Heart Failure

Pathophisiology, Assessment and Interventions

What is Heart Failure?

Chronic Condition Systolic Diastolic Usually left Risk Factors

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

Discharges

HF Hospitalization s
700,000 600,000 500,000 400,000 300,000 200,000 100,000 0
'7 9 '8 1 '8 3 '8 5 '8 7 '8 9 '9 1 '9 3 '9 5 '9 7 '9 9

Wm o en M en

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

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

HF Readmission Rates
60

50%
50 40 30 20 10

25%

m ae R s ne t a P d t i

2%

Within 2 days

Within 1 mo

Within 6 mo

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

Consequences of Heart Failure

High incidence in geriatrics High rate of hospital admissions and readmissions Most common Medicare DRG group Highest treatment cost than other Medicare DRGs

Common Factors in Hospitalization for 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.: Pulmonary embolus Nonsteroidal anti-inflammatory drugs Endocrine abnormalities
verapamil, nifedipine, diltiazem, beta blockers

Concurrent infections (e.g., pneumonia, viral illnesses)

AHA-2010

diabetes mellitus, hyper/hypothyroidism

CARDIAC ANATOMY & PHYSIOLOGY

1. Normal Ventricle Wall Width 2. Ventricular Septum

Watch a simple animation of how

See the heart in action

Linked from: Heal National digital library

Left - sided ( LV ) heart failure

Systolic failure : The left ventricle loses its ability to contract normally. The heart can't pump with enough force to push enough blood into circulation. Diastolic 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.

Heart Failure: Systolic

Decreased contraction of the left

ventricle; 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
11

Right - sided heart failure

usually occurs as a result of leftsided failure. blood backs up in the body's veins causes swelling in the legs and ankles

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

13

Cardiac Conduction System

Watch an animation of the normal heart's electrical system See a normal hearts electrocardiogram (ECG)

Congestive heart failure

Heart Failure Stages

American College of Cardiology (ACC)/American Heart Association (AHA)

Stage
A High risk for developing heart A failure (HF) No structural heart disease or HF symptoms

Patient Description

Hypertension Coronary artery disease Diabetes mellitus Family history of cardiomyopathy Metabolic syndrome Structural heart disease with no Previous myocardial infarction LV remodeling including LVH and low EF signs or symptoms of HF Asymptomatic valvular disease Structural heart disease with prior or current symptoms of HF Refractory end-stage HF Known structural heart disease Shortness of breath and fatigue Reduced exercise tolerance

Marked symptoms at rest despite maximal medical therapy

D
Hunt SA, et al. J Am Coll Cardiol. 2005;46:e1-e82.
16

cle
Heart Failure by Class
Class How Patient Feels During Physical Activity I No symptoms and no limitation in ordinary physical II Mild symptoms and slight limitation during ordinary activity. activity. Comfortable at rest. III Marked limitation in activity due to symptoms, even during less-than-ordinary activity. Comfortable only IV Severe limitations. Experiences symptoms even while at rest. at rest.

Signs and Symptoms Dyspnea

( Or Shortness of Breath )

On exertion or at rest Orthopnea Paroxysmal Nocturnal Dyspnea (PND) Cough WHY?

( Buildup of excess fluid in body tissues )

Edema

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

Persistent coughing or wheezing Tiredness, Fatigue Mental Impairment

Memory loss Confusion/ Disorientation / Impaired thinking

Anorexia/ Nausea
Feeling of being full or sick to your stomach

Increased heart rate

Risk Factors for heart failure

Coronary Artery Disease (CAD) Atherosclerosis.
the result may be chest pain (angina)

or, if blood flow becomes totally obstructed, 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

A n g i a Pectori & A cu te C oron ary n s S yn d rom e

Stable Angina Unstable Angina Angina Equivalents

Risk Factors for heart failure

Past heart attack (myocardial infarction) High blood pressure (hypertension) See an illustration of Abnormal heart valves high blood pressure Watch an animation of how the valves work Watch disease Heart muscle an animation of heart valve disease
Watch an animation of dilated cardiomyopathy Watch an animation of hypertrophic cardiomyopathy Watch an animation of heart attack

Signs and Symptoms of an MI

Uncomfortable pressure, fullness, squeezing or pain in the center of the chest that lasts more than a few minutes. Pain (may radiate to other areas) Chest discomfort 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

Risk Factors for heart failure Arrhythmias

A fast heart rate (> 100 beats per minute) is called tachycardia. A slow heart rate (< 60 beats per minute) is referred to as bradycardia. Can contribute to heart failure
Watch an animation of arrhythmias

Risk Factors for heart failure

Heart defects present at birth (congenital heart disease) Severe lung disease Diabetes Sleep Apnea Severe anemia Hyperthyroidism

ection Fraction Heart Failure Measuremen

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

Cardiogenic Pulmonary Edema

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

Cardiogenic Pulmonary Edema S/SX

Cyanosis (due to
hypoxemia)

paroxysmal nocturnal dyspnea ( PND) Dyspnea, orthopnea Cheyne-Stokes respiration Increased Pulse Increased B/P Increased respirations

