Download Heart Failure 2013

Heart Failure 2013
Definition
• Inability of the heart to supply blood to
meet metabolic demands of tissues
resulting in inadequate tissue perfusion
and volume overload
Heart Failure
• Implies “biventricular failure”
• Origin usually left sided
• Left ventricle (LV)enlarges capacity,
muscle size & shape = “ventricular
remodeling”
• LV weakens
decreased ejection of
blood, decreased stroke volume,
decreased cardiac output
Incidence
5 million cases
660,000 new cases/year
Most common discharge diagnosis age >65
Causes of Heart Failure
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Myocardial infarction
Pulmonary embolism (RV failure)
Cardiomyopathy (both RV & LV failure)
Mitral insufficiency (LV failure)
Aortic regurgitation/stenosis (LV failure)
Hypertension (LV failure)
Volume overload
Myocarditis
Infections/toxins
Mechanism of Failure
• Decline in cardiac function
decreased cardiac
output
• Drop in cardiac output
decreased ejection
fraction
• Ejection Fraction= percentage of blood left
ventricle pumps out with each beat
– Normal= 55-70%
– <40% = impaired function
Inciting Event
Increased myocardial demand
Ventricular Remodeling
Sodium & water
retention
(Aldosterone)
Decreased cardiac output
Vasoconstriction
(renin-angiotensisn)
Neurohormonal Activation
Sympathetic
increase in heart
rate & contractility
Increased intravascular volume
Increased wall stress and afterload
Chronic Congestive Failure
Compensatory Mechanisms
Increased heart
rate
Heart
Enlargement
Vasoconstriction
Increased
afterload
& cardiac
workload
Etiology
• Cardiac Output dependent on:
– Preload: amount of blood in left ventricle (LV)
– Afterload: pressure against which LV must eject
– Contractility: strength of contraction
– Coordination of contraction between atria/ventricles
– Heart Rate: amount of time available for filling and
emptying ventricles
Systolic Dysfunction
“Poor Contraction”
• Heart enlarges/does not contract normally
• Decrease in muscle strength (thin walls)
• Forward blood flow decreases
systemic hypoperfusion
• Stroke volume & ejection fraction
decrease (EF<40%)
• Pulmonary congestion
Diastolic Dysfunction
“Impaired Filling”
• Inability of the ventricle to fully relax
• Increased pressure & volume in ventricle
• Pressures back up to pulmonary veins
pulmonary congestion
• Stroke volume reduced
• Echo: normal EF?, left atrial enlargement,
pulmonary hypertension, heart wall
abnormalities, right ventricular dilation
Clinical Manifestations
• Left sided Failure (“Forward Failure”)
– Blood backs into pulmonary veins & capillaries
congestion
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Dyspnea on exertion
Paroxysmal nocturnal dyspnea
Orthopnea
Pulmonary edema
Crackles
Cough
Tachycardia
S3, S4, systolic murmur
Insomnia, restlessness
lung
Clinical Manifestations
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Right Sided Failure (“Backward Failure”)
– Elevated pressures & congestion in systemic veins & capillaries
• Peripheral/Dependent edema
• Weight gain
• Liver congestion
• Distended neck veins
• Abnormal fluid in body cavities
– Pleural, abdominal
• Anorexia & nausea
• Nocturia
• Weakness
Assessment
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History of symptoms
Limits of activity/response to rest
Peripheral pulses: quality, character
Inspect/palpate precordium for lateral
displacement of point of maximum impulse
• Sleeping patterns/sleep aids
Diagnostic Evaluation
EKG
• Ventricular hypertrophy
Echo
• Ventricular hypertrophy
• Chamber dilation
• Abnormal wall motion
CXR
• Cardiomegaly
• Pleural effusion
• Vascular congestion
Stages: American College of Cardiology/
American Heart Association
Stage
Definition
Examples
A
High risk, no structural
heart disease or HF
HTN, CAD, diabetes,
family hx cardiomyopathy
B
Structural heart disease,
no signs of failure
