Heart Failure Julie Hutsick MSN 621 Alverno College Heart Failure Statistics from the Center for Disease Control and Prevention • 5.8 million Americans have heart failure, with 670,000 new diagnoses each year • One in every five patients dies from heart failure with in the first year from diagnosis • This results in costs of 39.2 billion dollars per year for treatments including physician visits, hospitalizations and medications Outcomes- this tutorial will help the audience develop and understanding of: • The basic anatomy and physiology of the heart • The effects of the Sympathetic nervous system, Renin-Angiotensin-Aldosterone Mechanism, Inflammation, Aging and Genetics on Heart Failure • The different classifications of Heart Failure • Treatments for Heart Failure • Importance of patient teaching and teaching needs Before you get started… • This is an interactive presentation • You will be asked questions, and will need to pick answers. Feedback will be provided. • If at any time you would like to return to the navigational page click the home button. • The next arrows (on the right top or bottom of the page) will automatically take you to the next slide in the presentation. • Have fun and enjoy your learning experience! Main Areas- Click the words to go to that part of the presentation Anatomy and Physiology of the Heart Diagnosing Heart Failure Medications Compensatory mechanisms Types of Heart Failure Nursing Interventions Inflammation Risk Factors Teaching Needs Genetics Signs and Symptoms References Aging Stages and Classes of Heart Failure What is Heart Failure? • Heart failure is the body’s inability to properly circulate blood throughout the body due to decreased pumping ability. • Slow disease progression. • Can be prevented or can decrease progression with early diagnosis and intervention. (Porth, 2009). Anatomy and Pathophysiology of the Heart and the Effects of the Sympathetic Nervous System, the Renin-AngiotensinogenAldosterone Mechanism, Inflammation and The Role of Genetics and Aging Blood Flow Through the Heart Blood from the lungs enters into the left atrium via the pulmonary veins (Porth, 2009). Blood flows to the left ventricle through the mitral valve From the ventricle blood flows to the lungs via the pulmonary arteries From the ventricle it enters the body via the aorta Retrieved from http://www.nhlbi.nih.gov/health/dci/Diseases/hhw/hhw_anatomy.html Passes through the tricuspid valve into the right ventricle Blood enters the Right Atrium Blood returns from the body via the inferior and superior vena cava Physiology • Cardiac output is the amount of blood pumped from the heart per minute – Based on heart rate and amount of blood pumped with each beat (stroke volume) • Preload is the volume of blood in the heart and the end of diastole. When the heart muscle becomes stiff and unable to relax the preload decreases. (Porth, 2009). Physiology, cont. • Afterload is the force of contraction needed to eject blood from the heart. When the ventricles become weakened and enlarged the force is diminished • Myocardial contractility is the ability of the heart to contract independently of preload and afterload. This occurs due the interaction between actin and myosin filaments which results in muscle shortening. (Porth, 2009). Compensatory Mechanisms • Sympathetic nervous system (SNS)initially assists with maintenance of perfusion to body organs. • Renin-Angiotensin-Aldosterone Mechanism (RAA). When cardiac output is decreased, there is reduced blood flow to the kidneys and decreased glomerular filtration rate resulting in increased sodium and water retention. (Porth, 2009). Decreased cardiac output and increased water retention stimulates the SNS SNS (Porth, 2009). increased release of catecholamines, epinephrine and norepinephrine tachycardia, vasoconstriction and cardiac arrhythmia Prolonged activation results in ischemia due to increased work load and increased myocardial oxygen demand decreased contractility resulting in faster heart function deterioration Decreased sensitization to norepinephrine, resulting in increased systemic vascular resistance, increased after load and decreased blood flow to skin, muscle and abdominal organs RAA (Porth, 2009). Decreased cardiac output, resulting in reduction of renal blood flow and decreased glomerular filtration rate Sodium and water retention Increase circulating levels of angiotensin II Increased vasoconstriction Facilitate norepinephrine release and prevents reuptake by the SNS Increased renin secretion Increases the level of antidiuretic hormone Stimulates aldosterone production which increases reabsorption of sodium Accumulation of excess fluid leads to ventricular dilation and increased wall tension Inflammation and Heart Failure Angiotensin II and aldosterone stimulate inflammatory and repair processes after tissue damage Stimulate cytokine production (tumor necrosis factor and interleukin-6) Neutrophils and macrophages are attracted to the site Macrophages are activated and stimulate the growth of fibroblasts and synthesis of collagen fibers Repair results in ventricular