Heart failure

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Heart failure

  1. 1. Heart failure Suchithra .p.v 1st year Msc Nursing College of Nursing
  2. 2. Heart failure • Heart Failure is the inability of the heart to pump sufficient blood to meet the needs of the tissues for oxygen and nutrients. • It is otherwise known as Congestive Cardiac Failure. • Heart failure results in intravascular and interstitial volume overload and poor tissue perfusion.
  3. 3. causes • Reduced ventricular contractility • Ventricular outflow obstruction (pressure overload ) • Ventricular inflow obstruction • Ventricular volume overload • Arrhythmia • Diastolic dysfunction
  4. 4. Acute causes • Acute myocardial infarction • Dysrrhythmias • Pulmonary emboli • Thyrotoxicosis • Hypertensive crisis • Rupture of papillary muscle( eg: mitral valve) • Ventricular septal defect • Myocarditis
  5. 5. Chronic causes • Coronary artery disease • Hypertension • Rheumatic heart disease • Congenital heart disease • Cor pulmonale • Cardiomyopathy • Anemia • Bacterial endocarditis • Valvular disorders •
  6. 6. RISK FACTORS • Advancing age • Hypertension • Diabetes • Obesity • High serum cholesterol • Cigarette smoking
  7. 7. PRECIPITATING CAUSES • Anemia • Infection • Hypothyroidism • Bacterial endocarditis • Paget’s disease • Nutritional deficiencies • Hypervolemia
  8. 8. PATHO PHYSIOLOGY Compensatory mechanism • 1. Hemodynamic alterations • 2. Neurohormonal responses • 3. Ventricular dilation • 4. Ventricular hypertrophy
  9. 9. Alterations in Beta-adrenergic Receptor pathway • Increased NE concentration cause down regulation of beta-1 adrenergic receptors in the ventricles. • Beta- adrenergic receptor kinase(BARK) enzyme level increases.
  10. 10. Role of Arginine Vasopressin (AVP) • Circulating AVP is elevated. This leads to salt and water retention and systemic vasoconstriction.
  11. 11. Role of cytokinine • They have crucial roles in mediating the changes in myocardial structure and function in CHF.
  12. 12. Cellular and Molecular Mechanisms • Role of calcium • Calcium plays a central role in myocardial contraction and relaxation. In CHF, there is prolonged elevation of intracellular calcium during relaxation
  13. 13. • Role of free radicals and apoptosis • Altered mitochondrial oxygen metabolism results in formation of free radicals. • Free radicals produced by various mechanisms have been shown to result in apoptosis of cardiac myocytes in CHF.
  14. 14. DECOMPENSATED HEART FAILURE • Ventricular remodeling • Sustained neurohumoral activation
  15. 15. Counter regulatory mechanism • ANP and BNP are hormones produced by the heart muscle . • ANP is released in response to stretch or increased volume in the chambers. • Levels of circulating ANP can be correlate with functional class prognosis and hemodynamic state.
  16. 16. • Inhibit renin, aldosterone and ADH secretion and results in excretion of sodium and water • Promotes venous and arterial vasodilatation. • BNP is released in response to an increase in wall stress or triggered by pressure.
  17. 17. TYPES OF HEART FAILURE • Left –sided heart failure or left ventricular dysfunction • Right sided heart failure or right ventricular failure • Biventricular heart failure • Diastolic and systolic dysfunction
  18. 18. High output versus low output failure High output failure occurs when the heart despite normal output to high output levels is simply not able to meet the accelerated needs of the tissues Low output failure occurs in most forms of heart disease resulting in hypoperfusion of tissue cells .
  19. 19. Backward versus forward failure • Backward failure focuses on the ventricles inability to eject completely ,which increases ventricular filling pressures ,causing venous and pulmonary congestion . • Forward failure is a problem of inadequate perfusion. It results when reduced contractility produces a decrease in stroke volume and cardiac output
  20. 20. • Acute versus chronic heart failure
  21. 21. CLINICAL MANIFESTATIONS • Left Sided HeartFailure • Acute LVF presents with a sudden onset of dyspnoea at rest. • progresses to acute respiratory distress, orthopnoea and prostration. • appears agitated ,pale and clammy • Rapid pulse
  22. 22. • Cool periphery • High BP • Elevated JVP if associated with RVF. • Auscultaition – crepitations,triple gallop rhythm. • Displaced apex beat.
