Congestive Heart Failure

1. Congestive Heart Failure J.O. Medina,RN,MSN,FNP,CCRN Education Specialist Nurse Practitioner Critical Care&EmergencyServices California Hospital Medical Center

2. Congestive Heart Failure and Pulmonary Edema • Overview • Definition – heart failure is inability of the heart to pump enough blood to meet the metabolic demands of the body • Diagnosed by • Manifestations of inadequate tissue perfusion • Signs and symptoms of intravascular volume overload • Over 2 million Americans have heart failure • 10% will die in one year; 50% in five years • America’s highest volume DRG

3. Congestive Heart Failure and Pulmonary Edema • Pathophysiology • Neurohormonal theory • Increased TNF – alpha – cachectin • Endothelin – vasoconstrictor released by endothelial cells • Natriuretic Peptides released by atrial and ventricular stretch and counterbalance effects of endothelin • Common causes • CAD; MI;HTN • Dilated cardiomyopathy • Aortic stenosis ; Aortic regurgitation • Mitral regurgitation

4. Atrial / Brain Natriuretic Peptides

5. Congestive Heart Failure and Pulmonary Edema • Types • Forward vs. backward failure • Forward failure – inadequate tissue perfusion to meet metabolic demands of the body • Backward failure – seen in pulmonary and systemic congestion • Right vs. left failure • May involve RV, LV or both • Usually LV failures precedes RV failure, producing symptoms of pulmonary congestion • RV failure is usually result of LV failure but may occur with primary pulmonary hypertension

7. Congestive Heart Failure and Pulmonary Edema • Systolic vs. diastolic failure • Systolic failure – inability of the ventricles to eject adequate volume • Diastolic failure – inability of ventricles to relax and fill • High output vs. low output failure • Most HF – result of low contractility producing low CO • High output HF occurs when acute metabolic needs are not met even with high CO

8. Congestive Heart Failure and Pulmonary Edema • Acute vs. chronic failure • Acute failure – heart is overwhelmed by abrupt alteration in cardiac function and unable to bring compensatory mechanisms to play • Chronic failure – compensatory mechanisms have time to partially of completely restore cardiac function • Refractory vs. compensated HF • Compensated – body or medical therapies are working and heart is responding • Refractory – heart is not responding to therapies

9. Congestive Heart Failure and Pulmonary Edema • New York Heart Association Classification of Heart Failure • Class I - no limitations with ordinary activity • Class II – slight limitations of physical activity • Class III – marked limitations of physical activity • Class IV – inability to engage in any physical activity without symptoms

10. Congestive Heart Failure and Pulmonary Edema • Clinical Presentation • Intravascular and interstitial fluid overload • SOB; Dyspnea on exertion;Orthopnea • Paroxysmal nocturnal dyspnea • Non-productive cough; crackles; wheeze • Weight gain; S3;sinus tach; atrial dysrhythmias • Displaced PMI ; systolic murmur ; GI symptoms • Inadequate tissue perfusion • Decreased exercise tolerance • Unexplained fatigue • Unexplained mental confusion • Decreased urine output • Arrythmias • Peripheral vasoconstriction

11. JVD / Pitting Edema

12. Congestive Heart Failure and Pulmonary Edema • Diagnosis • CXR – cardiomegaly; pulmonary vascular congestion;pleural effusions • Echocardiogram – dilated cardiac chambers; hypertrophy; vascular insufficiency and/or stenosis; wall motion abnormalities (akinesis, hypokinesis; dyskinesis); low EF • EKG – tachycardia; arrythmias; chamber enlargement; ischemia/infarction • Cardiac Catheterization – increased PA/PCWP; low EF and low CO with high LVEDP; valvular dysfunction and CAD

13. Congestive Heart Failure and Pulmonary Edema • Management • Goals of therapy • Reduce Preload • Venodilators • NTG ; diuretics ; ace inhibitors • Morphine • Dopamine (low dose) • Optimize Heart rate • Digoxin • Reduce Afterload • Arteriodilators • Ace inhibitors; hydralazine • Nitroglycerin ; nitroprusside • Improved contractility • Digoxin • Dopamine; dobutamine; amrinone

14. Congestive Heart Failure and Pulmonary Edema • Atrial Natriuretic Peptide (ANP) • Adrenergic Blockade • Nitric Oxide Synthetase • Spirolactone

15. Congestive Heart Failure and Pulmonary Edema • Pulmonary Edema • Severe pulmonary congestion due to excess fluid in interstitial and/or alveolar spaces • Pathogenesis same as HF • Can develop spontaneously; day or night; at rest; following exercise or stressful event; or in conjunction with HF

16. Congestive Heart Failure and Pulmonary Edema • Pulmonary Edema • Clinical Presentation • Mentation – anxious; restless ; agitation • CV signs – tachycardia with increased BP (unless compensatory mechanisms fail - BP); S3; PAWP >25 mmHg; CI <2.2 • Pulmonary Signs – orthopnea; O2 levels; crackles; pink frothy sputum; wheezes • Peripheral signs – skin diaphoretic; cool; pale or cyanotic • Diagnosis • CXR – diffuse interstitial edema with cloudy lung fields • ABG – hypoxemia; respiratory acidosis

17. Congestive Heart Failure and Pulmonary Edema • Pulmonary Edema • Furosemide • Morphine • NTG • Oxygen • Positive inotropes • Aminophylline IV : for bronchospasm

18. Alveoli With Fluid

19. Questions ?