hypertrophy and myocardial wall fibrosis (decreased contraction ability) Progression of ventricular dysfunction (Porth, 2009). Genetics and Heart Failure Heart cells have two main functions– to generate contractile force by sarcomere proteins – transmitting that force throughout the heart by intermediate proteins Scientists have found a genetic link between these components and heart failure. (Morita, Seidman, and Seidman, 2005.) Gene mutations in the sarcomeres can result in – hypertrophic cardiomyopathy (wall thickening) – dilated cardiomyopathy (thinned walls, enlarged chamber) Gene mutations is the intermediate proteins result in – Dilated cardiomyopathy – Heart failure Microsoft clip art Further research needs to be performed to learn the direct role of genetics in relation to Heart Failure. (Morita, Seidman, and Seidman, 2005.) Microsoft clip art Aging and Heart Failure • Decreased response to receptor stimulation reduces the hearts ability to increase heart rate and contractility to maximum level • Increased vascular stiffness results in increased systolic blood pressure which results in left ventricular hypertrophy and alteration in diastolic filling • Heart is stiffer and less compliant resulting in decreased cardiac output, elevated diastolic pressure and muscle stretching. (Porth, 2009). Commonly used tests to determine a diagnosis of Heart Failure • Echocardiogram- determine whether there is systolic or diastolic dysfunction • EKG- conduction changes can indicate heart failure, and previous MI • Chest x-ray- will show cardiomegaly, pulmonary congestion and pleural effusions • BNP- secreted by ventricles due to stretching of the muscle cells, the higher the number the more severe the heart failure. (Cunningham, 2006.) Case study (1) Mrs. Montgomery is a 72 yr old woman who was admitted to your unit directly from the physician’s office. She went to see her physician this morning because she was having increased shortness of breath, was waking up breathless three to four times a night, has increased swelling in both lower legs and doesn’t have the energy to follow her daily exercise routine. Her current weight is 157 pounds, which is up from 148 seven days ago. Mrs. Montgomery (2) She had an echocardiogram done during her last admission, which was 83 days ago. It showed an ejection fraction of 37%. What type of heart Failure does Mrs. Montgomery have? Systolic That’s right! Diastolic Sorry, that’s incorrect. Diastolic has a normal EF Mrs. Montgomery (3) Mrs. Montgomery is a current smoker and has been smoking for 50 years. She was diagnosed with Heart Failure six months ago. Before that, she frequently ate frozen dinners, canned foods or fast food, as she lives alone. She meets friends for a water aerobics class at the YMCA, but not on a regular basis. Mrs. Montgomery (4) She has a medical history that includes: • Hypertension • Pneumonia • Depression • Previous MI • Gerd • Glaucoma • Coronary artery disease (CAD) (American Heart Association, 2011). Lifestyle and Disease Factors (5) • What lifestyle factors put her at risk? High salt intake Yes that’s right Water aerobics at the Y Sorry, activity is recommended for people with heart failure Living alone Sorry, this has no relationship to heart failure Smoker Yes, that’s right. • Is she at risk for Heart Failure due to her past medical history? Yes Due to her history of HTN, previous MI and CAD No Sorry, she is at risk due to her history of HTN, previous MI and CAD Mrs. Montgomery (6) You enter the room to assess Mrs. Montgomery. You ask her what symptoms she has been having. She tells you she is short of breath, has been waking up during the night, has swelling in her legs and is more fatigued than usual. What signs of heart failure might you observe during your assessment? Mrs. Montgomery (7) You ask Mrs. Montgomery more about her activity intolerance. She states that since her last admission she has been trying to exercise on a regular basis. She says she is usually able to walk a mile around her neighborhood at a moderate pace. Lately, though, she becomes short of breath sooner, and is only able to make it half that distance due to increased fatigue. Mrs. Montgomery (8) Click the question to receive the answer In what stage of Heart Failure would you classify Mrs. Montgomery? She is in stage C, as she has structural heart disease, and is having symptoms. What class is Mrs. Montgomery in? She is in stage III, as shown by the increased symptoms and decreased tolerance for activity. Mrs. Montgomery (9) • Mrs. Montgomery is currently taking pepcid, zoloft, metoprolol and lasix. Will any of these medications help with her heart failure? Zoloft Sorry, that medication is for depression Lasix Yes, this medication is used to treat Edema, and is prescribed for Heart Failure patients Metoprolol Yes, this medication is for Hypertension, and is prescribed for Heart Failure patients Pepcid Sorry, that medication is for Gerd Continue on to see common Heart Failure Medications Mrs. Montgomery (10) Click the question to receive the answer Are there any other medications that