Individuals in Stage A at high risk for HF have predisposing factors that put them at high risk for developing the cardiomyocyte loss or dysfunction characteristic of HF. However, in many instances, steps can be taken to prevent or reduce the conditions that may progress to heart failure (Tello, et al. 2017). The goal for these patients is to prevent cardiac structural changes including hypertensive heart disease, cardiac remodeling, coronary heart disease (CHD) from developing (Yancy, et al., 2017).
Patient assessment of predisposing factors
Does the family history include any of the following?
- Sudden death
- Familial cardiomyopathy
- Idiopathic dilated cardiomyopathy
- Diabetes mellitus
- Family history of cardiomyopathy or sudden death
- Sleep apnea
- Cardiovascular disease (e.g., valvular heart disease, coronary heart disease, atrial fibrillation).
Does the patient’s medical history indicate any of these conditions?
- Diabetes mellitus
- Sleep apnea
- Cardiovascular disease (e.g., valvular heart disease, coronary heart disease, atrial fibrillation)
- Alcohol and substance abuse (current or past) (Klatsky, 2015)
- Age (60>)
- Thyroid disease
- Chronic kidney disease
- Metabolic Syndrome management
Does the patient’s medical history indicate exposure to any of the following cardiotoxic substances which can increase the incidence of HF?
- Cocaine - Direct and indirect effects on myocardium that can increase risk of CHF and sudden cardiac death, prolonged tachycardia - left ventricular systolic dysfunction
- Chemotherapy agents
- Anthrcyclines (doxorubicin)
- Fluorouracil (5-FU)
- Antimicrotubular agents (paclitaxel, docetaxel)
- Inotropic drugs
- High Na+ content drugs
- Etanercept (HF treatment with anti-tumor necrosis factor activity)
- Infliximab (an anticancer tumor necrosis factor and proinflammatory cytokine)
- Herbal/natural product
- Trastuzumab and other monoclonal antibody (mAb) based tyrosine kinase inhibitors
Physical assessment of the cardiovascular system
- A blood pressure check – (Change in BP standard from 140/90 to 120/80 recommended as normal, AHA, 2015).
- A general assessment of blood circulation. Check skin color, fingernails and toenails, and pulses in several locations, including the neck, wrist, and feet.
- An examination of the blood vessels of the neck.
- Bulging or swollen neck veins may be a sign of heart failure.
- Changes in how the blood sounds as it flows through a narrowed artery can be heard when listening to the arteries in the neck (carotid arteries).
- Listen to the heart for heart murmurs and extra heart sounds.
- Listen to the lungs for abnormal breath sounds. Soft crackling sounds (crepitations or rales) may be a sign that heart failure has caused fluid to build up in the lungs.
- An examination of the abdomen. Using a stethoscope, listen to blood flow in the abdomen. Changes in the sounds of blood flow (bruits) may indicate a narrowed blood vessel in the abdomen.
- Check for swelling in the feet and legs (a sign of heart failure). To assess swelling in the legs, press down on the skin over the lower leg bone. Edema is present if the pressure leaves a dent in the skin. (Thibodeau & Drazner, 2018).
- Obesity – BMI 30 or over
- High fasting blood glucose (norms vary from tests but typically less than 100 mg/dL)
- B-type natriuretic peptide (BNP): elevated levels may be helpful in diagnosing a patient suspected of having HF or used to consider a diagnosis of HF when the diagnosis is unknown
- Echocardiogram to assess ventricular function, size, wall thickness, wall motion, and valve function.
Metabolic syndrome includes a cluster of risk factors that raises a person's risk for coronary heart disease, diabetes and stroke. Medications may be required. Lifestyle changes include heart-healthy diet, weight control, managing stress, physical activity, and quitting smoking (Yanping, et al., 2018).
The National Institutes of Health have identified five risk factors common to metabolic syndrome. The presence of three or more of these factors may indicate metabolic syndrome. The more risk factors a person has, the greater the chance of heart disease, diabetes and stroke.
Five risk factors:
- A large waistline also called abdominal obesity or having an apple shape. The excess fat in the stomach area creates the greatest risk factor for heart disease compared with excess fat in other parts of the body.
- A high triglyceride level (or being treated for high triglycerides).
- A low HDL cholesterol level (or on medicine to treat low HDL cholesterol).
- High blood pressure (or on medicine to treat high blood pressure).
- High fasting blood sugar (or on medicine to treat high blood sugar) (NHLBI, 2019).
American Heart Association. (2015). The American Heart Association’s diet and lifestyle recommendations. Retrieved from http://www.heart.org/HEARTORG/HealthyLiving/HealthyEating/Nutrition/The-American-Heart-Associations-Diet-and-Lifestyle-Recommendations_UCM_305855_Article.jsp#.WhbRcbS9-QA
Drazner, M. (2011). The Progression of Hypertensive Heart Disease. Circulation. 123 (3), 327-34.
Klatsky, A.L. (2015). Alcohol and cardiovascular diseases: where do we stand today? J Intern Med., 278(3), 238-50.
Mesas, A. E., Leon-Munoz, L.M., Rodriguez-Artalejo & Lopez-Garcia, E. (2011). The effect of coffee on blood pressure and cardiovascular disease in hypertensive individuals: a systematic review and meta-analysis. Am J Clin Nutr, 94 (4), 1113-1126.
National Heart, Lung, and Blood Institute (NHLBI). (2019). Metabolic Syndrome?
National Heart, Lung, and Blood Institute (NHLBI). (2016). Assessing your weight and health risks. Retrieved from http://www.nhlbi.nih.gov/health/educational/lose_wt/risk.htm
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Szmitko, P. E. & Verma, S. (2005). Red Wine and Your Heart. Circulation. 111, e10-e11.
Tello, M. (2018). Healthy lifestyles: 5 keys to a longer life. Harvard Health Publishing. https://www.health.harvard.edu/blog/healthy-lifestyle-5-keys-to-a-longer-life-2018070514186.
Thibodeau, J. T. & Drazner, M.H. (2018). The Role of the Clinical Examination in Patients with Heart Failure. JACC Heart Fail. 6(7), 543-551.
Yanping, et al. (2018). Impact of healthy lifestyle factors on life expectancies in the US population. Circulation. 138(4), 345-355.
Yancy, C. W. et al. (2017). ACCF/AHA/HFSA Focused update of the 2013 Guideline for the management of heart failure. A report of the American College of Cardiology/American Heart Association task force on practice guidelines and the Heart Failure Society of America. Circulation. 136(6), 137-161.