can be made using echo, MUGA, or cath eterization. Really, DHF diagnosis is a matter of ruling out other possible causes in patients seeming to have heart failure but who have normal heart size and EF.
source: http://cme.med.umich.edu/pdf/guideline/HeartFailure06.pdf
ACUTE CHF - What To Look For
I. Diagnosis
A. Sensitive CHF markers (if absent, CHF is unlikely)
1. Dyspnea on exertion
2. EKG with anterior Q Waves or Left Bundle Branch Block
3. B-Type Natriuretic Peptide is elevated
B. Specific CHF markers (if present, suggest CHF)
1. Displaced Cardiac Apex on palpation
2. S3 Gallup rhythm
3. Jugular Venous Distention
a. With or without hepatojugular reflex
Chest X-Ray with cardiomegaly or vascular congestion
Source: http://www.fpnotebook.com/CV23.htm
Clinical Manifestations
Certain manifestations are associated with either right or left heart failure - these are outlined below.
Left Heart Failure
Right Heart Failure
1. Congestion occurs mainly in the
1. Congestion occurs mainly in
lungs, resulting in:
systemic veins and capillaries:
a. Shortness of Breath
a. Distended neck veins
b. Dyspnea on exertion
b. Edema of ankles/legs
c. Paroxysmal nocturnal dyspnea
c. Weight gain
d. Orthopnea
d. Ascites
e. Pleural effusion,
e. Liver congestion
f. Pulmonary Rales.
f. Pitting edema
2. Fatigue with exertion
2. Anorexia & nausea
3. Insomnia, restlessness
3. Weakness and syncope
4. Tachycardia
4. Nocturia
5. Nocturia
5. Cardiomegaly
6. Cardiomegaly
6. Cool, clammy skin
Left Heart Failure
Right Heart Failure
7. Cool, clammy skin
7. Dysrhythmias
8. Dysrhythmias
Diagnostic Studies
Thanks to all who shared I truly appreciate it!
Greta Goodman
Clinical Documentation Improvement Specialist
Health Information Management
Virginia Hospital Center
1701 North George Mason Drive
Arlington, VA 22205
703-558-5336
ggoodman@virginiahospitalcenter.com
Julie A. Skagen RN, BSN
Clinical Documentation Specialist
Medical Records
Bozeman Deaconess Hospital
Clues for Differentiating Between Systolic and Diastolic Dysfunction In Patients with Heart Failure.doc"