Heart Failure (CHF)

1
Heart Failure (CHF)

• Brunner, ch. 30, pp. 824-840

2
Chronic Heart Failure

• Has exacerbations and remissions. Acute phase is
  called acute decompensated heart failure.
• Most common hospital admission in pts over 65
• Second most common office visit
• ER visits and readmissions are common.
• Prevention and early intervention are important
  health initiatives.

3
Pathophysiology

• Impairment of ventricles from damage or
  overstretching (Starlings Law) makes them unable
  to fill with and effectively pump blood.
• As a result, cardiac output falls (decreased
  ejection fraction), leading to decreased tissue
  perfusion, making the heart unable to meet the
  metabolic demands of the body.

4
Physiologic Compensatory Mechanisms

• Decreased CO stimulates SNS to release
  catecholamines
• This increases HR, BP, peripheral resistance, and
  venous return
• This decreases ventricular filling time and
  decreases CO leading to decreased organ perfusion
• Results in increased myocardial workload and O2
  demand.

5
Compensatory Mechanisms contd

• Decreased CO and renal perfusion stimulates the
  Renin-Angiotensin-Aldosterone System creating a
  rock-slide effect (RAAS cascade)
• Angiotensin stimulates aldosterone
• Antidiuretic hormone is released
• leading to..

6
Compensatory Mechanisms contd

• Vasoconstriction
• Increased BP
• Salt and water retention
• Increased vascular volume
• Causing atrial natriuretic and b-type natriuretic
  peptides (ANP BNP, heart hormones) and nitric
  oxide to kick in resulting in vasodilation and
  diuresis.
• Compensation successful!

7
Pathophysiology DecompensationADHF

• Occurs when these mechanisms become exhausted and
  fail to maintain the CO needed for adequate
  tissue perfusion.
• Alveoli become filled with serosanguineous fluid
  from congestion and the fluid leaks into
  interstitial spaces. Lung tissue becomes less
  compliant and airways constrict (AKA Pulmonary
  Edema)

8
S/S of ADHF AKA Pulmonary Edema

• Severe dyspnea, tachypnea, orthopnea
• Dry hacking cough, audible wheezing and moist
  sounds, hemoptysis,
• Lungs with crackles, wheezes, rhonchi
• ltSBP, gtDBP, ltPP, tachy, S3 gallop rhythm
• Anxious, pale, cyanotic, dropping O2 sat
• Cold, clammy skin

9
S/S of Chronic Heart Failure

• Wt gain, edema
• JVD
• Hepatomegaly
• Oliguria, nocturia
• DOE, PND, orthopnea
• Fatigue, anorexia
• Restlessness, confusion, decreased attn span
• Skin changes in extremities

10
Etiology of Heart Failure

• Long standing CADcreates prolonged ischemia
• Previous MIweakens muscle
• HTNincreases afterload in great vessels, causes
  LV hypertrophy
• Hx of pericarditisscar tissue causes
  constriction
• Dysrhythmiasaffect pump action

11
Etiology contd

• Anemiaincreases HR
• Thyroid diseaseincreases HR and BP
• Lyte imbalancesaffects regularity, contractility
• COPDincreases afterload in PA
• Diabetesconstricts small arteries
• Valvular disorderscauses leakage

12
Classifications of Heart Failure Right and Left

• Right-sided
• Congestion in right chambers
• Increase in CVP
• Increase in size of RV
• Backflow to vena cava
• Congestion in jugular veins, liver, lower
  extremities

• Left-sided
• Congestion in left chambers
• Increase in size of LV
• Backflow to pulmonary veins
• Congestion in lungs

13
Classifications Forward and Backward

• Systolic Failure (Forward Failure)poor cardiac
  contraction results in poor CO and decreased EF.
  Kidneys suffer the most.
• Diastolic Failure (Backward Failure)ventricles
  are stiff and thick and will not relax enough
  during the resting phase to receive adequate
  amount of blood to maintain good CO. Also causes
  backflow into lungs and systemic circulation.

14
Classifications Functional

• According to activity tolerance
• 1 no limitations
• 2 slight limitations
• 3 marked limitation
• 4 inability to tolerate without discomfort

• According to risk and symptoms (826)
• A risk but no sx
• B HD but no sx
• C HD with sx of CHF
• D Advanced HD with severe sx

15
Classifications Wet/Dry Warm/Cold

• Wet means the patient has fluid overload
• Dry means the patient does not.
• Warm means the patient has good perfusion
• Cold means the patient does not.

16
Diagnostic Assessment

• CXRfluid and heart enlargement
• ECGcan reveal hx of heart problems
• Echo or TEEenlargement, valvular function,
  condition of great vessels, ejection fraction
• ABGs, O2 sat, cardiac markers, BMP
• Liver functions, thyroid functions, BUN,
  creatinine, BNP
• Stress testing

17
Collaborative Management Core Measures

• Discharge Instructions (see Pt Ed slide)
• Evaluation of Left Ventricular Systolic (LVS)
  Function (ejection fraction). Must be documented
  on the chart.
• ACEI or ARB for LVSD (ejection fraction less than
  40).
• Adult Smoking Cessation Advice

18
Admission Criteria

• Left-sided

• Right-sided

• O2 sat lt 89
• BUN or creatinine 1½ times upper limits of normal
• Change in mental status
• Failed OP tx (2 vs/7d)
• Sustained HR 100-120

• O2 sat lt 89
• Weight gain gt 3 lb/2d
• Edema of extremities

19
Management of ADHF

• Hi-Fowlers
• O2 mask or BiPAP. Intubation and mechanical
  ventilation is possible if needed
• VS, Pulse ox, UOP hourly
• Telemetry
• Daily wt
• Meds diuretics (Lasix), vasodilators (NTG),
  inotropics (dobutamine), morphine, (brain
  (B-type) natriuretic peptide) Natrecor
• Hemodynamic monitoringCVP, PAWP
• Circulatory assistive devicesVAD, IABP

20
Management of Chronic HF

• Meds
• Digoxin
• Lasix
• ACEIs (Vasotec)
• ARBs (Cozaar)
• Renin inhibitor (Tekturna)
• Beta-blockers (Lopressor)
• Nitrates (isosorbide initrate)
• Be mindful of potential dangerous side effects
  (837)

21
Management contd

• 6 small meals of NAS diet with gtcalories, protein
• Fowlers position
• O2 by NC 3-6 L/min
• Rest-activity schedule, stress reduction
• IO, daily wts, possible fluid restriction
• Circulatory assistive device
• Long-term cardiac transplantation

22
Complications

• Pleural effusion from pulmonary congestion
• Dysrhythmias caused by stretching of the chambers
  particularly the atria (a-fib) and especially if
  EF lt 35
• LV thrombus from atrial fib and poor ventricular
  function. Need anticoagulant therapy.
• Liver dysfunctioncan result in cirrhosis
• Renal failure from poor renal perfusion

23
Patient Education

• Disease process
• Medsindications, SEs
• Balancing rest and activity
• Low Na diet fluid restriction if indicated
• Monitoring of fluid statusdaily wtsame time,
  same clothes
• SS to reportchest pain, palpitations, DOE, PND,
  orthopnea, hemoptysis, wt gain (gt3 lb/2d or gt5
  lb/wk), increase in edema, fatigue, cough,
  anorexia
• Emotional supporthigh level of anxiety and
  depression
• Keep appts