1. Tarolli, Karen A. MSN, ARPN

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Heart failure is a complex, potentially life-threatening disease that takes the lives of thousands, and costs millions of dollars annually. As issue editor of this month's Critical Care Nursing Quarterly (CCNQ), I want to stress the importance of recognizing the signs and symptoms of heart failure, initiating treatment with approved medical therapies, as well as identifying risk factors that lead to the development of heart failure.


Because of misdiagnoses many people are treated for asthma, pneumonia, upper airway infections, and anxiety long before the diagnosis of heart failure is made. I want to dedicate this edition to expanding the nurses' knowledge of heart failure so that they can act as the patient's advocate to promote the early diagnosis and treatment of this patient population.


Although heart failure is a complex disease, diagnosing, treating, and involving the nurse in the care of the patient can be achieved by following the ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult 1 and Heart Failure Society of America (HFSA) Practice Guidelines. 2 The registered nurse (RN) plays a pivotal role in the management of the patient by encouraging dietary and medication compliance, monitoring daily weight, and assessing for worsening signs and symptoms of decompensated heart failure. The relationship that develops between the patient and RN can enable the patient to have an improved quality of life and live longer.


The article in the journal will differentiate between ischemic and nonischemic left ventricular systolic dysfunction. The terms ischemic versus nonischemic identifies those patients who have suffered some type of myocardial dysfunction related to ischemia as opposed to those who have some other etiology. Diastolic dysfunction is also poorly understood, and has a different etiology and treatment than that for systolic dysfunction. In order to adequately treat the patient, it is necessary to know the etiology of the dysfunction.


Since primary pulmonary hypertension is a rare disorder, some health care providers may never treat a patient with this diagnosis. However, many patients are often sent to larger academic hospitals for diagnosis and initiation of treatment, and then referred back to their community for maintenance care.


Drawing blood levels to evaluate brain naturetic peptide levels can quickly identify those patients presenting with signs and symptoms of heart failure versus some other pulmonary cause. The cost is inexpensive, about $25, roughly the cost of evaluating electrolytes in many hospitals. This level is a useful and simple piece of information that can be gathered in a quick and relatively noninvasive manner. It is especially useful in patients who are presenting with decompensated heart failure for the first time, as well as in those with concomitant respiratory illnesses.


Newer modes of treating heart failure also include an intravenous medication called nessiritide, and cardiac pacing devices knows as internal cardiac defibrillators and biventricular pacers. Knowing when and how to initiate nessiritide has a complex set of interactions, and should be used carefully, in a monitored setting. There is also specific echocardiographic and elektrokardiogramm criteria regarding the implantation of an internal cardiac defibrillator as opposed to a biventricular pacer, with advanced understanding and adherence of the studies that support their use.


And the final article in this edition will explain the process of orthotopic cardiac transplantation, which is often the final treatment option for certain patients. Although the media has raised awareness regarding organ donation and transplantation, it has also given the appearance that transplantation is easily performed and without complications. This is by no means a commentary to dissuade people from considering organ donation or transplantation, but a means of educating health care professionals in the complexity of choosing the proper candidate who would benefit from such a rare gift, and explaining the careful treatment that must continue throughout the transplant patient's lifetime.


It is because of my interest in heart failure that I chose these topics, and hope to make its diagnosis, treatment, and management less of a mystery. Having said this, I also want to stress that it takes a trained cardiologist in heart failure to manage the complexities of this disease. Also, it is of utmost importance to have a trained RN who understands the early signs and symptoms of heart failure, and build a rapport with the patient to improve or maintain the patient's quality of life.


I have been fortunate to have mentors such as Dr Michael Mathier, Dr Richard Shannon, and Shelly McCormick, MSN, APN, who have taught me that understanding heart failure is more than knowing how to treat a patient who presents with shortness of breath and ankle swelling. In nursing, we do not often have mentors or colleagues who take an interest in our career development, but because of their dedication to the advancements in heart failure they have inspired me to pursue a greater understanding of heart failure. I also thank my newest colleagues, Dr Srinivas Murali, Dr Guy Andrew McGowan, and Dr Dennis McNamara, who challenge me daily to provide the best care for those patients who suffer with heart failure.


Also a special thanks to Carmen G. Warner who asked me to be issue editor for CCNQ. She singlehandedly has guided RN's from the bedside to the publishing desks, and encouraged us to share our clinical expertise with others who are caring for the critically ill on a daily basis.




1. Hunt JS, Baker DW, Chin MH, Cinquegrani MP, Feldmanmd AM, Francis GS. ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult: Executive Summary. A Report of the American college of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2001. [Context Link]


2. Heart Failure Society of America Practice Guidelines. [Context Link]