Managing Heart Failure
By Lacey Buckler, RN, ACNP-BC, MSN
Nursing made Incredibly Easy!
May/June 2009
2.5 ANCC contact hours
Online: www.nursingcenter.com
© 2009 by Lippincott Williams & Wilkins. All world rights reserved.
Statistics
Leading cause of hospitalization
50% of patients with heart failure over a 4-year
period will die of the disease
287,000 people die annually of heart failure
40% of patient’s admitted to the hospital die or
are readmitted within 1 year
Definition
The heart’s inability to pump enough blood to
meet the body’s oxygen and nutrient demands
Can be systolic or diastolic, left- or right-sided,
acute or chronic
Types
Systolic (pumping problem)—inability of the heart
to contract to provide enough blood flow forward
Diastolic (filling problem)—inability of the left
ventricle to relax normally, resulting in fluid back
up into the lungs
Left-sided—inability of the left ventricle to pump
enough blood, causing fluid back up into the lungs
Right-sided—inefficient pumping of the right side
of the heart, causing fluid buildup in the abdomen,
legs, and feet
Acute vs. Chronic
Acute—an emergency situation in which a patient
was completely asymptomatic before the onset of
heart failure; seen in acute heart injury such as
MI
Chronic—long-term syndrome in which a patient
exhibits symptoms over a long period of time,
usually as a result of a preexisting cardiac
condition
Conditions That Can Lead to
Heart Failure
Coronary artery disease—primary cause of
heart failure in 60% of patients
Cardiomyopathy—disease of the myocardium;
three types: dilated, hypertrophic, and restrictive
Hypertension—increases cardiac workload, leads
to hypertrophy
Valvular heart disease—increases pressure
within the heart and cardiac workload
Picturing Dilated Cardiomyopathy
Picturing Left Ventricular
Hypertrophy
Other Conditions That
Contribute to Heart Failure
Increased metabolic
rate
Electrolyte
abnormalities
Iron overload
Cardiac dysrhythmias
Hypoxia
Diabetes
Severe anemia
Left-Sided Heart Failure
Signs & Symptoms
Dyspnea
Unexplained cough
Pulmonary crackles
Low oxygen saturation
Third heart sound
Reduced urine output
Altered digestion
Dizziness and lightheadedness
Confusion
Restlessness and
anxiety
Fatigue and weakness
Right-Sided Heart Failure
Signs & Symptoms
Lower extremity
edema
Abdominal pain
Nausea
Weight gain
Weakness
Liver enlargement
Ascites
Anorexia
Diagnostic Tests
Medical history and physical exam
Brain natriuretic peptide measurement
Lab tests: complete blood cell count, metabolic
panel, liver function studies, and urinalysis
Other tests: thyroid function tests and fasting
lipid profile
Diagnostic Tests
Echocardiogram to
assess ejection
fraction (EF)
Chest X-ray
ECG
Cardiac stress test
Cardiac
catheterization
Cardiac computed
tomography scan or
magnetic resonance
imaging
Radionuclide
ventriculography
Ambulatory ECG
monitoring (Halter
monitor)
Pulmonary function
tests
Heart biopsy
Exercise testing (6minute walk)
Staging & Severity
After all data are gathered, cause and
classification can be determined and an
appropriate treatment plan
Two well-accepted classification systems used:
ACC/AHA stages of heart failure and NYHA
functional classifications
Managing The Stages
Stage A identifies patients at high risk for heart failure
because of conditions such as hypertension, diabetes,
and obesity.
• Treat each comorbidity according to current evidence-based
guidelines.
Stage B includes patients with structural heart
disease, such as left ventricular remodeling, left
ventricular hypertrophy, or previous MI, but no
symptoms.
• Provide all appropriate therapies in Stage A.
• Focus on slowing the progression of ventricular remodeling
and delaying the onset of heart failure symptoms.
• Strongly recommended in appropriate patients: Treat with
ACE inhibitors or beta-blockers unless contraindicated; these
drugs delay the onset of symptoms and decrease the risk of
death and hospitalization.
Managing The Stages
Stage C includes patients with past or current heart
failure symptoms associated with structural heart
disease such as advanced ventricular remodeling.
• Use appropriate treatments for Stages A and B.
