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Heart Failure

Pathophisiology, Assessment andInterventions

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:// . . / / . = & =http www medmovie com mmdatabase MediaPlayer aspx?ClientID 69 TopicID 563Heart failure video from American Heart association

What is Heart

Failure?

Chronic Condition

SystolicDiastolic Usually left Risk Factors

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0

100,000

200,000

300,000

400,000

500,000

600,000

700,000

'79

'81

'83

'85

'87

'89

'91

'93

'95

'97

'99

D

isch

Women

Men

Heart Disease and Stroke Statistics2004 Update. Available at:http://www.americanheart.org/downloadable/heart/1072969766940HSStats2004Update.pdf

CDC/NCHS: Hospital discharges include patients both living and dead

FHospitalizations

http://www.americanheart.org/downloadable/heart/1072969766940HSStats2004Update.pdfhttp://www.americanheart.org/downloadable/heart/1072969766940HSStats2004Update.pdf

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0

10

20

30

40

50

60

Within2 days

Within1 mo

Within6 mo

Patie

ntsReadm

2%

25%

50%

Aghababian RV. Rev Cardiovasc Med. 2002;3(suppl 4):S3

HF Readmission Rates

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Consequences of HeartFailure

High incidence in geriatrics High rate of hospital admissionsand readmissions Most common Medicare DRG group

Highest treatment cost thanother Medicare DRGs

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ommon Factors in Hospitalizationor HF Noncompliance with medical regimen /sodium and or fluid restriction Acute myocardial ischemia Uncorrected high blood pressure Atrial fibrillation and other arrhythmias ;Recent addition of negative inotropic drugs. .:e g

, , ,verapamil nifedipine diltiazem beta blockers Pulmonary embolus -Nonsteroidal anti inflammatory drugs Endocrine abnormalities

, /diabetes mellitus hyper hypothyroidism ( . ., ,Concurrent infections e g pneumonia viral)illnesses

-AHA 2010

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CARDIAC ANATOMY &PHYSIOLOGY

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.1 Normal Ventricle WallWidth

.2 Ventricular Septum

Watch a simple animation of how

http://www.medmovie.com/mmdatabase/MediaPlayer.aspx?ClientID=65&TopicID=768http://www.medmovie.com/mmdatabase/MediaPlayer.aspx?ClientID=65&TopicID=768http://www.youtube.com/v/H04d3rJCLCE?fs=1&hl=en_US&rel=0&color1=0x2b405b&color2=0x6b8ab6%22%3E%3C/param%3E%3Cparam%20name=%22allowFullScreen%22%20value=%22true%22%3E%3C/param%3E%3Cparam%20name=%22allowscriptaccess%22%20value=%22always%22%3E%3C/param%3E%3Cembed%20src=%22http://www.youtube.com/vhttp://www.medmovie.com/mmdatabase/MediaPlayer.aspx?ClientID=65&TopicID=768

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:Linked from Heal National digitallibrary

See the heart in action

http://library.med.utah.edu/kw/pharm/hyper_heart1.htmlhttp://library.med.utah.edu/kw/pharm/hyper_heart1.htmlhttp://library.med.utah.edu/kw/pharm/hyper_heart1.htmlhttp://library.med.utah.edu/kw/pharm/hyper_heart1.html

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- ( )eft sided LV heartfailure:ystolic failure The left ventricle loses its

.ability to contract normally The heart can't pumpwith enough force to push enough blood into

.circulation

:iastolic failure The left ventricle loses its(ability to relax normally because the muscle has

).become stiff The heart can't properly fill with

.blood during the resting period between each beat

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Heart Failure: Systolic

Decreased contraction of the leftventricle; weakened pump

Decreased Left Ventricular Ejection

Fraction (LVEF) Majority of HF in men

Causes: #1 Ischemic heart disease

(CAD, MI) Dilated Cardiomyopathy (30% familial)

Valvular Heart Disease

Viral Endocarditis

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-ight sided heartfailure -usually occurs as a result of left

.sided failure blood backs up in the body's veins causes swelling in the legs andankles

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Heart Failure: Diastolic

Often normal LVEF Decreased contraction and relaxation

during filling

50% of HF patients > age 75 More common in women Fewer treatment guidelines

Causes: HTN, Hypertrophic,Restrictive Cardiomyopathy,Pericardial constriction

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Cardiac Conduction System

Watch an animation of the normal heart's electrical system

( )See a normal heart s electrocardiogram ECG

http://www.medmovie.com/mmdatabase/MediaPlayer.aspx?ClientID=66&TopicID=774http://www.medmovie.com/mmdatabase/MediaPlayer.aspx?ClientID=66&TopicID=560http://www.medmovie.com/mmdatabase/MediaPlayer.aspx?ClientID=66&TopicID=560http://www.medmovie.com/mmdatabase/MediaPlayer.aspx?ClientID=66&TopicID=560http://www.medmovie.com/mmdatabase/MediaPlayer.aspx?ClientID=66&TopicID=774

