Elizabeth Johnson RN, BSN, PCCN

Upon completion of this competency the learner will:

Describe the pathophysiology of Heart Failure

Relate the differences between right and left Heart Failure

Define the differences between systolic and diastolic Heart Failure

Describe the treatments for heart failure & indicate their uses

Describe appropriate nursing considerations that is needed during and at the time of discharge

Blood pressure is the amount of force (pressure) that blood exerts on the walls of the blood vessels as it passes through them. Two pressures are measured for a blood pressure reading:

Definitions Systolic: maximum pressure when blood

is expelled from the left ventricle Diastolic: diastolic pressure is the

residual arterial pressure when the heart is in diastole and is a reflection of vasomotor tome as measured by SVR Diastole counts for 2/3 of your cardiac cycle

Mean Arterial Pressure  (MAP) the average pressure within an artery over a complete cycle of one heartbeat.

MAP=Systolic + 2(Diastolic) / 3MAP=(CO x SVR) + CVPWhat is an average MAP?

~60mmHg

100/40=93/60=70/61=94/40=110/32=84/66=70/40=

Which is the best?

About 5.8 million people in the United States have heart failure.

HF is the #1 cause for admission to the hospital in adults ≥ 65 years old

HF is the #2 cause for admission to the hospital in adults ≥ 18 years old

Heart failure is a complex clinical syndrome that can develop from any cardiac disorder that impairs the ability of the ventricle to either fill properly or eject optimally. This syndrome results in a pathologic state in which the heart is unable to pump enough oxygenated blood to meet the metabolic needs of the body. Patients with heart failure present with one or both of the hallmark manifestation of heart failure. Dyspnea and fatigue Peripheral edema

Patients may have only one of the two manifestations of heart failure at any given time. For this reason, the term “Heart Failure” is more accurate than “Congestive Heart Failure” .

People who are 65 years old or older. Aging can weaken the heart muscle. Older people also may have had diseases for many years that led to heart failure.

African Americans are more likely to have heart failure than people of other races. They're also more likely to have symptoms at a younger age, have more hospital visits due to heart failure, and die from heart failure.

People who are overweight. Excess weight puts strain on the heart. Being overweight also increases your risk of heart disease and type 2 diabetes. These diseases can lead to heart failure.

People who have had a heart attack. Men have a higher rate of heart failure than women.

High Blood Pressure (about 75% of cases of heart failure start with hypertension).

Coronary Artery Disease Damage post MI Valvular Heart Disease Myocarditis Congenital heart diseases Cardiac arrhythmias, or

irregular heartbeats Diabetes Family history of heart

failure Excess alcohol consumption

A diet high in salt Advanced age Sedentary lifestyle Obesity Sleep apnea Angina Hx of Smoking Elevated low-density

lipoprotein (LDL) Abnormally high or low

hemoblobin Proteinuria Pulmonary embolism Hyperlipidemia

The two main categories of heart failure are: Systolic heart failure Diastolic heart failure

Systolic heart failure is the most common type of heart failure, and occurs when the heart not contracting well. The heart can't pump with enough force to push enough blood into the circulation. As a result, blood coming into the heart from the lungs can back up, causing fluid to leak into the lungs. Left ventricle is usually dilated

Commonly seen in men between ages of 50-70 who have had a heart attack

Diastolic heart failure occurs when the heart not relaxing well. Very often, it's associated with high blood pressure and left ventricular hypertrophy. This form may lead to fluid accumulation, especially in the feet, ankles, and legs. Some patients may have lung congestion. Although doctors can treat blood pressure and fluid volume, there are not as many treatment options for this type of heart failure▪ Usually have a normal or preserved LVEF▪ Typically women who are overweight, elderly,

hypertensive, and diabetic▪ 75% of patients admitted to hospital with a

diagnosis of HF have preserved or only minimally decreased LVEF.

Right Heart Failure - The inability of the right side of the heart to adequately pump venous blood into the pulmonary circulation. This causes a back-up of fluid in the body, resulting in abdominal bloating and lower extremity edema

Left Heart Failure – The inability of the left side of the heart to pump into the systemic circulation. Symptoms are predominantly those of pulmonary congestion.

