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					     Heart Failure

Laura Savage, MSN, RN, PCCN
     Cardiothoracic CNS
                  Definition
                   AHCPR
   Characterized by inadequate tissue
    perfusion
    –   Fatigue
    –   Poor exercise tolerance
    –   Oliguria
    –   Arrhythmias
    –   Altered mental status
    –   Peripheral vasoconstriction
                      OR
   INTRAVASCULAR VOLUME
    OVERLOAD
    –   SOB
    –   Crackles
    –   Edema
    –   Tachycardia
    –   Tachypnea
            Key concepts
 Preload
 After load
 Contractility
       Types of Heart Failure
   Systolic dysfunction
    – Impaired
      contractility of the
      LV
    – Leads to decreased
      SV and CO
        Etiologies of Systolic
            Dysfunction
   CAD ***
    – Ischemic heart disease
 MI
 Cardiomyopathies
 Valvular Heart Disease
 Pericardial disease
Presentation
        Dyspnea/Orthopnea
        Exercise intolerance
        Altered mental status
        Peripheral edema
            Physical Exam
   S3 or S4
   Tachyarrhythmias
   Crackles
   JVD
   Hepatomegaly
Diastolic Dysfunction
              Inability of the
               ventricle to relax
              Leads to decreased
               SV and CO
              Increased filling
               pressures
Etiology of Diastolic
    Dysfunction
              Hypertrophy of LV
              Ischemia
              Infiltrative disease
Presentation of Diastolic
      Dysfunction

         Dyspnea
          Fatigue
        Normal EF
  New York Heart Association
    (NYHA) Classification
•Class I:
   •no limitation of activities; no symptoms from
   ordinary activities.
•Class II:
   •slight, mild limitation of activity; comfortable at rest
   or with mild exertion.
•Class III:
   •marked limitation of activity; comfortable only at
   rest.
•Class IV:
   •physical activity brings on symptoms & occur at
   rest.
       Classification of heart
        disease ACC/AHA
   Stage A
    – At risk for developing HF; no sx
   Stage B
    – Structural abnormality with no sx of HF
   Stage C
    – Past or current sx of HF associated with structural
      abnormality
   Stage D
    – End stage HF requiring advanced therapies
    Pathophysiology of Heart
            Failure
 Inadequate organ perfusion 
  activation of multiple systemic
  neurohormonal pathways
 Initially, response is compensatory
  redistributing blood flow to vital organs
 Ultimately,compensatory mechanisms
  exacerbate symptoms and lead to
  clinical deterioration
    Compensatory Mechanisms
   Sympathetic stimulation
    – Alpha receptors
    – Beta receptors
 Renin-angiotensin aldosterone system
  (RAAS)
 Ventricular remodeling
    – Hypertrophy
    Results of Compensatory
          Mechanisms
 Tachycardia
 Peripheral vasoconstriction
 Fluid retention
 Decreased LV function
Management of Heart Failure
   Enhance beneficial effects of
    compensatory mechanisms
    – Inotropes
    – Preload reduction
    – Afterload reduction
      Management (con’t)
 Block RAAS (ACEi ARBs)
 Block SNS (beta blockers)
 Enhance natriuretic peptide
 Resynchronization therapy
 Circulatory Assist Devices
 Cardiac transplantation
                   Diuretics
 Promote renal sodium and water
  excretion
 Decrease CVP and PWP
 Provide symptom relief
    – Lasix***
    – Bumex
    – Metolazone
         Benefits of Diuresis
   Decreased end         Decreased preload
    diastolic volume      Increased exercise
   Decreased SVR          capacity
   Increased CO/SV
   Decreased SOB,
    crackles, edema
         Considerations
 Monitor K+
I&O
 Other labs
 Monitor rhythm
    Beta Adrenergic Agonists
 Used short term for exacerbations
 Decrease heart’s ability to respond to
  sympathetic stimulation
 Increase cardiac output
 Enhance contractility
    – Dopamine
    – Dobutamine
    – Levophed
              Dobutamine
   Sympathomimetic
   Used short term
   Improve CO, renal
    blood flow
   Arrhythmogenic
   Tolerance
               Digoxin
 Inotropic support
 Watch for toxicity
 Drug interactions
 Check Dig level
     Angiotensin converting
    enzyme inhibitors (ACE-I)
 Inhibit conversion of angiotension I to
  angiotensin II
 Provide arterial and venous dilation
 Block RAS activation
 Decrease afterload and preload
    – Enalapril
    – Lisinopril
    – Captopril
     Angiotensin II Receptor
          Antagonists
             ARBs
 Directly block angiotensin receptors
 Preload and afterload reduction
 Less cough than ACE-I
    – Losartan (Cozaar)
    – Valsartan (Diovan)
             Beta blockers
 Blocks sympathetic compensation
 Improves mortality and morbidity
    – Metoprolol
    – Carvedilol
    Nursing considerations
     with Beta Blockers
 Pts with IDDM
 CNS effects
 Triglyceride levels
 Discontinuing drug
Phosphodiesterase Inhibitors


