Heart failure is a common syndrome in the United States and is increasing in prevalence. Approximately 6.2 million adults older than 20 years had heart failure in 2013-2016 compared with approximately 5.7 million in 2009-2012 (Virani et al., 2020). Heart failure is one of the most common reasons for hospitalization in adults and the risk for heart failure increases with age (McDermott, 2017; Virani et al., 2020). Early heart failure symptoms can be insidious and if nurses are not aware, subtle symptoms and risks may be overlooked. It is common for adults older than 65 years to be admitted to the hospital for orthopaedic surgery. Although the specialty of orthopaedic surgery in older adults is largely focused on bone quality, the risks and complications of heart failure should not be overlooked. The purpose of this article is to present two cases of orthopaedic patients with heart failure, describe the pathophysiology and management of heart failure with reduced or preserved ejection fraction (HFrEF or HFpEF), and the role of the nurse in managing patient care in the acute orthopaedic setting.

Patient Presentation

An orthopaedic nurse is caring for two postoperative patients with heart failure. Patient A is a 65-year-old man who has undergone an elective right hip arthroplasty for osteoarthritis. His medical conditions include coronary artery disease with myocardial infarction, HFrEF (32%), hypercholesterolemia, and hypertension. He takes the following scheduled medications: aspirin, atorvastatin, carvedilol, furosemide, hydralazine-isosorbide dinitrate, sacubitril, spironolactone, dapagliflozin, and valsartan. Postoperative pain management includes parenteral morphine or ketorolac as needed tapered to oral ibuprofen. His current vital signs and relevant laboratory values are temperature: 99.1 [degrees]F, heart rate: 66 beats per minute, respirations: 16 per minute, blood pressure: 138/88 mmHg, oxygen saturation: 98% on 2 L of oxygen, height: 5'9", weight: 200 lb, and body mass index: 29.5 kg/m². The patient is receiving 0.9% sodium chloride at 125 ml/hour with orders to taper and saline lock as diet is advanced. He has 300 ml of fluid balance positive for the past 24 hours. His current laboratory values are listed in Table 1.

Table 1. Patient A's Laboratory Values

Patient B is an 80-year-old woman admitted after a fall in which she fractured her right femoral neck. She has undergone a minimally invasive open reduction-internal fixation of the right hip. Her medical conditions include atrial fibrillation, HFpEF (56%), hypercholesterolemia, hypertension, and Type 2 diabetes mellitus. She takes the following scheduled medications: apixaban, aspirin, atorvastatin, empagliflozin, enalapril, metformin, and metoprolol. Postoperative pain management includes parenteral morphine or ketorolac as needed tapered to oral ibuprofen. Her current vital signs and relevant laboratory values are temperature: 98.5 [degrees]F, heart rate: 89 beats per minute, respirations: 22 per minute, blood pressure: 158/92 mmHg, oxygen saturation: 90%, height: 5[spacing acute] 6[spacing double acute], weight: 200 lb, and body mass index: 32 kg/m². The patient is receiving 0.9% sodium chloride at 125 ml/hour with orders to taper and saline lock as diet is advanced. She has 1,200 ml fluid balance positive for the past 24 hours. Patient B's current laboratory values are listed in Table 2.

Table 2. Patient B's Laboratory Values

Although patient A and patient B appear similar, a careful review of each patient's clinical condition, comorbid conditions, and pharmacological management illustrates that the patients have different forms of heart failure.

Pathophysiology and Hemodynamics

Heart failure is a complex clinical syndrome that occurs when low cardiac output deprives the cells and tissues of oxygen (King et al., 2012; Yancy et al., 2013). Low cardiac output, which usually involves the left ventricle, can be caused by a functional or structural change in the heart muscle cells (cardiomyocytes). Cardiomyocytes may undergo fibrotic remodeling and dilation, which decreases the pumping action, or, may become shorter, thicker, and stiffer, which prevents the ventricle from filling. In either case, stroke volume (amount of blood pumped from the heart per beat) and cardiac output (amount of blood pumped from the heart per minute) decrease. Neurohormonal dysregulation causes cardiac functional intolerance, fluid retention, and decreased patient longevity. See Table 3 for common hemodynamic terms used in heart failure.

