2Chronic Heart FailureHas exacerbations and remissions. Acute phase is called acute decompensated heart failure.Most common hospital admission in pts over 65Second most common office visitER visits and readmissions are common.Prevention and early intervention are important health initiatives.
3PathophysiologyImpairment of ventricles from damage or overstretching (Starling’s 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.
4Physiologic Compensatory Mechanisms Decreased CO stimulates SNS to release catecholaminesThis increases HR, BP, peripheral resistance, and venous returnThis decreases ventricular filling time and decreases CO leading to decreased organ perfusionResults in increased myocardial workload and O2 demand.
5Compensatory Mechanisms cont’d Decreased CO and renal perfusion stimulates the Renin-Angiotensin-Aldosterone System creating a rock-slide effect (RAAS cascade)Angiotensin stimulates aldosteroneAntidiuretic hormone is releasedleading to……………………..
6Compensatory Mechanisms cont’d VasoconstrictionIncreased BPSalt and water retentionIncreased vascular volumeCausing atrial natriuretic and b-type natriuretic peptides (ANP & BNP, heart hormones) and nitric oxide to kick in resulting in vasodilation and diuresis…….Compensation successful!
7Pathophysiology: Decompensation—ADHF 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)
8S/S of ADHF; AKA: Pulmonary Edema Severe dyspnea, tachypnea, orthopneaDry hacking cough, audible wheezing and moist sounds, hemoptysis,Lungs with crackles, wheezes, rhonchi<SBP, >DBP, <PP, tachy, S3 gallop rhythmAnxious, pale, cyanotic, dropping O2 satCold, clammy skin
9S/S of Chronic Heart Failure Wt gain, edemaJVDHepatomegalyOliguria, nocturiaDOE, PND, orthopneaFatigue, anorexiaRestlessness, confusion, decreased attn spanSkin changes in extremities
10Etiology of Heart Failure Long standing CAD—creates prolonged ischemiaPrevious MI—weakens muscleHTN—increases afterload in great vessels, causes LV hypertrophyHx of pericarditis—scar tissue causes constrictionDysrhythmias—affect pump action
11Etiology cont’d Anemia—increases HR Thyroid disease—increases HR and BPLyte imbalances—affects regularity, contractilityCOPD—increases afterload in PADiabetes—constricts small arteriesValvular disorders—causes leakage
12Classifications of Heart Failure: Right and Left Right-sidedCongestion in right chambersIncrease in CVPIncrease in size of RVBackflow to vena cavaCongestion in jugular veins, liver, lower extremitiesLeft-sidedCongestion in left chambersIncrease in size of LVBackflow to pulmonary veinsCongestion in lungs
13Classifications: 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.
14Classifications: Functional According to activity tolerance:1: no limitations2: slight limitations3: marked limitation4: inability to tolerate without discomfortAccording to risk and symptoms (826):A: risk but no sxB: HD but no sxC: HD with sx of CHFD: Advanced HD with severe sx
15Classifications: Wet/Dry; Warm/Cold Wet means the patient has fluid overloadDry means the patient does not.Warm means the patient has good perfusionCold means the patient does not.
16Diagnostic Assessment CXR—fluid and heart enlargementECG—can reveal hx of heart problemsEcho or TEE—enlargement, valvular function, condition of great vessels, ejection fractionABGs, O2 sat, cardiac markers, BMPLiver functions, thyroid functions, BUN, creatinine, BNPStress testing
17Collaborative 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
18Admission Criteria Left-sided Right-sided O2 sat < 89 BUN or creatinine 1½ times upper limits of normalChange in mental statusFailed OP tx (2 vs/7d)Sustained HRO2 sat < 89Weight gain > 3 lb/2dEdema of extremities
19Management of ADHF Hi-Fowlers O2 mask or BiPAP. Intubation and mechanical ventilation is possible if neededVS, Pulse ox, UOP hourlyTelemetryDaily wtMeds: diuretics (Lasix), vasodilators (NTG), inotropics (dobutamine), morphine, (brain (B-type) natriuretic peptide) NatrecorHemodynamic monitoring—CVP, PAWPCirculatory assistive devices—VAD, IABP
20Management of Chronic HF Meds:DigoxinLasixACEIs (Vasotec)ARBs (Cozaar)Renin inhibitor (Tekturna)Beta-blockers (Lopressor)Nitrates (isosorbide initrate)Be mindful of potential dangerous side effects (837)
21Management cont’d 6 small meals of NAS diet with >calories, protein Fowler’s positionO2 by NC 3-6 L/minRest-activity schedule, stress reductionI&O, daily wts, possible fluid restrictionCirculatory assistive deviceLong-term: cardiac transplantation
22Complications Pleural effusion from pulmonary congestion Dysrhythmias caused by stretching of the chambers particularly the atria (a-fib) and especially if EF < 35%LV thrombus from atrial fib and poor ventricular function. Need anticoagulant therapy.Liver dysfunction—can result in cirrhosisRenal failure from poor renal perfusion
23Patient Education Disease process Meds—indications, SEs Balancing rest and activityLow Na diet; fluid restriction if indicatedMonitoring of fluid status—daily wt—same time, same clothesS&S to report—chest pain, palpitations, DOE, PND, orthopnea, hemoptysis, wt gain (>3 lb/2d or >5 lb/wk), increase in edema, fatigue, cough, anorexiaEmotional support—high level of anxiety and depressionKeep appts