CHF type

tkreiling

Hi,
I am wondering can the type of CHF be further specified if the echo is showing a normal EF and no diastolic dysfunction is also mentioned? I did not query a case because of the fact the echo was completely normal and the H/P had mentioned the type was unspecifed at that time (before the echo was completed though). I am being asked to do a retro query and want to see what others think. Can a CHF type be specified with a normal echo. Maybe my way of thinking was incorrect when I was concurrently reviewing but would like another opinion before I so or don't query the doctor.
Thanks,
Tara RN, CCDS

catladyrn

With diastolic heart failure, you are going to have a "normal" EF because the problem during diastole isn't with ejecting blood from the ventricle, it's with filling the ventricle in the first place. So the % of blood being ejected is "normal," even though the actual volume is inadequate. With a diagnosis of heart failure and a measured EF, please go ahead and make that query.

Hope that helps.

Renee

Linda Renee Brown, RN, CCDS, CCS, CDIP
CDI Educator
Novant Health System

tkreiling

In the instances I am in question about the echo itself says "normal diastolic function" along with the normal EF.. Still query?
Thanks,

jschoonhoven

If you query, I would suggest providing the option "CHF ruled out."
What was done for treatment (besides the evaluation with ECHO)?
Is there any atrial dilation? Cardiomegaly? Leaky valves?
In other words, where did the notion of HF come from with this 'normal' heart?

We have found that there are many opportunities to do what I call "reverse queries" -- clarifying whether something should actually be in the record. For instance, if Sepsis is in the H&P but never mentioned again, and there are no clinical indicators or the suspected infection is ruled out-- we ask was Sepsis ruled out, listing the normal vital signs and lab values that lead one to believe sepsis was a mis-call.

I'm guessing we are not the only ones to find this tricky but very critical to broach.
Janice
Janice Schoonhoven RN, MSN, CCDS
Clinical Documentation Integrity
Manager- PeaceHealth Oregon West Network

rmhosler1

I agree w Janice



Mary A Hosler MSN, RN
Clinical Documentation Specialist
Alumnus CCRN
McLaren Bay Region
1900 Columbus Ave.
Bay City, Michigan 48708
(989) 891-8072
mary.hosler@mclaren.org

katysuegood@gmail.com

I agree. If the patient does have CHF there has to be a type. Right? If the echo is normal and there is no indication of HF, did the patient actually have CHF? Was it treated? I would consider a query asking for type including an option for CHF Ruled out (please specify more appropriate dx).

Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404

annnd2009@gmail.com

I think her point wasn't the normal Ef it was the stating of normal
diastolic function. I've wondered as well.
Ann

evanspx@sutterhealth.org

Attached are some of the clinical criteria the coding team is required to review and verify for the condition of DCHF.

I am not able to highlight or underline any particularly helpful portions due to software. I am sure the spacing will be affected when I send.

******************************************************************************************************************


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

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)

that a thickened LV wall (hypertrophy) in a patient with an LVEF >40% is one criteria for the diagnosis of diastolic CHF)

Upper Reference Limits for Healthy Hearts
left atrium 36 to 47 mm
aortic root 33 to 44 mm
left ventricular end-diastolic diameter 52 to 70 mm
left ventricular end-systolic diameter 30 to 40 mm
left ventricular wall thickness 11 to 13 mm

Source: http://www.chfpatients.com/tests/echo.htm

Paul Evans, RHIA, CCS, CCS-P, CCDS

tkreiling

Thanks, I will review the info you have sent.
I have seen several times the echo be completely normal but the patient still has CHF on Chest xray, BNP is elevated and pt is given IV Lasix. This particular case I don't think an ace or ARB was started. All through the chart the cardiologist and attending are charting and treating CHF. The patient had tachycardia induced CHF. I don't feel this is a question of whether or not CHF was there- to me it apparent it was with the s/s. My main question is can you specify a CHF type with a normal echo? I will review the info below and maybe that will help me too. I just wonder if sometimes we have to go with unspecified??
Thanks.
Tara RN,CCDS

evanspx@sutterhealth.org

I think you may be able to issue a query for diastolic heart failure if the LV ejection is 'normal' - but, the 'performance' of the left Ventricle should be considered abnormal in some fashion - for instance, the LV should not fill or empty normally due to hypertension causes stiff walls, as one simply example.

