1. Heart failure is a clinical syndrome where the heart is unable to pump enough blood to meet the body's needs. It becomes more prevalent with age due to cardiovascular changes and diseases. 2. Over 550,000 new cases of heart failure are diagnosed yearly in the US, with rates doubling each decade after age 45. The most common causes in the elderly are high blood pressure, coronary artery disease, and valvular heart disease. 3. Management of heart failure in the elderly focuses on treating the underlying cause, nonpharmacological therapies like exercise and diet, and use of medications like ACE inhibitors, beta-blockers, diuretics, and aldosterone antagonists. Regular monitoring and support are

1. Nursing the Failing Ol` Heart
MARC EVANS M. ABAT, MD, FPCP, FPCGM
Section of Adult Medicine, Department of Medicine, PGH
Head, Center for Healthy Aging, The Medical City

2. Introduction
• Heart failure
An inability of the heart to pump sufficient blood to meet
the metabolic needs of the body’s tissues or the ability to
do so only at the expense of elevated intracardiac pressures
• A clinical syndrome

3. Epidemiology and Economic Impact
• Incidence and prevalence is rising
• Contributing factors to its rise
• increasing number of older adults
• Advances in treatment of acute and chronic cardiac and
noncardiac diseases

4. • 550,000 new cases yearly
• doubles with each decade after 45 years, 10% by 80 years
• Major source of chronic disability and impaired quality of
life
• Leading indication for hospitalization for ages >65 years
old
• 60% of HF patients, > 65 years old, are women

5. Pathophysiology
• Age-related cardiovascular changes with increasing
prevalence of cardiovascular diseases exponentially raise
prevalence of HF
• Resting cardiac function in healthy elderly patients is well
preserved
• Maintained LV EF
• Maintained LV cardiac output

6. • 4 factors contributing to the heart’s attenuated capacity to
augment cardiac output
• Reduced β-adrenergic responsiveness (reduced chronotropic and
inotropic response, decreased peripheral vasodilation)
• Increased vascular stiffness (increased LV impedance and systolic
HPN)
• Altered LV diastolic filling due impaired relaxation and compliance
• Altered myocardial energy metabolism (less ability of
mitochondria to generate ATP during stress)

7. •Clinical implications of impaired diastolic filling
• Failure of the Frank-Starling mechanism
• Shift to the left of the normal ventricular volume-
pressure curve (larger pressure for small increase in
volume) pressure transmitted to LA
• Increased propensity for diastolic HF

8. • Other changes that may impact management of HF
• Decline in GFR by 8cc/min per decade
• Reduced renal capacity to respond to volume expansion or
sodium excess
• Less responsive to diuretics
• V/Q mismatching
• Sleep-related breathing disorders
• Impaired thirst
• Reduced CNS autoregulation
• Impaired baroreceptor responsiveness
• Changes in pharmacokinetics and pharmacodynamics of drugs

9. Etiology and Precipitating Factors
• 70% cases-HPN and CAD
• VHD
• Calcific AS-most common form requiring surgical intervention
with AVR as 2nd most common open heart surgery in patients >
75 yrs
• MR
• MS-RHD is a relatively uncommon cause
• AI

10. • Cardiomyopathies
• IHD with 1 or more MImost common cause of DCMP; other
causes (alcohol, cocaine, anthracyclines)
• Hypertrophic and restrictive cardiomyopathy are increasingly
recognized
• Endocarditis
• Uncommon but important due to curability
• Myocarditis and constrictive pericarditis
• Rare causes
• High-output failure due to thiamine deficiency,
thyrotoxicosis, anemia, AV malformations or fistulas)

11. Precipitating factors
• Most commonnoncompliance with medications or
diet
• As many as 2/3 of exacerbations
• Among cardiac factors
• Ischemia
• Infarction
• New-onset AF
• Ventricular arrhythmias
• bradyarrhythmias

12. •Acute or worsening noncardiac conditions
• Pneumonia
• COPD
• Pulmonary embolism
• Other infections
• Inadequate hypertension control
• Thyroid disease
• Anemia
• Renal disease

13. •Drugs and medications
• Alcohol
• β-blockers and calcium channel blockers
• Antiarrhythmic drugs like quinidine, propafenone,
flecanide)
• NSAIDS
• Corticosteroids
• Minoxidil
• thiazolidenediones

14. Nursing Pearls
• be specially observant of the subtle clues as to the etiology and
contributing factors to heart failure

15. Clinical Features
Symptoms
• Exertional shortness of breath
• Orthopnea
• Dependent edema
• Fatigue
• Exercise intolerance
• Atypical symptoms
• Malaise, exhaustion, declining physical activity, delirium, irritability, sleep
disturbance, anorexia, abdominal discomfort, nausea, diarrhea