Mrs. Montgomery should be on before discharge? Yes, she should also be on an ACE or ARB. Mrs. Montgomery (11) While Mrs. Montgomery is hospitalized, what are the important interventions that you as the nurse should ensure are occurring? If Mrs. Montgomery awakens during the night, should you make her get back into bed, or are there interventions you should attempt? Mrs. Montgomery (12) Mrs. Montgomery was just diagnosed with heart failure six months ago, and admits that she still smokes, and did not follow a diet or exercise routine prior to diagnosis. What should Mrs. Montgomery be taught before she is discharged? Mrs. Montgomery (13) How will you know if the teaching you did with Mrs. Montgomery is effective? What should you do to ensure she truly understands the information you gave her? Just assume the patient understands everything Sorry, that is incorrect. Many patients may become overwhelmed when provided with a lot of new information, but unwilling to ask for clarification. Teach Back, Teach Back, Teach Back! Yes, this is important to ensure the patient understood the information provided, and has no further questions. Types of Heart Failure • Systolic heart failure is when the heart becomes weak and the ventricle becomes enlarged. The weakened ventricle is then unable to pump enough blood out during contractions. Due to the decreased ability to pump the ejection fraction is decreased to less than 40%. • Diastolic heart failure is when the ventricle becomes stiff and does not relax appropriately between contractions. Due to this the ventricles are unable to fully fill with blood so there is less to eject during contractions. Since there is less blood to push out, the ejection fraction for this type of heart failure is usually normal, >40%. (Porth, 2009). Used with permission from http://www.medmovie.com/index.htm Left vs. Right • Refers to the ventricle that is primarily affected • Initially heart failure can affect only one side, but long term heart failure usually affect both ventricles. • Left sided heart failure is when the left ventricle is unable to move blood from the pulmonary circulation to the arterial circulation. This results in blood pooling in the pulmonary veins. • Right sided heart failure is when the right ventricle is unable to move un-oxygenated blood from the venous system into the pulmonary system, which results in blood pooling in the systemic vessels. (Porth, 2009). (Porth, 2009). Picture retrieved from http://www.starsandseas.com/SAS%20Physiolog y/Cardiovascular/Cardiovascular.htm Microsoft clip art Life Style Factors that Cause Increased Risk • SMOKING CAUSES INCREASED BLOOD PRESSURE AND HEART RATE • OBESITY RESULTS IN INCREASED WORK LOAD • EATING HIGH FAT FOODS CAN RESULT IN CORONARY ARTERY DISEASE • LACK OF PHYSICAL ACTIVITY IS A RISK FACTOR FOR CORONARY ARTERY DISEASE AND OTHER CARDIOVASCULAR PROBLEMS Microsoft clip art (American Heart Association, 2011). Disease Factors that Increase Risk Hypertension- Due to increased pressure the heart has to pump harder which results in the enlarging and weakening of the chambers. Used with permission from http://www.medmovie.com/index.htm • Coronary artery disease resulting in high blood pressure and possible heart attack • Diabetes may result in hypertension and atherosclerosis (American Heart Association, 2011). • Previous MI resulting in decreased contractility Used with permission from http://www.medmovie.com/index.htm • Sleep apnea is a risk factor for heart failure • Lung disease causes increased work on the heart to pump the available oxygen • Prolonged arrhythmias- heart pumps ineffectively (American Heart Association, 2011). Signs and Symptoms of Heart Failure • • • • • • • • • • Dyspnea, nocturnal and with exertion Tachypnea Crackles Nocturia Diaphoresis Capillary refill >3 seconds Venous distension Dependent pitting edema Arrhythmias Ascites (Hudson, 2009.) Stages and Classes of Heart Failure Guidelines for diagnosing and treating Heart Failure have been developed by the American College of Cardiology and The American Heart Association There are four stages, A-D. Stages A and B are patients are risk for Heart Failure and stages C and D are patients who have Heart Failure. Heart Failure is also classified based upon the patients severity of symptoms. The New York Heart Association has devised a functional classification chart which divides symptoms into four classes, I-IV. (Cunningham, 2006.) Stage A and B A- These patients do not have symptoms or structural heart disease but are considered at high risk These patients have: Hypertension, Coronary artery disease, Diabetes, Obesity and a history of cardiomyopathy within the family. B- These patients do have symptoms of heart failure, but don’t have. These patients have a history of Left ventricular (LV) dysfunction, previous myocardial infarction, asymptomatic valvular disease. (Cunningham, 2006.) Stage C and D C- These patients have structural heart disease and have or have had symptoms including: dyspnea, fatigue and reduced activity tolerance. D- These patients are in end stage heart failure. They have