2 Statistics Leading cause of hospitalization 50% of patients with heart failure over a 4-year period will die of the disease287,000 people die annually of heart failure40% of patient’s admitted to the hospital die or are readmitted within 1 year
3 DefinitionThe heart’s inability to pump enough blood to meet the body’s oxygen and nutrient demandsCan be systolic or diastolic, left- or right-sided, acute or chronic
4 TypesSystolic (pumping problem)—inability of the heart to contract to provide enough blood flow forwardDiastolic (filling problem)—inability of the left ventricle to relax normally, resulting in fluid back up into the lungsLeft-sided—inability of the left ventricle to pump enough blood, causing fluid back up into the lungsRight-sided—inefficient pumping of the right side of the heart, causing fluid buildup in the abdomen, legs, and feet
5 Acute vs. ChronicAcute—an emergency situation in which a patient was completely asymptomatic before the onset of heart failure; seen in acute heart injury such as MIChronic—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 patientsCardiomyopathy—disease of the myocardium; three types: dilated, hypertrophic, and restrictiveHypertension—increases cardiac workload, leads to hypertrophyValvular heart disease—increases pressure within the heart and cardiac workload
12 Diagnostic Tests Medical history and physical exam Brain natriuretic peptide measurementLab tests: complete blood cell count, metabolic panel, liver function studies, and urinalysisOther tests: thyroid function tests and fasting lipid profile
13 Diagnostic Tests Echocardiogram to assess ejection fraction (EF) Chest X-rayECGCardiac stress testCardiac catheterizationCardiac computed tomography scan or magnetic resonance imagingRadionuclide ventriculographyAmbulatory ECG monitoring (Halter monitor)Pulmonary function testsHeart biopsyExercise testing (6-minute walk)
14 Staging & SeverityAfter all data are gathered, cause and classification can be determined and an appropriate treatment planTwo well-accepted classification systems used: ACC/AHA stages of heart failure and NYHA functional classifications
15 Managing The StagesStage 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 StagesStage 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 StagesStage 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 fibrillationSmoking cessation counselingDischarge instructions: activity, diet, medications, weight monitoring, reportable symptoms, follow-up appointmentsSeasonal flu shotPneumococcal vaccineOptional beta-blocker therapy
19 Three Basic Treatment Strategies Pharmacologic managementDevices and surgical managementLifestyle management
20 Pharmacologic Management Foundation is the ACE inhibitor• Improves ventricular function• Improves patient well-being• Reduces hospitalization• Increases survivalIf the patient is unable tolerate an ACE inhibitor, an ARB can be usedA 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 inhibitorOther drugs: hydralazine/isorbide, diuretics, and digoxin
22 Devices and Surgical Management First option if the cause of heart failure can be treated surgicallySeveral therapeutic options: pacing, an ICD, a ventricular assist device, an artificial heart, or a heart transplantPacing 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 deathA left ventricular assist device may be used as a bridge to transplant or destination therapyEnd-stage heart failure patients may consider heart transplant
24 Lifestyle Management Adherence to treatment regime Symptom recognition Weight monitoringDiet and nutritionFluid intakeAlcohol and smoking cessationPhysical activity
25 Nursing Interventions Administer medications and monitor responseWeigh 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 providerAuscultate lung soundsMonitor vital signsIdentify and evaluate edema severityExamine skin turgor
26 Patient Teaching The disorder, diagnosis, and treatment Signs and symptoms of worsening heart failureWhen to notify the healthcare providerThe importance of follow-up careThe need to avoid high-sodium foodsThe 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 weekThe importance of smoking cessation, if appropriateMedication dosage, administration, adverse reactions, and monitoring