1-2%

1/4 Million

CAUSES OF CHF

2/3 of all case

CAUSES OF CHF

4% of all cases

High Blood Pressure

CAUSES OF CHF by %

Toxic Injury such as: alcohol, viral disease

CAUSES OF CHF in %

Heart Valve Disease

4%

Causes of CHF in %

Unknown

Increased Blood Volume; very rare.

Valve disorders

Congenital Heart defects

Hypertension

Anemia

Volume overload

Hyperthyroidism

Fever, Infection

Massive pulmonary embolus

Compensatory mechanisms decrease CO which stimulates baroreceptors to send help signals to the adrenal gland. which stimulate SNS to release Norepinephrine which increase HR and contractility. As a result the CO output increase as HR increases.

All this activity increases venous return which stretches the ventricle and increases the force of contraction.  This causes over stretching and eventual ineffective contraction.

The renin-angiotensin system is activated.

The adrenal corte produces Aldosterone which stimulates sodium retention in renal tubules. (promoting water retention) Where sodium goes, water follows. 

At the same time, the posterior pituitary releases antidiuretic hormone (ADH) which inhibits water excretion and causes VASOCONSTRICTION.

• Increased HR results in decreased diastolic filling leading to decreased coronary artery perfusion, increased oxygen demand resulting in ischemia and decreased Cardiac Output.
• Beta receptors become LESS sensitive to SNS stimulation resulting in decreased HR and decreased contractility.
• Norepinephrine stores in cardiac muscle become depleted.
• Alpha receptors on peripheral blood vessels become MORE sensitive to persistent stimulation resulting in vasoconstriction and increased afterload and cardiac work.

1. Diminished ability of the heart to pump blood.
2. Coronary Blood Supply is inadequate causing ischemia.
3. No cardiac reserve.

What is Myocardial Hypertrophy or

Hypertrophic Cardiomyopathy 

• The heart muscle becomes thickened with increased muscle mass and is unable to rela to accept blood.
• Ejection Fraction remains normal

• Most often caused by long standing Hypertension
• Aortic Stenosis
• Mitral Stenosis
• Primary Pulmonary Hypertension

NYHA classification:

What is Class I

• No limitations on physical exercise and no symptoms on ordinary activity.
• Poor prognosis

NYHA Classification 

Class II

• Slight limitation of physical activity.
• Symptoms on ordinary activity.
• Bad Prognosis

• Marked limitation of physical activity.
• Symptoms on less than normal activity.
• Awful prognosis

• Inability to carry out any physical activity without discomfort.
• Symptoms at rest.
• Terminal

Stages of Heart Failure ACC/AHA

STAGE A

How does fluid escape out of blood vessels?

The smallest blood vessels are:

In Heart Failure:

If capillary pressure > Oncotic pressure then:

1. The walls of the heart are elastic.
2. They stiffen and thicken when pressure rises within the heart.
3. Results in backward congestion.
4. Symptoms caused by congestion of lungs.

• Lungs become stiff as a result of congestion making breathing difficult.
• Fluid that enters the alveolar sac interferes with oxygenation.

1. Decreases the amount of blood ejected from the ventricle which stimulates the SNS.
2. Increases preload and afterload.
3. Causes increased stress on ventricle.
4. Causes increased workload.
5. Symptoms: weakness, fatigue, decreased exercise tolerance.

Left-sided heart failure

• Increased fatigue                                 Splenomegaly
• Hepatomegaly                                                   Dependent pitting edema
• Ascites/weight gain                                           Abdominal pain
• Oliguria                                                             Hypotension
• JVD                                                                   Hepatojugular reflux
• s3/s4 heart sounds                               Elevated central venous picture

• History and physical
• EKG
• Chest x-ray

• Tachycardia/ Tachypnea
• Hypertension/Diaphoretic or cold, gray, and cyanotic
• JVD/ Lower extremity edema
• Wheezing or rales /Apical Pulse frequently displaced laterally.
• Cardiac auscultation may reveal aortic or mitral valve abnormalities, S3 or S4

Ventricles produce these when they can't pump enough blood to meet the body's needs.

The production of these indicate HF

B-type Natriuretic Peptide

Point of care test is done right there at bedside.

