Classification of Heart Failure• Onset: • Acute heart failure • Chronic heart failure• Affected side of the heart: • Left heart failure • Right heart failure• Stages of heart failure severity: • New York Heart Association • American Heart Association/American College of Cardiology
Heart Failure Classification NYHA Classification of Description Functional Capacity NYHA class I Asymptomatic Table 1 NYHA class II Symptoms with moderate exertion NYHA class III Symptoms with minimal exertion NYHA class IV Symptoms at rest New Classification based on symptoms Corresponding NYHA class Asymptomatic NYHA class ITable 2 Symptomatic NYHA class II/ III Symptomatic with recent history of dyspnea NYHA class IIIB at rest Symptomatic with dyspnea at rest. NYHA class IV
Therapy for heart failure Myocardial dysfunction Neurohomonal Increased load activation Drug therapy Cardiomyocyte dysfunction Drug therapy Cell transplantation Cell death Gene therapy Heart transplantation Heart failure
Treatment ConsiderationsNon-Pharmacologic•Diet: 1. Salt restriction 2. Fluid restriction 3. Weight loss 4. Lipid control Pharmacologic•Alcohol•Smoking•Exercise•Cardiac Rehab•Palliative Services•Social Support
Pharmacologic InterventionsGood Evidence to use the following exist: 1. ACE-Inhibitors 2. Beta Blockers 3. Spironolactone 4. Diuretics 5. Digoxin
Angiotensin Converting Enzyme Inhibitors• Indication: All HF patients with sDysfunction (symptomatic or not); [A]• Goal :Reduce morbidity & Mortality• Dose: Ideal dose controversial, start low and increase to common dose• Precautions:- Baseline Serum K+ and Cr. at initiation of therapy required.- Careful monitoring if sBP <100mmHg, or if elevated serum Cr.- Titrate as tolerated if administered with b-blockers [C].
ß-BLOCKERSLimit the donkey’s speed, thus saving energy
Spironolactone• Indication: Symptom at rest or new onset of symptom in last 6mo. Beneficial for moderate to severe HF.• Dose: 25mg OD• Precautions: Monitor kidney function & K+, >25mg is rarely indicated.
Diuretics• Indication: to control fluid overload (Edema, Ascites, Wt gain)• Goal: Improve morbidity• Dose: - Usually Furosemide, start @ 20mg/d and incr/decr as needed - Diuretics can be stopped if fluid overload resolves.• Precautions: K+ wasting, typically given with KCl supplements, Monitor serum K+.
ACE-InhibitorsEvidence for Use: Systemic reviews & RTCs show that ACE-Inhibitors • reduced ischemic events • slow disease progression • improve exercise capacity • decrease hospitalization & mortality for heart failure compared with placebo.
DIURETICS, ACE INHIBITORSReduce the number of sacks on the wagon
Digoxin• Indication: 1. HF + A.fib [A] 2. Patients still symptomatic despite use of Diuretics, ACEI & b-Blockers. 3. PRN use to control dyspnea at rest (existing or new onset) [A].• Goal: Improve morbidity• Dose: 0.125 – 0.25mg /d• Precautions: -Digoxin levels [when toxicity is suspected]. -Pushed to backburner b/c of recent discovery that it can incr risk of death from any cause amongst women [not men] w/HF and decr LVEF.
DIGITALIS COMPOUNDSLike the carrot placed in front of the donkey
CARDIAC RESYNCHRONIZATIONTHERAPY Increase the donkey’s (heart) efficiency
Heart Failure: Nursing Diagnoses• Impaired gas exchange related to ventilation perfusion imbalance.• Ineffective (cardiopulmonary) tissue perfusion related to impaired arterial blood flow.
Heart Failure: Nursing Diagnoses• Excess fluid volume related to excess fluid or sodium intake and retention of fluid secondary to heart failure and its treatments.• Anxiety related to breathlessness and / or restlessness secondary to inadequate oxygenation.• Powerlessness related to inability to perform usual role responsibilities.• Knowledge deficit related to heart failure and its treatments.
Nursing Management: Heat Failure • Nursing Considerations • Respiratory • Supplemental oxygen • Good lung assessment • Monitoring • Hemodynamic Monitoring • Daily Weights • I & O’s • Laboratory Results • i.e. electrolytes, BNP & digoxin levels • Maintain • Small frequent meals; low in salt • Skin integrity
Nursing Management: Heat Failure• Nursing considerations Cont., • Promote rest and avoid fatigue • Assess for peripheral edema• Client Education • Medications • Lifestyle changes • i.e. low-sodium diet & activity-rest balance • Daily weights • S/Sx of worsening heart failure to report • Importance of follow-up care