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Congestive Heart Failure
- 1. CONGESTIVE HEART FAILURE By :- Baljinder Singh M.sc (MSN)
- 2. C H F Definition: It is a clinical syndrome resulting from the inability of heart to pump enough blood at rest or during exercise even though the filling pressures are adequate.
- 3. Incidence Major public health problem in industrialized countries. Common in elderly.
- 4. Etiology Divided in to 3 subgroups -Abnormal loading conditions -Abnormal muscle function -Precipitating factors
- 5. Etiology (contd..) Abnormal loading conditions Increased preload Refers to the length of the ventricular myocardial fibers just before ventricular contraction and EDV -Valvular regurgitation -Hypervolemia -Congenital diseases (ASD,VSD,PDA)
- 6. Etiology (contd..) Increased after load Correspond to the amount of intra myocardial wall tension that the heart must generate to overcome systolic pressure and allows ventricular emptying. -Aortic valvular stenosis -pulmonary valve stenosis -Systemic and pulmonary hypertension -Increased PVR -Increased blood viscosity
- 7. Etiology (contd.) Abnormal muscle function -Conditions that interfere with myocardial contractibility MI Myocarditis Cardiomyopathy ventricular aneurism -External compression (constrictive pericarditis,cardiac tamponade)
- 8. Precipitating factors Physical and emotional stress Dysrrhythmias Infection Anemia Thyroid disorders Pregnancy Paget disease Nutritional deficiency Pulmonary diseases Hypervolemia
- 9. Pathophysiology Diseased Normal myocardium myocardium Unable to meet the demands Activation of compensatory system (sympathetic stimulation) Fails Increased residual volume in left ventricle
- 10. Pathophysiology (contd..) Decreased ability to receive blood from left atrium Left atrium work hard to eject blood dilation and hypertrophy Pulmonary edema and congestion
- 11. Pathophysiology (contd…) Increased pressure in pulmonary vascular system Right ventricular dilation&hypertrophy Fails Engorgement of systemic venous system Congestion in GIT,Liver viscera,Kidneys,Legs,sacrum
- 12. Pathophysiology (contd..) Conditions that causes RVF - Pulmonary diseases (PAH,Pulmonary embolism,COPD,cor pulmonale) -Constrictive Pericarditis -Tricuspid and pulmonary valvular disorders -RV infarction
- 13. Pathophysiology (contd..) Cardiac reserve (Hearts ability to increase the output in response to stress(5 the times the normal) But in the diseased heart, it fails to respond to body’s increased demands Compensatory mechanism will be initiated
- 14. Pathophysiology contd.. Compensatory mechanisms are -Ventricular dilation: Lengthening of the muscle fibers Increased volume of heart chambers Increased preload and cardiac out put leads to reduced contractibility when stretched beyond capacity Increased oxygen demand hypoxia
- 15. Pathophysiology (contd..) Ventricular hypertrophy-Increase in the diameter of muscle fibers Size and weight of heart increases Increased oxygen demand Hypoxia and reduced contractibility
- 16. Pathophysiology(contd..) Increased sympathetic stimulation Increased heart rate and peripheral vascular resistance Reduced renal flow and increased renal conservation of water and sodium Fluid overload and increased workload
- 17. Forms of heart failure Systolic versus diastolic failure Systolic-Inability to contract normally Diastolic-Inability to relax or fill normally High output versus low output Low output-IHD, HT,cardiomyopathy,pericardial diseases Highoutput- Hyperthyroidism,anemia,pregnancy,paget disease
- 18. Forms (contd..) Acute versus chronic Acute –Acute large MI Chronic-Dilated cardiomyopathy multivalvular heart disease Right sided versus left sided RVF-PAH,Pulmonary stenosis,pulmonary embolism, LVF-Aortic stenosis,Post MI