Prior MI, systolic
dysfunction, valvular
disease, RV hypertrophy
C
Structural heart disease,
signs of failure
Dyspnea, fatigue,
exercise intolerance,
orthopnea
D
Refractory HF despite
maximal medical therapy
Classification: New York Heart Association
Class
Functional Capacity
I
Patients with cardiac
disease: no limitation on
physical activity
II
Patients with cardiac
disease: slight limitation on
physical activity(fatigue,
SOB, palpitation, anginal
pain). Comfortable at rest
III
Marked limitation of
physical activity (fatigue,
SOB, palpitation, anginal
pain). Comfortable at rest
IV
Inability to carry on any
physical activity without
discomfort. Symptoms of
HF at rest
Goal: improve ventricular dysfuncton &
prevent progression
Inotropes
Reduce Afterload
Reduce Preload
Management
• Inotropes
– Improve contractility, stroke volume, ejection
fraction, cardiac output
– Increase myocardial oxygen consumption
– Dobutamine, milrinone, digoxin
• Biventricular pacing: cardiac resynchroniztion
therapy (CRT). Synchronizes LV systolic
function so that LV walls contract at same time
Management
• Reduction of Afterload
– Decrease in resistance of blood, valves, blood
vessels
– Decreases work of left ventricle
– Improved contractility, stroke volume, cardiac output
• Angiotensin Converting Enzyme (ACE) inhibitors
(captopril, enalapril)
• Calcium Channel Blockers (nifedipine,verapamil)
• Beta Blockers (metoprolol)
• Angiotensin Receptor Blockers (ARBs) (valsartan,
losartan)
Management
• Reduction of Preload
– Diuretic therapy
• Loop Diuretics: lasix, bumex
• Thiazide Diuretics: hydrochlorothiazide
• Potassium Sparing: spironolactone, triamterene
– Venodilators (nitroglycerin)
– Fluid & sodium restriction
Interventions
• Maintain adequate cardiac output
• Physical/emotional rest
• Evaluate for progression of left sided
failure
– Lowered systolic pressure
– Narrowing of pulse pressure
– Alterations in strong/weak pulsations
– Auscultate heart sounds
Interventions
• Improve oxygentation
– Raise head of bed
– Auscultate lung fields
– Observe for respiratory distress
– Small frequent feedings
– Oxygen as needed
Interventions
• Restore fluid balance
– Diuretics
– Strict I & o
– Daily weight
• Assess for weight fluctuations
• *Include weight assessment in intershift report*
– Observe for electrolyte depletion
– Monitor for edema
– Diet education
Complications
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Intractable/refractory heart failure
Cardiac dysrhythmias
Myocardial failure
Digitalis toxicity
Pulmonary infarction
Pneumonia
Emboli
Core Measures
• Evaluation of LV Function (EF)
– Echo report
– Cath report
– Nuclear stress test
Core Measures
• Adult Smoking Cessation
– Heart failure patient with a history of smoking
within the past year
• ACEI or ARB presecribed at discharge
– Left Ventricular ejection fraction (LVEF) <40%
Core Measure Exclusions
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Patient refusal
Patient on LVAD
Patient <18 years of age
Transfer to acute care hospital
Comfort/Hospice care
Discharged to hospice
Expired
Left AMA
Patient involved in clinical trial
Patient Education
• Disease process: pumping action
• Signs & symptoms of recurrence
– Weight gain
– Swelling of ankles, feet, abdomen
– Cough
– Fatigue
– Frequent urination at night
• Review medications, activity, diet
Teach Back
http://ruralhealth.uams.edu/healthliteracy/teachback
References
• Aherns, T., Prentice, D., & Kleinpell, R. (2011).
Progressive care nursing certification. New York:
McGraw Hill Medical.
• Alspach, J. (2006). Core curriculum for critical care
nursing. (6th ed., pp. 271-284). St Louis: Saunders
Elsevier.
• American Heart Associatin. (2005). Guideline update for
the diagnosis and management of chronic heart failure in
the adult. Circulation, 112, 154-235.
• Aronow, W. (2006). Heart failure update. Geriatrics,
61(8), 16-20.