RIGHT

JVD Elevated CVP S3 S4 at sternum Murmur of tricuspid

insufficiency Hepatomegaly Splenomegaly Ascites Anorexia Dependent pitting

edema Oliguria Fatigue Weight gain Abnormal liver fx

studies

LEFT

Rales/crackles SOB Dyspnea on exertion Orthopnea PND (paroxismal

nocturnal dyspnea) Pulmonary edema Tachypnea Diaphoresis S3 S4 at apex

Mental confusion Narrowed pulse

pressure Pulsus Alternans

Class I Class I - Patients with cardiac disease but without resulting limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitations, dyspnea, or anginal pain.

Class IIClass II - Patients with cardiac disease resulting in slight limitation of physical activity. They are comfortable at rest. Ordinary physical activity results in fatigue, palpitations, dyspnea, or anginal pain.

Class III Class III - Patients with cardiac disease resulting in marked limitation of physical activity. They are comfortable at rest. Less than ordinary activity causes fatigue, palpitations, dyspnea, or anginal pain.

Class IV Class IV - Patients with cardiac disease resulting in inability to carry on any physical activity without discomfort. Symptoms of heart failure or the anginal syndrome may be present even at rest. If any physical activity is undertaken, discomfort is increased.

Stage A- Stage A- High risk for developing HF. No identified structural or functional abnormalities. No signs or symptoms or HF.

Stage B- Stage B- Presence of structural heart disease strongly associated with development of HF.

Stage C- Stage C- Past or present symptoms of HF associated with underlying structural heart disease.

Stage DStage D- Advanced structural heart disease. Specialized interventions required. Marked symptoms of HF at rest, despite maximal medical therapy.

EKGChest x-rayBNPBMPEchocardiogram

▪ Remains the gold standard for evaluating patients Remains the gold standard for evaluating patients with a suspected diagnosis of HF and for with a suspected diagnosis of HF and for monitoring patients with a known diagnosis of HFmonitoring patients with a known diagnosis of HF

Cardiac CatheterizationStress TestNuclear Stress TestCardiac MRIOSA Screen

The term "ejection fraction" refers to the percentage of blood that's pumped out of a filled ventricle with each heartbeat.

Left Ventricular Ejection Fraction (LVEF)Left Ventricular Ejection Fraction (LVEF) 55-68% normal55-68% normal 45-54% mild45-54% mild 35-44% moderate35-44% moderate <35% severe<35% severe

BNP is a 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.

Heart damage from obstructive sleep apnea may worsen heart failure. Sleep apnea is a common disorder in which you have one or more pauses in breathing or shallow breaths while you sleep.

Sleep apnea can deprive your heart of oxygen and increase its workload. Treating this sleep disorder might improve heart failure.

Beta Blockers- slow your heart rate and lower your blood pressure to decrease your heart's workload.▪ Carvedilol- Max dose 25mg BID (can increase to 50mg

BID for pts > 85kg)▪ Metoprolol succinate – Max dose 200mg daily▪ Bisoprolol- Max dose 10mg daily

ACE inhibitors- lower blood pressure and reduce strain on your heart

Lisinopril- Max dose 20-40 mg daily Captopril- Max dose 50mg TID Enalapril- Max dose 10-20 mg BID Ramipril- Max dose 10mg daily

Angiotensin receptor blockers (ARBs)- relax your blood vessels and lower blood pressure to decrease your heart's workload. Substitute for patients who cannot tolerate ACE inhibitors due to cough.

Losartan- Max dose 50-100mg daily Valsartan- Max dose 160mg BID

Aldosterone antagonists trigger the body to get rid of salt and water through urine. This lowers the volume of blood that the heart must pump

Spironolactone or epleranone Cannot be used if creatinine > 2.5mg/dL due to risk of

hyperkalemia

Isosorbide Dinitrate/Hydralazine- helps relax your blood vessels so your heart doesn't work as hard to pump blood. Studies have shown that this medicine can reduce the risk of death in African Americans.

Digoxin makes the heart beat stronger and pump more blood.

Dose normally at 0.125 mg daily Need to check serum Digoxin levels

Diuretics- help reduce fluid buildup in your lungs and swelling in the feet and ankles.

Furosemide Torsemide Bumetanide

Milrinone belongs to a class of medications known as inotropes used to treat heart failure by helping the heart contract, which allows the heart to pump blood more effectively.

