Heart Failure

Right-Sided Heart Failure / Left-Sided Heart failure

HEART FAILURE

HF, often referred to as “congestive heart failure” (CHF), is the inability if the heart to pump sufficient blood to meet the needs of the tissues for oxygen and nutrients. However, the term CHF is misleading, because it indicates that patients must experience pulmonary or peripheral congestion to have HF, and it implies that patients with congestion have HF.

HEART FAILURE• HF does not manifest pulmonary or systemic

congestion. The term HF is preferred and indicates myocardial heart disease in which there is a problem with contraction of the heart (systolic dysfunction) or filling of the heart (diastolic dysfunction) and which may or may not cause pulmonary or systemic congestion. Some cases of HF are reversible, depending on the cause. Most often, HF is a life-long diagnosis that is managed with lifestyle changes and medications to prevent acute congestive episodes. CHF is usually an acute presentation of HF.

Pathophysiology

Causes: LSCHF

Pulmonary EmbolismLung diseases (chronic bronchitis and emphysema)

Right ventricular infarctionCongenital septal defects

Reduced myocardial contractility

Increase cardiac workload

Decrease diastolic filling

Contraction of right sided atrial filling

Obstruction of right atrial emptying

Increase right atrial pressure

Right sided CHF

Blood drains back from RV to RA

Increased pressure in the veins

Shortness of breathSwelling of feet and ankles

Urinating more frequently at nightPronounced neck veins

PalpitationsIrregular fast heart beat

FatigueWeaknessFainting

Right-sided HF vs. Left-sided HFRIGHT-SIDED HEART FAILURE LEFT-SIDED HEART FAILURE

Right ventricle fails to eject blood and cannot accommodate all the blood that normally returns to it from the venous circulation

Peripheral tissues predominates

Impaired gas exchange

Left-ventricular failure

pulmonary congestion occurs when the left ventricle cannot pump the blood out of the ventricle of the body

increased left-ventricular end-diastolic blood volume increases the left-ventricular end-diastolic pressure

leads to decreased blood flow from the left atrium into the left ventricle during diastole

blood volume and pressure in the left atrium increases which decreases blood flow from the pulmonary vessels

pulmonary venous blood volume and pressure rise, forcing the fluid from the pulmonary capillary into the pulmonary tissues and alveoli

Manifestations

CLINICAL MANIFESTATIONS:

RIGHT-SIDED HEART FAILURE LEFT-SIDED HEART FAILURE Jugular vein distention (JVD) Edema (dependent) Pitting edema Anorexia Nocturnal dyspnea Nocturia Weakness Nausea Abdominal pain Jaundice Hepatomegaly Palpable spleen and liver Ascites Weight gain Gastrointestinal distress

dyspnea cough pulmonary crackles low oxygen saturation level paroxysmal nocturnal dyspnea large quantities of frothy sputum oliguria altered digestion dizziness lightheadedness confusion restlessness anxiety skin feels cool and clammy skin appears pale or ashen tachycardia fatigue

Diagnosis

NURSING DIAGNOSES:

• activity intolerance • decreased cardiac output• excessive fluid volume• fatigue• imbalanced nutrition : < body requirements• impaired gas exchange• ineffective airway clearance• ineffective breathing pattern• ineffective tissue perfusion

Diagnostic Tests and Exams

• Physical examination may reveal an irregular or heartbeat and increased breathing rate. The doctor may feel abnormal heart motion when touching the chest wall.

• Listening to the heart may reveal heart murmurs or extra heart sounds, and listening to the lungs may reveal crackles or decreased breath sounds at the bottom. The lower legs may be swollen and remain dimpled when pressed.Tests may include:

• An ECG, to look for signs of thickened heart muscle or enlarged heart chambers. The electric system of the heart and heart rhythm may not be normal.

• A chest x-ray, to look for enlargement of the heart and fluid accumulation in the lungs.

• An echocardiogram (heart ultrasound) and a Doppler study, which may show heart chambers enlargement, leaky valves, and poor pumping function.

• Cardiac catheterization may be performed. In right heart catheterization, a catheter is inserted through a vein into the right side of the heart to measure the pressures. Sometimes, an injection of contrast material ("dye") in the right ventricle is necessary to help understand the problem (right ventriculography).

• Coronary angiography to determine the underlying cause of heart failure.

• Heart stress test to assess the severity of condition by monitoring the patient’s activity intolerance.

The following lab tests may be performed:

• CBC• Blood chemistry• Liver function tests• Urinalysis• make decisions about hospitalizations,

aggressive treatments, and future prognosis.Thyroid function tests

• B-Type Natriuretic Peptide (BNP)

What is BNP???

BNP is…• substance secreted from the ventricles or lower

chambers of the heart in response to changes in pressure that occur when heart failure develops and worsens.

