1. Managing Heart Failure
By Lacey Buckler, RN, ACNP-BC, MSN
Nursing made Incredibly Easy!
May/June 2009
2.5 ANCC contact hours
Online:
© 2009 by Lippincott Williams & Wilkins. All world rights reserved.

2. 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

3. 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

4. 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

5. 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

6. 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

7. Picturing Dilated Cardiomyopathy

8. Picturing Left Ventricular Hypertrophy

9. Other Conditions That Contribute to Heart Failure
Increased metabolic rate
Iron overload
Hypoxia
Severe anemia
Electrolyte abnormalities
Cardiac dysrhythmias
Diabetes

10. Left-Sided Heart Failure Signs & Symptoms
Dyspnea
Unexplained cough
Pulmonary crackles
Low oxygen saturation
Third heart sound
Reduced urine output
Altered digestion
Dizziness and light-headedness
Confusion
Restlessness and anxiety
Fatigue and weakness

11. Right-Sided Heart Failure Signs & Symptoms
Lower extremity edema
Liver enlargement
Ascites
Anorexia
Abdominal pain
Nausea
Weight gain
Weakness

12. 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

13. 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 (6-minute walk)

14. 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

15. 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.

16. 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 anti-inflammatory 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.

17. 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.

18. 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

19. Three Basic Treatment Strategies
Pharmacologic management
Devices and surgical management
Lifestyle management

20. 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

21. 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

22. 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

23. 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

24. Lifestyle Management Adherence to treatment regime Symptom recognition
Weight monitoring
Diet and nutrition
Fluid intake
Alcohol and smoking cessation
Physical activity

25. 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

26. 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

27. 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