Table 3. Common Hemodynamic Terms Used in Heart Failurea

Heart failure is classified by ejection fraction (EF) (Bozkurt et al., 2021). HFrEF (EF <40%) commonly occurs in middle aged men with a history of atherosclerosis, coronary artery disease, and myocardial infarction (Murphy et al., 2020). Structural changes include thinning and weakening of the myocardium and ventricular chamber dilation. In response, end-diastolic volume increases and stroke volume and cardiac output decrease. Figure 1 is an image of a heart without heart failure and Figure 2 is an image of a heart with HFrEF.

Figure 1. Heart without heart failure. Reprinted with permission from Novartis Pharmaceuticals.

Figure 2. Heart failure with reduced ejection fraction. Reprinted with permission from Novartis Pharmaceuticals.

In contrast, HFpEF (EF >50%) typically occurs in women who are older, obese, chronically hypertensive, and have a history of atrial fibrillation (Adamczak et al., 2020; Reddy et al., 2018). Structural changes include concentric thickening of the myocardium and reduced ventricular chamber size. In response, end-diastolic volume, stroke volume, and cardiac output decrease (see Figure 3).

Figure 3. Heart failure with preserved ejection fraction. Reprinted with permission from Novartis Pharmaceuticals.

Manifestations

Symptoms of heart failure depend on the patient's day-to-day clinical status and chronic disease management. Well-managed patients may be asymptomatic. More commonly though, patients experience episodes of fatigue and dyspnea that limit physical activity. Corresponding objective findings of fluid overload include weight gain, pulmonary crackles, jugular venous distension, and peripheral edema.

Distinguishing between HFrEF and HFpEF can be challenging because of their similar manifestations. The cardiac examination and chest radiography provide additional clues. Patients with HFrEF may have an abnormal S3, a heart sound associated with increased early diastolic volume. Instead of the typical S₁-S₂ heart sound pattern, the nurse will hear an abnormal rhythm: S₁-S₂-S3-S₁-S₂-S3 (lub-dub-duh--lub-dub-duh). Because an S3 is associated with volume overload, the chest radiograph shows pulmonary congestion and cardiomegaly.

In contrast, patients with HFpEF may have an abnormal S4, a heart sound associated with atrial contraction into a stiff ventricle. The sound of an S4 is subtly different from that of an S3 with the abnormal sound preceding S₁-S2: S4-S₁-S₂-S4-S₁-S₂ (duh-lub-dub-duh-lub-dub). The chest radiograph shows pulmonary congestion, but cardiomegaly is typically not present.

Diagnostic Tests

A noninvasive ultrasonic echocardiography is performed at diagnosis, when there is a change in clinical status, and as part of operative clearance. The images produced provide information about heart size and motion, chamber size, contractility, and valve function. End-diastolic volume, end-systolic volume, stroke volume, and cardiac output measures are used to calculate the ejection fraction.

Blood tests including B-type natriuretic peptides (BNP) and N-terminal (NT)-prohormone BNP (NT-Pro BNP) hormones are useful in diagnosing heart failure and monitoring its status. The NT and NT-Pro BNP are released by myocardial cells in response to increased volume, pressure, and stretch, and generate a beneficial sodium diuresis and vasodilation. The BNP and NT-Pro BNP values within the reference range of normal reliably rule out symptomatic heart failure. Elevated NT and NT-Pro BNP are associated with symptomatic heart failure, directly related to severity, and inversely related to prognosis. Like all tests, though, there is potential for false-positive elevations by conditions other than heart failure. For example, ischemic, valvular, and atrial arrhythmic cardiac conditions; advancing age; renal failure; pulmonary hypertension; and certain heart failure medications may falsely elevate values (Mayo, 2021). Generally accepted heart failure laboratory reference ranges are listed in Table 4.

Table 4. Generally Accepted Heart Failure Laboratory Reference Ranges

Management

As shown in Table 5, The American Heart Association/American College of Cardiology and New York Heart Association provide frameworks for conceptualizing heart failure based on structural disease and severity of symptoms (Dolgin, 1994; Minton, 2019). Treatment goals focus on slowing disease progression and minimizing heart failure symptoms. This article focuses on the management of Stage C heart failure.

Table 5. American College of Cardiology/American Heart Association and New York Heart Association Classification Comparison

Pharmacologic Therapy

The patients presented earlier illustrate medical guided management approaches. Generally, medicines are used to treat underlying conditions, ease symptoms, improve quality of life, and reduce morbidity and mortality.

