Download Heart failure

Heart failure
Frank – Starling law – (an increase in diastolic filling increases the force of heartbeat)
the more stretch placed on a cardiac muscle the stronger the contraction (the more blood
a heart is presented with the harder/stronger the heart pumps)
Tricuspid valve – the valve between the right atrium and the right ventricle
Bicuspid/mitral valve – the valve between the left atrium and the left ventricle
Aortic valve – the valve between the left ventricle and the aorta
(No picture available)
Pulmonary valve – the valve between the right ventricle and the pulmonary artery
Normal venous return
Inferior vena cava drains the area below the diaphram
Superior vena cava drains the area above the diaphram
Coronary sinus drains the heart itself
The above 3 drain into the right atrium (80 % is delivered passively)
The right atrium is at a –5mm of pressure (this creates a vacuum)
Valve control
The papillary muscles assist the chordea tendineae in closing the valves (they act like
umbrella struts) while the ventricles contract to eject the blood within.
Each lung has 2 veins delivering blood to the left atrium (once again 80 % is delivered
passively)
Congestive heart failure (CHF)
General signs and symptoms
Failure in the heart in its function as a pump
Acute (CHF) – inability of the heart to
pump against an overwhelming obstacle.
(i.e. massive pulmonary embolism, or
massive myocardial infarction)
- Chronic (CHF) – progressive
loss of the heart, strength or
effectiveness as a pump due to
chronic stresses
Chronic (CHF) is the result of factors
intrinsic to the heart itself that weaken its
effectiveness as a pump and/or exposure to
extrinsic stresses, which chronically
overwork it. The heart is congested, it is
over-filled with blood that the heart cannot
get rid of, causing it to back up into the
veins.
Left sided ventricular weakness causes
blood to back up into the left atrium which
in turn backs up into the pulmonary veins,
which in turn congests the pulmonary
circulatory system which in turn increases
the load of the right ventricle, then the left
atrium, then the systemic circulatory
system.
Intrinsic factors



Wall (septum) or chamber defect (leakage into adjacent chamber)
Valve dysfunction (backflow into previous chamber)
Heart beat regulation problems
o (neural [av/sa node firing], irritable focus)
Figure 1 neural pathway with Av and Sv and perkinje fibres



Heart wall infarction
o Contractile strength decreases (decreased amount of healthy muscle tissue,
causes a decrease in the force of contraction)
o Chamber elasticity decreases (necrosis of tissue, and subsequent scarring
decreases the ability of muscle to elongate and thus contraction strength is
decrease ) (F/S law)
Decreased heart wall fitness (due to decreased perfusion of tissue)
Ischemic states/decreased perfusion of the heart wall
Extrinsic factors








Hypertension
Chronic respiratory conditions (heart has to work harder to transport O2 to
tissues)
Malnutrition of body tissues
Obesity (increased distance heart has to transport blood, ~1 mile of blood vessel
per pound of adipose)
Anemia (decreased erythrocytes to carry O2, heart has to work harder to
adequately perfuse body tissue)
Smoking (elasticity of artery wall, atherosclerosis, aging)
Sedentary life style (the heart is a muscle, and muscles that aren’t used weaken)
Liver/ kidney disorders (fluid regulation,)




Endocrine dysfunction (thyroid)
Conditions/diseases which damage the blood vessels (diabetes, rheumatic fever)
Emotional stress
Excessive physical stress
CHF progression
Under stress the heart will utilize 3 adaptations to improve its output and meet the
demands on it.
1. Increase heart rate
2. Chamber dilation (increases chamber volume, increases force of contraction by
prestretching fibers) see Frank – Starling law
3. Myocardial hypertrophy
Each of these adaptations is effective to a certain point; each has inherent potential
problems when used to excess.
1. Increased heart rate
 Less time spent in diastole causes decreased perfusion of the heart wall (the
myocardium is perfused during diastole) (an extreme example is ventricular
fibrillation)
 Decreased time for chamber fill / decreased contraction
 Oxygenation of the blood/ removal of CO2 can be compromised
 The increased rate will in itself stress the heart
2. Chamber dilation
 Decreased elasticity of chamber wall
 Exceed optimal stretch parameters of the cardiac cells
 Valvular incompetence (valve flaps can no longer close)
3. Myocardial hypertrophy



