Each issue of the CoramClick provides an in-depth focus on timely and practical solutions. In this issue of the Click, we are focusing on Heart Health. Back issues of the Click are available in the CoramClick archive for easy reference!
Heart Failure
Heart failure is a rapidly growing concern in our society. Approximately 5.5 million Americans have heart failure, with over 550,000 new cases diagnosed each year. It causes approximately 40,000 deaths annually and contributes to another 250,000 deaths. The economic burden of managing these patients is staggering; the estimated cost is $29 billion dollars annually. Ideally, the best defense against heart failure is the prevention of heart disease, making clinical interventions that promote heart-healthy lifestyles of paramount importance.
Heart failure occurs when the heart loses its ability to pump enough blood through the body. It usually is a slowly progressing clinical syndrome, and the severity of the condition determines the impact on a person’s life. However, even in its mildest form, heart failure must be treated to prevent progression.
The term congestive heart failure is often used to describe all patients with heart failure. Actually, there are two main categories of heart failure: systolic heart failure (the heart’s ability to contract decreases); and diastolic heart failure (the diminishing of the heart’s ability to relax). In addition, there are four classes of heart function capacity, as defined by the New York Heart Association (NYHA) for heart failure patients. They are as follows:
- Class 1 - No limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation or dyspnea.
- Class 2 - Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in fatigue, palpitation or dyspnea.
- Class 3 - Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes fatigue, palpitation or dyspnea.
- Class 4 - Unable to carry out any physical activity without discomfort. Symptoms of cardiac insufficiency at rest. If any physical activity is undertaken, discomfort is increased.
Many patients with class 3 or 4 heart failure have symptoms of both systolic and diastolic heart failure. The primary signs and symptoms of heart failure include dyspnea, paroxymal nocturnal dyspnea (increased dyspnea when lying down), fatigue, edema (especially peripheral and abdominal fluid accumulation), weight gain, persistent cough and tachycardia.
Risk factors for the development of heart failure include natural consequences of aging and congenital abnormalities. However, the major risk factors include history of coronary heart disease, smoking, high cholesterol levels, hypertension, diabetes and obesity. Of these risk factors, uncontrolled hypertension literally doubles an increased risk of heart disease, and patients with diabetes run a risk that is two to eight times greater than that of nondiabetic patients. A history of heart attack with muscle damage and scarring along with cardiac arrhythmias also increase the risk of heart failure.
Patients are usually diagnosed with heart failure after an assessment of symptoms and risk factors in conjunction with other clinical tests, including electrocardiograms, echocardiographies, chest x-rays, cardiac stress tests, and cardiac catheterizations. Once diagnosed, a patient is categorized according to the NYHA functional classifications described above.
Managing Heart Failure
Heart failure management may include a combination of factors, including lifestyle changes, oral and intravenous drug therapy, device support and surgical intervention. Examples of lifestyle changes include diet (decreased sodium, cholesterol, calories and limited alcohol intake), exercise and smoking cessation. Drug therapy in the initial stages of heart failure usually includes two or more of the following therapies:
- ACE (angiotensin-converting enzyme) inhibitors
- ARBs (angiotensin-II receptor blockers)
- Beta blockers
- Digitalis
- Diuretics
- Vasodilators
Additionally, other therapies such as lipid lowering agents (to treat high cholesterol) and anticoagulation with warfarin (recommended for patients with atrial fibrillation and considered for patients with left ejection fraction of 35 percent or less) may be prescribed.
Many times, surgical interventions may be performed. For example, surgery may be required to treat coronary artery disease with bypass surgery. Congenital pediatric abnormalities and abnormal heart valves are frequently repaired surgically. For severe class 3 or 4 cases, cardiac transplantation may be a treatment option. Additonally, heart devices such as artificial hearts, left ventricular assist devices (LVADs), implanted cardioverter defibrillators (ICDs) and pacemakers may be utilized.
When heart failure worsens despite optimal treatment with available oral pharmaceutical agents and other supportive care, intravenous inotropic agents may be prescribed to help a patient bridge to cardiac transplantation or provide palliative care.
Contact CardiacProgram@coramhc.com for more information about heart failure and its treatment.
