Download 211 Heart Failure notes

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Heart Failure
John Miller
Heart Failure
 Etiology
o Contractility problems (inotropic state, ejection fraction)
o Preload excess (amount of blood in ventricle at the end of diastole)
o Afterload excess (pressure against which the left ventricle ejects)
o Heart rate
o Mortality rate higher in African Americans than Whites
o Ischemic heart disease leading risk factor
 Congestive: Backward failure, causing lung congestion and edema, peripheral edema
 Cardiogenic shock: Forward failure causing shock
Causes of CHF (backward failure)
 Right side
o Right ventricular MI or CHF
o Cor pulmonale
o Left ventricular CHF
o Pericardial tamponade
o Tricuspid or pulmonic valve problems
o Dysrhythmias
 Left side
o Left ventricular MI or CHF
o Pericardial tamponade
o Mitral or aortic valve problems
o Dysrhythmias
Right Sided Failure Assessment
 Increased preload
o Peripheral edema
o Enlarged neck veins
 Increased central venous pressure (CVP)
 Compensation
o Increased cardiac output
 Atrial and ventricular muscle hypertrophy
 Cardiac chamber dilation
 Increased heart rate
o Eventually failure returns because the heart has outgrown its blood supply.
Figure 31–2 The hemodynamic effects of right-sided heart failure.
Left Sided Failure Assessment
 Pulmonary edema
o Crackles, hypoxia, hypercarbia
 ICU: Elevated pulmonary artery pressure and decreased cardiac output measured with catheter
o Cardiogenic shock affecting brain, kidneys, GI, and skin.
o Increased ADH and aldosterone
 Compensation
o Same as right side CHF.
o Arterial vasoconstriction, also known as increased afterload
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Figure 31–1 The hemodynamic effects of left-sided heart failure.
Diagnostic findings
 Brain natriuretic peptide (BNP)
 Atrial natriuretic factor (ANF)
 Echocardiogram
 Chest x-ray
 Electrocardiogram (ECG)
 Doppler flow
 Arterial blood gas (ABG) analysis
 Liver enzymes
 Renal tests: blood urea nitrogen (BUN), and creatinine
Figure 31–4 Inflation of the balloon on the flow-directed catheter allows it to be carried through the
pulmonic valve into the pulmonary artery.
Treatment of CHF: General
 Oxygen
 ET intubation and ventilation if in respiratory failure
 Medications
o Diuretics
o ACE inhibitors
o Angiotensin II receptor blockers
o Nitrates (reduces pre- and afterload)
o Beta blockers
o Inotropes
o Anticoagulants
Treatment of CHF: Decrease Preload
 Diuretics
 Vasodilators
o Morphine used for pulmonary edema
 Fluid monitoring
o Weight /I&O: Helps detect the degree of fluid overload
o Limit fluid intake
 Mild sodium restriction
o No added salt or extremely salty foods
o 2,400 mg or less / day
 Positioning: Head of bed up at 45 degrees
Treatment of CHF: Decrease Afterload
 Reduce stress.
 Avoid isometrics and Valsalva.
 Vasodilator medications
 Avoid caffeine.
 ICU: Intra-aortic balloon pump (IABP)
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Treatment of CHF: Increase Force of Contraction
 Digoxin and other inotropes
 ICU
o Left ventricular assist devices (LVAD)
o Heart transplant
Living With the HeartMate LVAD - Laura
https://youtu.be/_djouz093Us
Treatment of CHF: Keep Heart Regular
 Rate between 60-100
 Sinus in origin
 Antidysrhythmic medications
 Pacemaker
 Pulmonary Edema
 More severe signs and symptoms of left sided CHF
o Pink, frothy sputum
 Results in acute respiratory failure
 ICU
o Pulmonary artery pressures increased
 Also measures left ventricle filling or preload and cardiac output
Diuretics
 Furosemide (works in loop of Henle)
 Use: CHF peripheral edema and pulmonary edema
 Therapeutic effect: Removes fluids and electrolytes, including potassium.
 Adverse effects
o Hypotension
o Hypokalemia
o Acute renal failure
o Thrombocytopenia
Angiotensin Converting Enzyme (ACE) Inhibitors
 Captopril
 Uses
o Reduce mortality in Heart failure
o Prevent MI
 Therapeutic effect: Vasodilation reduces afterload and improves cardiac output, which reduces L and R
heart failure
 Adverse effects
o Hypotension
o Heart block
o Hyperkalemia
o Neutropenia
o Bronchospasm
o Acute renal failure
Angiotensin II Receptor Blockers
 Candesartan
 Use: Similar to ACE Inhibitors
 Therapeutic effect: Similar to ACE Inhibitors
 Adverse effects: Similar to ACE Inhibitors
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Nitrates
 Nitroglycerin
o Different forms: SL, spray, PO, IV, topical
 Use: Congestive heart failure, angina, MI
 Therapeutic effect: Vasodilation reduces afterload and improves cardiac output, which reduces L and R
heart failure as well as relieves angina.
 Adverse effects
o Hypotension
o Headache
Beta Blockers
 Metoprolol
 Use: Hypertension, coronary artery disease (angina, MI)
 Therapeutic effect: Reduces beta1 effect causing a reduction in BP
 Adverse effects
o Dizziness, hypotension
o Thrombocytopenia
o Impotence
o Heart block
Inotropes
 Digoxin
 Use: CHF, atrial fibrillation and flutter
 Therapeutic effect: Increases contraction, decreases ventricular rate by blocking at AV node, converts
dysrhythmia to SR.
 Adverse effects: More prevalent in toxicity precipitated by hypokalemia; monitor serum levels
o Heart block, ventricular heart rate less than 60, and any other dysrhythmias
o Vision: halos, blurred
o Confusion
o GI: Nausea and vomiting
Pericarditis
 Risk factors: After MI or heart surgery
 Assessment
o Chest pain
o Pericardial friction rub
o Fever
 Complications
o Pericardial effusion
o Cardiac tamponade
 Increased CVP; decreased CO, BP, heart sounds
 Pulsus paradoxus: Systolic BP drops more than 10 mm in inspiration
o Chronic constrictive pericarditis
Pericarditis Interventions
 Anti-inflammatory and analgesic medications
o Aspirin and acetaminophen
o NSAIDs
o Corticosteroids
 Pericardiocentesis
 Surgery
 Partial or total pericardiectomy
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Valvular Heart Disease
 Risk factors
o Rheumatic fever
o Endocarditis
 Types
o Mitral, aortic, tricuspid, pulmonic
o Stenosis: Valve not opening completely, reducing flow forward to lungs or arteries causing shock
o Insufficiency: Valve not closing shut, leaking flow backwards to lungs or veins, causing CHF
Valvular Heart Disease Interventions
 Medications
o Same as for CHF
o Prophylactic antibiotics prior to any dental work or surgery
 Surgery
o Endovascular
 Balloon valvuloplasty (repair)
o Replacement
 Mechanical
 Anticoagulation is required.
 Tissue
 Fail sooner, may have to replace in 10 years
Figure 31–16 Balloon valvotomy. The balloon catheter is guided into position straddling the stenosed valve.
The balloon is then inflated to increase the size of the valve opening.
Heart Valve Replacement (types of valves) https://health.sjm.com/heart-valve-answers/treatmentoptions/heart-valve-replacement
Aortic Valve Replacement: Operative Technique. https://youtu.be/C-sIdppyaPQ
Congestive Heart Failure: Tony Carosella's Story https://youtu.be/7js2PAWYCW8