CARDIAC FAILURE

Defintion
HF, often referred to as congestive heart failure (CHF), is the inability of the heart to pump
sufficient blood to meet the needs of the tissues for oxygen and nutrients
The term HF is preferred and indicates myocardial heart disease in which there is a problem
with contraction of the heart (systolic dysfunction) or filling of the heart (diastolic dysfunction)
and which may or may not cause pulmonary or systemic congestion.
Anatomy and Physiology of the Heart
The basic function of the heart is to pump blood.
The hearts ability to pump is measured by cardiac output (CO), the amount of blood pumped in
1 minute.
CO is determined by measuring the heart rate (HR) and multiplying it by the stroke volume (SV),
which is the amount of blood pumped out of the ventricle with each contraction. CO usually is
calculated using the equation CO = HR SV.
Preload is the amount of myocardial stretch just before systole caused by the pressure created by the
volume of blood within the ventricle. Like a rubber band, the ventricular muscle fibers need to be
stretched (by the blood) to produce optimal ejection of blood. Too little or too much muscle fiber
stretch decreases the volume of blood ejected.
Another factor that determines preload is ventricular compliance, which is the elasticity or amount of
give when blood enters the ventricle.
Afterload refers to the amount of resistance to the ejection of blood from the ventricle. To eject blood,
the ventricle must overcome this resistance. Afterload is inversely related to SV. The major factors that
determine afterload are the diameter and distensibility of the great vessels (aorta and pulmonary
artery) and the openingand competence of the semilunar valves (pulmonic and aortic valves).
Contractility, which refers to the force of contraction, is related to the number and status of myocardial
cells. Catecholamines, released by sympathetic stimulation such as exercise or from administration of
positive inotropic medications, can increase contractility and stroke volume.
Etiology
coronary artery disease,
cardiomyopathy,
Pulmonary hypertension,

valvular disorders.

Atherosclerosis of the coronary arteries is the primary cause of HF.

Ischemia causes myocardial dysfunction because of resulting hypoxia and acidosis from the
accumulation of lactic acid.
Risk factors
Age
Lifestyle
Race
Religion
Environment
Pathopysiology
Systolic Heart Failure
Diastolic Heart Failure
Left Ventricular Heart Failure
Left ventricle cannot pump blood for arterial circulation, causing increase blood volume and
pressure in the left side of the heart
Increase in left ventricular pressure decrease in blood volume in the atrium accumulation of blood
in the left Atrium and Ventricle leads to increase pressure increase pulmonary blood volume and
pressure pulmonary fluids is forced from capillaries back to pulmonary tissue and alveoli impaired
gas exchange [backward failure]
Clinical Manifestation
Pulmonary venous congestion
Dyspnea
Cough
Pulmonary crackles
Decrease oxygen saturation
S3 on auscultation

Right Ventricular Heart failure

Right ventricle cannot pump blood to the pulmonary arteries causing increase in blood volume
and pressure in the right side of the heart
Right side of the heart cannot eject blood accumulation of the blood at the right side increase
pressure causes jugular vein distention and edema formation due to decrease of albumin circulating in
the arterial circulation
Clinical Manifestation
Jugular vein distention

*Hepatomegaly

Edema of the lower extremities (dependent edema)

*Nausea and vomiting

Ascites

*Weakness

Weight gain d/t fluid retention

*Anorexia

Assessment and Diagnosiss

HF may go undetected until the patient presents with signs and symptoms of pulmonary and
peripheral edema (congestion), which can lead the physician to make a preliminary diagnosis of
CHF.
However, the physical signs that suggest HF may also occur with other diseases, such as renal
failure, liver failure, oncologic conditions, and COPD.
Medical Intervention
A critical step in the management of HF is early identification and documentation of the type of
HF. Medical management, especially the pharmacologic therapy, varies with the type of HF..
The basic objectives in treating patients with HF are the following:
Eliminate or reduce any etiologic contributory factors, especially those that may be reversible, such as
atrial fibrillation or excessive alcohol ingestion.
Reduce the workload on the heart by reducing afterload and preload
Managing the patient with HF includes:

providing general

counseling and education about sodium restriction,

monitoringdaily weights and other signs of fluid retention,

encouraging regular exercise,

 recommending avoidance of excessive fluid intake, alcohol, and smoking.

Oxygen therapy is based on the degree of pulmonary congestion and resulting hypoxia. Some
patients may need supplemental oxygen therapy only during activity. Others may require
hospitalization and endotracheal intubation.
If the patient has underlying coronary artery disease, coronary artery revascularization with
percutaneous transluminal coronary angioplasty (PTCA) or bypass surgery may be considered
If the patients condition is unresponsive to advanced aggressive medical therapy, innovative
therapies, including mechanical assist devices and transplantation, may be considered.
Pharmacologic Therapy
Angiotensin-Converting Enzyme Inhibitors.
ACE-Is promote vasodilation and diuresis by decreasing afterload and preload.
By doing so, they decrease the workload of the heart. Vasodilation reduces resistance to left
ventricular ejection of blood, diminishing the hearts workload and improving ventricular
emptying.
In promoting diuresis, ACE-Is decrease the secretion of aldosterone, a hormone that causes the
kidneys to retain sodium.
ACE-Is stimulate the kidneys to excrete sodium and fluid (while retaining potassium), thereby
reducing left ventricular filling pressure and decreasing pulmonary congestion.
Angiotensin II Receptor Blockers (ARBs)
lowered blood pressure and lowered systemic vascular resistance
Hydralazine and Isosorbide Dinitrate
cause venous dilation, which reduces the amount of blood return to the heart and lowers
preload.
Hydralazine lowers systemic vascular resistance and left ventricular afterload
Beta-Blockers
beta-blockers, such as carvedilol (Coreg), metoprolol (Lopressor, Toprol), or bisoprolol (Zebeta)
recommended for patients with asymptomatic systolic dysfunction, such as after acute
myocardial infarction or revascularization to prevent the onset of symptoms of HF

Diuretics
medications used to increase the rate of urine production and the removal of excess
extracellular fluid from the body
Of the types of diuretics prescribed for patients with edema from HF, three are most common:
thiazide, loop, and potassium-sparing diuretics
Digitalis
The most commonly prescribed form of digitalis for patients with HF is digoxin (Lanoxin).
The medication increases the force of myocardial contraction and slows conduction through the
AV node.
It improves contractility, increasing left ventricular output.
The medication also enhances diuresis, which removes fluid and relieves edema.
The effect of a given dose of medication depends on the state of the myocardium, electrolyte
and fluid balance, and renal and hepatic function
Calcium Channel Blockers
First-generation calcium channel blockers, such as verapamil (Calan, Isoptin, Verelan), nifedipine
(Adalat, Procardia), and diltiazem (Cardizem, Dilacor, Tiazac), are contraindicated in patients
with systolic dysfunction, although they may be used in patients with diastolic dysfunction.
Amlodipine (Norvasc) and felodipine (Plendil), dihydropyridine calcium channel blockers, cause
vasodilation, reducing systemic vascular resistance.
They may be used to improve symptoms especially in patients with nonischemic
cardiomyopathy, although they have no effect on mortality.
Heart Failure: Nursing Intervention
Promoting Activity Tolerance

* Minimizing Powerless

Reducing fatigue

* Monitoring and Managing Potential Complication

Managing Fluid Volume

* Controlling Anxiety