Heart Failure Med Ed Ppt

8/19/2019 Heart Failure Med Ed Ppt

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Critical Care Nuts & Bolts Acute and Chronic Heart Failure:The Epidemic

P R E S EN T E D B Y :

LISA M. SOLTIS, APRN, MSN, CCRN-CSC, CCNS

Heart Failure2

Clinical syndrome of decreased cardiacfunction

One or both ventricles are unable tomaintain adequate output

Can be systolic or diastolic

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Characteristics

Circulatory disorder characterized by abnormalitiesin the control of sodium balance, cardiac function,and Neurohormonal activation.

Systolic- the syndrome of heart failure occurring because of a difficulty emptying the left ventricle dueto impairment of myocardial contractility

Characteristics

Diastolic- the syndrome of heart failure occurring because the heart if unable to relax, and thereforeunable to fill at normal diastolic pressuressufficiently enough to accommodate an adequate

amount of oxygenated blood returning frompulmonary vasculature. Leads to either a decreased left ventricular (LV) end

diastolic volumes with a fall in cardiac output (CO) or arise in left ventricular filling pressures to maintain CO.

Lead to pulmonary hypertension, leading to pulmonarycongestion.



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Causes of Heart Failure

Coronary Artery Disease-

Myocardial Infarction-

Hypertension

Valvular Disease

Arrhythmias

Substance abuse

Viral Syndromes

Pathophysiology

Norepinepherine- Increases heart rate, contractility, vasoconstriction

Angiotensin

RAAS activation

Aldosterone secretion

Stimulates fibroblast proliferation, myocardial fibrosis

ACE effect on bradykinins

ACE-I block degradation of bradykinins, promotes vasodilation

Vasopressin

ADH fluid reabsorption at distal tubules



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Neuro-Hormonal Response

Low CardiacOutput

SympatheticNS

AdrenalMedulla

EpinephrineNor-

epinephrine

Renin

AT I to ATII

Aldosterone

HPA Axis

PituitaryGland

Vasopressin

AdrenalCortex

Cortisol

Ventricular Remodeling



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Homeostatic Mechanisms

The atria and ventricles secrete hormones, atrialnatriuretic peptide (ANP) and brain natriureticpeptide (BNP) in response to increased EDV and

ventricular stretch

ANP and BNP secretion causes vasodilatation anddiuresis (natriuresis - renal sodium loss) by

inhibiting the release of renin, angiotensin,aldosterone and epinephrine.

Left-Sided Heart Failure/Systolic Dysfunction

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Poor LV function

Decreased ability to pump blood forward

EF < 65%



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Compensation Gone a Wry

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LV Dilation

Increased LVPressure

Increased LA &pulmonary venous

pressure

Pulmonarycongestion &

edema

R heart failure

Systemiccongestion/edema

Patient Symptoms-Chronic

Shortness of breath (SOB)

Dyspnea on exertion (DOE)

Activity intolerance

Fatigue/weakness Lack of appetite

Nocturia

Swelling of feet, ankles, legs, or abdomen



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Patient Symptoms- Acute

Severe/sudden shortnessof breath

Paroxysmal nocturnaldyspnea

Orthopnea

Cough, possiblyproductive with pink,foamy sputum

Chest pain/fullness

Increased fatigue, weakness

Nausea/vomiting

Abdominal distention

Rapid or irregular heart beat

Sudden increase in weight

Increased edema

Physical Findings

Edema (including sacral edema, and ascites) Rales, pulmonary edema, tachypnea Hypotension Third heart sound S3- indicating fluid overload; S4 –

indicating stiff ventricle (as in HTN) Jugular vein distention –JVD indicating fluid overload

and right heart failure Hepatojugular reflux- increase venous congestion

leading to hepatic congestion (due to increased preload) Pale skin color/Cyanosis Resting tachycardia or arrhythmias including

bradycardia



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Pulmonary Edema

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Life-threatening complication of CHF