  23. 23. Respiratory system • Tachypnea • Capillary refill > 3 seconds • Orthopnea • Dyspnea on exertion • Nocturnal dyspnea • Cough with frothy sputum (indicative of pulmonary edema)
  24. 24. • Basilar crackles or rhonchi • Cyanosis • Hypoxia (respiratory acidosis) • Kussmaul’s sign • Cheyne stokes respiration
  25. 25. Cardiovascular system • Diaphoresis • Audible S3 and S4 heart tones • Murmur or mitral insufficiency • Enlarged left ventricle on X-ray • Enlarged left atrium on X-ray • Narrowing pulse pressure • Pulses alternans (alteration of weak and strong beats)
  26. 26. • Basilar crackles or rhonchi • Cyanosis • Hypoxia (respiratory acidosis) • Kussmaul’s sign • Cheyne stokes respiration • Elevated pulmonary artery pressures • Elevate pulmonary artery occlusive pressures
  27. 27. Central nervous system • Mental confusion Generalized symptoms • Weight gain. • Fatigue/weakness/lethargy
  28. 28. Right sided heartfailure Gastro intestinal system • Hepatomegaly • Splenomegaly • Hepatojugular reflux • Ascites
  29. 29. • Weight gain • Weight loss and emaciation as a result of inadequate intake of food and wasting of tissues. This picture is termed as cardiac cachexia
  30. 30. Cardiovascular system • Arrhythmias • Elevated CVP • Elevated right atrial pressure • Elevated right ventricular pressure • Narrowing pulse pressure • Murmur or tricuspid insufficiency
  31. 31. • Audible S3 and S4 heart tones • Enlarged right atrium on X-ray • Enlarged right ventricle on X-ray • Dependant pitting edema • Venous distention
  32. 32. • Urinary system • Oliguria • Nocturia
  33. 33. Chronic heart failure • Fatigue • Dyspnea • Orthopnea • Paroxysmal nocturnal dyspnea • Tachycardia • Edema
  34. 34. • Nocturia • Skin changes Chronic swelling result in pigment changes causing the skin to appear brown • cool and damp to the touch • Behavioral changes • Chest pain • Weight changes
  35. 35. COMPLICATIONS • Pleural effusion • Dysrhythmias EF less than 35%have a high risk of fatal dysrhythmias and sudden cardiac death. • Renal failure • Impaired liver function & Cardiac cirrhosis • Thromboembolism Hypokalemia & Hyperkalemia
  36. 36. DIAGNOSTIC STUDIES • History • Physical Examination
  37. 37. • Electrocardiogram • Laboratory data(cardiac enzymes, BNP,serum chemistries ,liver function studies ,thyroid function studies and complete blood count). In severe CHF dilutional hyponatremia occurs. BUN and creatinine are moderately elevated.
  38. 38. • BNP levels are used to assess the HF. • BNP<100pg/ml - heart failure very improbable • BNP100-500pg/ml -HF probable • BNP>500pg/ml -HF very probabl
  39. 39. • Echocardiogram : EF less than 40% accepted as evidence of systolic dysfunction. • Asessment of myocardial viability This can be done by using dobutamine or dipyridamole stress echocardiography, nuclear imaging using thallium or sestamibi and positron emission tomography
  40. 40. Identify patients who will benefit from long term therapy with drugs such as ACE inhibitors • Stress testing,(treadmill test, stress echocardiography and nuclear perfusion studies) • Cardiac catheterization and coronary angiography:
  41. 41. • Endomyocardial biopsy This is indicated in patients with clinical indication of myocarditis and systemic disease with possible cardiac involvement such as hemochromatosis, amyloidosis, sarcoidosis and those who have received adriamycin chemotherapy.
  42. 42. MANAGEMENT OF ACUTE PULMONARY EDEMA • Sit the patient up • Give oxygen(high flow ,high concentration ). non invasive positive pressure ventilation (CPAP-5-10 mmhg) • IV glceryl trinitrate 10-200 microgram /minute until clinical improvement occurs or systolic blood pressure falls to ˂110mmHg. • loop diuretic such as frusemide 50-100mg IV
  43. 43. • continuous monitoring • Ionotropic agents • Intra aortic balloon pump
  44. 44. Management • General measures • Pharmacologic therapy • Devices • Surgery • Newer evolving therapies
  45. 45. General measures • Rest • Correction of aggravating factors • Salt restriction – sodium intake should be limited to ˂ 2g/day • Fluid restriction- to 1-2l/day is advisable in patients with dilutional hyponatremia. • Smoking cessation • Avoid alcohol • Management of co morbidities
  46. 46. Pharmacologic therapy To Reduce workload • Angiotensin converting enzyme inhibitors • Angiotensin II receptor blockers • Vasodilators • Diuretics • Beta blockers
  47. 47. ACE inhibitors • Interrupts the vicious cycle of neurohumoral activation • Prevents salt and water retension ,peripheral arterial and venous vasoconstriction • Also increase the concentrations of the vasodilator bradykinin. • Decreases SVR and improves myocardial performance.
