1. Heart Failure (CHF)
Brunner, ch. 30, pp

2. Chronic Heart Failure
Has exacerbations and remissions. Acute phase is called acute decompensated heart failure.
Most common hospital admission in pts over 65
Second most common office visit
ER visits and readmissions are common.
Prevention and early intervention are important health initiatives.

3. Pathophysiology
Impairment 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.

4. Physiologic Compensatory Mechanisms
Decreased CO stimulates SNS to release catecholamines
This increases HR, BP, peripheral resistance, and venous return
This decreases ventricular filling time and decreases CO leading to decreased organ perfusion
Results in increased myocardial workload and O2 demand.

5. Compensatory Mechanisms cont’d
Decreased CO and renal perfusion stimulates the Renin-Angiotensin-Aldosterone System creating a rock-slide effect (RAAS cascade)
Angiotensin stimulates aldosterone
Antidiuretic hormone is released
leading to……………………..

6. Compensatory Mechanisms cont’d
Vasoconstriction
Increased BP
Salt and water retention
Increased vascular volume
Causing atrial natriuretic and b-type natriuretic peptides (ANP & BNP, heart hormones) and nitric oxide to kick in resulting in vasodilation and diuresis…….
Compensation successful!

7. Pathophysiology: 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)

8. S/S of ADHF; AKA: Pulmonary Edema
Severe dyspnea, tachypnea, orthopnea
Dry hacking cough, audible wheezing and moist sounds, hemoptysis,
Lungs with crackles, wheezes, rhonchi
<SBP, >DBP, <PP, tachy, S3 gallop rhythm
Anxious, pale, cyanotic, dropping O2 sat
Cold, clammy skin

9. S/S of Chronic Heart Failure
Wt gain, edema
JVD
Hepatomegaly
Oliguria, nocturia
DOE, PND, orthopnea
Fatigue, anorexia
Restlessness, confusion, decreased attn span
Skin changes in extremities

10. Etiology of Heart Failure
Long standing CAD—creates prolonged ischemia
Previous MI—weakens muscle
HTN—increases afterload in great vessels, causes LV hypertrophy
Hx of pericarditis—scar tissue causes constriction
Dysrhythmias—affect pump action

11. Etiology cont’d Anemia—increases HR
Thyroid disease—increases HR and BP
Lyte imbalances—affects regularity, contractility
COPD—increases afterload in PA
Diabetes—constricts small arteries
Valvular disorders—causes leakage

12. Classifications of Heart Failure: Right and Left
Right-sided
Congestion in right chambers
Increase in CVP
Increase in size of RV
Backflow to vena cava
Congestion in jugular veins, liver, lower extremities
Left-sided
Congestion in left chambers
Increase in size of LV
Backflow to pulmonary veins
Congestion in lungs

13. Classifications: 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.

14. Classifications: Functional
According to activity tolerance:
1: no limitations
2: slight limitations
3: marked limitation
4: inability to tolerate without discomfort
According to risk and symptoms (826):
A: risk but no sx
B: HD but no sx
C: HD with sx of CHF
D: Advanced HD with severe sx

15. Classifications: Wet/Dry; Warm/Cold
Wet means the patient has fluid overload
Dry means the patient does not.
Warm means the patient has good perfusion
Cold means the patient does not.

16. Diagnostic Assessment
CXR—fluid and heart enlargement
ECG—can reveal hx of heart problems
Echo or TEE—enlargement, valvular function, condition of great vessels, ejection fraction
ABGs, O2 sat, cardiac markers, BMP
Liver functions, thyroid functions, BUN, creatinine, BNP
Stress testing

17. Collaborative 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

18. Admission Criteria Left-sided Right-sided O2 sat < 89
BUN or creatinine 1½ times upper limits of normal
Change in mental status
Failed OP tx (2 vs/7d)
Sustained HR
O2 sat < 89
Weight gain > 3 lb/2d
Edema of extremities

19. Management of ADHF Hi-Fowlers
O2 mask or BiPAP. Intubation and mechanical ventilation is possible if needed
VS, Pulse ox, UOP hourly
Telemetry
Daily wt
Meds: diuretics (Lasix), vasodilators (NTG), inotropics (dobutamine), morphine, (brain (B-type) natriuretic peptide) Natrecor
Hemodynamic monitoring—CVP, PAWP
Circulatory assistive devices—VAD, IABP

20. Management of Chronic HF
Meds:
Digoxin
Lasix
ACEIs (Vasotec)
ARBs (Cozaar)
Renin inhibitor (Tekturna)
Beta-blockers (Lopressor)
Nitrates (isosorbide initrate)
Be mindful of potential dangerous side effects (837)

21. Management cont’d 6 small meals of NAS diet with >calories, protein
Fowler’s position
O2 by NC 3-6 L/min
Rest-activity schedule, stress reduction
I&O, daily wts, possible fluid restriction
Circulatory assistive device
Long-term: cardiac transplantation

22. Complications 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 cirrhosis
Renal failure from poor renal perfusion

23. Patient Education Disease process Meds—indications, SEs
Balancing rest and activity
Low Na diet; fluid restriction if indicated
Monitoring of fluid status—daily wt—same time, same clothes
S&S to report—chest pain, palpitations, DOE, PND, orthopnea, hemoptysis, wt gain (>3 lb/2d or >5 lb/wk), increase in edema, fatigue, cough, anorexia
Emotional support—high level of anxiety and depression
Keep appts