Diseases Of The Heart

Heart Failure

• Heart failure is a clinical syndrome

• Heart is unable to pump sufficient blood to meet the needs of the tissues

• Heart failure is the number 1 DRG for hospitalization in people over 65 years

Etiology of Heart Failure

• CAD

• Systemic or pulmonary hypertension

• Cardiomyopathy

• Valvular disease

• Septal defects

• Myocarditis

• Dysrhythmias

• Hypervolemia

• Metabolic disorders

• Autoimmune disorders

• Anemia in the elderly

Pathophysiology Of Heart Failure

• Decreased amount of blood ejected from ventricles

• Stimulation of SNS - increases myocardial workload or O2 demand

• Ventricular hypertrophy• Decreased renal perfusion

• Activation of Renin-Angiotensin-Aldosterone System– Renin interacts with Angiotensinogen to

produce Angiotensin I– Angiotensin I converts to Angiotensin II– Angiotensin II stimulates release of

Aldosterone

• Blood backs up in left atrium and pulmonary veins

• Increased hydrostatic pressure forces fluid out of pulmonary capillaries into alveoli and interstitial spaces

• Right ventricle dilates due to increased pulmonary pressures (pulmonary HTN)

• Engorgement of venous system extends backwards into systemic veins and organs

• Right ventricular failure usually follows left ventricular failure

• Right ventricular failure can occur solely without left ventricular failure – cor pulmonale

• Heart failure can affect systolic function or diastolic function

Clinical Manifestations Of Left Ventricular Failure (LVF)

• Dyspnea– Dyspnea on exertion (DOE)– Orthopnea– Paroxysmal nocturnal dyspnea (PND)

• Cough• Crackles• Hypoxia, cyanosis• Tachycardia, palpitations

• S3, S4, murmurs

• Weak, thready pulses

• Fatigue

• Pale, cool, clammy skin

• Restlessness, anxiety, confusion

• Nocturia, oliguria

• Decreased GFR, increased creatinine

Clinical Manifestations of Right Ventricular Failure (RVF)

• Elevated JVD

• Positive HJR

• Hepatomegaly, splenomegaly

• Ascites

• Anorexia, nausea, constipation

• Sacral edema

• Peripheral edema

• Anasarca

• Weight gain

• Decreased activity tolerance

Acute Pulmonary Edema

• Life threatening situation• Large accumulation of fluid in lungs• Manifestations

– Severe dyspnea, sense of suffocation– Cough, large amounts of frothy, blood tinged

sputum– Wheezing and coarse crackles– Cyanosis

New York Heart Association’sFunctional Classification of Heart Disease

• Class I – Ordinary activity does not cause symptoms

• Class II – Slight limitation of ADLs

• Class III – Comfortable at rest but any activity causes symptoms

• Class IV – Symptoms at rest

Diagnostic Findings With Heart Failure

• Echocardiogram with Doppler flow studies

• Chest x-ray

• ECG

• B-Type Natriuretic Peptide (BNP)

• BUN and creatinine

• T4 and TSH

• Liver function tests

• Stress testing or cardiac cath

Objectives In Treating Heart Failure

• Identify and eliminate the precipitating cause

• Reduce the workload on the heart

• Enhance patient and family coping with lifestyle changes

Medical Management of Heart Failure

• Exercise– Bed rest in upright position in acute and

refractory stages– Regular exercise program

• Oxygen therapy• Dietary restrictions

– Sodium restriction– Fluid restriction

• Cardiac resynchronization – biventricular pacing (Medtronic InSyn)

• Mechanical assist devices

• Transplantation

Pharmacologic Management of Heart Failure

• ACE inhibitors– Vasodilate– Promote diuresis– Drugs – Vasotec, Captopril, Zestril,

• Angiotensin II Receptor Blockers (ARBs)– Prescribed when patient intolerant of ACE-I– Drugs – Diovan, Aticand

• Beta1 Blockers– Decrease cytotoxic effects of constant

stimulation of SNS– Decrease workload by decreasing heart rate– Drugs - Coreg, Lopressor, Atenolol

• Vasodilators– Cause venous dilation– Cause arterial dilation– Drugs – Nitrates ie. Isordil (isosorbide) and

other meds ie. Apresoline (hydralazine); BiDil ( isosorbide & hydralazine combination)

• Diuretics– Control Na and H2O retention– Three types

• Potassium sparing –Aldactone (spironalactone), Inspra (eplerenone)

• Loop diuretics – Lasix (furosemide)

• Thiazide diuretics – Zaroxolyn (metolazone), HCTZ (hydrochlorazide)

– Monitor for hypotension, lyte imbalances and dehydration, worsening renal failure

• Cardiac glycosides– Increase force of myocardial contraction

and slow conduction through AV node– Drugs – Lanoxin (digoxin), Primacor,

Inocor– Precautions with Lanoxin administration

• Decreased renal function slows elimination• Will need to decrease dose with certain meds

ie. amiodarone, erythromycin, quinidine• Usual dose – 0.125 mg to 0.5 mg (PO,IV,IM)

