Us. Waleed Ameen

Heart Failure

AT THE END OF THIS SESSION STUDENTS WILL BE ABLE TO:

1. Define HF2. Understand mechanism of controlling HF

Symptoms.3. NYHA Classification of HF.4. List types of HF5. Identify risk factors and causes of HF6. Illustrate the clinical manifestations7. Predict complications8. Provide diagnostic tests for HF.9. Demonstrate appropriate nursing process

Learning Objectives

Heart failure is the inability of the heart to pump sufficient blood to meet the needs of the tissues for oxygen and nutrients.

Definition

The loss of a critical quantity of functioning myocardial cells after injury to the heart due to:

1. Ischemic Heart Diseases 2. Hypertension 3. Idiopathic Cardiomyopathy4. Infections (e.g., viral myocarditis)5. Toxins (e.g., alcohol or cytotoxic drugs) 6. Valvular Diseases 7. Prolonged Arrhythmias

Etiology of Heart Failure

Classification of Heart Failure• Onset:

• Acute heart failure • Chronic heart failure

• Affected side of the heart: • Left heart failure • Right heart failure

• Stages of heart failure severity:• New York Heart Association • American Heart Association/American College of

Cardiology

NYHA Classification of Functional Capacity

Description

NYHA class I AsymptomaticNYHA class II Symptoms with moderate exertion

NYHA class III Symptoms with minimal exertion

NYHA class IV Symptoms at rest

Tabl

e 1

New Classification based on symptoms

Corresponding NYHA class

Asymptomatic NYHA class ISymptomatic NYHA class II/ IIISymptomatic with recent history of dyspnea at rest

NYHA class IIIB

Symptomatic with dyspnea at rest. NYHA class IV

Tabl

e 2

Heart Failure Classification

Myocardial Disease / InjuryImpaired Ventricular Performance

Cardiac Output

↑ SNS↑ HR↑ Contractility Vasoconstriction

↑ RAASVasoconstrictionNa/H2O Retention

CardiacWorkload

Ventricular RemoldingDilation & Hypertrophy

Vicious Cycleof Heart Failure

The signs and symptoms of HF are most often described in terms of the effect on the ventricles.

1. Right sided heart failure (Right ventricular failure).

2. Left-sided heart failure (left ventricular failure), causes different manifestations than right-sided heart failure (right ventricular failure).

Clinical Manifestations

SymptomsDyspnea on ExertionParoxysmal Nocturnal Dyspnea

TachycardiaCoughHemoptysis

Left-sided heart failure :

Symptoms:• Abdominal Pain• Anorexia• Nausea• Bloating• Swelling

Right-sided heart failure

© 2008 Heart Failure Society of America, Inc.

What Are The Symptoms of Heart Failure?

Think FACES...• Fatigue• Activities limited• Chest congestion• Edema or ankle swelling• Shortness of breath

Response to treatmentECGCXRECHO Angiography

DIAGNOSIS

Treatment

1. Reduce the respiratory and cardiac workload

2. Reduce agitation of patient3. Induce diuresis &

vasodilatation4. Reduce respiratory rate5. Decrease heart rate6. Establish the cause and treat.

Goals of Treatment

Therapy for heart failureMyocardial dysfunction

Increased load Neurohomonalactivation

Cardiomyocytedysfunction

Cell death

Heart failure

Drug therapy

Drug therapy

Gene therapy Heart transplantation

Cell transplantation

Treatment Considerations

Non-Pharmacologic•Diet:

1. Salt restriction2. Fluid restriction3. Weight loss 4. Lipid control

•Alcohol•Smoking•Exercise•Cardiac Rehab•Palliative Services•Social Support

Pharmacologic

Pharmacologic Interventions

Good Evidence to use the following exist:

1. ACE-Inhibitors2. Beta Blockers3. Spironolactone4. Diuretics5. Digoxin

Angiotensin Converting Enzyme Inhibitors

• Indication: All HF patients with sDysfunction (symptomatic or not); [A]

• Goal :Reduce morbidity & Mortality• Dose: Ideal dose controversial, start low and increase

to common dose

• Precautions: - Baseline Serum K+ and Cr. at initiation of therapy

required.- Careful monitoring if sBP <100mmHg, or if elevated

serum Cr. - Titrate as tolerated if administered with b-blockers

[C].

ẞ-BLOCKERSLimit the donkey’s speed, thus saving energy

Spironolactone

• Indication: Symptom at rest or new onset of symptom in last 6mo. Beneficial for moderate to severe HF.

• Dose: 25mg OD

• Precautions: Monitor kidney function & K+, >25mg is rarely indicated.

Diuretics• Indication: to control fluid overload (Edema,

Ascites, Wt gain)• Goal: Improve morbidity• Dose:

- Usually Furosemide, start @ 20mg/d and incr/decr as needed

- Diuretics can be stopped if fluid overload resolves.

• Precautions: K+ wasting, typically given with KCl supplements, Monitor serum K+.

ACE-Inhibitors

Evidence for Use: Systemic reviews & RTCs show that ACE-

Inhibitors • reduced ischemic events • slow disease progression • improve exercise capacity • decrease hospitalization & mortality for

heart failure compared with placebo.

DIURETICS, ACE INHIBITORS

Reduce the number of sacks on the wagon

Digoxin• Indication:

1. HF + A.fib [A]2. Patients still symptomatic despite use of Diuretics,

ACEI & b-Blockers. 3. PRN use to control dyspnea at rest (existing or new

onset) [A]. • Goal: Improve morbidity• Dose: 0.125 – 0.25mg /d

• Precautions:-Digoxin levels [when toxicity is suspected].-Pushed to backburner b/c of recent discovery that it

can incr risk of death from any cause amongst women [not men] w/HF and decr LVEF.

