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Heart Failure 2013

Heart Failure 2013. Definition. Inability of the heart to supply blood to meet metabolic demands of tissues resulting in inadequate tissue perfusion and volume overload. Heart Failure. Implies “biventricular failure” Origin usually left sided

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Heart Failure 2013

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  1. Heart Failure 2013

  2. Definition • Inability of the heart to supply blood to meet metabolic demands of tissues resulting in inadequate tissue perfusion and volume overload

  3. Heart Failure • Implies “biventricular failure” • Origin usually left sided • Left ventricle (LV)enlarges capacity, muscle size & shape = “ventricular remodeling” • LV weakens decreased ejection of blood, decreased stroke volume, decreased cardiac output

  4. Incidence • 5 million cases • 660,000 new cases/year • Most common discharge diagnosis age >65

  5. Causes of Heart Failure • Myocardial infarction • Pulmonary embolism (RV failure) • Cardiomyopathy (both RV & LV failure) • Mitral insufficiency (LV failure) • Aortic regurgitation/stenosis (LV failure) • Hypertension (LV failure) • Volume overload • Myocarditis • Infections/toxins

  6. Mechanism of Failure • Decline in cardiac function decreased cardiac output • Drop in cardiac output decreased ejection fraction • Ejection Fraction= percentage of blood left ventricle pumps out with each beat • Normal= 55-70% • <40% = impaired function

  7. Inciting Event Increased myocardial demand Ventricular Remodeling Vasoconstriction (renin-angiotensisn) Decreased cardiac output Sodium & water retention (Aldosterone) Neurohormonal Activation Sympathetic increase in heart rate & contractility Increased intravascular volume Increased wall stress and afterload Chronic Congestive Failure

  8. Compensatory Mechanisms

  9. Etiology • Cardiac Output dependent on: • Preload: amount of blood in left ventricle (LV) • Afterload: pressure against which LV must eject • Contractility: strength of contraction • Coordination of contraction between atria/ventricles • Heart Rate: amount of time available for filling and emptying ventricles

  10. Systolic Dysfunction“Poor Contraction” • Heart enlarges/does not contract normally • Decrease in muscle strength (thin walls) • Forward blood flow decreases systemic hypoperfusion • Stroke volume & ejection fraction decrease (EF<40%) • Pulmonary congestion

  11. Diastolic Dysfunction“Impaired Filling” • Inability of the ventricle to fully relax • Increased pressure & volume in ventricle • Pressures back up to pulmonary veins pulmonary congestion • Stroke volume reduced • Echo: normal EF?, left atrial enlargement, pulmonary hypertension, heart wall abnormalities, right ventricular dilation

  12. Clinical Manifestations • Left sided Failure (“Forward Failure”) • Blood backs into pulmonary veins & capillaries lung congestion • Dyspnea on exertion • Paroxysmal nocturnal dyspnea • Orthopnea • Pulmonary edema • Crackles • Cough • Tachycardia • S3, S4, systolic murmur • Insomnia, restlessness

  13. Clinical Manifestations • Right Sided Failure (“Backward Failure”) • Elevated pressures & congestion in systemic veins & capillaries • Peripheral/Dependent edema • Weight gain • Liver congestion • Distended neck veins • Abnormal fluid in body cavities • Pleural, abdominal • Anorexia & nausea • Nocturia • Weakness

  14. Assessment • History of symptoms • Limits of activity/response to rest • Peripheral pulses: quality, character • Inspect/palpate precordium for lateral displacement of point of maximum impulse • Sleeping patterns/sleep aids

  15. Diagnostic Evaluation

  16. Stages: American College of Cardiology/ American Heart Association

  17. Classification: New York Heart Association

  18. Goal: improve ventricular dysfuncton & prevent progression

  19. Management • Inotropes • Improve contractility, stroke volume, ejection fraction, cardiac output • Increase myocardial oxygen consumption • Dobutamine, milrinone, digoxin • Biventricular pacing: cardiac resynchroniztion therapy (CRT). Synchronizes LV systolic function so that LV walls contract at same time

  20. Management • Reduction of Afterload • Decrease in resistance of blood, valves, blood vessels • Decreases work of left ventricle • Improved contractility, stroke volume, cardiac output • Angiotensin Converting Enzyme (ACE) inhibitors (captopril, enalapril) • Calcium Channel Blockers (nifedipine,verapamil) • Beta Blockers (metoprolol) • Angiotensin Receptor Blockers (ARBs) (valsartan, losartan)

  21. Management • Reduction of Preload • Diuretic therapy • Loop Diuretics: lasix, bumex • Thiazide Diuretics: hydrochlorothiazide • Potassium Sparing: spironolactone, triamterene • Venodilators (nitroglycerin) • Fluid & sodium restriction

  22. Interventions • Maintain adequate cardiac output • Physical/emotional rest • Evaluate for progression of left sided failure • Lowered systolic pressure • Narrowing of pulse pressure • Alterations in strong/weak pulsations • Auscultate heart sounds

  23. Interventions • Improve oxygentation • Raise head of bed • Auscultate lung fields • Observe for respiratory distress • Small frequent feedings • Oxygen as needed

  24. Interventions • Restore fluid balance • Diuretics • Strict I & o • Daily weight • Assess for weight fluctuations • *Include weight assessment in intershift report* • Observe for electrolyte depletion • Monitor for edema • Diet education

  25. Complications • Intractable/refractory heart failure • Cardiac dysrhythmias • Myocardial failure • Digitalis toxicity • Pulmonary infarction • Pneumonia • Emboli

  26. Core Measures • Evaluation of LV Function (EF) • Echo report • Cath report • Nuclear stress test

  27. Core Measures • Adult Smoking Cessation • Heart failure patient with a history of smoking within the past year • ACEI or ARB presecribed at discharge • Left Ventricular ejection fraction (LVEF) <40%

  28. Core Measure Exclusions • Patient refusal • Patient on LVAD • Patient <18 years of age • Transfer to acute care hospital • Comfort/Hospice care • Discharged to hospice • Expired • Left AMA • Patient involved in clinical trial

  29. Patient Education • Disease process: pumping action • Signs & symptoms of recurrence • Weight gain • Swelling of ankles, feet, abdomen • Cough • Fatigue • Frequent urination at night • Review medications, activity, diet

  30. Teach Back http://ruralhealth.uams.edu/health-literacy/teachback

  31. References • Aherns, T., Prentice, D., & Kleinpell, R. (2011). Progressive care nursing certification. New York: McGraw Hill Medical. • Alspach, J. (2006). Core curriculum for critical care nursing. (6th ed., pp. 271-284). St Louis: Saunders Elsevier. • American Heart Associatin. (2005). Guideline update for the diagnosis and management of chronic heart failure in the adult. Circulation, 112, 154-235. • Aronow, W. (2006). Heart failure update. Geriatrics, 61(8), 16-20.

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