Congestive Heart Failure(CHF)

CONGESTIVE HEART FAILURE
Presented by:
Sankappa Gulaganji
Asst Professor
BLDEA’s Shri B M Patil INS
BLDEA’s SHRI B M PATIL INSTITUTE OF NURSING SCIENCES, VIJAYAPUR

Introduction
 Heart failure does not mean the heart has stopped
working. Rather, it means that the heart's pumping
power is weaker than normal.
 With heart failure, blood moves through the heart and
body at a slower rate, and pressure in the heart
increases. As a result, the heart cannot pump enough
oxygen and nutrients to meet the body's needs.

CONGESTIVE HEART FAILURE Congestive heart failure is not a disease but a
condition that occurs when the heart is unable to
pump enough blood to meet the needs of the body's
tissues.
 When the heart fails, it is unable to pump out all the
blood that enters its chambers.
 An ejection fraction, is the percent of the blood
pumped out during each heartbeat.
 An ejection fraction of 50% to 75% is normal .
 The ejection fraction in CHF falls below 40%; in
severe failure it may drop as low as 5%.

Definition
Heart failure describes the clinical syndrome that
develops when the heart cannot maintain an
adequate cardiac output. The heart pumps blood
inadequately, leading to reduced blood flow, back-
up (congestion) of blood in the veins and lungs, and
other changes that may further weaken the heart.

Heart Failure can divided:
 Right Sided Heart Failure
 Left Sided Heart Failure
 Diastolic heart failure (Inability to relax)
Systolic heart failure (Inability to Contract)

Right Sided Heart Failure
In right-sided heart failure, the right ventricle loses
its pumping function, and blood may back up into other
areas of the body, producing congestion.

Left Sided Heart Failure
Inability of the left heart to maintain its
circulatory load, with corresponding rise in
pressure in the pulmonary circulation usually
with pulmonary congestion and ultimately
pulmonary edema.

Diastolic heart failure
Diastolic dysfunction refers to an abnormality in how
the heart fills with blood during diastole. The heart
muscles do not relax in a normal manner and the heart
may fill too slowly, asynchronously or with an elevation
in filling pressure only.

Systolic heart failure
The left ventricle loses its ability to contract normally.
The heart can't pump with enough force to push
enough blood into circulation.

CAUSES
Damage to the mechanisms that control the input and
output of blood from the heart is usually the last stage
of one of several heart or circulatory diseases. Heart
failure can be a direct result of one of these diseases or
it can occur over time as the heart tries to compensate
for abnormalities caused by these conditions.

Coronary Artery Disease
Congestive heart failure may develop slowly from
heart damage due to atherosclerosis, Heart failure
in such cases most often results from a localized
pumping defect in the left side of the heart
Damage After a Heart Attack
People now often survive heart attacks, but
eventually many develop heart failure from the
physical damage done to the heart muscles by the
attack

High Blood Pressure
In hypertension, the heart muscles thicken to
compensate for increased blood pressure, and over
time the force of their contractions weaken and they
have difficulty relaxing, thereby preventing the
normal filling of the heart with blood
Diabetes
Diabetes contributes to heart failure, not only because
of its association with obesity, high blood pressure,
and coronary artery disease, but also because specific
disease mechanisms that contribute to diabetes may
also damage the heart.

Valvular Heart Disease
The valves of the heart, which control the flow of
blood leaving the heart, can narrow, causing a back-
up of blood, or they can close improperly, causing
blood to leak back into the heart
Cardiomyopathies
Cardiomyopathies are diseases that damage the heart
muscles and lead to heart failure. Genetic factors or
birth defects may play a role in the development of
these conditions. HIV infection and chemotherapies
also increase the risk for cardiomyopathies.

