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Congestive Heart Congestive Heart FailureFailure

HNI 473HNI 473

Adult Health NursingAdult Health Nursing

Professor Patricia VoelpelProfessor Patricia Voelpel

Revised 2014

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CONGESTIVE HEART CONGESTIVE HEART FAILUREFAILURE

Textbook definition: inability Textbook definition: inability of the myocardium to pump of the myocardium to pump sufficient blood to the tissues sufficient blood to the tissues of the body to meet metabolic of the body to meet metabolic demandsdemands

Hemodynamic and Hemodynamic and neurohormonal derangements neurohormonal derangements

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RENIN-ANGIOTENSIN SYSTEM

Renin + Angiotensinogen

Angiotensin I

Angiotensin II

Peripheral vasoconstriction Aldosterone secretion

BP Na + H20 retention

Increased plasma volume

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Congestive Heart FailureCongestive Heart Failure

Normal Heart Diseased Heart

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Pulmonary EdemaPulmonary Edema

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Magnitude of the Problem of Magnitude of the Problem of CHFCHF

Most common admission diagnosis over Most common admission diagnosis over age 65age 65– risk for readmission within 30-90 days risk for readmission within 30-90 days

High financial tollHigh financial toll– 654,000 admissions cost $5.6 billion in 1992654,000 admissions cost $5.6 billion in 1992

Low adherence ratesLow adherence rates– account for approximately 50% of admissionsaccount for approximately 50% of admissions

Inaccurate symptom appraisal or Inaccurate symptom appraisal or awarenessawareness– symptoms thought to be due to normal agingsymptoms thought to be due to normal aging

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ETIOLOGYETIOLOGY

– Anything that induces chronic Anything that induces chronic ’d ’d volume or volume or ’d pressure or ’d pressure or ’d metabolic ’d metabolic demand on myocardiumdemand on myocardium HypertensionHypertension Coronary heart diseaseCoronary heart disease Idiopathic cardiomyopathyIdiopathic cardiomyopathy Valvular heart diseaseValvular heart disease Thyrotoxicosis, anemia, hypoxiaThyrotoxicosis, anemia, hypoxia

DefinitionsDefinitions

Cardiac Output: volume of blood in liters Cardiac Output: volume of blood in liters pumped by the heart in one minute.pumped by the heart in one minute.

Cardiac Index: CO adjusted for BSA.Cardiac Index: CO adjusted for BSA. Preload: volume within the ventricleat the Preload: volume within the ventricleat the

end of diastole.end of diastole. Afterload: forces opposing ventricular Afterload: forces opposing ventricular

ejection.ejection. Vascular resistance: resistance of either Vascular resistance: resistance of either

the systemic or pulmonary vascular bed.the systemic or pulmonary vascular bed.

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Hemodynamic MonitoringHemodynamic MonitoringMeasurement Normal

CVP (preload RV) 2-8 mm Hg

PAWP (preload LV) 6-12 mm Hg

SVR (afterload LV) 800-1200 dynes/sec/cm

PVR (afterload RV) <250 dynes/sec/cm

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Hemodynamic MonitoringHemodynamic Monitoring

So what do these numbers mean to So what do these numbers mean to me?me?

How do we acquire them?How do we acquire them?

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Cardiac outputCardiac outputCOCO = heart rate X stroke = heart rate X stroke

volumevolume

–Stroke volumeStroke volumepreloadpreloadafterloadafterloadcontractilitycontractility

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Etiology and Cardiac OutputEtiology and Cardiac Output

preloadpreload– aortic regurgitationaortic regurgitation– VSDVSD

afterloadafterload– aortic stenosisaortic stenosis– hypertensionhypertension

contractilitycontractility– myocardial infarctionmyocardial infarction– cardiomyopathycardiomyopathy

Systolic vs Diastolic FailureSystolic vs Diastolic FailureSystolic Diastolic

Problem Inability of the heart to pump blood effectively.

Inability of the ventricles to relax and fill during diastole.

Cause Impaired contraction (MI)Increased afterload (HTN)Mechanical abnormality (Valve disease)

Stiff ventricles that lead to high filling pressures.LVH 2° HTNMyocardial ischemiaValve diseaseCardiomyopathy

Hallmark sign Decreased LV EF Decreased stroke volume and cardiac output.HF with normal EF

Ejection FractionNorm=55-60%

< 45% Normal

Population affected Men>Women Women>Men

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CHF Compensatory CHF Compensatory MechanismsMechanisms

’’d sympathetic adrenergic activityd sympathetic adrenergic activity

’’d preload secondary to activation d preload secondary to activation of renin-angiotensin-aldosterone of renin-angiotensin-aldosterone systemsystem

Ventricular hypertrophyVentricular hypertrophy

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Common CHF Symptoms Common CHF Symptoms

Fatigue Sleeplessness

Edema Angina

Weight gain Palpitations

Cough

Dyspnea

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HF Management HF Management

Lifestyle modificationsLifestyle modifications– low Na dietlow Na diet– pacing of activitiespacing of activities

Medication complexityMedication complexity– multiple medicationsmultiple medications

Symptom monitoringSymptom monitoring– daily weightdaily weight– symptom monitoringsymptom monitoring– often insidious symptom patternoften insidious symptom pattern

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Research Recommendations Research Recommendations from Recent CHF Studies from Recent CHF Studies

Interventions needed to improve Interventions needed to improve symptom awarenesssymptom awareness

Utilize patient perspective in Utilize patient perspective in interventionsinterventions

Interventions to promote earlier Interventions to promote earlier treatmenttreatment

Address quality of life issues as well as Address quality of life issues as well as decreased mortality rates (AHCPR, 1994)decreased mortality rates (AHCPR, 1994)

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Goals of ManagementGoals of Management

Identify and eliminate precipitating Identify and eliminate precipitating causecause

Management of symptomsManagement of symptoms Increase functional capacityIncrease functional capacity Prevention of exacerbationsPrevention of exacerbations Educate and assist patient and family Educate and assist patient and family

to cope with lifestyle changes (self to cope with lifestyle changes (self care)care)

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Pharmacological Pharmacological Management Management

ACEI’s - “….pril” drugs (enalapril/Vasotec)ACEI’s - “….pril” drugs (enalapril/Vasotec) Diuretics - thiazides and loops (HCTZ or Diuretics - thiazides and loops (HCTZ or

furosemide/Lasix)furosemide/Lasix) Beta blockers - “….olol” drugs Beta blockers - “….olol” drugs

(carvediol/Coreg)(carvediol/Coreg) Digoxin/LanoxinDigoxin/Lanoxin ARB’s (angiotensin II receptor blockers) - ARB’s (angiotensin II receptor blockers) -

“….sartan” drugs (losartan/Cozaar)“….sartan” drugs (losartan/Cozaar) MorphineMorphine AnticoagulantsAnticoagulants

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Considerations for Home Considerations for Home CareCare

Discharge planning begins on admissionDischarge planning begins on admission Assess support systemsAssess support systems Symptom monitoringSymptom monitoring Provide resources and educational Provide resources and educational

materialsmaterials Dietary needsDietary needs Daily weightsDaily weights Medication supplyMedication supply ExerciseExercise

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Left side vs. Right sideLeft side vs. Right side

What will you see?What will you see? What are some causes?What are some causes? How are they treated?How are they treated? What is the other name for Right What is the other name for Right

sided failure?sided failure? Can you have Right and Left sided Can you have Right and Left sided

failure at the same time?failure at the same time?