Common Cardiac Codes
The following is a list of certain ICD-9 codes and V-codes associated with diagnosing major heart failure. Please note, this list is not all-inclusive and ICD-9 codes are updated on a regular basis. Always double check that you are using the current and correct code.
| 391.1; 397.9 |
Rheumatic endocarditis |
| 421-421.9 |
Acute/subacute endocarditis |
424.9-424.99
|
Endocarditis NOS |
| 425-425.9 |
Cardiomyopathy |
429.2
|
Cardiovascular disease, unspecified |
745-747.4
|
Congenital heart disease |
440-440.1; 414.0
|
Coronary artery disease |
428.0-428.9
|
Heart failure |
429.1
|
Myocardial degeneration with arteriosclerosis |
429.0
|
Myocarditis, unspecified with arteriosclerosis |
394.0-396.9
|
Valvular heart disease |
V42.1
|
Heart transplant |
996.83
|
Complications or rejection of heart transplant |
078.5
|
Cytomegalovirus infection |
|
Bug of the Month
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Clinical manifestations of Exophiala jeanselmei, (above) include endocarditis, mycetoma, localized cutaneous infections, subcutaneous cysts, endocarditis, cerebral involvement, and systemically disseminated infections. Image courtesy of the CDC/Dr. Libero Ajello. |
Infective Endocarditis
Infective endocarditis (IE) is an infection of the inner lining of the heart, most commonly involving heart valves. The infection is typically caused by bacteria, but fungal and viral infections also are possible. Endocarditis develops when: 1) nosocomial or spontaneous pathogens enter the bloodstream; 2) the organisms adhere and clump, causing vegetations; and 3) the organisms begin to invade the valvular leaflets.
Acute and Subacute Bacterial Endocarditis
Infective endocarditis is divided into two main categories: acute and subacute. Acute bacterial endocarditis (ABE) presents with marked toxicity and progresses over days to weeks to valvular destruction and metastatic infection. There is significant risk of developing congestive heart failure among patients with IE, the most common cause of death among those with the condition. Patients with ABE typically require immediate hospitalization.
By contrast, subacute bacterial endocarditis (SBE) evolves over weeks to months, with only modest toxicity and rare incidences of metastatic infection. Patients may present with vague and mild symptoms that may be ignored or misdiagnosed. A prolonged course of antibiotics is generally required for SBE and little residual damage is anticipated.
Incidence
There are fewer than 10,000 cases of endocarditis diagnosed annually in the United States, with an incidence of approximately one-and-a-half to six per 100,000 persons, but the risk of morbidity and mortality is high. Endocarditis is most typically found in adults, with increasing incidence as patient’s age, although children with underlying congenital and rheumatic heart disease may also be at risk. Risk factors include:
- Existing cardiac abnormalities (native valve disease) such as mitral valve prolapse, congenital heart diseases and rheumatic heart disease
- Prosthetic valve implantation
- Intravenous drug use
- Diabetes
- Pneumonia or other upper respiratory infections
- Osteomyelitis
- Skin or soft tissue infections
- Immunosuppression secondary to HIV/AIDS or transplant
As mentioned previously, IE can be due to a disease or defect in either a native valve endocartitis (NVE) or prosthetic valve endocartitis (PVE), each revealing unique characteristics. There also are several unique characteristics in IE secondary to intravenous drug abuse (IVDA). Intravenous drug abusers are at significant risk for IE with an incidence of an estimated one to two cases per 100,000 IV drug abusers per year. Infective endocarditis is responsible for 5 percent to 8 percent of hospital admissions among IV drug abusers. It most commonly affects the right side of the heart at the tricuspid valve. The organisms that cause IE in IV drug abusers likely originate from the skin or from contamination of the injected drug itself, its diluent or the paraphernalia used to prepare or inject.
Diagnosis
Diagnostic studies will likely include a search for positive blood cultures, an elevated sedimentation rate, low hematocrit, microscopic hematuria and proteinuria. They may also include cardiomegaly on x-ray, presence of new or changing murmurs, prolonged PR internal EKG changes, and abnormal ejection fractions as seen on echocardiograms.
Treatment
The goals of therapy are to identify and treat the causative organisms; provide fever and pain management; protect the heart and heart valves from further damage; and, as necessary, surgically correct a damaged valve. Treatment includes prolonged antimicrobial therapy to eradicate all infecting organisms. Parenteral therapy is preferred in order to achieve effective and consistent serum levels.
Specific antimicrobial treatment depends on the causative organisms, although empiric therapy with vancomycin and gentamycin may be initiated until the exact organisms and its sensitivities are known. For example, penicillin-sensitive streptococci may be treated with a four-week course of intravenous penicillin or ceftriaxome. In addition, the physician must assess the patient’s overall medical status, allergic reactions to medications, response to therapy and potential for home therapy.