In HFrEF, pharmacological therapy is directed toward reducing the maladaptive responses to reduced cardiac output: renin-angiotensin-aldosterone and sympathetic activity. Pharmacological therapy with renin-angiotensin-aldosterone inhibitors and [beta] receptor blockers has been proven to reduce morbidity and mortality in patients with HFrEF. Although many of these same drugs are used to treat patients with HFpEF, to date none have proven the ability to reduce morbidity and mortality and instead are used to manage comorbid conditions (Yancy et al., 2013; Yancy et al., 2017).

Comorbid Conditions

Hypertension, atherosclerosis, and diabetes mellitus are risk factors for the development and progression of heart failure. Goal-directed treatment should aim to achieve blood pressure control (goal: <130/<80; Whelton et al., 2018), reduce low-density lipoproteins (goal: 30%-50% reduction; Grundy et al., 2019), and control diabetes (goal: A_1C<7%; Garber et al., 2020).

Diuretics

Diuretics should be used for patients with fluid retention to ease the symptoms of dyspnea and shortness of breath and to maintain a stable weight. Generally, loop (furosemide) or thiazide (hydrochlorothiazide) diuretics are used and carry a risk of hypokalemia. Diuretics are less effective in patients with a high sodium diet, impaired renal function, and excessive use of non-steroidal anti-inflammatory drugs.

Renin-Angiotensin-Aldosterone/Neprilysin Inhibitors

Two classes of drug inhibit the renin angiotensin-aldosterone (RAA) system: angiotensin-converting enzyme inhibitors (ACE_i; e.g., lisinopril) and angiotensin receptors blockers (A₂RB; e.g., valsartan). One of these drugs should be used in all patients with HFrEF to reduce morbidity and mortality (Yancy et al., 2013). The benefit is likely achieved by three mechanisms: (1) vasodilation easing the work of the heart, (2) increased renal blood flow and sodium excretion reducing blood volume, and (3) reduced myocardial and vascular remodeling and fibrosis.

For patients whose symptoms persist despite RAA inhibition, substituting the ACE_i or A₂RB with a newer drug that combines valsartan with sacubitril, a neprilysin inhibitor, is recommended (Lewis et al., 2017; Murphy et al., 2020; Yancy et al., 2017). Sacubitril blocks the enzymatic breakdown of natriuretic peptides resulting in beneficial sodium diuresis and vasodilation and may reverse cardiac remodeling (Murphy et al., 2021).

When ACE_i or A₂RBs are used to treat patients with HFpEF, the indication is typically hypertension or chronic kidney disease (Yancy et al., 2013; Yancy et al., 2017). Sacubitril provides no benefit compared with valsartan alone and is not indicated for HFpEF (Solomon et al., 2019).

[beta]-Blockers

Three [beta]-blockers (BB) (e.g., carvedilol, metoprolol, and bisoprolol) reduce morbidity and mortality in patients with HFrEF (Yancy et al., 2013). The beneficial effects are likely related to blunting sympathetic activity and its associated vasoconstriction and tachycardia. The BBs are also used to control heart rate in patients with chronic atrial fibrillation, a common complication of heart failure but particularly prevalent in patients with HFpEF (Reddy et al., 2018; Sartipy et al., 2017).

Aldosterone Receptor Antagonist

Patients with HFrEF of less than 35% should be prescribed an aldosterone receptor antagonist (e.g., spironolactone) in addition to an ACE_i or A₂RB and BB. Unopposed aldosterone has deleterious effects including fluid retention and cardiovascular remodeling and fibrosis. Spironolactone offsets these effects and reduces morbidity and mortality (Yancy et al., 2013). The use of spironolactone in patients with HFpEF is less clear and dosing should be guided by elevated natriuretic peptides (Pitt et al., 2014; Yancy et al., 2013). Because spironolactone is associated with hyperkalemia, periodic monitoring of potassium is indicated.

Sodium Glucose Cotransporter Inhibitors

Sodium glucose cotransporter inhibitors drugs (e.g., empagliflozin and dapagliflozin) used for glucose control in patients with Type 2 diabetes mellitus have also been studied in patients with HFrEF. In patients on standard therapy for HFrEF, the addition of empagliflozin or dapagliflozin reduced cardiovascular death and heart failure hospitalization in patients with diabetes and those with no diabetes alike (Packer et al., 2020; Zannad et al., 2020). The benefit is attributed to glucosuria-induced volume loss with a resulting lowering of blood pressure. A current trial is underway to determine a therapeutic benefit of empagliflozin in patients with HFpEF (Anker et al., 2019).