Other Causes for Heart Failure
 Chronic alcohol abuse
 Severe emphysema
 Excessive salt consumption,
 Hyperthyroidism,
 Thiamin deficiency,
 Pneumonia,
 High fever,
 Kidney & Liver Failure
 Amyloidosis, a disease in which a starchy protein
(amyloid) builds up in tissues and organs, can cause
congestive heart failure.
 Acute myocarditis,
 Long term use of anabolic steroids

PATHOPHYSIOLOGY
Systolic Heart Failure
Decreased ejection fraction
Sympathetic nervous system stimulation
Release of epinephrine & norepinephrine
Support the failing heart
Further damage to the heart
Decreased renal perfusion
Release of rennin from kidney
Combines with Angiotensin I
ACE converts Angiotensin I to Angiotensin II
Vasoconstrictor & release of aldosterone
Retention of Na+ & fluid

Increase preload & after load
Decrease the contractility of myocardium
Change myofibers structure & ventriculodilation
Compensated by ventricular hypertrophy
Myocardial ischemia
Myofibril death

SIGNS & SYMPTOMS
Many symptoms of heart failure result from the
congestion that develops as fluid backs up into
the lungs and leaks into the tissues. Other
symptoms result from inadequate delivery of
oxygen-rich blood to the body's tissues.
18

Symptoms of Left-Side Heart Failure
 Fatigue
 Shortness of breath
 Asthma-like wheezing
 Dry hacking cough & later cough that produces a
pinkish froth.
 Loss of muscle weight due to low cardiac output.
 Central sleep apnea, in which the brain fails to
signal the muscles to breathe during sleep, is a
common condition associated with heart failure.
 Sleep apnea
 Pulmonary edema
 The skin is clammy and pale
19

Symptoms of Right-Side Heart Failure
 Fatigue
 Shortness of breath or difficulty breathing, at
first during exercise, and later with any activity
 Episodes of awaking at night with difficulty
breathing or difficulty in lying flat in bed•
 A dry cough that lasts a long time
 Swollen ankles and feet, along with weight gain
due to too much fluid in the body•
 Loss of appetite.
20

RIGHT HEART FAILURE
 H- Hepatomegaly
 E- Edema
 A- Ascitis
 D- Distended neck veins
July 17, 2020 cne 21

LEFT HEART FAILURE
 C- Cough
 H- Hemoptysis
 O- Orthpnea
 P- Pulmonary congestion

DIAGNOSTIC EVALUATION
@ History
@ Physical examination.
@ Stress test
@ Electrocardiogram
@ Echocardiography
@ Angiography
@ X-ray
* Laboratory Tests
@ Hematology
@ Biochemistry
23

Exercise Stress Test
Measuring heart rate, blood pressure, and
oxygen consumption while patient is
exercising.
Appears to be a more accurate method for
determining the degree of heart
impairment than taking such
measurements while the patient is at rest.
24

Electrocardiogram
An electrocardiogram (ECG) cannot diagnose
heart failure, but it is simple and painless to
perform and can indicate underlying heart
disease by suggesting enlargement of the heart
muscle, coronary artery disease, or abnormal
cardiac rhythms.
It may be effective in determining patients who do
not need a more accurate (but more expensive)
echocardiogram.
25

Echocardiography
The best diagnostic test for congestive heart failure
is echocardiography coupled with studies known
as Doppler flow .
Cardiac ultrasounds provide accurate indications of
valve function and the flow of blood through the
heart's chambers.
They can reveal whether the failure is on the left,
the right side, or both.
Echocardiograms also indicate the ejection
fraction, the percent of the blood pumped out
during each heart beat.
26

X-Rays
X-rays, can reveal cardiac enlargement or
evidence of fluid accumulation around the
heart and lungs.
X-rays are helpful to both diagnose congestive
heart failure and confirm the effectiveness of
treatment.
27

Angiography
Angiograms, help locate problems in the
heart's pumping action or blockage in the
arteries.
Major complications of angiography
include stroke, heart attacks, and kidney
damage, but these risks are very low
(about 0.1%).
28

