Congestive Heart Failure

I. Introduction
A. Epidemiology B. Etiology C. Definition of CHF

Epidemiology
GENERAL INCIDENCE RATE

CHF is present in 2 percent of persons age 40 to 59, more than 5 percent of persons age 60 to 69, and 10 percent of persons age 70 and older. Prevalence is at least 25 percent greater among the black population than among the white population. Prevalence at each age increased substantially between two periods surveyed nationally: 1976-80 and 1988-91 (American Heart Association)

WORLD HEALTH ORGANIZATION -More than 22 million people worldwide suffer from congestive heart failure. (WHO) INCIDENCE IN THE PHILIPPINES As of December 2010, Out of the 86,241,697 people in the Philippines, 1,521,912 have Congestive Heart Failure - CHF is the 6th leading cause of mortality in the Philippines, affecting males more often than females. (DOH.GOV.PH)

Etiology
Myocardial Infarction Cardiomyopathy/myocarditis Congenital heart disease Valvular heart defects Pericarditis/cardiac tamponade Systemic hypertension Chronic obstructive pulmonary disease Pulmonary embolism Anemia Thyrotoxicosis Metabolic/respiratory acidosis Blood volume excess/polycythemia Cardiac Dysrhytmias

Congestive Heart Failure

A state of circulatory congestion produced by myocardial dysfunction The ability of the ventricle to empty lessens, the stroke volume falls, residual volume increases. Heart failure is the inability of the heart to pump the amount of oxygenated blood necessary to affect venous return and to meet the metabolic requirements of the body.

Preload
The amount of blood presented to the ventricles just before systole. Blood volume - stretches cardiac muscle fibers Ventricular compliance the elasticity or amount of give when blood enters ventricle.
Ventricular hypertrophy = decreased ventricular compliance

II. Structural Organization

A. Anatomical Background B. Physiological Background Normal Abnormal

Anatomical Background

Anatomical Background

Heart Anatomy: Heart Wall Epicardium - the outer layer of the wall of the heart.

- the muscular middle layer of the wall of the heart. Endocardium - the inner layer of the heart.
Myocardium

Heart Anatomy: Chambers Atria - upper two chambers of the heart. Ventricles - lower two chambers of the heart. Heart Anatomy: Valves Heart valves - are flap-like structures that allow blood to flow in one direction. Below are the four valves of the heart: Aortic Valve - prevents the back flow of blood as it is pumped from the left ventricle to the aorta. Mitral Valve - prevents the back flow of blood as it is pumped from the left atrium to the left ventricle. Pulmonary Valve - prevents the back flow of blood as it is pumped from the right ventricle to the pulmonary artery. Tricuspid Valve - prevents the back flow of blood as it is pumped from the right atrium to the right ventricle.

Physiological Background: Normal

The cardiac cycle is the sequence of events that occurs in one complete beat of the heart. The pumping phase of the cycle, also known as systole., occurs when heart muscle contracts. The filling phase, which is known as diastole. occurs when heart muscle relaxes. At the beginning of the cardiac cycle, both atria and ventricles are in diastole. During this time, all the chambers of the heart are relaxed and receive blood. The atrioventricular valves are open. Atrial systole, follows this phase. During atrial systole, the left and right atria contract at the same time and push blood into the left and right ventricles, respectively. The next phase is ventricular systole. During ventricular systole, the left and right ventricles contract at the same time and pump blood into the aorta and pulmonary trunk, respectively. In ventricular systole, the atria are relaxed and receive blood. The atrioventricular valves close immediately after ventricular systole begins to stop blood going back into the atria. However, the semilunar valves are open during this phase to allow the blood to flow into the aorta and pulmonary trunk. Following this phase, the ventricles relax that is ventricular diastole occurs. The semilunar valves close to stop the blood from flowing back into the ventricles from the aorta and pulmonary trunk. The atria and ventricles once again are in diastole together and the cycle begins again.

Physiological Background: Abnormal

Compensatory Mechanisms:
Ventricular dilation Muscle fibers stretch.. Increase contractile force Increases cardiac output / blood pressure Eventually inadequate overstretched/overstrained Ventricular hypertrophy Increase in muscle mass Hypertrophic muscle has POOR contractility Increased SNS stimulation First mechanism triggered LEAST EFFECTIVE mechanism Increased workload causes increased demand for O2

Chronic Heart Failure : o Systolic failure

Chronic Heart Failure

Diastolic failure
Heart muscle that doesnt relax properly between beats. This is called diastolic heart failure.

