Heart Failure
Heart Failure
• An abnormal condition involving impaired cardiac pumping/filling
• Heart is unable to produce an adequate cardiac output (CO) to meet
metabolic needs
• HF = ↓ CO
• Characterized by:
o Ventricular dysfunction
o Reduced exercise intolerance
o Diminished quality of life
o Shortened life expectancy
• Is not a disease but a “syndrome”
Common Cause of HF
• Long-standing hypertension
• Coronary artery disease (CAD)
• MI
• Cardiomyopathy
• Valvular disorders
• Pulmonary disease
Risk
•
•
•
•
•
•
•
Factors for HF
CAD
Advancing age
Hypertension
Diabetes
Tobacco use
Obesity
High serum cholesterol
Pathology of HF
• HF with Reduced Ejection Fraction
o Most common
o Referred to as systolic failure
• HF with Preserved Ejection Fraction
o Referred to as Diastolic failure
• Mixed HF
o Poor EFs (<35%)
o Biventricular failure
Review of Definitions
• Systole- contraction of the myocardium
• Diastole- relaxation of the myocardium
• Stroke Volume (SV)- the amount of blood ejected by the ventricle with
the heartbeat (mL)
• Cardiac Output (CO)- the amount of blood pumped by each ventricle in
one minute
•
•
•
Preload- the volume of blood in the ventricles at the end of
diastole, before the next contraction
Afterload- the peripheral resistance against which the left ventricle
must pump
Contractility- force of contraction of myocardial fibres
Cardiac Preload
• Preload increases with:
o ↑ Fluid volume
o Vasoconstriction
• Preload decreases with:
o ↓ Fluid volume
o Vasodilation
Cardiac Afterload
• Afterload increases with:
o Vasoconstriction
• Afterload decreases with:
o Vasodilation
Cardiac Contractility (pumping action of the heart)
• Starling’s Law
o Describes the relationship between preload and cardiac output
o The greater the heart muscle fibers are stretched, the greater
their subsequent force of contraction, but only up to a point.
Beyond that point, fibers get over-stretched and the force of
contraction is reduced
Factors Affecting Cardiac Output
Excessive preload and/or
afterload = excessive
stretch → reduced
contraction → reduced
SV/CO
Diagnostic Studies
• Primary goal is to determine and treat underlying cause
o History and physical examination
o Chest x-ray (CXR)
o ECG
o Lab studies (i.e. cardiac enzymes)
• Echocardiogram
• Stress testing
• Cardiac catheterization
• Ejection fraction
Compensation in HF
• Compensatory mechanisms are activated to maintain adequate CO.
• The main compensatory mechanisms include:
o Sympathetic Nervous System Activation
o Neurohormonal Response
o Ventricular Dilation
o Ventricular Hypertrophy
• Sympathetic NS (SNS) Activation:
o Increased heart rate (HR)
o Increased myocardial contractility
o Peripheral vasoconstriction
• Over time, these previous mechanisms are detrimental as they increase
the workload of the failing myocardium and the need for O2.
• Neurohormonal responses: kidneys trigger the renin-angiotensinaldosterone system (RAAS) leading to:
o sodium and water retention (↑ preload)
o increased peripheral vasoconstriction (↑ BP)
• Ventricular dilation
o Enlargement of the chambers of the heart that occurs when
pressure in the left ventricle is elevated
o Initially an adaptive mechanism
o Eventually this mechanism becomes inadequate, and CO decreases.
• Ventricular hypertrophy (remodeling)
o Increase in muscle mass and cardiac wall thickness in response
to chronic dilation, resulting in
 Poor contractility
 Higher O2 needs
 Poor coronary artery circulation
 Risk for ventricular dysrhythmias
Dilated and Hypertrophied Heart Chambers
A, Dilated heart chambers
B, Hypertrophied heart chambers.
Types of HF
• Right-sided HF (RV)
• Left-sided HF (LV); most common
• Biventricular HF (both LV and RV)
This patient has both
R&L HF
Right-Sided HF
• Commonly caused by left-sided HF (Hypertension)
• Other causes cor pulmonale, right ventricular MI
• Clinical manifestations are related systemic venous
congestion
• Right sided = Rest of Body
• Jugular venous distension (JVD)
• Hepatomegaly, splenomegaly
• Ascites
• Peripheral edema
• Weight gain (> 2 kg within 5 days)
• Nausea, vomiting, anorexia
Left-Sided HF (LUNGS)
• Most common type
• May be caused by an MI, hypertension, CAD, cardiomyopathy
• Clinical manifestations are related to pulmonary congestion
• Left sided = Lungs
• Dyspnea
• Tachypnea
• Cough (most often dry)
• Crackles
• Impaired oxygen exchange
• Decreased O2 saturation
Additional Clinical Manifestations of Chronic HF
• Fatigue
• Orthopnea
•
•
•
•
•
Paroxysmal nocturnal dyspnea
Nocturia
Chest pain (angina)
Restlessness, confusion, ↓ memory
Dusky, cool, damp to touch
Complications of HF
• Dysrhythmias
• Severe hepatomegaly that may lead to hepatic cirrhosis
• Renal insufficiency or failure
• Pulmonary Edema
Collaborative Management Chronic HF: Treatment Goals
• Treat the underlying cause and contributing factors.