             Refractory heart failure
             Indicated for exacerbation
              of HF
             Short term use
              – Milrinone
                 Vasodilators
   Decrease preload and afterload
    – Nitrates
   Increase contractility
    – Calcium channel blockers
Aldosterone Antagonists
               Blocks aldosterone
                action on SNS
                – Aldactone
                – Eplenerone*




                – *European Heart Journal 2003
                   24(19):1705-1706; doi:10.1016/S0195-
                   668X(03)00392-0
             Anticoagulants
   Indication: atrial
    fibrillation
   Venous stasis due to
    decrease cardiac
    output
    – Warfarin
      (Coumadin)
      Natrecor (Nesiritide)
 Synthetic natriuretic peptide (BNP)
 IV for acute decompensated HF
 Reduces PCWP
 Improves dyspnea
 Contraindicated with systolic BP < 90
 Weight -based bolus
 Infuse at 0.1 ml/kg/hr
Internal Cardioverter
    Defibrillator
              Recommended for
               pts with “Sudden
               Death”
    Cardiac Resynchronization
   Purpose:         Uses atrial
    – to restore       synchronization
      ventricular      with biventricular
      synchrony        pacing
    – Improves       Pace RV and LV
      hemodynamics     together to improve
                       coordination of LV
                       contraction
Cardiac resynchronization
      Biventricular Pacing
 Improves systolic contractility
 Cardiac resynchronization
 Stimulates ventricles to increase
  contractility
    Circulatory Assist Options
   Bridges to cardiac
    transplantation




          HEART MATE 2




IMPELLA   HEART WARE
                       CardioWest TAH




NEJM 2004;350:542-4.
FREEDOM DRIVER
    Cardiac transplantation
 Definitive therapy
 Requires life long immunosuppression
  therapy
HEART
TRANSPLANT
          Test your knowledge
   Pt is admitted with HF develops hypotension,
    tachycardia, decreased urine output, cool
    clammy skin, decreased LOC and tachypnea.
    Which should be included in the pt’s plan of
    care?
   A. Positive inotrope, diuretic, vasodilator
   B. ACE inhibitors, adenosine, beta blocker
   C. Beta blocker, diuretics, Ca channel blockers
   D. Negative inotrope, digoxin, antiarrhythmics
   Pt is admitted with HF develops hypotension,
    tachycardia, decreased urine output, cool
    clammy skin, decreased LOC and tachypnea.
    Which should be included in the pt’s plan of
    care?
             inotrope, diuretic,
    A. Positive
    vasodilator
   B. ACE inhibitors, adenosine, beta blocker
   C. Beta blocker, diuretics, Ca channel blockers
   D. Negative inotrope, digoxin, antiarrhythmics
Cardiomyopathies
Types:


   Dilated
 Hypertrophic
  Restrictive
Dilated CM
        Systolic dysfunction
        Ventricle dilated
        Hypertrophy of
         myocytes
                 Etiology
   Myocarditis
   Heredity 20%
   Substance Abuse
   Viral infection