DIGITALIS COMPOUNDS

Like the carrot placed in front of the donkey

CARDIAC RESYNCHRONIZATION THERAPY

Increase the donkey’s (heart) efficiency

1. intractable heart failure – patient becomes progressively refractory to therapy.

2. cardiac dysrhythmias 3. digitalis toxicity ( from decrease

renal function).4. Pulmonary emboli, pneumonia5. Cardiogenic shock

Complications

Nursing

Process

NURSING HISTORY:- 1.Family history of heart diseases

2.Previous episodes of IHD 3.Dietary habits and salt intake4.Target organ diseases5. Sleep patterns.

Nursing assessment

1. Auscultate heart rate and palpate peripheral pulses

2. Auscultate the chest for crackles and wheezing

3. Examine the heart for enlargement4. Determine mentation status by asking

pt about memory, ability to concentrate

Physical examination

1. Decreased cardiac output R\T impaired contractility & increase preload and after load.

GOAL : MAINTAINING ADEQUATE CARDIAC

OUTPUT.

Nursing diagnosis (1)

1. place patient at physical & emotional rest to reduce work of heart.

2. Observe for sign and symptoms of reducing tissue perfusion , cool temperature of skin, facial pallor, poor capillary refilling.

Implementations

3. Re-assure patient and family4. Maintain patient in High Fowlers position5. O2 100% via non re-breathable mask or CPAP.6. monitor O2 saturations.7. Attach to cardiac monitor, assess rhythm,

rate.8. Cyclomorph (frequent small doses)9. Record ECG to identify &promptly treat

cardiac cause.

Implementations

2. Activity intolerance (or risk for activity intolerance) related to imbalance between oxygen supply and demand because of decreased CO.

GOAL : PROMOTING ACTIVITY TOLERANCE

Nursing diagnosis (2)

1. The schedule should alternate activities with periods of rest and avoid having two significant energy-consuming activities occur on the same day.

2. Before undertaking physical activity, the patient should be given the following safety guidelines:

Implementations

Begin with a few minutes of warm-up activities. Avoid performing physical activities outside in

extreme hot, cold, or humid weather. Ensure that you are able to talk during the physical

activity; if you are unable to do so, decrease the intensity of activity.

Wait 2 hours after eating a meal before performing the physical activity.

Stop the activity if severe shortness of breath, pain, or dizziness develops.

End with cool-down activities and a cool-down period.

Implementations

Heart Failure: Nursing Diagnoses

• Impaired gas exchange related to ventilation perfusion imbalance.

• Ineffective (cardiopulmonary) tissue perfusion related to impaired arterial blood flow.

Heart Failure: Nursing Diagnoses

• Excess fluid volume related to excess fluid or sodium intake and retention of fluid secondary to heart failure and its treatments.

• Anxiety related to breathlessness and / or restlessness secondary to inadequate oxygenation.

• Powerlessness related to inability to perform usual role responsibilities.

• Knowledge deficit related to heart failure and its treatments.

Nursing Management: Heat Failure

• Nursing Considerations • Respiratory

• Supplemental oxygen • Good lung assessment

• Monitoring • Hemodynamic Monitoring • Daily Weights• I & O’s • Laboratory Results

• i.e. electrolytes, BNP & digoxin levels • Maintain

• Small frequent meals; low in salt • Skin integrity

Nursing Management: Heat Failure

• Nursing considerations Cont.,• Promote rest and avoid fatigue • Assess for peripheral edema

• Client Education• Medications • Lifestyle changes

• i.e. low-sodium diet & activity-rest balance • Daily weights • S/Sx of worsening heart failure to report • Importance of follow-up care

1. Continue standard heart failure medications2. Monitor of biochemistry and haematology

profiles.3. Daily weight monitoring, before breakfast &

after voiding.4. Daily intake / output chart5. Salt restriction6. Continue education of patient and family

member.7. Mobilization8. Preparation for discharge ‘Two day rule’9. Follow up 7-10 days

Ward Management

‘2 Day Rule’1. Symptomatically stable and improved!!!!!2. Off all IV therapy for 2 days3. Stable oral therapy with no dose changes for 2

days4. Stable dry weight for 2 days

Stability for Discharge

1. Stable heart failure patients generally have low blood pressure!!!!!!

2. ACE inhibitors and Beta blockers given to protect the heart muscle not to control BP!!!

3. As a rule if patient is asymptomatic and has BP > 90/60 mmHg then regime can continue.

4. Ensure that patient is not dehydrated. 5. Check fluid intake, get patient to drink a glass

of water and recheck BP in 30 mins6. Do not elevate end of bed!!!!!If still unsure

check with medical team or Heart Failure.

Never stop Heart Failure Meds!!!!

1. Six signs of decompensaton ↑Fatigue, ↑Weight, ↑Oedema, ↑SOB,

Nausea, Palpitations .2. Stable weight Significance of weight gain3. How to report clinical deterioration4. Medications & dosages5. Salt restriction & fluid intake6. Alcohol7. Appropriate lifestyle changes

What Heart Failure Patients MUST know!!!

Any question?

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THANK YOU

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1. (Medical dictionary definition of hypertension from KMLE Medical Dictionary retrieved on 07-04-1

2. Johnson JA, Turner ST (June 2009). "Hypertension pharmacogenomics: current status and future directions.". Current Opinion in Molecular Therapy 7 (3): 218-225. PMID 15977418. 

3. Up-to-date software program, 2010.4. Brunner , Medical-surgical nursing 11th edition.5. Shatzer, M. (2003). Using a BNP test to identify

heart failure. Nursing, 33(1), 68.6. Svendsen, A., Arnold, J. M., & Parker, J. (2006).

Caring for patients with heart failure. Canadian Nurse, 102(3), 14-17.

References