Heart Failure

Definition

Systolic heart failure indicates a pumping problem, the left ventricle is unable to contract forcefully. The reduced ventricular contractility fails to increase the stroke volume enough to meet the systemic demands. Echocardiogram results will show fractional shortening less than 28%.

Echocardiogram results with fractional shortening

  • between 22-27% for mildly decreased ventricular function and could represent early signs of systolic heart failure.

  • less than 22% are generally indicative of moderately decreased ventricular function or systolic heart failure

  • less than 15% are generally indicative of severely decreased ventricular function or systolic heart failure

Serum B-type natriuretic peptide (BNP), a cardiac neurohormone released in response to increased ventricular wall tension, is elevate. In children, BNP may be elevated in patients with heart failure due to systolic dysfunction (cardiomyopathy), as well as in children with volume overload (left-to-right shunts such as ventricular septal defect).

NT-proBNP level < 125 pg/mL = normal NT-proBNP level 125-350 pg/mL = indeterminate NT-proBNP level > 350 pg/mL = consistent with cardiac involvement

Diastolic Failure Definition

Diastolic heart failure indicates a filling problem. This dysfunction has normal ejection fraction.  There is decreased ventricular compliance as the ventricle is unable to relax that result in increase in venous pressure to retain the adequate filling in ventricles.

Echocardiogram results may show left or right ventricular diastolic function as “impaired filling or relaxation” typically written in report as forward flow in  right ventricular outflow tract during atrial contraction/systole, E-A peak velocity flow reversal, or flow reversal in the pulmonary veins or pseudonormal inflow pattern indicative of ventricular diastolic heart failure.  Other results may reference restrictive or hypertrophic cardiomyopathy – indicative of diastolic heart failure.

  •  Moderate diastolic heart failure may be evidenced by impaired filling or relaxation with elevated atrial pressure and/or dilation.

  • Severe diastolic heart failure may be evidenced by impaired filling or relaxation with restrictive ventricular diastolic physiology.

Classifications

Acute heart failure indicators:  rising lactate levels, abnormal BUN/Creatinine and/or liver function tests, elevated BNP

  • Symptomatic indicators:  dyspnea on exertion, shortness of breath, orthopnea, cool extremities, poor perfusion, Paroxysmal nocturnal dyspnea, or peripheral edema.  Infants may show increased work of breathing, poor feeding.  Gastrointestinal symptoms may be present such as feeding intolerance, vomiting, abdominal pain, mesenteric ischemia.

  • Supportive evidence of RIGHT heart failure --> enlarged liver/passive liver congestion, pitting edema of extremities, elevated/abnormal liver functions tests

  • Supportive evidence of LEFT heart failure rising lactate levels --> abnormal BUN/Creatinine, poor perfusion, pulmonary edema, low cardiac output

  • Treatment with IV diuretics (IV push or IV drip)

Chronic heart failure indicators:  ongoing treatment with oral medications

Acute on chronic heart failure indicators:  onset of new symptoms while on medications requiring additional therapy or escalation of medications with compensated heart failure.

Tips For Documentation

Address the underlying cause for medications being administered to manage heart failure

  1. Document heart failure classification (acute, chronic,  acute on chronic, or congestive heart failure)

  2. Document the underlying cause for the heart failure, i.e. structural (PDA, VSD, ASD, etc.) or congenital, toxins, etc.