PROGNOSIS
Women have a better survival rate than men do when
heart failure is caused by valvular heart disease, high
blood pressure, or alcohol abuse. (Some studies
indicate that this is because men may be more
susceptible to the process of heart muscle-cell
remodeling, a damaging effect of hypertension).
The survival rates of women and men are more equal,
however, when heart failure is caused by coronary
artery disease or heart attack.
29

Classification of Severity
A classification system was developed by the
New York Heart Association to grade
congestive heart failure by severity of
symptoms.
NYHA Classification System for Heart
Failure
30

Class I:
 No limitation of physical activity.
 No shortness of breath, fatigue, or heart
palpitations with ordinary physical activity.
31

Class II.
 Slight limitation of physical activity.
 Shortness of breath, fatigue, or heart
palpitations with ordinary physical activity,
but patients are comfortable at rest.
32

Class III.
 Marked limitation of activity.
 Shortness of breath, fatigue, or heart
palpitations with less than ordinary physical
activity, but patients are comfortable at rest.
33

Class IV.
 Severe to complete limitation of activity.
 Shortness of breath, fatigue, or heart palpitations
with any physical exertion and symptoms appear
even at rest.
34

Complications
The most serious complications of heart
failure are arrhythmias (irregular beatings
of the heart).
Acute pulmonary edema (fluid in the lungs),
which is strongly associated with heart
failure, can also be life-threatening.
36

COMPLICATION
 Pulmonary Edema
 Pulmonary Hypertension
 Pleural Effusion
 Cardiogenic shock
 Portal Hypertension
 Arrhythmias.
37

MANAGEMENT
General Guidelines
The primary conditions causing heart failure
should be treated first, including coronary artery
disease, valvular abnormalities, high blood
pressure, arrhythmias, anemia, and thyroid
dysfunction. Treating heart failure itself at as
early a stage as possible offers the best chance for
a longer and better quality life.
38

Four classes of medications are used to
treat heart failure:
39
 Diuretics (drugs to reduce fluid),
 Vasodilators, particularly ACE inhibitors (drugs
that dilate blood vessels),
 Inotropics, usually digoxin (drugs that increase the
heart's ability to contract), and more recently,
 Beta blockers (drugs that block activities of
stress hormones on the failing heart).

Diuretics
 Diuretics act on the kidneys to rid the body of
excess salt and water. They reduce the
accumulation of fluid in the legs, abdomen, and
lungs, lower blood pressure, and improve the
efficiency of the circulation.
 Side effects of diuretics include low blood
pressure, dehydration, and kidney dysfunction;
40

ACE Inhibitors
 These drugs block the formation of angiotensin II, a
powerful enzyme that raises blood pressure, constricts blood
vessels, and leads to salt retention. Commonly used ACE
inhibitors are captopril (Capoten), enalapril (Vasotec).
 The primary adverse effect of ACE inhibitors is low blood
pressure, kidney failure,dry cough , excessive potassium
levels;
41

Beta Blockers
 Beta blockers prevent norepinephrine (adrenaline) from
binding to heart cells, which affects the frequency and
force of heart beats. Elevated levels of norepinephrine, a
stress hormone, can over stimulate the failing heart and
are associated with severe heart failure. Beta blockers
must be carefully monitored and the dosages regulated
very carefully, since heart failure may actually worsen in
the early stages of treatment.
 It should not be used in people with asthma,
bradycardia, low blood pressure, or people with certain
heart conduction disorders.
42

Digitalis
 Digitalis is referred to as an inotropic drug; it increases
the strength of the heart's contractions, reduces heart
size, and reduces certain arrhythmias.
Derived from the foxglove plant.
Digitalis may be useful for patients with systolic
dysfunction characterized by low ejection fractions and
is helpful in heart failure patients with atrial fibrillation.
 Digitalis may even be harmful in some patients with
heart failure, particularly when caused by diastolic
dysfunction characterized by normal to high ejection
fraction.
43