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ongestive heartfailure

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Class How Patient Feels During Physical ActivityI No symptoms and no limitation in ordinary physical

activity.II Mild symptoms and slight limitation during ordinaryactivity. Comfortable at rest.III Marked limitation in activity due to symptoms, even

during less-than-ordinary activity. Comfortable onlyat rest.IV Severe limitations. Experiences symptoms even whileat rest.

eart Failure byClass

http://tmp/svah0.tmp/svh12.tmp/hyperlink-path:#20

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Signs and Symptoms

Dyspnea( )r Shortness of Breath On exertion or at rest

Orthopnea ( )Paroxysmal Nocturnal Dyspnea PNDCough WHY?

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Edema( Buildup of excess fluid in bodytissues )

, ,Swelling in feet ankles legs or abdomen

Weight gain

WHY? Due to decreased blood flow out of the

,weakened heart blood returning to the heart from the veins backs up causing

fluid to build up in tissues

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Persistent coughing or

wheezing ,Tiredness Fatigue Mental Impairment

Memory loss

/ /Confusion Disorientation Impaired thinking

/Anorexia NauseaFeeling of being full or sick to your stomach

Increased heart rate

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Risk Factors for heart failure

Coronary Artery Disease (CAD)

Atherosclerosis. the result may be chest pain (angina)

or, if blood flow becomes totallyobstructed, a heart attack.

high blood pressure which, over time,may lead to heart failure.

Watch an animation of atherosclerosis

Watch an animation of coronary artery disea

http://www.medmovie.com/mmdatabase/MediaPlayer.aspx?ClientID=65&TopicID=573http://www.medmovie.com/mmdatabase/MediaPlayer.aspx?ClientID=65&TopicID=535http://www.medmovie.com/mmdatabase/MediaPlayer.aspx?ClientID=65&TopicID=535http://www.medmovie.com/mmdatabase/MediaPlayer.aspx?ClientID=65&TopicID=573

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&A n g in a Pectoris A cute C oron aryS yn d rom e

Stable Angina Unstable Angina Angina Equivalents

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( )Past heart attack myocardial infarction Watch an animation of heart attack ( )High blood pressure hypertension Abnormal heart valves

Heart muscle disease

Watch an animation of dilated cardiomyopathy Watch an animation of hypertrophic cardiomyopathy

Risk Factors for heart failure

See an illustration of high blood pressure

Watch an animation of how the valves work

Watch an animation of heart valve disease

http://www.medmovie.com/mmdatabase/MediaPlayer.aspx?ClientID=65&TopicID=536http://www.medmovie.com/mmdatabase/MediaPlayer.aspx?ClientID=69&TopicID=558http://www.medmovie.com/mmdatabase/MediaPlayer.aspx?ClientID=69&TopicID=558http://www.medmovie.com/mmdatabase/MediaPlayer.aspx?ClientID=69&TopicID=565http://www.medmovie.com/mmdatabase/MediaPlayer.aspx?ClientID=65&TopicID=564http://www.medmovie.com/mmdatabase/MediaPlayer.aspx?ClientID=65&TopicID=564http://www.medmovie.com/mmdatabase/MediaPlayer.aspx?ClientID=65&TopicID=727http://www.medmovie.com/mmdatabase/MediaPlayer.aspx?ClientID=65&TopicID=727http://www.medmovie.com/mmdatabase/MediaPlayer.aspx?ClientID=65&TopicID=773http://www.medmovie.com/mmdatabase/MediaPlayer.aspx?ClientID=65&TopicID=773http://www.medmovie.com/mmdatabase/MediaPlayer.aspx?ClientID=65&TopicID=727http://www.medmovie.com/mmdatabase/MediaPlayer.aspx?ClientID=65&TopicID=564http://www.medmovie.com/mmdatabase/MediaPlayer.aspx?ClientID=69&TopicID=565http://www.medmovie.com/mmdatabase/MediaPlayer.aspx?ClientID=69&TopicID=558http://www.medmovie.com/mmdatabase/MediaPlayer.aspx?ClientID=65&TopicID=536