Levels run from 100 to >900

Heart Failure Meds

MORPHINE

• Analgesic
• Arterial  dilation- decreases systemic vascular     resistance (SVR) and increases CO
• Venodilation-decreases preload

DIURETICS

• Lasix (1st line of defense)
• Diuril
• Bumex
• Hydrochlorathiazide
• Aldactone (Potassium Sparing)
• Diamox

• Baseline weight & vitals
• Monitor BP, I/O, weight, skin turgor, edema
• Assess volume depletion, dizziness, OH, tachycardia, muscle cramping.
• check labs
• Evaluate renal function
• IVP SLOWLY (watch for ototoxicity)

Improves CO

Improves BP

Increases norepinephrine

Improves edema secondary to kidney function.

• Dobutamine (Doubutrex)** tolerate better**
• Improves heart function
• Lowers BP
• Better use of norepinephrine
• Tolerance

• + Ionotrope, - chronotrope, -dronotrope
• Used for Chronic CHF
• Check Apical Pulse: administer if >60, if<60 monitor and recheck in 1 hr.  After an hr if <60 do not administer and call doctor.
• Assess Labs

What are the side effects of Digoxin?

What is the antidote for toxicity?

• Headache
• Neck Vein Distension
• Hypokalemia
• Visual disturbances (halos)
• Dysrhythmias

Digibind

What do negative IONOTROPIC agents do?

What are some examples of - Ionotropics?

They decrease contractility.

Barbituates

Alcohol

Procainamide

Propanalol (beta blockers)

• They lower your BP.
• They Block Alpha Receptors which relaxes (expands) your arteries, lowering the resistance your heart pumps against..
• They reduce dysrhythmias, hospitalizations, death.

Toprol-XL and Coreg

Tell the pt that they will probably feel worst for at least 3 weeks.  They will have less energy and feel bedridden. However, they need to keep taking them and it will improve over time b/c it will increase ejection fraction tremendously.

Side effects and Nursing implications for

Beta Blockers

• Increase blood sugars
• Asthmatics should not take it- constricts airway.
• Potentiates Digoxin
• Take with food
• May experience: fatigue, SOB, lightheadedness, dizziness, decreased HR and BP, impotence.

• It is an IV drug approved for relieving acute HF in 2001.
• It is both a vasodilator and diuretic.
• It's a synthetic BNP
• Helps body decrease sodium
• Watch for hypotension

• BNP is released from the ventricles in response to increased volume exerting the following effects:
• Natriuresis-excreting sodium in urine (water follows) therefore it decreases circulating volume.
• Vasodilation- decreases venous return to the heart.

Why do we treat CHF with ACE Inhibitors?

(Angiotensin Converting Enzyme Inhibitor)

We are trying to stop the renin reflex:

They decrease the secretion of aldosterone because aldosterone causes sodium and water retention.  By decreasing aldosterone, the workload of the heart is decreased allowing arteries and arterioles to dilate and promoting vasodilation which decreases afterload and preload and promotes diuresis.

Captopril, Enalpril, Lisinopril

Side effects:

Hypotension   Hypovalemia

Hyponatremia  Hyperkalemia

Neutropenia

Decreased Cardiac Output

Excess Fluid Volume

Activity Intolerance

Deficient Knowledge: Low sodium diet

Sodium restriction

No alcohol because it is a cardiac depressant

Exercise program should be initiated to increase stamina.

Weight lifting is not recommended b/c it increases afterload.

Weigh daily and report 3+ lbs in 1 wk

Manage fluid overload prior to needing hospitalization.  

KEEP THEM OUT OF THE HOSPITAL.

Know when to call the MD

Know s/s of worsening HF

Importance of keeping appointments

Use of Vitamin Supplements

Flu and Pneumonia Vaccines

Advanced directives

Avoidance of NSAIDS b/c they decrease renal perfusion.

THIS IS A CHRONIC CONDITION THAT REQUIRES LIFESTYLE CHANGES

Core measures for CHF are interventions identified by research and EVP implemented by the JOINT COMMISSION to improve dx of HF patients by decreasing morbidity and mortality.

Linked to Medicare and Medicaid Reimbursement

1. Written discharge instructions to include diet and activity level
2. Assessment of LV function (Echo)
3. ACE-I pr ARB @ discharge
4. Smoking cessation advice/counseling documented.