Patient Care By Mar 11, 2015 This CE activity is approved by EMS World Magazine, an organization accredited by the Continuing Education Coordinating Board for Emergency Medical Services (CECBEMS) for 1 CEU.To take the CE test that accompanies this article, go to to take the test and immediately receive your CE credit.Heart failure (HF) is a common medical problem in the United States.It’s experienced by approximately 5.1 million persons, with more than 650,000 new cases diagnosed annually.1–3 The incidence of HF increases with age,2 and for Americans over 40 the lifetime risk of developing HF is 20%.4 It occurs most frequently among black men and least frequently in white women.5 HF is the primary diagnosis in more than a million annual U.S.hospital admissions.1 Patients admitted for HF are at risk for rehospitalization, with a one-month all-cause readmission rate of about 24% and a six-month rate greater than 50%.6–8 There were 60,341 deaths from heart failure in U.S.

in 2012, the last year for which data is available.9 Considering that in 2012 cardiovascular disease (the leading cause of death in the U.S.that year) killed 782,985 persons, we can determine that 7.7% of all cardiovascular deaths in 2012 were from HF.9 While survival rates for persons with HF have improved, the absolute mortality rates for HF are approximately 50% within five years of diagnosis.3,10 This month’s EMS World CE article uses three case scenarios to explore the evaluation and prehospital treatment of the patient with HF.These cases explore the clinical context of all the elements of the history and clinical exam to form a “big picture” understanding of the event, and also discuss the appropriate management of the patient with chronic and acute HF in the prehospital setting.Heart failure is the inability of the heart to produce adequate cardiac output to meet the perfusion and oxygenation requirements of the body’s tissues.It is a complex clinical syndrome that can arise from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood, resulting in decreased cardiac output.5 There are two mechanisms by which HF can occur: In systolic heart failure (SHF), the heart has impaired contractile function, resulting in a decreased stroke volume (SV) and cardiac output (CO) and subsequent low blood pressure.

Patients with SHF also have a decreased ejection fraction (EF).The EF is the percentage of blood pumped out of the ventricle with each heartbeat.A healthy adult would be expected to have an ejection fraction between 50%–75%.A patient with an EF less than or equal to 40% is said to have HF.5 A number of factors can lead to impaired myocardial contractile function.Acute myocardial infarction (AMI) can acutely lead to impaired contractility, as infarcted myocardium is significantly weaker than healthy myocardium.After an AMI the scarred, remodeled ventricular myocardium will have less contractile force than healthy myocardium.Dilated cardiomyopathy can result from many etiologies, including chronic hypertension.Chronically increased blood pressure stretches and dilates the ventricular tissue, making it weaker.Valvular disease and ineffective heart valves can allow the retrograde movement of blood during systole, resulting in decreased SV.In addition, faulty heart valves (such as the aortic and pulmonary semilunar valves) can impede the forward movement of blood, resulting in decreased SV as well as increased intraventricular pressures, which can cause further problems such as cardiomyopathies.11

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