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igns and Symptoms of anI , ,Uncomfortable pressure fullness squeezingor pain in the center of the chest that

lasts more than.a few minutes

( )Pain may radiate to other areas Chestdiscomfort

- , ,with light headedness fainting,sweating nausea

.or shortness of breath , / ,Anxiety nervousness and or cold sweaty.skin

paleness Increased or irregular heart rate A feeling of doom

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rrhythmias (>A fast heart rate 100 beats

)per minute is called

tachycardia . (

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Risk Factors for heart failure

Heart defects present at birth( )congenital heart disease Severe lung diseaseDiabetes Sleep Apnea

evere anemiaHyperthyroidism

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tion Fraction Heart Failure Measureme determines effectiveness of heart

pumping

measurement of how much blood the left

ventricle pumps out with

each contraction

.Normal may be between 55 and 70

> 40 may be evidence of heart failure

or

cardiomyopathy

,In severe cases EF can be very lowSee an illustration of the ejection fraction

http://www.medmovie.com/mmdatabase/MediaPlayer.aspx?ClientID=69&TopicID=662http://www.medmovie.com/mmdatabase/MediaPlayer.aspx?ClientID=69&TopicID=662http://www.medmovie.com/mmdatabase/MediaPlayer.aspx?ClientID=69&TopicID=662

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ardiogenic PulmonaryEdema Left ventricular failure Congenital heart defects Mitral valve or aortic disease Myocardial infarction

Systemic hypertension Excessive fl uid administration Rheumatic heart disease

)myocarditis Pulmonary embolus Renal failure

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Cardiogenic Pulmonary Edema S/SX

Cyanosis (due tohypoxemia)

paroxysmal nocturnaldyspnea ( PND)

Dyspnea, orthopnea Cheyne-Stokes

respiration

Increased Pulse

Increased B/P

Increased respirations

Cough and sputum(frothy and pink in

appearance)

Increased tactile andvocal fremitus

Crackles, rhonchi, and

wheezing

Abnormal X-Rays

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Watch an animation about angioplasty

edical Interventions foreart Failure ercutaneous coronary intervention( )PCI

(formerly referred to as)angioplasty

Coronary artery bypassSee an illustration of a coronary artery bypass

Valve replacement Watch an animation of how heart valves work

Watch an animation about heart valve surgery

Defibrillator implantation Watch an animation about implantable defibrillators

( )Left ventricular assist device LVADSee an illustration of a left ventricular assist device

http://www.medmovie.com/mmdatabase/MediaPlayer.aspx?ClientID=65&TopicID=534http://www.medmovie.com/mmdatabase/MediaPlayer.aspx?ClientID=65&TopicID=557http://www.medmovie.com/mmdatabase/MediaPlayer.aspx?ClientID=65&TopicID=557http://www.medmovie.com/mmdatabase/MediaPlayer.aspx?ClientID=65&TopicID=727http://www.medmovie.com/mmdatabase/MediaPlayer.aspx?ClientID=65&TopicID=727http://www.medmovie.com/mmdatabase/MediaPlayer.aspx?ClientID=65&TopicID=727http://www.medmovie.com/mmdatabase/MediaPlayer.aspx?ClientID=65&TopicID=594http://www.medmovie.com/mmdatabase/MediaPlayer.aspx?ClientID=65&TopicID=728http://www.medmovie.com/mmdatabase/MediaPlayer.aspx?ClientID=65&TopicID=728http://www.medmovie.com/mmdatabase/MediaPlayer.aspx?ClientID=65&TopicID=576http://www.medmovie.com/mmdatabase/MediaPlayer.aspx?ClientID=65&TopicID=576http://www.medmovie.com/mmdatabase/MediaPlayer.aspx?ClientID=65&TopicID=576http://www.medmovie.com/mmdatabase/MediaPlayer.aspx?ClientID=65&TopicID=728http://www.medmovie.com/mmdatabase/MediaPlayer.aspx?ClientID=65&TopicID=594http://www.medmovie.com/mmdatabase/MediaPlayer.aspx?ClientID=65&TopicID=727http://www.medmovie.com/mmdatabase/MediaPlayer.aspx?ClientID=65&TopicID=557http://www.medmovie.com/mmdatabase/MediaPlayer.aspx?ClientID=65&TopicID=534

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CARDIOVASCULARASSESSMENT

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oJugular VenousDistentionn Comes from back

pressurebuilding from

right heart intovenouscirculation

oVital Signsn Due to: Significant

increase in

sympatheticdischarge tocompensate.

n BPelevated ifcompensated

n Pulse rateelevated tocompensate for

Cardiovascular Assessment

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:Auscultation:Heart Decreased heart sounds Extra heart sounds

