Causes of Heart Failure

Impaired Function

Myocardial disease

valvular disease

congenital heart disease

constrictive pericarditis

Causes of Heart Failure

Excess Work Demands

Increased Workload: Pressure

Increased Worload: Volume

Increased workload perfusion

Causes of Heart Failure

Examples of Myocardial Disease

Cardiomyopathy

Myocarditis

Myocardial Infarction

Causes of Heart Failure

Examples of Valvular Disease

Stenoic Valve

Regurgitant Valve

Causes of Heart Failure

Examples of Increased Workload Pressure

systemic HTN

pulmonary HTN

coarctation of the aorta

Causes of Heart Failure

Examples of Increased Workload: Volume

arteriovenous shunt

fluid volume overload

Causes of Heart Failure

Examples of Increased Workload: Perfusion

Anemia

Thryotoxicosis

left ventricular infarction

HTN

aortic and mitral valve stenosis

Pulmonary Congestion

Dyspnea

Activity intolerance

Pulmonary Disease

left sided failure

pulmonic and tricuspid valve stenosis

Edema and weight gain

hepatic congestion

CAD

HTN

valve disease

decrease afterload (diuretics, beta blockers ACE-I/ARBs)

decrease Preload (ACE-I/ARBs)

Minimize remodeling (Beta blockers)

HTN

hypertrophy

AS

CAD

decreased CO but preserved EF

dyspnea

pulmonary congestion

treat underlying cause

treat blood pressure

patients with cardiac disease, but without resulting limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, dyspnea, or anginal pain

No objective evidence of CVD

Patients with cardiac disease resulting in slight limitation of physical activity. They are comfortable at rest. Ordinary physical activity results in fatigue, palpitation, dyspnea, or anginal pain

Objective evidence of  minimal cardiovascular disease

Patients with cardiac disease resulting in marked limitation of physical activity. They are comfortable at rest. less than ordinary activity causes fatigue, palpitation, dyspnea or anginal pain.

Objective evidence of moderately severe CVD

patients with CVD resulting in inability to carry on any physical activity without discomfort. Symptoms of heart failure of the anginal syndrome may be present even at rest. If any physical activy is undertaken, discomfort is increased

Objective evidence of severe CVD

orthopnea

dyspnea, tachypnea

use of accessory muscles

cyanosis

cool and clammy skin

cough with frothy, blood tinged sputum

breath sounds: crackles, wheezes, rhonchi

tachycardia

hypotenion or HTN

fatigue

dyspnea, orthopnea, paroxymal nocturnal dyspnea

presistent, dry cough

dependent edema

nocturia

Skin: dusty, cool, damp to touch

Restlessness, confusion, decreased memory

Chest pain

anorexia, nausea

assess for early signs, such as crackles in the lung bases, dyspnea at rest, disorientation, and confusion

High-fowler's

O2 therapy

Nitroglycerine, rapid-acting diuretics, IV morphine sulfate

assessment

decrease pt symptoms

improve LV fxn

reverse ventricular remodeling

improve quality of life

decrease mortality and morbidity

Collaborative Mgmnt of ADHF

Decrease Intravascular Volume

*Reduces Venous return and preload

Treat with:

loop diuretics (furosemide)

Ultrafiltration or aquaphoresis

Collaborative Mgmnt of ADHF

Decrease Venous Return (Preload)

*reduces the amount of volume returned to the LV during diastole

Treat with:

High-fowler's position

IV nitroglycerine

Nursing and Collaborative Mgmnt ADHF

Decrease Afterload

*Improves CO and decreases Pulmonary Congestion

Treat with:

IV sodium nitroprusside (Nipride)

Morphine Sulfate

Nesirtide (Natrecor)

Nursing and Collaborative Mgmnt ADHF

Improve gas exchange and oxygenation

Supplemental O2

Morphine sulfate

Noninvasive ventilatory support (BiPAP)

Nursing and Collaborative Mgmnt ADHF

Improve Cardiac Function

For patients who do not respond to conventional pharmacotherapy (e.g. diuretics, vasodilators, morphine sulfate)

Inotropic Therapy:

Digitalis

B-Adrenergic agonists (dopamine)

Phosphodiesterase inhibitors (milrinone)

Hemodynamic Monitoring

distraction, imagery

Sedative medications (morphine sulfate, benzodiazepines)

Collaborative Mgmnt Chronic HF

Main Treatment Goals

Treat the underlying cause and contributing Factors

maximize CO

provide treatment to alleviate symptoms

imrpove ventricular function

preserve target organ function

improve mortality and morbidity

Mitral stenosis

mitral regurgitation (insufficiency)

Mitral valve prolapse

aortic stenosis

aortic regurgitation (insufficiency)

patient may become suddenly ill or slowly develop symptoms over many years

Question patient about attack of rheumatic fever and infective endocarditis and about possibility of IV drug abuse

obtain chest x-ray, echocardiogram, and exercise tolerance test

decreased cardiac output related to altered stroke volume

impaired gas exchange related to ventilation perfusion imbalance

activity intolerance related to inability of the heart to meet metabolic demands during activity

acute pain related to physiologic injury agent (hypoxia)

Nonsurgical management focuses on drug therapy and rest

drug therapy, including diuretics, beta blockers, digoxin, oxygen, and sometimes nitrates

prophylactic antibiotic

management of atrial fib

anticoagulant

rest with limited activity

reparative procedure

balloon valvuloplasty

direct, or open, commissurotomy

mitral valve annuloplasy

replacement procedures

Microbial infection involving the endocardium

occurs primarly in pts who abuse IV drugs, have had valve replacements, have experienced systemic infections, or have structural cardiac defects

Possible ports of entry-- oral cavity, skin rash, lesion, abscess, infections, surgery, or invasive procedures including IV line placement

murmur

HF

arterial embolization

splenic infarction

neurologic changes

petechiae

splinter hemorrhages

antimicrobials

anticoagulants are of no value in preventing embolization from vegetations

pt's activities are balanced with adequate rest

removing the infected valve

repairing or removing congenital shunts

repairing injured valved and chordae tendineae

draining abscesses in the heart or elsewhere

inflammation or alteration of the pericardium, the membranous sac that encolses the heart

dressler's' syndrome

post-pericardiotomy syndrome

chronic constrictive pericarditis

pericardial friction rub

grating, oppressive pain, aggravated by breathing, coughing, swallowing

pain worsened by the supine position; relieved when the patient sits up and leans forward

Substernal precordial pain radiating to left side of the neck, shoulder, or back

Pain management

Pericardiectomy

Cardiac Tamponade:

Jugular vein distension

paradoxical pulse

decreased CO

muffled heart sounds

circulatory collapse

Cardiact tamponade: extreme emergency

increased fluid volume

hemodynamic monitoring

pericardiocentesis

pericardial window

pericardiectomy