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Critical Care Nuts & Bolts

Acute and Chronic Heart Failure:


The Epidemic

PRESENTED BY:

LISA M. SOLTIS, APRN, MSN, CCRN-CSC, CCNS

Heart Failure
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Clinical syndrome of decreased cardiac

function
One or both ventricles are unable to
maintain adequate output
Can be systolic or diastolic

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Characteristics
Circulatory disorder characterized by abnormalities

in the control of sodium balance, cardiac function,


and Neurohormonal activation.

Systolic- the syndrome of heart failure occurring

because of a difficulty emptying the left ventricle due


to impairment of myocardial contractility

Characteristics
Diastolic- the syndrome of heart failure occurring

because the heart if unable to relax, and therefore


unable to fill at normal diastolic pressures
sufficiently enough to accommodate an adequate
amount of oxygenated blood returning from
pulmonary vasculature.
Leads to either a decreased left ventricular (LV) end
diastolic volumes with a fall in cardiac output (CO) or a
rise in left ventricular filling pressures to maintain CO.
Lead to pulmonary hypertension, leading to pulmonary
congestion.

MED-ED, Inc. | 1911 Charlotte Dr., Charlotte, NC 28203 | 800-763-3332 | www.MedEdSeminars.net


Copyright 2016 MED-ED, Inc., All Rights Reserved

Causes of Heart Failure


Coronary Artery Disease Myocardial Infarction Hypertension
Valvular Disease
Arrhythmias
Substance abuse
Viral Syndromes

Pathophysiology
Norepinepherine Increases heart rate, contractility, vasoconstriction
Angiotensin
RAAS activation
Aldosterone secretion

Stimulates fibroblast proliferation, myocardial fibrosis

ACE effect on bradykinins

ACE-I block degradation of bradykinins, promotes vasodilation

Vasopressin
ADH fluid reabsorption at distal tubules

MED-ED, Inc. | 1911 Charlotte Dr., Charlotte, NC 28203 | 800-763-3332 | www.MedEdSeminars.net


Copyright 2016 MED-ED, Inc., All Rights Reserved

Neuro-Hormonal Response
Low Cardiac
Output

Sympathetic
NS

Renin

Adrenal
Medulla

Epinephrine

AT I to AT
II

Norepinephrine

Aldosterone

HPA Axis

Pituitary
Gland

Adrenal
Cortex

Vasopressin

Cortisol

Ventricular Remodeling

MED-ED, Inc. | 1911 Charlotte Dr., Charlotte, NC 28203 | 800-763-3332 | www.MedEdSeminars.net


Copyright 2016 MED-ED, Inc., All Rights Reserved

Homeostatic Mechanisms
The atria and ventricles secrete hormones, atrial

natriuretic peptide (ANP) and brain natriuretic


peptide (BNP) in response to increased EDV and
ventricular stretch
ANP and BNP secretion causes vasodilatation and

diuresis (natriuresis - renal sodium loss) by


inhibiting the release of renin, angiotensin,
aldosterone and epinephrine.

Left-Sided Heart Failure/


Systolic Dysfunction
Poor LV function
Decreased ability to pump blood forward
EF < 65%

10

MED-ED, Inc. | 1911 Charlotte Dr., Charlotte, NC 28203 | 800-763-3332 | www.MedEdSeminars.net


Copyright 2016 MED-ED, Inc., All Rights Reserved

Compensation Gone a Wry


LV Dilation

Systemic
congestion/edema

Increased LV
Pressure

R heart failure

Increased LA &
pulmonary venous
pressure
Pulmonary
congestion &
edema

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Patient Symptoms-Chronic
Shortness of breath (SOB)
Dyspnea on exertion (DOE)
Activity intolerance
Fatigue/weakness
Lack of appetite
Nocturia
Swelling of feet, ankles, legs, or abdomen

MED-ED, Inc. | 1911 Charlotte Dr., Charlotte, NC 28203 | 800-763-3332 | www.MedEdSeminars.net


Copyright 2016 MED-ED, Inc., All Rights Reserved

Patient Symptoms- Acute


Severe/sudden shortness

Chest pain/fullness

of breath
Paroxysmal nocturnal
dyspnea
Orthopnea
Cough, possibly
productive with pink,
foamy sputum

Increased fatigue,

weakness
Nausea/vomiting
Abdominal distention
Rapid or irregular heart
beat
Sudden increase in
weight
Increased edema

Physical Findings

Edema (including sacral edema, and ascites)


Rales, pulmonary edema, tachypnea
Hypotension
Third heart sound S3- indicating fluid overload; S4
indicating stiff ventricle (as in HTN)
Jugular vein distention JVD indicating fluid overload
and right heart failure
Hepatojugular reflux- increase venous congestion
leading to hepatic congestion (due to increased preload)
Pale skin color/Cyanosis
Resting tachycardia or arrhythmias including
bradycardia

MED-ED, Inc. | 1911 Charlotte Dr., Charlotte, NC 28203 | 800-763-3332 | www.MedEdSeminars.net


Copyright 2016 MED-ED, Inc., All Rights Reserved

Pulmonary Edema

Life-threatening complication of CHF


LV failure
Pressure in pulmonary vessels > 18-25 mmHg
Fluid leaks from pulmonary capillaries into the

interstitial tissue and intra-alveolar spaces

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Signs and Symptoms


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Dyspnea
Orthopnea

Sputum:

Pink, frothy

Hypoxemia
Auscultation:

Crackles/rales

MED-ED, Inc. | 1911 Charlotte Dr., Charlotte, NC 28203 | 800-763-3332 | www.MedEdSeminars.net