 The most serious side effects are arrhythmias. Factors
which increase the risk of toxicity include advanced age,
low blood potassium levels (which can be caused by
diuretics), hypothyroidism, anemia, valvular heart
disease, and impaired kidney function.
 Early signs of toxicity may be irregular heart beat,
nausea and vomiting, stomach pain, fatigue, visual
disturbances, and emotional and mental disturbances.
 Toxic side effects used to be experienced by nearly 25%
of patients taking digitalis, but now that a blood test can
be used to monitor the level of the drug in the blood,
toxicity is down to 2%.
44

NSAIDs: A Special Warning
 Recent use of NSAIDs has been associated with
a higher risk of hospitalization in heart failure
patients, particularly if they are also taking
diuretics or ACE inhibitors.
 In fact, one study suggested that anyone with a
history of heart disease who is taking NSAIDs may
be at higher risk for heart failure
45

NURSING MANAGEMENT
OBJECTIVES
 To maintain adequate ventilation
 To increase cardiac output.
 To provide physical & emotional rest.
 To reduce / eliminate edema.
 To provide health teaching.
46

INTERVENTIONS
 Monitor respiratory status & provide
adequate ventilation:
 O2 therapy
 Semi or high fowler position.
 Monitor ABGs.
 Assess for breath sounds.
 Provide physical & emotional support.
47

 Increase Cardiac Output.
 Digitalis as ordered.
 Electrolytes level (K+) monitoring.
 ECG
 Vital Signs.
 S. Digoxin Level
48

 Reduce / eliminate edema
 Diuretics
 I/O monitoring
 Daily weight & abdominal girth
 Monitor CVP & electrolytes levels
 Low salt & fat diet.
 Skin care
49

LIFESTYLE RECOMMENDATIONS
Between 30% to 47% of patients who require
hospitalization for heart failure are back in the
hospital again within six months. Many people
return because of lifestyle factors, such as
poor diet, failure to comply with medications,
and social isolation.
50

Home Support and Rehabilitation
 Elderly people who had no emotional support at
home had triple the risk of a heart attack after
hospitalization for heart failure than those who did
have such support.
 In another study, the greatest risk factor for death and
readmission to the hospital after a first hospitalization
for heart failure was being single, regardless of the
health of the patient at discharge.
 Programs that offer intensive follow-up to ensure that
the patient complies with lifestyle changes and
medication regimens at home are reducing
rehospitalization and costs and improving survival.
51

Diet and Weight
52
Diet: All heart failure patients should limit their salt
intake. Patients should not add salt to their cooking and
their meals. They should also avoid foods high in sodium;
these include ham, bacon, hot dogs, lunch meats, prepared
snack foods, dry cereal, cheese, canned soups, soy sauce.
Some patients may need to reduce their water intake as
well. People with high cholesterol levels or diabetes
require additional dietary precautions.
Weight: A sudden increase in weight of more than two or
three pounds may indicate fluid accumulation and should
prompt an immediate call to the physician.

Exercise
Traditionally, heart failure patients have been
discouraged from exercising. Now, exercise is
proving to be helpful for many patients and, when
performed under medical supervision, does not pose a
risk for a heart attack for patients whose condition is
stable. Studies have reported that patients with
stable conditions who engage in moderate exercise
(twice a week) for a year experience a better quality
of life and lower mortality rates. One study found that
performing daily hand grip exercises improved blood
flow through the arteries of patients with heart failure
53

Bed Rest
Bed rest may be required in cases of severe
congestive heart failure. To reduce congestion in
the lungs, the patient's upper body should be
elevated; for most patients, resting in an
armchair is better than lying in bed. Relaxing
and contracting leg muscles is important to
prevent clots. As the patient improves,
progressively more activity will be
recommended.
54

Stress Reduction
Stress reduction techniques may have direct
physical benefits lowering stress hormones,
including cortisol (which suppresses the
immune system) and norepinephrine (also
known as adrenaline), the chemical messenger
associated with heart dysfunction. Many
effective stress reduction techniques, including
meditation and relaxation methods, are
available.
55

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Congestive Heart Failure(CHF)

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