Decreased elasticity
Decreased chamber size
(decreases the amount of blood
that can enter the
 chamber and therefore
decreases the amount that can
be circulated throughout the
body.)
 Greater difficulty in perfusing
the overbulked heart wall
Enlarged heart compresses (restricts ventilation/lung capacity which increases
stress on the heart)
CHF progression
(Example of left sided heart failure. The diagram is displaying normal blood circulation)
1.
Systemic hypertension
2. Left ventricle stress- left
ventricle hypertrophy and
chamber dilation
3. Mitral (bicuspid) valve
incompetence
a. Regurgitation into the left
atrium
4. Myocardial hypertrophy and
chamber dilation more time spent
in active pumping (remember
normal is 80% passive)
5. Blood from lungs encounters
resistance entering the left atrium
a. Increased hydrostatic
pressure in vasculature of
lungs
b. Pulmonary hypertension
c. Pulmonary edema
6. Right ventricle stress
a. Right ventricle
hypertrophy and chamber
dilation
7. Tricuspid valve incompetence
a. Regurgitation into right
atrium
8. Right atrium stress
a. Right atrium hypertrophy
and chamber dilation
b. Right atrium loses
negative pressure
“vacuum effect”
9.
Venous return encounters
resistance entering the right
atrium
10. System hypertension
a. Systemic edema
remember the arrows would be going backwards to display the backwards progression
of CCHF
Cor pulmonale
Heart failure originating on right side due to respiratory dysfunction (occasionally known
to be caused by living for extended periods at high altitude)
General R.M.T. concerns or issues in treating a Chronic Heart Failure client.

Positioning – based on degree, the following may/must be applied:
o Prone – applies pressure on the aorta and inferior vena cava and can stress
the heart. It also creates more restriction on breathing.
o Supine – usually best tolerated but some degree of trunk elevation is
usually necessary. (Fowler’s position?)
o Sidelying - often good, maybe a limitation on time, but may be too
uncomfortable is there is cardiomegaly and/or pulmonary edema.
o Seated – is usually well tolerated if it’s physically comfortable. Caution
with trunk forward (re. Avoiding aorta and/or inferior vena cava
compression.
o a strong suggestion is to ask the client what position they normally sleep
in

Hydrotherapy
o Extremes of temperature and contrast increase the hearts workload so
adaptations are needed which match the client’s degree of chronic heart
failure.
o Factors affecting hydrotherapy treatment:
 Emersion of percentage of body
 Temperature extremes
 Duration
 Hydrostatic pressure on body – weight of water on the body (client
may have to bath in a shallow amount of bath water)
 Type of application – amount of body surface covered.
o *All must be considered and rejected or modified.

Monitor for sympathetic nervous system activation and avoiding elements
that will increase it:
o Surprise
o Techniques that stimulate – tapotement, brisk strokes, etc.
o Temperature (room and body)
o Comfort level generally in the room and with the therapist and treatment
plan.
o Pain
o Full bladder

Time of day, treatment duration etc.
o Sometimes “less can be more”
o Consider your treatment a mild form of exercise for the chronic heart
failure patient and match to the information you have about (ADL’s)
affects of daily living, (CHF) chronic heart failure level, etc.
o * Start moderately conservatively and enhance treatment if well tolerated.
Monitor reactions to treatment during and after.

Modify self care advice to be appropriate
o Hydro
o Exercise

Tissue fragility concerns:
o Modify pressure and traction to avoid tissue injury and bruising
o Be aware of dry, fragile skin. (Apply oil or substances, which assist skin
integrity.
o Ulceration concerns
o Massage therapy role is in prevention
o Open sores should not be massaged or have oil applied, (Major hygiene
concern).
o Early stage decubitis ulcer formation “red spot stage” contraindicated for
onsite massage.
o Be aware of delayed healing
o Trophic changes usually caused by decreased tissue nourishment

Awareness of treatment plan elements that increase venous return.
o These may need modification (i.e. long, broad, continuous strokes of
effleurage, while covering their whole back with a thermaphore)