• Maximize CO.
• Improve ventricular function.
• Improve quality of life/ alleviate symptoms.
• Preserve target organ function.
• Decrease mortality and morbidity.
• Oxygen administration
• Physical and emotional rest
• Nonpharmacological therapies
o Cardiac resynchronization therapy (CRT) or biventricular pacing
o Implantable cardioverter-defibrillator (ICD)
o Cardiac transplantation
Additional nonpharmacological
therapies:
Intra-aortic balloon pump
(IABP) therapy
Ventricular assist devices
(VADs)
Destination therapy—Permanent,
implantable VAD
Collaborative Management Chronic HF
• Therapeutic goals for drug therapy
o Correction of sodium and water retention and volume overload
o Reduction of cardiac workload
o Improvement of myocardial contractility
• Drug Therapy
o Diuretics:

•
Non-Potassium Sparing
 Thiazide
 Loop
 Potassium- Sparing
 Spironolactone
o ACE inhibitors
o Angiotensin II receptor blockers
o Aldosterone antagonists
o Nitrates
o -Adrenergic blockers
o Positive inotropic agents
 Digitalis
Nutritional Therapy
o Diet and weight reduction
o Recommend Dietary Approaches to Stop Hypertension (DASH) diet.
o Sodium is usually restricted to 2 g per day.
o Fluids generally restricted to 1.5 to 2 L per day
o Daily weights are very important.
 Same time, same clothing each day
Acute Decompensated HF (ADHF): Pulmonary Edema
• An acute, life-threatening situation in which the lung alveoli become
filled with serous or serosanguinous fluid
• Most common cause of pulmonary edema is acute LV failure secondary to
acute MI
• Clinical Manifestations
o Early
 Increase in the respiratory rate
 Decrease in PaO2
o Later
 Tachypnea
Pulmonary Edema cont.
•
•
•
•
As pulmonary edema progresses, it inhibits oxygen and carbon
exchange at the alveolar-capillary interface.
A, Normal relationship.
B, Increased pulmonary capillary hydrostatic pressure causes
move from the vascular space into the pulmonary interstitial
C, Lymphatic flow increases in an attempt to pull fluid back
vascular or lymphatic space.
dioxide
fluid to
space.
into the
•
D, Failure of lymphatic flow and worsening of left heart failure
result in further movement of fluid into the interstitial space and
into the alveoli.
Pulmonary Edema cont.
• Physical findings ‘unmistakable’
o Orthopnea
o Dyspnea, tachypnea
o Use of accessory muscles
o Cyanosis
o Cool and clammy skin
o Anxious
• Physical findings cont.
o Physical findings
o Cough with frothy, blood-tinged sputum
o Breath sounds: crackles, wheezes, rhonchi
o Tachycardia
o Hypotension or hypertension
• Collaborative Management
o High-Fowler’s position
o Supplemental oxygen
o Continuous ECG monitoring
o Hemodynamic monitoring
o Improve gas exchange and oxygenation
 Noninvasive ventilatory support (BiPAP)
 Intubation and mechanical ventilation
o Drugs to decrease preload:
 Diuretics
o Drugs to decrease preload and afterload:
 IV Nitroglycerine
 IV sodium nitroprusside (Nipride)
 Morphine sulphate
o For clients who do not respond to conventional pharmacotherapy
 Inotropic therapy
 Digitalis
 -Adrenergic agonists (e.g., dopamine)
 Phosphodiesterase inhibitors (e.g., milrinone)
o Reduce Anxiety
 Distraction, imagery
 Sedative medications (e.g., morphine sulphate,
benzodiazepines)
Cardiac Transplantation
•
•
Transplant candidates are placed on a list
o Stable clients wait at home and receive ongoing medical care
o Unstable clients may require hospitalization
o Transplant wait list is long; many clients die while waiting
Nursing Management
o Surgery involves removing the recipient’s heart, except for the
posterior right & left atrial walls and their venous connections
o Recipients heart is replaced with the donor heart
o Donor SA node is preserved so that a sinus rhythm may be
achieved postoperatively
o Immunosuppressive therapy usually begins in the operating room
o Infection is the primary complication followed by acute
rejection in the first year after transplantation
o Beyond the first year, malignancy (especially lymphoma) and
coronary artery vasculopathy are major causes of death
Questions
• Which of the following indicates right-sided heart failure?
select all that apply
o A. Pulmonary edema
o B. Ascites
o C. Peripheral edema
o D. Postural nocturnal dyspnea
o E. JVD
•
A patient with heart failure has fluid volume excess. which nursing
action would decrease their preload? Select all that apply
o A. Administer furosemide
o B. Elevate the patient’s legs
o C. Place patient in high fowler’s position
o D. Administer morphine sulphate
o E. Monitor sodium and fluid intake