Heart Failure (CHF)
Brunner, ch. 30, pp. 824-840
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.
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.
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.
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……………………..
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!
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)
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
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
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
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
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
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.
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
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.
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
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
Admission Criteria
Left-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 100-120
Right-sided
O2 sat < 89 Weight gain > 3 lb/2d Edema of extremities
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
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)
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
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
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