                      Example of infection in myocytes
            Presentation DCM
   Signs of Peripheral          Signs of right
    hypoperfusion ( LV            ventricular failure
    failure)                      (Systemic venous
    –   Dyspnea, orthopnea,       congestion)
    –   Hypotension               – Abdominal
    –   Cool, clammy                distension
    –   EF <45%                   – RUQ pain
    –   S3                        – Nausea
    –   MR or TR                  – JVD
          Management of DCM
   Treat underlying
    cause                Heart transplant
   Inotropes
   Vasodilators
   Heparin/Coumadin
   ACEi or ARBs                      ICD
   Beta blockers
   Aldosterone
    blockers
                       LVAD
 Hypertrophic
Cardiomyopathy

          Myocardial
           hypertrophy
          Diastolic
           dysfunction
Etiology of Hypertrophic CM
   Heredity 60-80%
   Acquired– for eg.
    – Hypertension
    – Aortic stenosis
Hypertrophic CM
     – Obstructive or non obstructive
     – Septal hypertrophy can block
       outflow
     – Most common cause of death
       in young athletes
Presentation Hypertrophic
           CM
                Often without sx
                Seen on echo
                Sudden cardiac
                 death
                Angina
                Fatigue
                Syncope or
                 presyncope
                    HCM
   Large QRS voltage
   ST-T wave changes
   SVT and ventricular
    arrhythmias
      Management HCM
                           Surgical
   Medical
                            management
    management
                            – Septal myectomy
    – Beta blockers
                            – Septal ablation
    – Calcium channel
      blockers
    – Amiodarone
    – ICD
              Restrictive CM
   Impaired filling of
    ventricles
   Normal wall
    thickness and
    systolic function
Etiology- Restrictive CM
               Genetic or
                idiopathic
               Infiltrative disease
               Chemo or radiation
               Presentation
   High pulmonary      High systemic
    pressure             venous pressure
    – Dyspnea            – JVD
    – Elevated PA        – Ascites, peripheral
      pressure             edema
    – S3
    – TR or MR
    – Atrial fib
Treatment RCM
          Supportive care
           – Diuretics
           – Anticoagulation
           – Inotropes
          Cardiac Transplant
              Check yourself
   A patient with systolic heart failure has
    slight dyspnea at rest. The nurse
    should anticipate management to
    include
    –   A. Metoprolol (Lopressore)
    –   B. Milrinone (Primacor)
    –   C. Enalapril (Vasotec)
    –   D. Diltiazem (Cardizem)
   A patient with systolic heart failure has
    slight dyspnea at rest. The nurse
    should anticipate management to
    include
    – A. Metoprolol (Lopressore)
    – B. Milrinone (Primacor)
    – C. Enalapril (Vasotec)
    – D. Diltiazem (Cardizem
          Check it out…
 A patient with heart failure received
  Digoxin and has now developed
  frequent, unifocal PVCs. Dig level is
  upper range of normal. Assessment is
  as follows:
 BP 112/82 HR 78, irreg, RR 24 Na 138
 Which is the most appropriate to
  administer?
 A. Lidocaine
 B. Magnesium
 C. Digibind
 D. Potassium
   A. Lidocaine
 B.   Magnesium
 C. Digibind
 D. Potassium
   A teenager post cardiac arrest has a new
    diagnosis of HCM. The parents are concerned
    about what to do if the pt collapses again.
    Your best response:
   A. Now that your son has been diagnosed,
    you don’t need to worry
   B. Would teaching you CPR help ease your
    anxieties?
   C. Do you know how to access EMS?
   D. I’ll have the cardiologist speak with you
   A teenager post cardiac arrest has a new
    diagnosis of HCM. The parents are concerned
    about what to do if the pt collapses again.
    Your best response:
   A. Now that your son has been diagnosed,
    you don’t need to worry
 B.  Would teaching you CPR help
    ease your anxieties?
   C. Do you know how to access EMS?
   D. I’ll have the cardiologist speak with you

				
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