Heart Failure - Alverno College Faculty

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
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
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• 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
Types of Heart Failure
Nursing Interventions
Risk Factors
Teaching Needs
Signs and Symptoms
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,
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
• 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
(Porth, 2009).
increased release of catecholamines,
epinephrine and norepinephrine
tachycardia, vasoconstriction and cardiac
Prolonged activation results in
ischemia due to
increased work
load and increased
myocardial oxygen
resulting in
faster heart
Decreased sensitization to
norepinephrine, resulting in increased
systemic vascular resistance,
increased after load and decreased
blood flow to skin, muscle and
abdominal organs
(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
Facilitate norepinephrine
release and prevents
reuptake by the SNS
Increased renin
Increases the level
of antidiuretic
Stimulates aldosterone
production which increases
reabsorption of sodium
Accumulation of excess fluid leads to ventricular dilation and increased wall
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
– 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
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Further research needs to be performed to learn the
direct role of genetics in relation to Heart Failure.
(Morita, Seidman, and Seidman, 2005.)
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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,
Case study
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
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?
That’s right!
Sorry, that’s incorrect.
Diastolic has a normal EF
Mrs. Montgomery
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
Mrs. Montgomery
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
• 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
Yes, that’s right.
• Is she at risk for Heart Failure due to her past medical
Due to her history of HTN,
previous MI and CAD
Sorry, she is at risk due to
her history of HTN,
previous MI and CAD
Mrs. Montgomery
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
Mrs. Montgomery
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
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
• Mrs. Montgomery is currently taking pepcid,
zoloft, metoprolol and lasix. Will any of these
medications help with her heart failure?
Sorry, that medication is for depression
Yes, this medication is used to treat
Edema, and is prescribed for Heart
Failure patients
Yes, this medication is for Hypertension,
and is prescribed for Heart Failure
Sorry, that medication is for Gerd
Continue on to see common Heart Failure Medications
Mrs. Montgomery
Click the question to receive the answer
Are there any other medications that Mrs.
Montgomery should be on before
Yes, she should also be on an ACE or ARB.
Mrs. Montgomery
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
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
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
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Life Style Factors that Cause
Increased Risk
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(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
Capillary refill >3 seconds
Venous distension
Dependent pitting edema
(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,
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
• Decreased aldosterone levels resulting in
decreased sodium and water retention( American
Heart Association, 2011).
• 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
– Fluid restriction and low salt diet
– Strict recording of intake and output
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– 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.)
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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.
American Heart Assosiation. (2011). Heart Failure. Retrieved from
Centers for Disease Control and Prevention. (2010). Heart Failure Death Rates Among Adults Aged 65 Years
and Older, by State, 2006. Retrieved from
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
Hudson, K. (2009). Congestive Heart Failure. Retrieved from
Krames. (2011). Heart Failure Diagrams. Retrieved from Retrived from
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.
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