severe symptoms, even during rest despite maximum medical treatment, and have frequent hospitalizations or need specialized interventions at home. (Cunningham, 2006.) Classes of Heart Failure • Class I- No Symptoms or limitations during a normal level of physical activity • Class II- Mild symptoms, with slight difficulty during activity (long-distance walking or climbing more two or more flights of stairs). • Class III- Increased symptoms resulting in a increased limitation in activity. (walking only short distances, minimal stair climbing) Symptoms decreased only at rest. • Class IV- Severe symptoms even during rest. Unable to tolerate activity. (Cunningham, 2006.) Angiotensin-converting enzyme inhibitors (ACE) • Increase vasodilation by blocking conversion of angiotensin I to angiotensin II • Blocks aldosterone and ADH which decreases fluid retention. • Increased cardiac output due to decreased preload and left ventricular filling pressure American Heart Association, 2011). Used with permission from http://www.medmovie.com/index.htm Angiotensin receptor blockers (ARBs) • Blocks angiotensin II receptor sites to prevent vasoconstriction and preventing hypertension (American Heart Association, 2011). Used with permission from http://www.medmovie.com/index.htm Beta Blocker • Block epinephrine and norepinephrine resulting in decreased heart rate , and increased vessel dilation which results in decreased blood pressure • Decreased aldosterone levels resulting in decreased sodium and water retention( American Heart Association, 2011). Diuretics • Increase sodium and water excretion due to inhibition of sodium, potassium, and chloride reabsorption in kidneys • Reduction of preload • Adverse effects include hypokalemia, hypotension, and dizziness. (American Heart Association, 2011). Used with permission from http://www.medmovie.com/index.htm Calcium Channel Blockers • Decrease pumping strength by blocking the calcium needed for the heart to contract (American Heart Association, 2011). Used with permission from http://www.medmovie.com/index.htm Nursing Interventions for the Hospitalized Patient – Fluid restriction and low salt diet – Strict recording of intake and output Microsoft clip art – Daily weights, with re-weight and Physician notification if weight increase is more than two pounds in a day – Encourage smoking cessation and obtain order for nicotine patch for patients who smoke as needed – Assess medication adherence, and what prevents patients from taking medications, make referrals as needed – Elevate edematous extremities – During night, assess patient’s needs when awake, and help patient sit up to improve breathing, or use the bathroom as needed. (Hudson, 2009.) Microsoft clip art Patient Teaching Needs Patients need teaching reinforced during every admission to ensure understanding of self care needs. It is beneficial to the patient to teach when family is present so they can reinforce information after discharge and provide a support system for the patient. Needs Include: – Weigh themselves daily, call the physician if they have a weight gain of three pounds in one day or five pounds in one week – Low salt diet with 2L fluid restriction (the amount of fluid in a juice pitcher) – Quit smoking- offer resources if needed – Take all medications as prescribed. (Hudson, 2009.) Teaching cont. – – – – Always carry of list of current medications Importance of exercise Importance of keeping physician appointments Self-monitoring (when to call their physician) • Weight gain, Increased edema, Dyspnea during rest, Loss of appetite, Increased fatigue, Trouble sleeping (Hudson, 2009.) Teach Back, Teach Back, Teach Back Needs to be done to ensure that the patient understands the information provided to them, and provides them with opportunity to ask questions or receive clarification. Reference American Heart Assosiation. (2011). Heart Failure. Retrieved from http://www.heart.org/HEARTORG/Conditions/HeartFailure/HeartFailure_UCM_002019_SubHomePage.jsp Centers for Disease Control and Prevention. (2010). Heart Failure Death Rates Among Adults Aged 65 Years and Older, by State, 2006. Retrieved from http://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_heart_failure.htm Cunningham, C. (2006). Managing Hospitalized Patients with Heart Failure. American Nurse Today. Retrieved from http://www.nursingworld.org/mods/mod990/heartfailure.pdf. Hiroyuki Morita, Jonathan Seidman, and Christine E. Seidman. (2005). Genetic Causes of Human Heart Failure. American Society for Clinical Investigation, 115(3). Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1052010/. Reference Hudson, K. (2009). Congestive Heart Failure. Retrieved from http://dynamicnursingeducation.com/class.php?class_id=130&pid=23. Krames. (2011). Heart Failure Diagrams. Retrieved from Retrived from https://www.kramesondemand.com/HealthSheet.aspx?id=82055&ContentTypeId=3. MedMovie. (2007).Cardiovascular Media Library. Retrieved from http://www.medmovie.com/#. Porth, C.M. (2009). Pathophysiology: Concepts of Altered Health States. Philadelphia, PA: Lippincott Williams and Wilkins.