• Modify fluid and dietary intake.
• Use additional drug therapies, such as diuretics, aldosterone
inhibitors, and ARBs in patients who can’t tolerate ACE
inhibitors, digoxin, and vasodilators.
• Treat with nonpharmacologic measures such as biventricular
pacing, an ICD, and valve or revascularization surgery.
• Avoid drugs known to cause adverse reactions in
symptomatic patients, including nonsteroidal antiinflammatory drugs, most antiarrhythmics, and calcium
channel blockers.
• Administer anticoagulation therapy to patients with a
history of previous embolic event, paroxysmal or persistent
atrial fibrillation, familial dilated cardiomyopathy, and
underlying disorders that may increase the risk of
thromboembolism.
Managing The Stages
Stage D includes patients with refractory advanced
heart failure having symptoms at rest or with minimal
exertion and frequently requiring intervention in the
acute setting because of clinical deterioration.
• Improve cardiac performance.
• Facilitate diuresis.
• Promote clinical stability.
Achieving these goals may require I.V. diuretics,
inotropic support (milrinone, dobutamine, or
dopamine), or vasodilators (nitroprusside,
nitroglycerin, or nesiritide). As heart failure progresses,
many patients can no longer tolerate ACE inhibitors
and beta-blockers due to renal dysfunction and
hypotension and may need supportive therapy to
sustain life (a left ventricular assist device, continuous
I.V. inotropic therapy, experimental surgery or drugs,
or a heart transplant) or end-of-life or hospice care.
IHI Treatment Bundle
Assessment of left
ventricular systolic
function
An ACE or an ARB
when left ventricular
EF is less than 40%
Anticoagulant if
patient has atrial
fibrillation
Smoking cessation
counseling
Discharge
instructions: activity,
diet, medications,
weight monitoring,
reportable symptoms,
follow-up
appointments
Seasonal flu shot
Pneumococcal vaccine
Optional beta-blocker
therapy
Three Basic Treatment Strategies
Pharmacologic management
Devices and surgical management
Lifestyle management
Pharmacologic Management
Foundation is the ACE inhibitor
•
•
•
•
Improves ventricular function
Improves patient well-being
Reduces hospitalization
Increases survival
If the patient is unable tolerate an ACE inhibitor,
an ARB can be used
A beta-blocker should be started on all patients
with an EF less than 40% due to mortality benefit
shown in randomized control trials
Pharmacologic Management
An aldosterone antagonist may be added for
patients whose EF is less than 35% and who are
on an adequate ACE inhibitor
Other drugs: hydralazine/isorbide, diuretics, and
digoxin
Devices and Surgical
Management
First option if the cause of heart failure can be
treated surgically
Several therapeutic options: pacing, an ICD, a
ventricular assist device, an artificial heart, or a
heart transplant
Pacing or resynchronization therapy is
recommended for patients with NYHA Class III or
IV with QRS prolongation who are experiencing
symptoms despite medications
Devices and Surgical
Management
An ICD may be used in patients with arrhythmias
to prevent sudden cardiac death
A left ventricular assist device may be used as a
bridge to transplant or destination therapy
End-stage heart failure patients may consider
heart transplant
Lifestyle Management
Adherence to
treatment regime
Symptom recognition
Weight monitoring
Diet and nutrition
Fluid intake
Alcohol and smoking
cessation
Physical activity
Nursing Interventions
Administer medications and monitor response
Weigh the patient daily at the same time on the
same scale, early in the day after urination; report
a 2 to 3 lb gain in a day or 5 lbs in a week to the
healthcare provider
Auscultate lung sounds
Monitor vital signs
Identify and evaluate edema severity
Examine skin turgor
Patient Teaching
The disorder, diagnosis, and treatment
Signs and symptoms of worsening heart failure
When to notify the healthcare provider
The importance of follow-up care
The need to avoid high-sodium foods
The need to avoid fatigue
Patient Teaching
Instructions about fluid restrictions
The need for the patient to weigh himself every
morning at the same time, before eating and after
urinating, to keep a record of his weight, and to
report a weight gain of 3 to 5 lbs in 1 week
The importance of smoking cessation, if
appropriate
Medication dosage, administration, adverse
reactions, and monitoring