• Lanoxin toxicity – Therapeutic level 0.5-2.0 ng/mL

– Symptoms – anorexia, N/V, fatigue, H/A, yellow or green halos, new dysrhythmias

– Reversal – hold dose or administer Digibind (digoxin immune FAB)

• Nursing considerations for Lanoxin administration

– Assess heart rate for 1 min– Give after breakfast– Monitor for hypokalemia

• Calcium channel blockers– Contraindicated with severe systolic

dysfunction– Drugs – Norvasc, Cardizem, Procardia

• Natrecor (nesiritide)– Indicated for the IV treatment of clients with

acutely decompensated congestive heart failure with dyspnea at rest

– Manufactured from E-coli– Effects - dilates veins and arteries,

suppresses Aldosterone– Administration - IV bolus, then drip for 48

hrs– Contraindications - systolic pressure

<90mm Hg, binds with Heparin – Side effects - hypotension, VT, HA, nausea– Incompatible with Heparin in same line

Medical Management Of Pulmonary Edema

• Sit patient in high Fowlers with legs and feet dependent

• Oxygen

• Morphine

• Diuretics

• Other meds as with heart failure

Nursing Diagnoses For The Client With Heart Failure

Nursing Interventions For The Client With Heart Failure

• Monitor and manage potential complications– Assess cardiovascular status frequently

• Vital signs• Heart sounds• Degree of JVD & HJR• All peripheral pulses

– Assess respiratory status frequently• Lung sounds• Assess degree of dyspnea• Assess O2 sats

– Assess renal status• I&O• BUN & Cr• Assess for nocturia

• Assess GI system – HJR– Ascites– Appetite and constipation

• Monitor fluid status closely– Daily weights– I&O– Peripheral and sacral edema

• Reduce fatigue

• Promote activity tolerance

• Control anxiety

• Referrals

• Teach client and family

Client and Family Teaching Related to Heart Failure

• Weigh daily

• 2-3 gm Na diet

• Fluid restrictions

• Meds and side effects

• Signs and symptoms to report to physician– Weight gain– Loss of appetite– Syncopy or palpitations– Worsening SOB– Persistent cough

Expected Outcomes

• Maintains or improves cardiac function

• Maintains or increases activity tolerance

• Adheres to self-care program

• Absence of complications

Cardiomyopathy

• Disease of the myocardium which affects its function

• Three major types of cardiomyopathy– Dilated - DCM– Hypertropic - HCM– Restrictive

Dilated Cardiomyopathy

• Contractility decreases and ventricles dilate. Affects systolic function.

• Etiology – viral myocarditis, toxins, alcohol, pregnancy, ischemia

• Clinical manifestations same as with LVF

• Dx tests – ECHO, endomyocardial biopsy, ECG, chest x-ray, blood chemistries

• Tx – same as with LVF; tx dysrhythmias; heart transplant

Hypertropic Cardiomyopathy

• Myocardium increases in size and mass

• Reduces inner cavity of ventricles and ventricles take longer to relax and fill. Affects diastolic function

• Etiology – genetic, HTN, and hypoparathyroidism

• Appears most often in young adults• Clinical manifestations – sudden cardiac

death; dyspnea, palpitations, dizziness• Dx tests – radionuclide scans, ECHO,

chest x-ray, ECG• Tx – Beta blockers and Ca channel

blockers. Avoid meds that decrease preload or increase contractility (Lanoxin). Tx dysrhythmias - may insert ICD

Restrictive Cardiomyopathy

• Ventricle walls are rigid and do not stretch normally during filling. Cardiac output decreases. Affects diastolic function.

• Etiology - Amylodiosis, Sarcoidosis

• Clinical manifestations – fatigue, activity intolerance, dyspnea and other symptoms of LVF

• Dx tests – same as other cardiomyopathies

• Tx – similar to hypertropic cardiomyopathy; tx dysrhythmias. Also tx underlying cause

Rheumatic Endocarditis

• Results directly from group A beta-hemolytic strep

• Can be prevented if strep infection treated early

• Myocardium, valves and pericardium are affected– Contractility is decreased– Valve leaflets develop vegetative bodies

• Clinical manifestations– Signs of rheumatic fever (fever, chills, sore throat) – Heart murmur, heart failure

• Dx tests – Positive throat culture; ECHO; increased strep antibody titer

• Tx– Prevention is best treatment– Bed rest and treat heart failure if present– Penicillin or mycin drugs (Cleocin, EES) if

Penicillin allergy

Infective Endocarditis

• Infection of the endocardium and valves

• Etiology – staph, strep, fungi

• Increased risk in patients with valve disorders and IV drug abusers

• Clinical manifestations – malaise, intermittent fever and chills, night sweats, Roth spots, splinter hemorrhages in nails, Janeway lesions, Osler’s nodes, murmur, HF, stroke, pulmonary embolus

