Download Heart Failure Lecture Series

Elizabeth Johnson RN, BSN, PCCN
Upon completion of this competency the learner will:
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Describe the pathophysiology of Heart Failure
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Relate the differences between right and left Heart Failure
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Define the differences between systolic and diastolic Heart Failure
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Describe the treatments for heart failure & indicate their uses
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Describe appropriate nursing considerations that is needed during and at
the time of discharge
Blood pressure is the amount of force
(pressure) that blood exerts on the walls
of the blood vessels as it passes through
them. Two pressures are measured for a
blood pressure reading:
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Definitions
 Systolic: maximum pressure when blood is
expelled from the left ventricle
 Diastolic: diastolic pressure is the residual
arterial pressure when the heart is in diastole
and is a reflection of vasomotor tome as
measured by SVR
 Diastole counts for 2/3 of your cardiac cycle
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Mean Arterial Pressure (MAP) the
average pressure within an artery over a
complete cycle of one heartbeat.
MAP=Systolic + 2(Diastolic) / 3
MAP=(CO x SVR) + CVP
What is an average MAP?
 ~60mmHg
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100/40=
93/60=
70/61=
94/40=
110/32=
84/66=
70/40=
Which is the best?
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About 5.8 million people in the United
States have heart failure.
HF is the #1 cause for admission to
the hospital in adults ≥ 65 years old
HF is the #2 cause for admission to
the hospital in adults ≥ 18 years old
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Heart failure is a complex clinical syndrome that can develop
from any cardiac disorder that impairs the ability of the ventricle
to either fill properly or eject optimally. This syndrome results in
a pathologic state in which the heart is unable to pump enough
oxygenated blood to meet the metabolic needs of the body.
Patients with heart failure present with one or both of the
hallmark manifestation of heart failure.
 Dyspnea and fatigue
 Peripheral edema
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Patients may have only one of the two manifestations of heart
failure at any given time. For this reason, the term “Heart
Failure” is more accurate than “Congestive Heart Failure” .
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People who are 65 years old or older. Aging can weaken the heart
muscle. Older people also may have had diseases for many years
that led to heart failure.
African Americans are more likely to have heart failure than people
of other races. They're also more likely to have symptoms at a
younger age, have more hospital visits due to heart failure, and die
from heart failure.
People who are overweight. Excess weight puts strain on the heart.
Being overweight also increases your risk of heart disease and type
2 diabetes. These diseases can lead to heart failure.
People who have had a heart attack.
Men have a higher rate of heart failure than women.
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High Blood Pressure (about
75% of cases of heart failure
start with hypertension).
Coronary Artery Disease
Damage post MI
Valvular Heart Disease
Myocarditis
Congenital heart diseases
Cardiac arrhythmias, or
irregular heartbeats
Diabetes
Family history of heart failure
Excess alcohol consumption
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A diet high in salt
Advanced age
Sedentary lifestyle
Obesity
Sleep apnea
Angina
Hx of Smoking
Elevated low-density lipoprotein
(LDL)
Abnormally high or low
hemoblobin
Proteinuria
Pulmonary embolism
Hyperlipidemia
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The two main categories of heart failure
are:
 Systolic heart failure
 Diastolic heart failure
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Systolic heart failure is the most common
type of heart failure, and occurs when the heart
not contracting well. The heart can't pump with
enough force to push enough blood into the
circulation. As a result, blood coming into the
heart from the lungs can back up, causing fluid
to leak into the lungs.
 Left ventricle is usually dilated
 Commonly seen in men between ages of 50-70 who
have had a heart attack
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Diastolic heart failure occurs when the heart not
relaxing well. Very often, it's associated with high
blood pressure and left ventricular hypertrophy.
This form may lead to fluid accumulation, especially
in the feet, ankles, and legs. Some patients may have
lung congestion. Although doctors can treat blood
pressure and fluid volume, there are not as many
treatment options for this type of heart failure
▪ Usually have a normal or preserved LVEF
▪ Typically women who are overweight, elderly, hypertensive,
and diabetic
▪ 75% of patients admitted to hospital with a diagnosis of HF
have preserved or only minimally decreased LVEF.
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Right Heart Failure - The inability of the right side of
the heart to adequately pump venous blood into the
pulmonary circulation. This causes a back-up of fluid in
the body, resulting in abdominal bloating and lower
extremity edema
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Left Heart Failure – The inability of the left side of
the heart to pump into the systemic circulation.
Symptoms are predominantly those of pulmonary
congestion.