  48. 48. • Enalapril: 2.5 mg 12 hrly • Lisinopril 2.5 mg daily • Ramipril :1.25 mg daily • Captopril :50 mg tds
  49. 49. Adverse effects • Persistant cough • Hypotension • Hyperkalemia • deteriorating renal function • Loss of taste
  50. 50. Angiiotensin II receptor blockers • Similar hemodynamic effects to ACE inhibitors • Do not affect bradykinin metabolism • Losartan, Valsartan, Irbesartan and Eprosartan • Losartan :25 mg daily • Candesartan:4 mg daily • Valsartan : 40 mg daily
  51. 51. Vasodialators • Venous dialation blood is trapped in the veins ,and venous return to the heart is decreased .This reduces preload • eg: nitroglycerin and isosorbide dinitrate • Dilation of arterioles: arteriolar vasodilators decreases peripheral vascular resistance and afterload • Eg:ACE inhibitors
  52. 52. Combined action on veins and arterioles • decrease both preload and afterload • sodium nitroprusside relaxes the smooth muscle of both veins and arterioles.it does not directly affect the heart muscle or heart rate
  53. 53. Beta blockers • Directly block the direct effects of the SNS • Cardio selective agents block beta 1 adrenergic receptors.non selective agents block beta 1 and beta 2 adrenergic receptors. • Eg: atenolol,metoprolol , bisoprolol, bucindolol, labetalol,carvedilol,esmolol (25-50 mg bd)
  54. 54. Diuretics • To mobilize edematous fluid , reduce pulmonary venous pressure ,and reduce preload • Thiazide diuretics may be the first choice in chronic HF • Eg;benzthiazide,chlorothiazide,chlorthalidone, metolazone
  55. 55. • Loop diuretics • eg.Frusimide ,torsemide • Spironolactone is an inexpensive ,potassium sparing diuretic.
  56. 56. Human b-type natriuretic peptide Nesiritide is a synthetic form of human BN
  57. 57. Beta adrenergic agonists • short term treatment • E.g.:-dopamine, dobutamine
  58. 58. Cardiac glycosides • Eg ; Digoxin • Slow the ventricular rate, improves cardiac function • Optimum therapeutic level os digoxin in serum is 1-1.5 ng/ml • Toxic level is above 2ng/ml
  59. 59. Calcium channel blockers • Vasodilator • Anti ischemic effects • Eg: Verapamil, diltiazem, amlodipine
  60. 60. • Phosphodiesterase inhibitors:- Eg: amrinone,milrinone • Antidysrhythmic drugs e.g.adenosine, digoxin, ibutilide, magnesium
  61. 61. Devices • Implantable cardiac defibrillators and resynchronization therapy
  62. 62. Ventricular assist devices
  63. 63. Extracorporeal membrane oxygenator
  64. 64. Surgery • Heart transplantation • Coronary revascularization • Dynamic cardiomyoplasty • Partial left ventriculectomy( Batista procedure) • Aneurysmectomy • Mitral annuloplasty and mitral valve repair
  65. 65. Newer evolving therapies • Gene therapy • To increase the myocardial contractility at molecular level • Genes expressing SERCA2a are increased by using adenovirus transfection of myocytes
  66. 66. • NURSING ASSESSMENT
  67. 67. Nursing diagnosis Decreased cardiac output r/t heart failure ,dysrhythmia or both • Assess blood pressure for hypotension or hypertension • Assess heart rate and rhythm • Document rhythm strips q8h • Auscultate heart rate q2h • Monitor lung sounds
  68. 68. • Monitor intake and output • Assess for change in mental status • Administer prescribed medications • Encourage physical and mental support • Encourage client to eat small frequent feeds
  69. 69. • Excess fluid volume related to cardiac failure as evidenced by edema ,dyspnea on exertion ,increased weight gain • Monitor intake and output chart • Assess for presence of peripheral edema • Assess for jugular vein distention • Follow low sodium or fluid restriction • Auscultate breath sounds • Administer diuretic therapy
  70. 70. Impaired gas exchange related to increased preload, mechanical failure or immobility as evidenced by increased respiratory rate, shortness of breath, and dyspnea on exertion • Auscultate breath sounds q2h • Assess respiratory rate • Asses for cyanosis • Monitor pulse oximetry • Position the client to facilitate breathing • Administer diuretic therapy
  71. 71. Ineffective tissue perfusion related to decreased cardiac output • Note colour and temperature of the skin q4h • Monitor peripheral pulsesq4h • Provide a warm environment • Encourage active rang of motion • Monitor urine output
  72. 72. • Activity intolerance related to fatigue secondary to cardiac insufficiency and pulmonary congestion as evidenced by dyspnea,shortness of breath ,weakness, increased in heart rate on exertion • space nursing activities • Schedule rest periods • Monitor the clients response to activities • Instruct the client to avoid activities that increase cardiac workload
  73. 73. • Anxiety r/t to dyspnea or perceived threat of death as evidenced by restlessness, irritability • Deficient knowledge related to disease process as evidenced by questions about the disease and prognosis
  74. 74. References • KV Krishnadas. Text book of Medicine. 5th edition.Jaypee publications.New Delhi.2008 • Marscall S. Runge. Georege A.Netter’s Cardiology .2nd ed. USA .2014 • Nicki R.Colledge,Brian R. Walker,Stuart H.Ralston.Davidson’s Principles and Practice of Medicine 21st edition 2010 Churchil Living stoneElsevier page no 542-550 • Richard Hatchett, David R Thompson. Cardiac Nursing. Elsevier publications. USA.2007

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