Potential Complications
The potential complications of IE can be divided into two primary categories: intracardiac and embolitic.
Intracardiac complications range from the relatively minor infected vegetation that is treatable without negative sequelae to serious extending infection or valvular damage. Abscesses within the heart tissue, conduction abnormalities and pericarditis are examples of intracardiac complications. Among the intracardiac complications of IE, congestive heart failure has the greatest impact on prognosis.
Embolitic events can also occur. Pieces of vegetation can break off into the blood stream and cause, for example, abscesses in other areas of the body, with every organ or tissue being a potential target. These pieces also can block off flow to the arteries through which they travel. Systemic embolization occurs in 22 percent to 50 percent of cases of IE.
Relapse of the infection may occur, typically within one to two weeks following the cessation of therapy. Patients at risk for relapse include those for whom ineffective therapy was provided, perhaps due to wrong drug choice or patient noncompliance. Re-infection also is a significant risk for intravenous drug abusers.
Prognosis
If left untreated, IE is generally fatal. Early detection and appropriate treatment are lifesaving, and patients with bacterial endocarditis should be monitored carefully. Blood cultures should be obtained to ensure eradication of the organism. Fever usually resolves within several days of initiation of effective antibiotic treatment. Persistent fever after the first week of treatment suggests a septic embolic complication or inadequate antibiotic therapy. The recurrence of fever after an initial defervescence suggests a septic or nonseptic embolic event, a drug hypersensitivity reaction or the emergence of a resistant strain.
Home Infusion for Endocarditis
Evidence suggests that outpatient antibiotic therapy is a reasonable alternative to completion of therapy in the hospital for patients with uncomplicated endocarditis. This of course should only happen in medically stable patients after a proper pre-discharge assessment and careful patient selection with a clear plan for ongoing post-discharge assessment, monitoring and communication. Both the Infectious Disease Society of America and the American Heart Association acknowledge the success of treating selected patients with penicillin-susceptible endocarditis at home and several studies have borne out these results.
Do You Know?
What is the number one leading cause of death in America?
In the United States, 72 million adults have high blood pressure, 46 million smoke cigarettes, 36.6 million have cholesterol levels of 240 mg/dL or higher, 66 percent are overweight or obese, and less than 30 percent engage in light-moderate physical activity five times a week. The number one leading cause of death in America: coronary heart disease.
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Resource Center
American Heart Association
The American Heart Association is a national voluntary health agency whose mission is: “Building healthier lives, free of cardiovascular diseases and stroke.” To learn more, visit their website at www.americanheart.org.
Heart Failure Society of America
The Heart Failure Society of America, Inc. (HFSA) represents the first organized effort by heart failure experts from the Americas to provide a forum for all those interested in heart function, heart failure and congestive heart failure (CHF) research and patient care. To learn more, visit www.hfsa.org.
Start! Program Encourages Walking, Better Eating Habits
Developed by the American Heart Association, Start! is a movement calling on all Americans and their employers to live longer, more heart-healthy lives through walking and other healthy habits.
Heart Disease Deaths in American Women Decline
The National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health announced today that the number of heart disease deaths in American women is decreasing. Newly analyzed data shows that the number of women who die from heart disease has shifted from one in three women to one in four — a decrease of nearly 17,000 deaths from 2003 to 2004. View the NHBLI study online.
HFSA 2006 Comprehensive HF Practice Guideline Now Available
The HFSA has developed a heart failure practice guideline-specific website for healthcare professionals. This guideline addresses the full range of evaluation, care and management of patients with HF, including acute HF, disease management and HF in special populations. To view this guide, please visit the HFSA website at www.hfsa.org/hf_guidelines.asp. See also: updated scientific statements and practice guidelines from 2008-2009.
Bibliography
- Giessel, B.E., Koening, C.J., Blake, R.L. (March 2000). “Management of bacterial endocarditis.” Am Fam. Phys. 61 (6).
- Karchmer, A.W. (2001). “Infective endocarditis.” In Braunwald (Ed.). Heart Disease: A Textbook of Cardiovascular Medicine.
6th ed.
- Brown, P.D., Levine, D.M. (Sept. 2003). “Infective endocarditis in the injection drug user.” Inf. Dis. Clinics of N. Amer. 16 (3).
- Sexton, D.J., Spelman, D. (May 2003). “Current best practice and guidelines: Assessment and management of complications in infective endocarditis.” Cardiology Clinics 21 (2).
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