RIGHT
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JVD
Elevated CVP
S3 S4 at sternum
Murmur of tricuspid
insufficiency
Hepatomegaly
Splenomegaly
Ascites
Anorexia
Dependent pitting edema
Oliguria
Fatigue
Weight gain
Abnormal liver fx studies
LEFT
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Rales/crackles
SOB
Dyspnea on exertion
Orthopnea
PND (paroxismal
nocturnal dyspnea)
Pulmonary edema
Tachypnea
Diaphoresis
S3 S4 at apex
Mental confusion
Narrowed pulse pressure
Pulsus Alternans
 Class I - Patients with cardiac disease but without resulting limitation of
physical activity. Ordinary physical activity does not cause undue
fatigue, palpitations, dyspnea, or anginal pain.
 Class II - Patients with cardiac disease resulting in slight limitation of
physical activity. They are comfortable at rest. Ordinary physical activity
results in fatigue, palpitations, dyspnea, or anginal pain.
 Class III - Patients with cardiac disease resulting in marked limitation of
physical activity. They are comfortable at rest. Less than ordinary
activity causes fatigue, palpitations, dyspnea, or anginal pain.
 Class IV - Patients with cardiac disease resulting in inability to carry on
any physical activity without discomfort. Symptoms of heart failure or
the anginal syndrome may be present even at rest. If any physical
activity is undertaken, discomfort is increased.
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Stage A- High risk for developing HF. No identified
structural or functional abnormalities. No signs or
symptoms or HF.
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Stage B- Presence of structural heart disease strongly
associated with development of HF.
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Stage C- Past or present symptoms of HF associated
with underlying structural heart disease.
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Stage D- Advanced structural heart disease.
Specialized interventions required. Marked symptoms
of HF at rest, despite maximal medical therapy.
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EKG
Chest x-ray
BNP
BMP
Echocardiogram
▪ Remains the gold standard for evaluating patients with a
suspected diagnosis of HF and for monitoring patients with
a known diagnosis of HF
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Cardiac Catheterization
Stress Test
Nuclear Stress Test
Cardiac MRI
OSA Screen
The term "ejection fraction" refers to the
percentage of blood that's pumped out of a filled
ventricle with each heartbeat.
 Left Ventricular Ejection Fraction (LVEF)
 55-68% normal
 45-54% mild
 35-44% moderate
 <35% severe
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BNP is a substance secreted from the
ventricles or lower chambers of the heart in
response to changes in pressure that occur
when heart failure develops and worsens.
The level of BNP in the blood increases when
heart failure symptoms worsen, and
decreases when the heart failure condition is
stable. The BNP level in a person with heart
failure – even someone whose condition is
stable – is higher than in a person with
normal heart function.
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Heart damage from obstructive sleep
apnea may worsen heart failure. Sleep
apnea is a common disorder in which you
have one or more pauses in breathing or
shallow breaths while you sleep.
Sleep apnea can deprive your heart of
oxygen and increase its workload.
Treating this sleep disorder might
improve heart failure.
 Beta Blockers- slow your heart rate and lower
your blood pressure to decrease your heart's
workload.
▪ Carvedilol- Max dose 25mg BID (can increase to 50mg BID for
pts > 85kg)
▪ Metoprolol succinate – Max dose 200mg daily
▪ Bisoprolol- Max dose 10mg daily
 ACE inhibitors- lower blood pressure and reduce
strain on your heart
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Lisinopril- Max dose 20-40 mg daily
Captopril- Max dose 50mg TID
Enalapril- Max dose 10-20 mg BID
Ramipril- Max dose 10mg daily
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Angiotensin receptor blockers (ARBs)- relax your blood vessels and
lower blood pressure to decrease your heart's workload. Substitute
for patients who cannot tolerate ACE inhibitors due to cough.
 Losartan- Max dose 50-100mg daily
 Valsartan- Max dose 160mg BID
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Aldosterone antagonists trigger the body to get rid of salt and water
through urine. This lowers the volume of blood that the heart must
pump
 Spironolactone or epleranone
 Cannot be used if creatinine > 2.5mg/dL due to risk of
hyperkalemia
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Isosorbide Dinitrate/Hydralazine- helps relax your
blood vessels so your heart doesn't work as hard to
pump blood. Studies have shown that this medicine can
reduce the risk of death in African Americans.
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Digoxin makes the heart beat stronger and pump more
blood.
 Dose normally at 0.125 mg daily
 Need to check serum Digoxin levels
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Diuretics- help reduce fluid buildup in your lungs and
swelling in the feet and ankles.
 Furosemide
 Torsemide
 Bumetanide
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Milrinone belongs to a class of medications known as inotropes used to
treat heart failure by helping the heart contract, which allows the heart to
pump blood more effectively.