Pharmacologic Therapy for Specific Patient Groups

Members of the Black community experience heart failure at an earlier age and have more severe disease compared with patients who are White (Virani et al., 2020). Many drug studies have relatively low Black representation or study a large heterogenous group making the usefulness of a particular drug for people who are Black less clear (Sharma et al., 2014). There are a few exceptions.

Patients who are Black and have Stage III HFrEF benefit from a fixed combination of hydralazine and isosorbide dinitrate in addition to standard therapy with an ACE_i or an A₂RB (Taylor et al., 2004). Furthermore, because enalapril and carvedilol demonstrate similar benefit for Blacks and Whites, these specific agents should be used for patients who are Black until further studies are completed (Sharma et al., 2014).

Although knowledge about specific drugs may ensure that a basic standard of care is followed, nurses must acknowledge other variables that adversely influence patient outcomes. Awareness of implicit bias, knowledge of structural racism, and awareness of social determinants of health may help the nurse address the inequities experienced by patients who are Black (Breathett, 2020).

Nonpharmacologic Therapy

Exercise Training

Exercise training is recommended for patients with HFrEF and HFpEF. Exercise training improves quality of life while posing no significant danger to heart failure patients. Benefits of exercise depend on the type and stage of heart failure but generally include improved exercise capacity, decreased fatigue, and reduced hospitalizations and death (Long et al., 2019; Pandey et al., 2015).

Patient Education

Heart failure is a chronic, progressive disease that requires patient involvement to optimize health and delay disease progression. Patient education should be simple, realistic, and focused. The American Heart Association provides a variety of educational resources for patients. The "Rise Above Heart Failure Self-Check Plan for Heart Failure Management" is especially helpful because it prioritizes six key management areas by color (green-orange/yellow-red) depending on the patient's condition (see Supplemental Digital Content 1, available at: http://links.lww.com/ONJ/A18; American Heart Association, 2019). The Self-Check Plan provides simple and clear instructions for a variety of common heart failure scenarios a patient may experience. Nurses should use these resources to assist patients in understanding clinical symptoms and recommended management strategies.

Summary

The HFrEF and the HFpEF are two distinct syndromes based on different pathophysiological etiologies. Most patients with heart failure experience some restriction of physical activity due to fatigue, dyspnea, and fluid overload. Patient characteristics, disease history, and diagnostic testing help distinguish between reduced and preserved ejection fraction. Many of the same medicines are used for pharmacological management. Importantly, medicines that are known to reduce morbidity and mortality of HFrEF may not confer the same benefit for HFpEF but instead are used to manage comorbid conditions. Table 6 summarizes the similarities and differences between patient A, with HFrEF, and patient B, with HFpEF, and highlights the respective nursing considerations.

Table 6. Summary: Similarities and Differences Between Patient A, With HFrEF, and Patient B, With HFpEF

Implications for the Orthopaedic Nurse

Orthopaedic nurses will likely care for patients with heart failure during an episode of orthopaedic care. In the environment of bundled payment, nurses are working in a system where the hospital gets reimbursed at a set rate per patient. Nurses must ensure the standard of care and assist in minimizing complications, which can delay patient discharge or contribute to readmissions (Salmond & Echevarria, 2017). Patients undergoing orthopaedic surgery who have heart failure have an increased incidence of hospital complications, prolonged lengths of stay, and readmission (Correale et al., 2020; Gholson et al., 2017; Sweitzer, 2016; Xu-Cai et al., 2008). There are many opportunities for orthopaedic nurses to impact the trajectory of patients who have or are at risk for heart failure.

The preadmission nurse should identify patients with symptomatic heart failure. The Centers for Medicare & Medicaid Services requires all patients receiving regular care for heart failure to have a regular assessment of functional status (Centers for Medicare & Medicaid Services, 2020). The preadmission nurse should review these documents, if available, or ask the patient about recent heart failure symptoms using similar standardized questions. Worsening shortness of breath, fatigue, leg swelling, orthopnea, and limitations in activity of daily living 2-4 weeks before surgery should prompt the preadmission nurse to clarify cardiac clearance because symptomatic heart failure increases the likelihood of surgical complications (Fleisher et al., 2014). Especially in older adults, when orthopaedic pathology limits activities of daily living, the preadmission nurse should seek information about cardiac capacity for surgery from a recent pharmacological stress test, echocardiography, or other recent evaluation (Greenstein & Gorczyca, 2018).