• The level of BNP in the blood increases when heart failure symptoms worsen, and decreases when the heart failure condition is stable. The BNP level in a person with heart failure – even someone whose condition is stable – is higher than in a person with normal heart function.

Preparation

Preparation• To test the BNP level, a small amount of blood

is taken and placed in a machine that detects the level of BNP in your blood. The test takes about 15 minutes. The BNP level helps to determine if you have heart failure, rather than another condition that may cause similar symptoms. In addition, BNP help the physician

Results

• BNP levels below 100 pg/mL indicate no heart failure

• BNP levels of 100-300 suggest heart failure is present

• BNP levels above 300 pg/mL indicate mild heart failure

• BNP levels above 600 pg/mL indicate moderate heart failure

• BNP levels above 900 pg/mL indicate severe heart failure

Treatment

Treatment

The goals of treatments are:• Treat the disease that is causing the heart

failure• Reduce symptoms• Relieve stress on the heart• Reduce risks of worsening heart failure• Improve chances of survival

Medical Treatment• Diuretics• ACE Inhibitors• ARBs• Digoxin• Dopamine• Nitroglycerin

Diuretics• (water pills) can help reduce fluid

accumulation. Furosemide or bumetanide can help moderate to severe symptoms. Hydrochlorothiazide, chlorthalidone, and chlorothiazide may be used for mild symptoms. Another drug, spironolactone, can prevent salt retention and help patients with severe heart failure.

ACE Inhibitors

ACE Inhibitors• Medications for right-sided heart failure

include the use of ACE inhibitors or angiotensin-converting enzyme inhibitors. ACE inhibitors such as lisinopril help control blood pressure without affecting cardiac output.

ARBs

ARBs• Right-sided heart failure patients may take

angiotensin-receptor blockers for blood pressure control when ACE inhibitors are not tolerated. Not first-line drugs, physicians use caution when prescribing ARBs to patients with congestive heart failure and taking diuretics.

Digoxin

Digoxin• Many heart failure patients take the cardiac

glycoside digoxin. Digoxin slows down the heart rate and strengthens the contraction of the ventricles. This action increases the amount of blood pumped from the heart with each beat. Increased cardiac output helps decrease many symptoms associated with right-sided heart failure such as low blood pressure, fatigue and shortness of breath.

Nitroglycerin

Nitroglycerin• With right-sided heart failure, blood pressure can

become so low a patient experiences shock. Dopamine stimulates the heart by increasing cardiac output and blood pressure, relieving shock. Dopamine also improves blood flow to the kidneys which helps the kidneys eliminate excess fluid. The effects of dopamine are dose dependent, with low doses affecting the kidneys and higher doses stimulating the heart.

Nursing Management

Nursing Management:

The nurse is responsible for administering the medications and for assessing their beneficial and detrimental effects to the patient. It is balance of these effects that determines the type and dosage of pharmacology therapy. Nursing actions to evaluate therapeutic effectiveness include the following:

• Keeping an intake and output record to identify a negative balance

• Weighing the patient daily at the same time and on the same scale, usually in the morning after urination, monitoring for 2-to-3 lb gain in a day or 5 lb weight gain in a week

• Auscultating lung sounds at least daily to detect an increase or decrease in pulmonary crackles

• Determining the degree of JVD• Identifying and evaluating the severity of dependent edema• Monitoring pulse and blood pressure as well as monitoring

for postural hypotension and making sure that the patient does not become hypotensive from dehydration

• Assessing symptoms of fluid overload

Medical Management:

Implanted Devices• Some patients with ECG abnormalities may

benefit from a biventricular pacemaker, which helps both ventricles contract at the same time (CRT, cardiac resynchronization therapy).

• A defibrillation device such as an implantable cardioverter-defibrillator (ICD) helps some patients. CRT and ICD may be combined and implanted in a single device (biventricular pacemaker-ICD).

Transplant• A patient with severe heart failure that does

not respond to these therapies may require a heart transplant.

• A number of studies have shown that heart failure symptoms can be improved with a special type of pacemaker. It paces both the right and left sides of heart.

• This is referred to as biventricular pacing or cardiac resynchronization therapy. Ask your provider if you are a candidate for this.

• In very severe cases, when medicines alone do not work, a heart pump (ventricular assist device) can be implanted. A heart transplant may be needed.

• Management also includes, lifestyle changes such

as stopping drinking alcohol, taking maintenance medicines for high blood pressure. In severe cases, medicines are given through a vein.

• When heart function decreases significantly, a defibrillator may be recommended to prevent sudden cardiac death. A defibrillator is used to prevent dangerous heart rhythms, which often occur in people with very weak hearts.

The EndThank You for Listening!