Milrinone also widens blood vessels, making it easier for the heart to move
the blood through the arteries.
Patients with heart failure who are awaiting a heart transplant may also
benefit from Milrinone.
Initial loading dose, 50 mcg/kg IV over 10 min; maintenance, 0.375 to 0.75
mcg/kg/min continuous IV infusion preferably through a central line.
Adverse Effects
 Atrial Fibrillation
 Abnormal Liver function tests
 Thrombocytopenia
 Ventricular premature complex
 Hypotension
NEVER TURN PRIMACOR OFF OR FLUSH LINE WITHOUT A
DOCTOR’S ORDER!!!!
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Positive inotrope to increase cardiac output in acute LV
failure.
Dose: IV only, used as continuous infusion. 2-20
mcg/kg/min.
Adverse effects
 Tachycardia
 Ventricular arrhythmias
 Hypokalemia
Half life = 2 minutes
Maxial effect 10-20 minutes after starting
Central line preferred
A Non-Drug, Non-Diuretic Treatment Option for Fluid Overload:
Aquapheresis is a medical therapy designed to remove excess salt and water from the
body safely, predictably, and effectively from patients suffering from fluid overload
who have failed diuretic therapy. It removes excess salt and water and helps to
restore a patient’s fluid balance or euvolemia.
Physicians can specify and adjust the exact amount and rate of fluid to be removed from
each patient, resulting in a gradual reduction that has no significant clinical impact
on blood pressure, heart rate, or the balance of electrolytes (chemical substances,
such as sodium, potassium, and chloride) in the body.
Up to 500 ml or 1.1 lb of fluid can be safely removed per hour. The average removal
rate is 250 ml or ½ lb an hour and treatment usually lasts about 24 hours. The total
hospital stay with Aquapheresis therapy is around three to four days.
The therapy can be used in combination with or as an alternative to diuretics
inotropic drug therapies,or vasoactive drug therapies to achieve the target fluid
removal goal for the patient. And, because it removes sodium and resets body fluid
levels, Aquapheresis may also improve the effectiveness of oral diuretics that
patients take on an ongoing basis.
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The Cardiac Resynchronization
Therapy (CRT) device (biventricular
pacemaker) has 2 or 3 leads that are
positioned in the:
 Right atrium
 Right ventricle
 Left ventricle (via the coronary
sinus vein)
When your heart rate drops below the
set rate, the device generates small
electrical impulses that pass through
the leads to the heart muscle. These
impulses make the ventricles of the
heart muscle contract, causing the
right and left ventricles to pump
together. The end result is improved
cardiac function.
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Implantable cardiac
defibrillator (ICD)
ICD if LVEF <35%
ICD/CRT therapy if:
▪ NYHA Class III-IV
(ambulatory) despite
optimal medical
treatment
▪ QRS duration ≥ 150
msec
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A ventricular assist device
(VAD) is a mechanical pump
that's used to support heart
function and blood flow in
people who have weakened
hearts.
The device takes blood from a
ventricle and helps pump it to
the body and vital organs.
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Heart transplants are done as
a life-saving measure for endstage heart failure.
Because donor hearts are in
short supply, patients who
need heart transplants go
through a careful selection
process. They must be sick
enough to need a new heart,
yet healthy enough to receive
it.
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Cardiologist Dr Czerska
Cardiovascular surgeon
Dr Botta heart transplant
 Dr Bittner lung/heart Transplant
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Transplant coordinator
Social worker
Dietitian
Psychiatrist
Daily weights- every day between 4am and 6am!!!
 Fluid Restriction for severe HF with hyponatremia
 Sodium Restriction to 2gm daily
 Accurate I&O readings and documentation
 K+ and Mg+2 replacement
 Knowledge of admission weight and daily weights
 Knowledge of EF% and when it was obtained
 Knowledge of daily labs
 Knowledge of chest x-ray
 Does patient have a device?
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Education
 Consult cardiac rehab
 Proper documentation of education
Core Measures
Consult case management at time of admission
Follow up appointment made at time of discharge
Patient eligible for Heart Care Center (407-836-9262)
 Uninsured
 Medicaid or MediPASS
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Jacobson, C., Marzlin, K., Webner, C. (2007).
Cardiovascular nursing practice- a comprehensive
resource manual and study guide for clinical nurses.
Burien, Washington: Cardiovascular Nursing Education
Associates
http://www.nhlbi.nih.gov/health/health-topics/topics/vad/
http://my.clevelandclinic.org/heart/services/tests/procedu
res/biventricular_pm.aspx
http://aquadex.gambro.com/en/aquadex/