16. Signs
•Classic signs
•Pulmonary rales
•Elevated JVP
•Hepatojugular/abdominojugular reflux
•S3 gallop
•Pitting edema

17. Nursing Pearls
• To be able to pick up and recognize these signs and symptoms as they
evolve

18. Diagnostic Evaluation
• History
• PE
• May be unreliable in older patients
• Certain signs (e.g. pulsus alternans, S3 gallop, jugular venous
distension, hepatojugular reflux) are highly specific
• CXR
• may show cardiomegaly, pulmonary vascular engorgement,
parenchymal edema and pleural effusion
• May be non-diagnostic in mild disease or with concomitant
pulmonary disease

19. •Assessment of volume overload
•Weight
•JVP
•Functional assessment
•At the very least, assessment of ADLs, IADLs
•6-minute walk

21. • A favorable response to diuretics may be helpful in
diagnosis
• Elevated levels of brain natriuretic peptide
• May be elevated in patients >60 years old even if without
heart failure
• Other crucial aspects
• Etiology and pathophysiology of patient’s heart failure
• Contributing or precipitating factors

22. •Additional studies
•Consider first cost- and risk-benefit ratio
•Consider therapeutic implications

23. •Transthoracic 2D-echo
• Most useful technique
• Appropriate in virtually all with newly diagnosed heart
failure and in those with unexplained changes in
severity
• Assess EF, LV structure and presence of other
abnormalities

24. Nursing Pearls
• Be able to contribute to the overall diagnosis of heart failure and its
etiology
• Observation of typical and atypical signs and symptoms
• Picking up important points in the patient history
• Gather information on patients pharmacologic history
• Help in physical and functional assessment
• Monitor critical parameters

25. Management
http://heart.bmj.com/content/91/suppl_2/ii39

26. Management
• Primary goals
• Improve quality of life
• Reduce frequency of exacerbations
• Extend survival
• Secondary goals
• Maximized independence and exercise capacity
• Enhance emotional wellbeing
• Reducing resource use and cost of care

27. • 3 principal components
• Correction of underlying etiology and all comorbidities
and risk factors whenever possible
• Attention to nonpharmacologic and rehabilitative aspects
of treatment
• Judicious use of medications

28. Nonpharmacologic Therapy
• Lack of adherence to medications or diet64% of HF
exacerbations
• Emotional and environmental factors26%
• Other factors leading to readmission
• Inadequate social support
• Inadequate discharge planning
• Inadequate follow-up
• Failure to seek medical attention on recurrence of symptoms
• interventions directed towards these factors can reduce
readmissions and improve QoL

29. Physical Activity and Exercise
• Excessive limitation of physical activity may lead to a progressive
decline in functional capacity due to cardiovascular and muscular
deconditioning
• Structured exercise program
• In trials 4 weeks to 18 months
• Consists of primarily jogging, walking or cycling
• Benefit on exercise capacity 10-25%
• No consistent benefit on central hemodynamics
• No major adverse effects, although with noted breathlessness or angina
episodes in some

30. Exercise prescription
• Contraindications to exercise
• Recent MI or unstable angina (within 2 weeks)
• Severe, decompensated HF (NYHA IV)
• Life-threatening arrhythmias not adequately treated
• Severe AS or hypertrophic cardiomyopathy
• Any acute and serious illness
• Any condition precluding safe participation in an exercise
program

31. • Try to exercise everyday
• Component exercises
• Stretching
• Strength training using elastic bands or light weights
• Aerobic exercise
• Start within the patient’s comfort range, and should be
enjoyable and not stressful
• Intensity and duration gradually increased over a period of
weeks

32. • First target a duration of up to 30 minutes of continuous
exercise; once attained, may increase the intensity
• Common techniques for monitoring exercise intensity
• Target heart rate method
• PMHR=220-age
• Heart rate reserve=PMHR-resting heart rate
• Target HR for low intensity exercise=resting HR + (30 to 50% of
heart rate reserve)
• For moderate exercise=resting HR + (50 to 70% of heart rate
reserve)
• Patient’s subjective assessment

33. • All patients should be advised to discontinue exercise
if experiencing:
• Chest discomfort
• Undue dyspnea or fatigue
• Dizziness
• Rapid or irregular heart beats
• Excessive sweating
• Any undue symptom that may suggest exercising as
unsafe

34. Treatment of systolic heart failure
• Does not differ substantially from that in the younger
patient
• Includes
• ACE inhibitors
• Angiotensin II receptor blockers
• Other vasodilators
• β-blockers
• Diuretics (including spironolactone)
• Digoxin
• Ca-channel blockers
• antithrombotics

35. Nursing Pearls
• Ensure adherence to
• Fluid management
• Salt intake management
• Alcohol and vice management
• Monitoring
• Weight, habitus and anthropometrics
• BP
• Blood sugar
• Fluid intake and output
• Monitoring of side effects of treatment
• Ensure medication compliance
• Facilitate and ensure
• Avoidance stress and other psychosocial suport
• Regular follow-up
• Palliation and advance directives