The preadmission nurse should document critical preoperative data, which will provide a point of comparison once the patient is hospitalized. Critical data include a complete home medication list including doses, recent laboratory values (especially electrolytes and renal function), and usual home weight (Joshi & Gyllensten, 2019; Ronco et al., 2018). Preoperative optimization of weight, potassium levels, and kidney function may mitigate some of the complications associated with fluid imbalances during the intra- and postoperative periods (Bushnell et al., 2008).

The orthopaedic nurse providing postoperative care to a patient with comorbid heart failure must perform an assessment of volume status. Minimally, the assessment should include weight and fluid balance, respiratory auscultation for crackles, and examination of the lower extremities for peripheral edema. Findings should be analyzed in the context of trends rather than in isolation. The orthopaedic nurse must also consider the impact of orthopaedic care on a patient with heart failure. Unilateral leg swelling may indicate postoperative swelling, an expected finding, whereas bilateral swelling may indicate worsening heart failure. Routine use of non-steroidal anti-inflammatory analgesics such as ibuprofen and ketorolac may adversely affect renal function and cause renal sodium and fluid retention. The orthopaedic nurse should consider recommending alternative analgesic approaches if appropriate.

The orthopaedic nurse caring for a patient with heart failure, regardless of type, should carry out independent and dependent interventions that ensure that the patient remains euvolemic during the perioperative period (Bushnell et al., 2008). Overly aggressive fluid restriction may lead to hypotension, falls, and acute kidney injury. This is particularly true in patients with HFpEF who rely on ventricular volume to maintain cardiac output and blood pressure. Alternately, excessive and rapid fluid replacement can lead to fluid volume excess and acute decompensated heart failure, a medical emergency characterized by unstable vital signs, severe respiratory distress, diffuse pulmonary crackles, and hypoxemia (Barton-Maxwell, 2020). The orthopaedic nurse balances interventions to maintain euvolemia during the postoperative period.

The orthopaedic nurse must be aware of a patient's preoperative exercise capacity to ensure that postsurgical ambulation and physical therapy minimize deconditioning and do not increase heart rate excessively. Sustained, postoperative tachycardia is problematic for patients with heart failure. First, tachycardia may increase myocardial oxygen demand and trigger cardiac ischemia. Second, tachycardia shortens ventricular filling time, which decreases cardiac output and may lead to hypotension (Rudolph, 2020). Monitored ambulation using a pulse oximeter assists the nurse in determining the effect of exercise on heart rate.

Transitions of care from the hospital to home are complex for the patient because surgical recovery overlaps with heart failure management. Discharge instructions must address orthopaedic rehabilitation in the context of heart failure limitations. Physical and occupational therapy may need to be modified according to the patient's heart failure status. Medication reconciliation from hospital to home must address any confusion that may occur because of added pharmacotherapies (Manias et al., 2020). For example, short-term anticoagulation is standard for venous thrombosis prophylaxis in patients undergoing hip or knee arthroplasty. However, many patients may already be taking an antithrombin agent due to underlying atrial fibrillation. A careful review of a patient's medications may help reduce medication errors. Including a pharmacist in the interprofessional team may be helpful for discharge planning (Choi & Babiak, 2018).

The time of discharge is an effective opportunity for the orthopaedic nurse to remind a patient about or introduce a patient to the "Rise Above Heart Failure Self-Check Plan for Heart Failure Management" (American Heart Association, 2019). Regular self-assessment helps the patient gauge the need for adjusting treatment or contacting the provider (American Heart Association, 2019; Joshi & Gyllensten, 2019). Encouraging patients to engage in self-care activities is associated with improved survival (Park et al., 2017).

Conclusion

Improved management of cardiac conditions has led to increased survival and prevalence of patients with heart failure. This, along with the aging population in the United States, makes it likely that orthopaedic nurses will be caring for patients with heart failure. Knowledge about the specific forms of heart failure, reduced and preserved ejection fraction, and their management will assist the orthopaedic nurse in the clinical management of patients with heart failure undergoing orthopaedic procedures.

Acknowledgments

The authors acknowledge Dr. Howe for his assistance in preparing this article and Helen Frei-Howe for her assistance with the figures.

References