Heart Failure

1
Heart Failure

• Julie Hutsick
• MSN 621
• Alverno College

2
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

3
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

4
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!

5
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
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What is Heart Failure?

• Heart failure is the bodys 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).

7
Anatomy and Pathophysiology of the Heart and the
Effects of the Sympathetic Nervous System, the
Renin-Angiotensinogen-Aldosterone Mechanism,
Inflammation and The Role of Genetics and Aging
8
Blood Flow Through the Heart
(Porth, 2009).
Blood flows to the left ventricle through the
mitral valve
Blood from the lungs enters into the left atrium
via the pulmonary veins
From the ventricle it enters the body via the
aorta
From the ventricle blood flows to the lungs via
the pulmonary arteries
Retrieved from http//www.nhlbi.nih.gov/health/dci
/Diseases/hhw/hhw_anatomy.html
Blood returns from the body via the inferior and
superior vena cava
Blood enters the Right Atrium
Passes through the tricuspid valve into the right
ventricle
9
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).

10
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).

11
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).

12
SNS
Decreased cardiac output and increased water
retention stimulates the 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
13
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 renin secretion
Increased vasoconstriction
Increases the level of antidiuretic hormone
Stimulates aldosterone production which increases
reabsorption of sodium
Facilitate norepinephrine release and prevents
reuptake by the SNS
Accumulation of excess fluid leads to ventricular
dilation and increased wall tension
14
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).
15
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.)

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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.)

• 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
17
Aging and Heart Failure
Microsoft clip art

• 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).

18
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.)

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Case study (1)

• Mrs. Montgomery is a 72 yr old woman who was
• admitted to your unit directly from the
  physicians
• 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 doesnt have the energy to follow her
• daily exercise routine. Her current weight is 157
• pounds, which is up from 148 seven days ago.

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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 Thats right!
Diastolic Sorry, thats incorrect. Diastolic has
a normal EF
21
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.

22
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).
23
Lifestyle and Disease Factors (5)

• What lifestyle factors put her at risk?
• Is she at risk for Heart Failure due to her past
  medical history?

High salt intake Yes thats right
Living alone Sorry, this has no relationship to
heart failure
Water aerobics at the Y Sorry, activity is
recommended for people with heart failure
Smoker Yes, thats right.
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
24
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?

25
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.

26
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.

27
Mrs. Montgomery (9)

• Mrs. Montgomery is currently taking pepcid,
  zoloft, metoprolol and lasix. Will any of these
  medications help with her heart failure?
• Continue on to see common Heart Failure
  Medications

Zoloft Sorry, that medication is for depression
Lasix Yes, this medication is used to treat
Edema, and is prescribed for Heart Failure
patients
Pepcid Sorry, that medication is for Gerd
Metoprolol Yes, this medication is for
Hypertension, and is prescribed for Heart Failure
patients
28
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.

29
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?

30
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?

31
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.
32
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,
  gt40. (Porth, 2009).

33
Used with permission from http//www.medmovie.com/
index.htm
34
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).

35
(Porth, 2009). Picture retrieved from
http//www.starsandseas.com/SAS20Physiology/Cardi
ovascular/Cardiovascular.htm
36
Life Style Factors that Cause Increased Risk
Microsoft clip art

• 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(American Heart Association, 2011).

Microsoft clip art
37
Disease Factors that Increase RiskHypertension-
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).

38
Previous MI resulting in decreased contractility

• Used with permission from http//www.medmovie.co
  m/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).

39
Signs and Symptoms of Heart Failure

• Dyspnea, nocturnal and with exertion
• Tachypnea
• Crackles
• Nocturia
• Diaphoresis
• Capillary refill gt3 seconds
• Venous distension
• Dependent pitting edema
• Arrhythmias
• Ascites
• (Hudson, 2009.)

40
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.)

41
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 dont have. These patients have a
  history of Left ventricular (LV) dysfunction,
  previous myocardial infarction, asymptomatic
  valvular disease. (Cunningham, 2006.)

42
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.)

43
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.)

44
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
45
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
46
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).

47
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
48
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
49
Nursing Interventions for the Hospitalized Patient

• Fluid restriction and low salt diet
• Strict recording of intake and output
• 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 patients needs when awake,
  and help patient sit up to improve breathing, or
  use the bathroom as needed. (Hudson, 2009.)

Microsoft clip art
Microsoft clip art
50
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.)

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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.
52
Reference

• American Heart Assosiation. (2011). Heart
  Failure. Retrieved from http//www.heart.org/HEART
  ORG/Conditions/HeartFailure/Heart-Failure_UCM_0020
  19_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_stati
  stics/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/PMC105201
  0/.

53
Reference

• Hudson, K. (2009). Congestive Heart Failure.
  Retrieved from http//dynamicnursingeducation.com/
  class.php?class_id130pid23.
• Krames. (2011). Heart Failure Diagrams. Retrieved
  from Retrived from https//www.kramesondemand.com/
  HealthSheet.aspx?id82055ContentTypeId3.
• 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.