Don't miss 'red flags' for heart failure in females
Patients may deny or minimize symptoms
A woman with a history of carpal tunnel syndrome reports wrist pain while vacuuming. Would you suspect heart problems?
"The pain was gone, and she said yes, she had gotten a little sweaty during this, 'but doesn't everyone sweat when vacuuming?'" says Joan Somes, PhD, MSN, RN, CEN, FAEN, ED educator at St. Joseph's Hospital in St. Paul, MN. "Fortunately, my guardian angel told me to get an EKG [electrocardiogram] that day. The woman had ST elevation in her inferior leads and was rushed to the cath lab in 15 minutes from the time she was roomed."
Women and men present differently with heart failure, says a new study of 3,580 patients participating in the EuroHeart Failure Survey II. Women had new-onset acute heart failure, hypertension, and valvular disease more often, and they had coronary heart disease or dilated cardiomyopathy less often, compared with men.1
Johanna Bruner, MS, RN, FNP, director of cardiology services and the Emergency Medicine Center at University of California — Los Angeles Medical Center, says, "Across the board, all ED nurses need to recognize that there are many cases where women simply do not present with the same symptoms or in the same way as men."
Symptoms can be subtle
Heart failure may not present as crushing chest pain, into the jaw, and down the arm. A woman may tell you she is more tired than usual; getting short of breath more quickly; has palpitations or dizziness; or has vague shoulder, scapula, or wrist pain, says Somes.
"When ED nurses think about heart failure patients, they often picture the patient in decompensated heart failure, with acute respiratory distress, super wet lung sounds, and chest pain," says Somes. "Yet, a significant number of patients will present with less acute heart failure and its associated issues."
Women may minimize symptoms or deny they are continuing, she says. "Don't assume that it is just the wrong sized blood pressure cuff or anxiety that is causing the hypertension. It may actually be due to the heart having to work harder," Somes says.
Evaluate women with vague complaints carefully, especially if they have a history of diabetes or anemia, she says. "Swollen ankles, weight gain, or feeling bloated may be chalked up to too much salt, periods, allergies, taking nonsteroidals, being anxious, or being on their feet too much," Somes says. "Often, a woman will blame these symptoms on anything but a heart that is not working effectively."
Many times, these subtle symptoms may be glossed over in the ED, since the patient is not in acute distress, she Somes. "But it is important to identify those as risk, because they may become acute if not treated appropriately," Somes says.
Triage nurses need to be cognizant of any shifts or new symptoms in patients, male or female, says Bruner. "Shortness of breath, swelling in extremities or around eyes, and change in weight are all signs of fluid retention," she says.
Assess lung sounds thoroughly, and look closely for signs of fluid retention in the face and all extremities, says Bruner. "By the time these patients hit the ED, their symptoms, while subtle, may already indicate an acute progression," says Bruner. "Ongoing pulse oximetry, maintaining an upright position in bed, and giving oxygen are all immediate interventions not requiring a physician's order."
Carefully auscultate heart and lung sounds to identify the patient in trouble, says Somes. "Jugular venous distention, fine rales that do not clear with a deep breath or cough, or extra heart sounds should send up red flags," she says. "Blood pressures may not be affected, but heart rhythm should be monitored, as it appears new onset of atrial fibrillation is often associated with heart failure."
Patients presenting with stroke symptoms may have a clot as a result of the atrial fibrillation caused by acute heart failure, and they should have the cardiac system evaluated as well, adds Somes. Another red flag is an EKG with changes from previous EKGs, or a rhythm that cannot be documented as chronic due to lack of previous EKGs to compare it with, says Somes. "Careful monitoring of the blood pressure and identifying that it is not dropping, even after rest in a quiet area, should be a red flag as well," she says.
Obtaining a brain natriuretic peptide level to identify risk of fluid in the lungs may help with the differential if the chest X-ray is abnormal, adds Somes.
Hearts that are working harder will be strained, so look for cardiac markers being slightly elevated, says Somes. "It may not be enough to trigger the panic call from the lab, but the patient may have a high normal," she says. "The patient with low normal oxygen saturation should be considered in trouble, at least until proven otherwise."
Reference
- Nieminen MS, Harjola VP, Hochadel M, et al. Gender-related differences in patients presenting with acute heart failure. Results from EuroHeart Failure Survey II. Eur J Heart Fail 2008; 10:140-148.
Sources
For more information about heart failure patients in the ED, contact:
- Johanna Bruner, MS, RN, FNP, Director, Emergency Medicine Center, University of California — Los Angeles Medical Center. Phone: (310) 206-2447. E-mail: [email protected].
- Joan Somes, PhD, MSN, RN, CEN, FAEN, Staff Nurse/Department Educator, St. Joseph's Hospital, St. Paul, MN. Phone: (651) 232-3000. E-mail: [email protected].
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