• Dx – blood cultures, CBC, transesophageal ECHO (TEE)

• Prevent in patients with valve disorders with prophylactic antibiotics before and after invasive procedures

• Tx - parenteral antibiotics for 6 wks (penicillin, vancomycin, gentamycin, ciprofloxacin)

Myocarditis

• Inflammation of myocardium results in degeneration and dilation

• Thrombi form on endocardial lining (mural thrombi)

• Etiology – viruses, parasites, bacteria, toxins, radiation

• Clinical manifestations – asymptomatic or fever, fatigue, tachycardia, palpitations, dyspnea, symptoms of HF

• Dx – endomyocardial biopsy, ECHO, chest x-ray, ECG, elevated cardiac enzymes

• Tx– Tx underlying cause– Bed rest– Tx heart failure– Anti-inflammatory or immunosuppressive

medications

Pericarditis

• Inflammation of the pericardial sac

• Fibrinous adhesions or exudate can form in pericardial sac

• Etiology – viruses, bacteria, fungi, myocardial injury, collagen diseases, drug reaction, radiation, neoplasms

• Clinical manifestations – chest pain, pericardial friction rub, fever, chills, dyspnea

• Dx – ECG changes, elevated ESR and possibly WBC, enzymes negative,ECHO

• Tx – Tx cause– NSAIDS, analgesics, steroids

Valvular Disorders

• Stenosis – valve does not open completely

• Regurgitation – valve does not close properly

Mitral Valve Prolapse (MVP)

• Portion of a leaflet balloons backward during systole

• Valve may not remain closed and regurgitation can occur

• Clinical manifestations – fatigue, dyspnea, chest pain, anxiety, dizziness, syncope, palpitations (atrial or ventricular dysrhythmias)

• Dx – ECHO with Doppler flow studies

• Tx– Beta blockers– Eliminate caffeine, alcohol, and smoking– Antibiotics prophylactically before and after

invasive procedures

Mitral Regurgitation or Mitral Insufficiency

• Leaflets do not close properly and blood flows backward

• Pressure increases in left atrium and blood backs up into lungs

• Etiology - MI, heart enlargement, rheumatic endocarditis

• Clinical manifestations – asymptomatic or symptoms of LVF, palpitations (atrial fib or PVCs), systolic murmur

• Dx – ECHO with Doppler flow , TEE, cardiac cath

• Tx – tx LVF, mitral valve replacement (MVR) or valvuloplasty

• Prophylactic antibiotics for invasive procedures

Mitral Stenosis

• Leaflets are thickened and contracted

• Flow of blood from left atrium into left ventricle is obstructed

• Left atrium dilates and hypertropies

• Blood backs up into lungs and eventually the right side of heart

• Clinical manifestations – Diastolic murmur, fatigue, dyspnea, hemoptyosis, cough, crackles, atrial fib

• Dx – ECHO, cardiac cath

• Tx – tx LVF, valvuloplasty or MVR, anticoagulation if atrial fib

Aortic Stenosis

• Narrowing of aortic valve orifice or calcification of leaflets

• LV hypertrophies, dilates, and contractility eventually decreases

• Blood backs up into lungs and right heart

• Clinical manifestations – angina, dizziness or syncope, dysrhythmias, DOE, systolic murmur, and possibly a thrill

• Dx – ECHO, TEE, cardiac cath• Tx – Bed rest, aortic valve replacement

(AVR), valvuloplasty, prophylactic antibiotics for invasive procedures

Aortic Regurgitation or Aortic Insufficiency

• Backflow of blood into LV from aorta during diastole

• LV hypertropies and dilates

• Competent mitral valve keeps blood from backing up into LA and lungs for a long time

• Clinical manifestations – sensations of forceful heart beat especially in the head or neck, head bobbing, marked visible carotid pulsations, water-hammer pulse, widened pulse pressure, diastolic murmur, fatigue, DOE, signs of heart failure

• Dx – ECHO, TEE, cardiac cath• Tx – AVR or valvuloplasty, prophylactic

antibiotics

Valvuloplasty

• Commisurotomy – procedure to separate fused leaflets

• Annuloplasty – repair of the valve annulus• Chordoplasty – repair of chordae tendineae

Valve Replacement

• Open heart procedure and requires heart lung bypass

• Two types of valve prostheses– Mechanical valves

• Ball-and-cage or disc design• More durable• Valves are susceptible to thromboemboli

– Tissue grafts• Xenograft – porcine or bovine• Homograft (allograft) - from cadavar• Autograft (autologous) – use patient’s pulmonic

valve

Complications Related To Valve Replacement

• Hemorrhage

• Thromboembolism

• Infection

• Dysrhythmias

• Hemolysis of RBCs

• Heart failure

Educational Needs of Client With Valve Replacement

• Wound care, diet, meds, activity restrictions

• Long term anticoagulant therapy if mechanical valve used

• Prophylactic antibiotic therapy if mechanical valve used