Milrinone also widens blood vessels, making it easier for the heart to move the blood through the arteries.

Patients with heart failure who are awaiting a heart transplant may also benefit from Milrinone.

Initial loading dose, 50 mcg/kg IV over 10 min; maintenance, 0.375 to 0.75 mcg/kg/min continuous IV infusion preferably through a central line.

Adverse Effects Atrial Fibrillation Abnormal Liver function tests Thrombocytopenia Ventricular premature complex Hypotension

NEVER TURN PRIMACOR OFF OR FLUSH LINE WITHOUT A DOCTOR’S ORDER!!!!

Positive inotrope to increase cardiac output in acute LV failure.

Dose: IV only, used as continuous infusion. 2-20 mcg/kg/min.

Adverse effects Tachycardia Ventricular arrhythmias Hypokalemia

Half life = 2 minutes Maxial effect 10-20 minutes after starting Central line preferred

A Non-Drug, Non-Diuretic Treatment Option for Fluid Overload: Aquapheresis is a medical therapy designed to remove excess salt and water from

the body safely, predictably, and effectively from patients suffering from fluid overload who have failed diuretic therapy. It removes excess salt and water and helps to restore a patient’s fluid balance or euvolemia.

Physicians can specify and adjust the exact amount and rate of fluid to be removed from each patient, resulting in a gradual reduction that has no significant clinical impact on blood pressure, heart rate, or the balance of electrolytes (chemical substances, such as sodium, potassium, and chloride) in the body.

Up to 500 ml or 1.1 lb of fluid can be safely removed per hour. The average removal rate is 250 ml or ½ lb an hour and treatment usually lasts about 24 hours. The total hospital stay with Aquapheresis therapy is around three to four days.

The therapy can be used in combination with or as an alternative to diuretics inotropic drug therapies,or vasoactive drug therapies to achieve the target fluid removal goal for the patient. And, because it removes sodium and resets body fluid levels, Aquapheresis may also improve the effectiveness of oral diuretics that patients take on an ongoing basis.

The Cardiac Resynchronization Therapy (CRT) device (biventricular pacemaker) has 2 or 3 leads that are positioned in the: Right atrium Right ventricle Left ventricle (via the coronary

sinus vein) When your heart rate drops below

the set rate, the device generates small electrical impulses that pass through the leads to the heart muscle. These impulses make the ventricles of the heart muscle contract, causing the right and left ventricles to pump together. The end result is improved cardiac function.

Implantable cardiac defibrillator (ICD)

ICD if LVEF <35% ICD/CRT therapy if:

▪ NYHA Class III-IV (ambulatory) despite optimal medical treatment

▪ QRS duration ≥ 150 msec

A ventricular assist device (VAD) is a mechanical pump that's used to support heart function and blood flow in people who have weakened hearts.

The device takes blood from a ventricle and helps pump it to the body and vital organs.

Heart transplants are done as a life-saving measure for end-stage heart failure.

Because donor hearts are in short supply, patients who need heart transplants go through a careful selection process. They must be sick enough to need a new heart, yet healthy enough to receive it.

Cardiologist Dr Czerska Cardiovascular surgeon

Dr Botta heart transplant Dr Bittner lung/heart

Transplant Transplant coordinator Social worker Dietitian Psychiatrist

Daily weights- every day between 4am and 6am!!! Fluid Restriction for severe HF with hyponatremia Sodium Restriction to 2gm daily Accurate I&O readings and documentation K+ and Mg+2 replacement Knowledge of admission weight and daily weights Knowledge of EF% and when it was obtained Knowledge of daily labs Knowledge of chest x-ray Does patient have a device?

Education Consult cardiac rehab Proper documentation of education

Core Measures Consult case management at time of admission Follow up appointment made at time of

discharge Patient eligible for Heart Care Center (407-836-

9262) Uninsured Medicaid or MediPASS

Jacobson, C., Marzlin, K., Webner, C. (2007). Cardiovascular nursing practice- a comprehensive resource manual and study guide for clinical nurses. Burien, Washington: Cardiovascular Nursing Education Associates

http://www.nhlbi.nih.gov/health/health-topics/topics/vad/ http://my.clevelandclinic.org/heart/services/tests/procedures/biventricular_pm.aspx

http://aquadex.gambro.com/en/aquadex/