Copyright 2016 MED-ED, Inc., All Rights Reserved

Systolic Dysfunction: Treatment


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Treatment is the same

as the treatment for


left-sided heart failure
Oxygen

May need non-invasive


positive-pressure
ventilation (NIPPV) or
mechanical ventilation

Decrease preload with

loop diuretics
(furosemide, etc)

Morphine or

nitroglycerin
vasodilate, decreasing
afterload
Morphine also

decreases anxiety
Dobutamine or
milrinone to improve
cardiac output

Left-Sided Heart Failure/Diastolic


Dysfunction
18
Normal EF
LV stiff, non-compliant
Inadequate LV filling
Increased diastolic filling pressures
Leads to elevated LA, pulmonary venous, & PCWP
Can result in right heart failure & pulmonary HTN if

untreated

MED-ED, Inc. | 1911 Charlotte Dr., Charlotte, NC 28203 | 800-763-3332 | www.MedEdSeminars.net


Copyright 2016 MED-ED, Inc., All Rights Reserved

Left Sided Diastolic Dysfunction


19

Diastolic Dysfunction: Treatment


20

Negative chronotropic medications to

decrease heart rate & increase diastolic


filling time & stroke volume
Beta

blockers (metoprolol, atenolol, etc)


Calcium channel blockers (verapamil, diltiazem)

MED-ED, Inc. | 1911 Charlotte Dr., Charlotte, NC 28203 | 800-763-3332 | www.MedEdSeminars.net


Copyright 2016 MED-ED, Inc., All Rights Reserved

10

Right Heart Failure


21

What Causes Right Heart Failure?


22

Pulmonary Disease
COPD,

Chronic Bronchitis

Essential Pulmonary HTN


PE
Isolated Right Coronary Ischemia

MED-ED, Inc. | 1911 Charlotte Dr., Charlotte, NC 28203 | 800-763-3332 | www.MedEdSeminars.net


Copyright 2016 MED-ED, Inc., All Rights Reserved

11

Signs and Symptoms


23

Hepatic congestion
JVD
Edema
Ascites
Liver engorgement
Increased cardiac pressures, CVP
Treatment- Low Na diet, fluid restrictions
Nesiritide promotes diuresis and vasodilation

Heart Failure Classification


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I: Symptoms with strong exertion


II: Symptoms with normal exertion
III: Symptoms with minimal exertion
IV: Symptoms occur at rest

MED-ED, Inc. | 1911 Charlotte Dr., Charlotte, NC 28203 | 800-763-3332 | www.MedEdSeminars.net


Copyright 2016 MED-ED, Inc., All Rights Reserved

12

Work-up
25

BNP: Prognostic indicator. Generally increases as

HF worsens
BMP, TSH, CBC, LFTs
CXR
EKG
Echo: assess LVEF & side/type of failureR or L,
systolic or diastolic
Stress test: treadmill or nuclear
May need cardiac catheterization

Goals of Care
26

Alleviate symptoms
Stabilize hemodynamics
Correct fluid volume overload
Prevent complications, i.e. arrhythmias

MED-ED, Inc. | 1911 Charlotte Dr., Charlotte, NC 28203 | 800-763-3332 | www.MedEdSeminars.net


Copyright 2016 MED-ED, Inc., All Rights Reserved

13

Neurohormonal Influences
27

HF is a vicious cycle
Flogging of the myocardium by norepinephrine
Vasopressin released, SIADH common
Continuous activation of RAA system

Pharmacologic Agents
28

NON-Decompensated Heart Failure


Beta Blocker (metroprolol, Coreg)
ACE Inhibitor or ARB
Spironolactone (Class 3 or 4 heart failure)
Aldosterone antagonist
Loop diuretics

MED-ED, Inc. | 1911 Charlotte Dr., Charlotte, NC 28203 | 800-763-3332 | www.MedEdSeminars.net


Copyright 2016 MED-ED, Inc., All Rights Reserved

14

Acute Decompensated Heart Failure


(ADHF)
29

Signs & symptoms of worsening failure &

fluid overload
May see:
JVD,

weight gain, oliguria


Peripheral edema
Cool, pale, cyanotic skin
Dyspnea, crackles on auscultation

ADHF: Treatment
30

Oxygen
If

pulmonary edema, may need NIPPV or


mechanical ventilation

Loop diuretics
Positive inotropes: dobutamine or milrinone
Increase

myocardial contractility
Decrease afterload
No role for -blockers in ADHF

MED-ED, Inc. | 1911 Charlotte Dr., Charlotte, NC 28203 | 800-763-3332 | www.MedEdSeminars.net


Copyright 2016 MED-ED, Inc., All Rights Reserved

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Cardiomyopathies

Dilated

HyperHyper
trophic

Progressive congestive L/R sided heart failure


Increased volume size, impaired EF%
Dysrhythmias, thromboembolism, or sudden cardiac arrest

Fatigue, mild dyspnea, progressive LV failure, atrial fibrilaltion


Hypertrophic changes with increased collagen in septum and ventricular wall
Small ventricular cavity, decreased volume, normal EF%

Right sided HF, tachycardia, periph. edema, ascites, liver enlargement


Restrictive filling, reduced diastolic volume, normal wall motion
Restrictive Dilated atria from increased LVEDP, mitral & tricuspid regurgitation

MED-ED, Inc. | 1911 Charlotte Dr., Charlotte, NC 28203 | 800-763-3332 | www.MedEdSeminars.net


Copyright 2016 MED-ED, Inc., All Rights Reserved

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