Cough and sputum

(frothy and pink in appearance) Increased tactile and vocal fremitus Crackles, rhonchi, and wheezing Abnormal X-Rays

Medical Interventions for Heart Failure

Percutaneous coronary intervention (PCI) Watch an animation about angioplasty (formerly referred to as angioplasty) Coronary artery bypass Valve replacement
See an illustration of a coronary artery bypass Watch an animation of how heart valves work Watch an animation about heart valve surgery Watch an animation about implantable defibrillators See an illustration of a left ventricular assist device

Defibrillator implantation

Left ventricular assist device (LVAD)

CARDIOVASCULAR ASSESSMENT

Cardiovascular Assessment
o Jugular Venous Distention
n

Comes from back pressure building from right heart into venous circulation Due to: Significant increase in sympathetic discharge to compensate. BPelevated if compensated Pulse rate elevated to compensate for

o Vital Signs
n
<object width ="960" height ="745"><param name ="movie " value="http://www.youtube.com/v/yq74c6KhPuo? fs=1&amp;hl=en_US&amp;rel=0&amp;color1=0x2b405b&amp;color 2=0x6b8ab6"></param><param name="allowFullScreen" value="true"></param><param name="allowscriptaccess" value="always"></param><embed src="http://www.youtube.com/v/yq74c6KhPuo? fs=1&amp;hl=en_US&amp;rel=0&amp;color1=0x2b405b&amp;color 2=0x6b8ab6" type="application/x-shockwave-flash" allowscriptaccess="always" allowfullscreen="true" width="960" height="745"></embed></object>

n n

Auscultation: Heart:

Decreased heart sounds Extra heart sounds

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

Lungs

Abdomen

Enlarged liver in prolonged and severe cases, lead to jaundice

may

Splenomegaly may indicate infective endocarditis Pulsation can indicate an aortic aneurysm (an insensitive but specific finding) Auscultate the abdomen for any bruits suggestive of vascular disease Fluid wave

Extremities

Edema; when, how to check PAD: rashes; vasculitis; lack of hair, decreased pulses; cool to touch Venous Insufficiency: varicosities; brawny look Ulcers

for Prediction of Clinical Events from Time of Hospital Discharge

55 50 45 40 35 30 25 20 15 10 5 0 0 20 40 60 80 100 120 140 160 180
BNP < 230 pg / mL BNP 230 480 pg / mL BNP > 480 pg / mL

BNP Concentration

Cumulative Probability of HF Visit , Admission , or Death (%)

Time ( days )
Reference : Harrison A et al. Ann Emerg Med. 2002;39:131-138.

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 per other MD determined perameter

P h ysi lC h a n g e s to ca re p o rt
Less specific Symptoms presentations of HF Early satiety, nausea exertion Dyspnea at rest or onand Reduction in exercise capacity vomiting, abdominal discomfort Paroxysmal nocturnal dyspnea Wheezing or cough Unexplained fatigue (PND) or nocturnal cough Edema Confusion/delirium Ascites or scrotal edema Depression/weakness

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

Tracking daily fluid intake Fluid Restriction (MD ordered only) Diuretics Monitoring blood pressure. Cardiac Medications

Interventions

Medications
Lowering High Blood Pressure Managing Cholesterol Levels

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.

Direct effects of diuretics

nNatriuresis,

diuresis nElectrolyte excretion K, Ca, Mg

oIndirect

effects of diuretics

nVolume

depletion, decreased circulating volume nDecreased renal perfusion and ADH release nDecreased GFR nIncreased renin production; RAAS activation nIncreased SNS activation nIncreased water and sodium retention

ACE Inhibitors * lisinopril ( Zestril , Prinivil ) * enalapril ( Vasotec ) Side Effects low blood pressure , high potassium , swelling of mouth / lips , dry cough Aldosterone Antagonists * spironolactone ( Aldactone ) * eplerenone ( Inspra ) Side Effects: - low blood pressure, high potassium, breast enlargement or tenderness with spironolactone (rare) Angiotensin II Receptor Blockers ( ARBs ) * losartan ( Cozaar ) * valsartan ( Diovan ) * irbesartan ( Avapro ) Side Effects low blood pressure , high potassium , swelling of mouth / lips , dry cough

Beta Blockers * metoprolol ( Lopressor , Toprol ) * carvedilol ( Coreg ) * atenolol ( Tenormin ) Side effects low blood pressure , dizziness , low heart rate , tiredness Diuretics * furosemide ( Lasix ) * bumetanide ( Bumex ) * metolazone ( Zaroxolyn ) Side effects low blood pressure , dizziness , frequent urination , low potassium DIGOXIN : (Slows heart rate, helps pump more blood with each beat) * digitalis ( Lanoxin , Digoxin , Digitek ) Side Effects slow heart rate, yellow-tinted vision, loss of appetite, stomach pain, nausea, diarrhea, tiredness, weakness.

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 Task Force on Practice Guidelines: Developed in Collaboration With the International Society for Heart and Lung Transplantation Circulation 119: 1977-2016; published online before print as doi: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 (3rd ed.). New York: McGraw Hill. Quality Net (2010). Polish your practice Heart failure.