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Congestive Heart Failure
J.O. Medina,RN,MSN,FNP,CCRN Education Specialist Nurse Practitioner Critical Care&EmergencyServices California Hospital Medical Center
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Congestive Heart Failure and Pulmonary Edema
Overview Definition – heart failure is inability of the heart to pump enough blood to meet the metabolic demands of the body Diagnosed by Manifestations of inadequate tissue perfusion Signs and symptoms of intravascular volume overload Over 2 million Americans have heart failure 10% will die in one year; 50% in five years America’s highest volume DRG
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Congestive Heart Failure and Pulmonary Edema
Pathophysiology Neurohormonal theory Increased TNF – alpha – cachectin Endothelin – vasoconstrictor released by endothelial cells Natriuretic Peptides released by atrial and ventricular stretch and counterbalance effects of endothelin Common causes CAD; MI;HTN Dilated cardiomyopathy Aortic stenosis ; Aortic regurgitation Mitral regurgitation
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Atrial / Brain Natriuretic Peptides
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Congestive Heart Failure and Pulmonary Edema
Types Forward vs. backward failure Forward failure – inadequate tissue perfusion to meet metabolic demands of the body Backward failure – seen in pulmonary and systemic congestion Right vs. left failure May involve RV, LV or both Usually LV failures precedes RV failure, producing symptoms of pulmonary congestion RV failure is usually result of LV failure but may occur with primary pulmonary hypertension
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Congestive Heart Failure and Pulmonary Edema
Systolic vs. diastolic failure Systolic failure – inability of the ventricles to eject adequate volume Diastolic failure – inability of ventricles to relax and fill High output vs. low output failure Most HF – result of low contractility producing low CO High output HF occurs when acute metabolic needs are not met even with high CO
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Congestive Heart Failure and Pulmonary Edema
Acute vs. chronic failure Acute failure – heart is overwhelmed by abrupt alteration in cardiac function and unable to bring compensatory mechanisms to play Chronic failure – compensatory mechanisms have time to partially of completely restore cardiac function Refractory vs. compensated HF Compensated – body or medical therapies are working and heart is responding Refractory – heart is not responding to therapies
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Congestive Heart Failure and Pulmonary Edema
New York Heart Association Classification of Heart Failure Class I - no limitations with ordinary activity Class II – slight limitations of physical activity Class III – marked limitations of physical activity Class IV – inability to engage in any physical activity without symptoms
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Congestive Heart Failure and Pulmonary Edema
Clinical Presentation Intravascular and interstitial fluid overload SOB; Dyspnea on exertion;Orthopnea Paroxysmal nocturnal dyspnea Non-productive cough; crackles; wheeze Weight gain; S3;sinus tach; atrial dysrhythmias Displaced PMI ; systolic murmur ; GI symptoms Inadequate tissue perfusion Decreased exercise tolerance Unexplained fatigue Unexplained mental confusion Decreased urine output Arrythmias Peripheral vasoconstriction
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JVD / Pitting Edema
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Congestive Heart Failure and Pulmonary Edema
Diagnosis CXR – cardiomegaly; pulmonary vascular congestion;pleural effusions Echocardiogram – dilated cardiac chambers; hypertrophy; vascular insufficiency and/or stenosis; wall motion abnormalities (akinesis, hypokinesis; dyskinesis); low EF EKG – tachycardia; arrythmias; chamber enlargement; ischemia/infarction Cardiac Catheterization – increased PA/PCWP; low EF and low CO with high LVEDP; valvular dysfunction and CAD
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Congestive Heart Failure and Pulmonary Edema
Management Goals of therapy Reduce Preload Venodilators NTG ; diuretics ; ace inhibitors Morphine Dopamine (low dose) Optimize Heart rate Digoxin Reduce Afterload Arteriodilators Ace inhibitors; hydralazine Nitroglycerin ; nitroprusside Improved contractility Dopamine; dobutamine; amrinone
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Congestive Heart Failure and Pulmonary Edema
Atrial Natriuretic Peptide (ANP) Adrenergic Blockade Nitric Oxide Synthetase Spirolactone
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Congestive Heart Failure and Pulmonary Edema
Severe pulmonary congestion due to excess fluid in interstitial and/or alveolar spaces Pathogenesis same as HF Can develop spontaneously; day or night; at rest; following exercise or stressful event; or in conjunction with HF
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Congestive Heart Failure and Pulmonary Edema
Clinical Presentation Mentation – anxious; restless ; agitation CV signs – tachycardia with increased BP (unless compensatory mechanisms fail - BP); S3; PAWP >25 mmHg; CI <2.2 Pulmonary Signs – orthopnea; O2 levels; crackles; pink frothy sputum; wheezes Peripheral signs – skin diaphoretic; cool; pale or cyanotic Diagnosis CXR – diffuse interstitial edema with cloudy lung fields ABG – hypoxemia; respiratory acidosis
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Congestive Heart Failure and Pulmonary Edema
Furosemide Morphine NTG Oxygen Positive inotropes Aminophylline IV : for bronchospasm
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Alveoli With Fluid
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Questions ?
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