LV failure

Pressure in pulmonary vessels > 18-25 mmHg

Fluid leaks from pulmonary capillaries into theinterstitial tissue and intra-alveolar spaces

Signs and Symptoms16

Dyspnea

Orthopnea

Hypoxemia

Auscultation:

Crackles/rales

Sputum:

Pink, frothy



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Systolic Dysfunction: Treatment

Treatment is the sameas the treatment forleft-sided heart failure

Oxygen

May need non-invasivepositive-pressure ventilation (NIPPV) ormechanical ventilation

Decrease preload withloop diuretics

(furosemide, etc)

Morphine ornitroglycerinvasodilate, decreasingafterload

Morphine alsodecreases anxiety

Dobutamine ormilrinone to improvecardiac output

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Left-Sided Heart Failure/DiastolicDysfunction

Normal EF

LV stiff, non-compliant

◦ Inadequate LV filling

◦ Increased diastolic filling pressures

Leads to elevated LA, pulmonary venous, & PCWP

Can result in right heart failure & pulmonary HTN ifuntreated

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Left Sided Diastolic Dysfunction19

Diastolic Dysfunction: Treatment

Negative chronotropic medications todecrease heart rate & increase diastolic

filling time & stroke volume

Beta blockers (metoprolol, atenolol, etc)

Calcium channel blockers (verapamil, diltiazem)

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Right Heart Failure21

What Causes Right Heart Failure?

Pulmonary Disease

COPD, Chronic Bronchitis

Essential Pulmonary HTN PE

Isolated Right Coronary Ischemia

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Signs and Symptoms

Hepatic congestion

JVD

Edema

Ascites

Liver engorgement

Increased cardiac pressures, CVP

Treatment- Low Na diet, fluid restrictions

Nesiritide promotes diuresis and vasodilation

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Heart Failure Classification

I: Symptoms with strong exertion

II: Symptoms with normal exertion

III: Symptoms with minimal exertion

IV: Symptoms occur at rest

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Work-up

BNP: Prognostic indicator. Generally increases asHF worsens

BMP, TSH, CBC, LFTs CXR EKG Echo: assess LVEF & side/type of failure—R or L,

systolic or diastolic

Stress test: treadmill or nuclear May need cardiac catheterization

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Goals of Care

Alleviate symptoms

Stabilize hemodynamics

Correct fluid volume overload

Prevent complications, i.e. arrhythmias

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Neurohormonal Influences

HF is a vicious cycle

Flogging of the myocardium by norepinephrine

Vasopressin released, SIADH common

Continuous activation of RAA system

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Pharmacologic Agents

NON-Decompensated Heart Failure

Beta Blocker (metroprolol, Coreg) ACE Inhibitor or ARB

Spironolactone (Class 3 or 4 heart failure)

Aldosterone antagonist

Loop diuretics

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Acute Decompensated Heart Failure

(ADHF)

Signs & symptoms of worsening failure &fluid overload

May see:

JVD, weight gain, oliguria

Peripheral edema

Cool, pale, cyanotic skin

Dyspnea, crackles on auscultation

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ADHF: Treatment

Oxygen

If pulmonary edema, may need NIPPV ormechanical ventilation

Loop diuretics Positive inotropes: dobutamine or milrinone

Increase myocardial contractility

Decrease afterload

No role for -blockers in ADHF

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Cardiomyopathies

Dilated

• Progressive congestive L/R sided heart failure• Increased volume size, impaired EF%• Dysrhythmias, thromboembolism, or sudden cardiac arrest

Hyper-

trophic

• Fatigue, mild dyspnea, progressive LV failure, atrial fibrilaltion• Hypertrophic changes with increased collagen in septum and ventricular wall• Small ventricular cavity, decreased volume, normal EF%

Restrictive

• Right sided HF, tachycardia, periph. edema, ascites, liver enlargement• Restrictive filling, reduced diastolic volume, normal wall motion• Dilated atria from increased LVEDP, mitral & tricuspid regurgitation

Heart Failure Med Ed Ppt

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