- 19. Types (contd..) Backward versus forward H F backward-ventricles fail to fill normally Increased pressure in the atrium and venous system sodium and water retention edema Forward-Inadequate discharge of blood in to the arterial system
- 20. Clinical features LVF-Dyspnea(PND) Orthopnea cough(frothy&blood tinged sputum) chyne stoke respiration pulmonary edema (extreme breathlessness,anxiety,frothy sputum, nasal flarring)
- 21. C/F Contd Cardiovascular signs – Enlarged left laterally displaced apical impulse, Heart gallop(S3 & S4) pulses alternas Cerebral hypoxia- Anxiety,Irritability,Restlesness,confu sion,Impaired memory, Insomnia Renal changes-Oliguria,fatigue and muscular weakness
- 22. C/F Contd RVF-Peripherl edema and venous congestion, Hepatomegaly and abdominal pain Cardiac cirrhosis and ascitis Anorexia,nausea and bloating cardiac cachexia Pitting edema Jugular vein distention, Increased CVP Anxiety and depression
- 26. Complications Acute pulmonary edema Refractory heart failure
- 27. Diagnosis PND Neck vein distention Cardiomegaly Pulmonary edema Gallop Increased CV Hepatojugular reflex Framingham criteria Major criteria Minor criteria Peripheral edema Night cough Dyspnea on exertion Pleural effusion Hepatomegaley Reduced vital capacity Tachycardia(>120bpm) Presence of one major or 2 minor criteria confirms the diagnosis
- 28. Diagnosis(contd..) Chest radiography ABG analysis Liver enzymes BUN and creatinine ECG
- 29. Medical management Removal of precipitating factors Correction of underlying causes Prevention of deterioration of cardiac function Control of CHF state
- 30. Immediate management Positioning – high fowlers position 0xygen administration(8–10 Lts,)
- 31. Management contd Digitalis-Increses ventricular emptying, slow conduction of impulses through AV node, Increases stroke volume and cardiac output -effective in systolic heart failure -0.25 6 hourly for adults, for elderly o.125 mg 6 hourly -Reduce dose in renal impairement -Should not be given in heart failure with high output -Digitalis toxicity should be monitered
- 32. Management contd Dopamine and dobutamine Low output failure Dopamine-2-10 microgram/kg/mt Dobutamine-2.5-10 microgram/kg/mt Anticoagulants Antiarrythmics ACEI Aldosterone antagonist;spironolactone25mg /day Beta adrenergic blockers
- 33. CHF: Diuretics Reduce volume overload Reduce sodium overload Preload reduction
- 34. Diuretics Thiazide Diuretics Chlorthalidone Metolazone Loop Diuretics Furosemide Torsemide Potassium Sparing Diuretics Spironolactone Amiloride
- 35. CHF: ACE Inhibitors Improve hemodynamic status Improve symptoms Reduce incidence of hospitization Slow progression of disease Reduce mortality
- 36. ACE Inhibitors Captopril Enalapril Lisinopril Quinapril Trandolapril Fosinopril
- 37. Management contd Reduction of cardiac workload Reducing the physical activity Emotional rest and reduction of anxiety Diet: sodium 1 gm / day Water 1000 ml / day potassium supplements vasodilators – sodium nitroprusside and Isosorbid dinitrate Aminophylline 240- 480 mg IV
- 38. Surgical management Surgical correction of valvular disorders Heart transplantation Cardiopulmonary bypass Intra aortic balloon pump
- 39. Nursing management Impaired gas exchange related to to fluid in the alveoli Decreased cardiac output related to heart failure and Dysrrhythmias Fluid volume excess related to reduced cardiac output and Na and water retention Decreased peripheral tissue perfusion related to reduced cardiac output Activity intolerance related to reduced cardiac output
- 40. Nursing management High risk for impaired skin integrity related to reduced peripheral tissue perfusion High risk for digitalis toxicity related to impaired excretion Anxiety and fear of death related to reduced cardiac output and hypoxia