Lungs Anterior and posterior All lobes aerated? , ,Rales rhonchi wheezes

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Abdomen nlarged liver

,in prolonged and severe cases maylead to jaundice

plenomegalymay indicate infective endocarditis

ulsation(can indicate an aortic aneurysm an)insensitive but specific finding

Auscultate the abdomen for any bruitssuggestive of vascular disease

luid wave

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Extremities ; ,Edema when how to check

: ; ;PAD rashes vasculitis

,lack of hair decreased;pulses

cool to touch :Venous Insufficiency

;varicosities brawny lookUlcers

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Monitoring & Prevention

Sudden weight gain or weight loss

Weigh at the same time each morning,preferably before breakfast and after

urinating. Notify the MD if a gain 3+ pounds /day,

or 5+ pounds in one week, or perother MD determined perameter

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Symptoms Dyspnea at rest or on exertionReduction in exercise capacityParoxysmal nocturnal dyspnea(PND) or nocturnal cough

EdemaAscites or scrotal edema

Less specific presentations ofHF

Early satiety, nausea andvomiting, abdominal discomfortWheezing or coughUnexplained fatigue

Confusion/deliriumDepression/weakness

Table 4.3: Symptoms Suggesting the Diagnosis of HF (HF Society of America)

P h ysica l C h a n g e s toreport

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Medications

Lowering High Blood Pressure

Managing Cholesterol Levels

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Medications

Antihypertensives

diuretics, angiotensin-converting enzyme (ACE) inhibitors,

angiotensin-2 receptor antagonists, beta-blockers and calcium channel blockers.

may also be prescribed for heart failure and arrhythmia patients.

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o Direct effects of diureticsnNatriuresis, diuresisnElectrolyte excretion K, Ca, Mg

oIndirect effects of diureticsnVolume depletion, decreased circulating volumenDecreased renal perfusion and ADH releasenDecreased GFRnIncreased renin production; RAAS activationnIncreased SNS activation

nIncreased water and sodium retention

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CE Inhibitors* ( , )isinopril Zestril Prinivil* ( )nalapril Vasotec ,i d e E f f e ct s l o w b l o o d p r e ss u r e h i g h, / ,o t a s s i u m s w e l l i n g o f mo u t h l i p s d r y c o u g hAldosterone Antagonists* ( )pironolactone Aldactone* ( )plerenone Inspra

: - , ,Side Effects low blood pressure high potassium breast( )enlargement or tenderness with spironolactone rare

( )ngiotensin II Receptor Blockers ARBs* ( )osartan Cozaar* ( )alsartan Diovan* ( )rbesartan Avapro ,i d e E f f e ct s lo w b l o o d p r e ss ur e h i g h, / ,o t a s s i u m s w el l i n g o f m o u t h l i p s d r y c o u g h

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eta Blockers* ( , )etoprolol Lopressor Toprol* ( )arvedilol Coreg* ( )tenolol Tenormin , ,i de e f f e ct s lo w b l oo d p r e ss ur e d i z z i ne ss lo w,e ar t r a t e t i r e d n e s s

iuretics* ( )urosemide Lasix* ( )umetanide Bumex* ( )etolazone Zaroxolyn , ,i d e e f f e c t s lo w b l oo d p r e ss ur e d i z z i ne ss,r e q u e n t u r i n a ti o n l o w p o ta s s i u m

:IGOXIN( , )Slows heart rate helps pump more blood with each beat* ( , , )igitalis Lanoxin Digoxin Digitek

, - ,Side Effects slow heart rate yellow tinted vision loss, , , , ,of appetite stomach pain nausea diarrhea tiredness

.weakness

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References 2009 Focused Update: ACCF/AHA Guidelines for the Diagnosis and

Management of Heart Failure in Adults: A Report of the American

College of Cardiology Foundation/American Heart Association TaskForce on Practice Guidelines: Developed in Collaboration With theInternational Society for Heart and Lung Transplantation Circulation119: 1977-2016; published online before print asdoi:10.1161/CIRCULATIONAHA.109.192064

American College of Cardiology. [Online].Available:www.acc.org/clinical/topic/topic.htm

American Heart Association. [Online]. Available:www.americanheart.org

CNN.com. Diseases and Conditions: Pulmonary edema. [Online]. Available:www.cnn.com/

HEALTH/library/DS/00412.html

Kane, R.L., Ouslander, J.G., & Abrass, I.B. (2004). Essentials of clinical geriatrics(3rded.). New York:

McGraw Hill.

Quality Net (2010). Polish your practice Heart failure.