Paul Evans, RHIA, CCS, CCS-P, CCDS

katysuegood@gmail.com

I'm second guessing my knowledge here but I don't understand how you can have 'heart failure' without having either systolic or diastolic dysfunction. What is causing the 'failure'? This is one of those situations where I would be tracking down the cardiologist and asking them to help me understand then reporting that back to the coder.
Did this patient also have renal failure?

Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404

yuliyafish

Presence of diastolic dysfunction on TTE is not necessary for Dx of
diastolic HF. If a patient has a history of HF, treatment for HF and
preserved LVEF (>40 %), I would query for type of HF.

http://content.onlinejacc.org/article.aspx?articleid=1132259

"How do you make the diagnosis of DHF? There is an emerging consensus
that DHF can be diagnosed based on the presence of two criteria: 1)
symptoms and signs of HF, and 2) a normal ejection fraction (>50%).
The measurement of diastolic function is not mandatory but may be
confirmatory."

evanspx@sutterhealth.org

(One example would be high output CHF due to anemia for CHF w/o either)>

I am saying the LVEF 'may' be normal, but that some other morphology or function of the LV should be 'abnormal' in the diagnosis of DCHF. Some process, such as HTN, has caused a stiffening of the LV resulting in abnormal filling and emptying. Therefore, the echo can't be 'normal'.


Two aspects to consider: % of LV

Performance/morphology of LV pressure, filling, compliance, et al.


Paul Evans, RHIA, CCS, CCS-P, CCDS

katysuegood@gmail.com

Ahhh... high output HF. I vaguely recognize this term

Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404

tkreiling

Great article. Thanks.

Tara RN.CCDS

katysuegood@gmail.com

This is a VERY helpful article and seems to suggest that noninvasive measure of diastolic dysfunction is often inaccurate. They suggest that Diastolic HF would be appropriate with s/s of CHF and preserved EF alone.
Interesting stuff. Thank you!!


Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404

kerryseekircher

THANK YOU for sharing this article!
Kerry

Kerry Seekircher, RN, CCDS
Documentation Specialist Supervisor
Northern Westchester Hospital
400 East Main Street
Mount Kisco, NY 10549
Email: kseekircher@nwhc.net
Phone: 914-666-1243
Fax: 914-666-1013

sannwoody

There can also be heart failure caused by critical aortic stenosis.

kerryseekircher

I have a few doctors that on occasion will say that it isn't systolic or diastolic but valvular or as a result of rapid a fib/tachycardia. I have talked to my Advisor who agrees that sometimes it is not possible to differentiate. On the contrary, I have had a cardiologist tell me that if it is not systolic, it has to be diastolic!

cindy.pritchett04

I just read a National Teaching Institute (NTI) presentation from the
American Association of Critical Care Nurses that might help clarify/shed
light on the systolic vs diastolic HF issue r/t rapid atrial arrhythmias
and valvular disease. Here is the link (not a hyperlink - have to cut and
paste into the browser window):

http://events.mediasite.com/Mediasite/Play/e6e831f36b314894908267e487846dcd1d
(HF
slide presentation from the 2012 NTI critical care nursing conference in
Anaheim)

Slide #24 states that "Heart Failure with Preserved Ejection Fraction
(HFPEF) is almost always associated with diastolic dysfunction or impaired
relaxation of the left ventricle and is often equated with diastolic HF."

It makes clinical sense - if the patient has Afib/RVR there is decreased
left ventricular filling time and inadequate emptying of the left atrium
resulting in pulmonary congestion. The same problem could/would be present
with an incompetent/stenotic valve - improper functioning of the valve
resulting in forward-flow issues and impaired filling times. I found it a
great HF refresher - and it's a current & credible resource.

Cindy Pritchett, RN, BSN, CCDS
MedPartners CDI Consultant