III. Confirmatory Test

LABORATORY TEST
Chest x-ray -> this is very helpful in identifying the buildup of fluid in the lungs and also the heart that usually enlarges in CHF, and this may be visible on x-ray film.

LABORATORY TEST
Electrocardiogram (ECG) -> This painless test measure the electrical activity (rhythm) of the heart. It gives clues as to underlying cause of heart failure.

LABORATORY TEST
2-D Echocardiogram -> This is a type of ultrasound that shows the beating of the heart and the various cardiac structures. Useful in determining cause of heart failure and provides an accurate measurement of ejection fraction.

LABORATORY TEST
Stress test -> A treadmill or medication (nonwalking) is used to help evaluate the cause of heart failure regarding coronary artery disease. (combined with nuclear imaging or echocardiography to improve accuracy.)

DIAGNOSTIC TEST
Cardiac Catheterization -> allows the arteries to the heart to be visualized with angiography.

DIAGNOSTIC TEST
ECG & Chest x-ray -> useful diagnostic test that detect previous heart attacks, heart enlargement, and fluid in & around the lungs.

DIAGNOSTIC TEST
Biopsy of the heart tissue -> recommended to diagnose specific diseases. (through the use of heart catheter that is inserted into the vein.

IV. Signs and Symptoms

Left-sided Congestive Heart Failure Signs of pulmonary congestion Dyspnea Tachypnea Crackles in the lungs Dry, hacking cough Paroxysmal nocturnal dyspnea Increased BP (from fluid volume excess) Right-sided Congestive Heart Failure Dependent edema (legs and sacrum) Jugular vein distention Abdominal distention Hepatomegaly Splenomegaly Anorexia and nausea Nocturnal diuresis Swelling of the fingers and hands Increased BP (from fluid volume excess)

IV. Signs and Symptoms

Left-sided Congestive Heart Failure Signs of pulmonary congestion Dyspnea Tachypnea Crackles in the lungs Dry, hacking cough Paroxysmal nocturnal dyspnea Increased BP (from fluid volume excess) Right-sided Congestive Heart Failure Dependent edema (legs and sacrum) Jugular vein distention Abdominal distention Hepatomegaly Splenomegaly Anorexia and nausea Nocturnal diuresis Swelling of the fingers and hands Increased BP (from fluid volume excess)

IV. Signs and Symptoms

Left-sided Congestive Heart Failure Signs of pulmonary congestion Dyspnea Tachypnea Crackles in the lungs Dry, hacking cough Paroxysmal nocturnal dyspnea Increased BP (from fluid volume excess) Right-sided Congestive Heart Failure Dependent edema (legs and sacrum) Jugular vein distention Abdominal distention Hepatomegaly Splenomegaly Anorexia and nausea Nocturnal diuresis Swelling of the fingers and hands Increased BP (from fluid volume excess)

V. Management/Treatment
Drug Categories for Treating HF
Standard TX: ACE inhibitors ( Captopril ) Beta Blockers ( Metoprolol) Cardiac Glycosides (Digoxin) Diuretics (Furosemide) Vasodilator drugs (Nitroprusside) See Brunner pgs 952-956

NYHA Heart Classification System

Class I Mild No limitation of activity No symptoms with normal activity Class II Mild Slight limitation of activity Comfortable with rest or mild exertion Class III Moderate Marked limitation of activity Comfortable only at rest Class IV Severe Complete rest is required; confined to bed or chair Any activity brings discomfort; symptoms occur at rest NYHA = New York Heart Association

ACC/AHA Staging System

Stage A No structural abnormality of the heart No symptoms of HF Stage B Structural abnormality of the heart No symptoms of HF Stage C Structural abnormality of the heart Some symptoms of HF Stage D Structural abnormality of the heart Symptoms of HF that do not respond well to normal treatment

AHA = American Heart Association ACC = American College of Cardiology

Resources
Lehne, R.A., Pharmacology For Nursing Care, 7th Edition, 2010, Elsevier Brunner, L. S., Suddarth, D. S., & Smeltzer, S. C. (2008). Brunner & Suddarth's textbook of medical-surgical nursing (11th ed.). Philadelphia: Lippincott Williams & Wilkins.