CARDIOLOGY

dr M Arman Nasution SpPD

Congestive Heart Failure

Gagal jantung (Heart

Failure)

Classification

Generally classified as the following:

Left vs right failure
Systolic vs diastolic dysfunction
Backward vs forward failure
Low output vs high output cardiac failure
The degree of functional impairment

conferred by the abnormality (as in the

NYHA functional classification)

New York Heart Association Functional Classification

Class I: No limitation experienced in

any activity and no symptoms from

ordinary activities.

Class II: Mild limitation of activity and

comfortable at rest or mild exertion

Class III: Marked limitation of any

activity and comfortable only at rest

Class IV: Any physical activity brings

discomfort and symptoms appear at

rest

Signs and symptoms

Left Sided Failure- Symptoms

Backward Failure: Respiratory
compromise

Dyspnea on exertion
Dyspnea at rest (severe)
Orthopnea (on lying flat)
Paroxysmal nocturnal dyspnea

(cardiac asthma)
Nocturnal cough

Left Sided Failure- Symptoms

Forward Failure: Poor systemic
circulation

Dizziness
Confusion
Cool extremities at rest
Easy fatigueability
Exercise intolerance

Right Sided Failure- Symptoms

Backward Failure: Congestion of systemic capillaries
Excess fluid accumulation in the body
Peripheral edema/ anasarca
Dependent edema (foot, ankle, sacral)
Nocturia
Ascites
Liver congestion (hepatomegaly, jaundice and coagulopathy)

Forward Failure: Hypotension

Left Sided Failure- Signs

Non specific signs of respiratory distress:
Tachypnea
Increased work of breathing
Decreased vital capacity
Development of pulmonary edema:
Rales/Crackles initially at base, throughout the lung
when severe
Extremely severe pulmonary edema:
Cyanosis (severe hypoxemia)

Left Sided Failure- Signs

Laterally displaced apex beat (heart enlargement)
S3 gallop rhythm (increased blood flow/ increased

intra cardiac pressure)

Heart murmurs- indicative of valvular diseases (Cause

or result of heart failure)

Right
Sided
FailureSigns

Peripheral pitting edema

Hepatomegaly
Jugular venous pulse accentuated
by hepatojugular reflux (marker
of fluid status)
Positive abdominojugular test
Parasternal heave (increased RV
pressure)
Ascites (late onset)

Pitting Edema of
Ankle

Ascites

Pulmonary Edema

Cardiomegaly

Biventricular
Failure
Pleural effusions- more common in
biventricular failures.

Unilateral failures cause right sided

effusions (large area of right lung)

Signs:
Dullness of lung fields
Reduced breath sounds at lung bases

Other signs
Cardiomegaly
Weight loss
Tachycardia (>120 bpm)
Pink frothy sputum (severe)

Common symptoms of
CCF (overview)

Measuring elevated JVP

THE HEART
Normal
Pathology
Heart Failure: L, R
Heart Disease
Congenital: LR shunts, RL shunts, Obstructive
Ischemic: Angina, Infarction, Chronic Ischemia, Sudden
Death
Hypertensive: Left sided, Right sided
Valvular: AS, MVP, Rheumatic, Infective, Non-Infective,
Carcinoid, Artificial Valves
Cardiomyopathy: Dilated, Hypertrophic, Restrictive,
Myocarditis, Other
Pericardium: Effusions, Pericarditis
Tumors: Primary, Effects of Other Primaries
Transplants

NORMAL Features
6000 L/day
250-300 grams
40% of all deaths (2x cancer)
Wall thickness ~ pressure
(i.e., a wall is only as thick as it has to

be)
LV=1.5 cm
RV= 0.5 cm
Atria =.2 cm

Systole/Diastole
Starlings Law

TERMS
CARDIOMEGALY
DILATATION, any chamber, or

all
HYPERTROPHY, and chamber,
or all

S.A. NodeAV NodeBundle of HIS L. Bundle, R.

Bundle

Anterio
r
Lateral
Posteri
or
Septal

VALVES
AV:
TRICUSPID

13 cm

MITRAL

11 cm

SEMILUNAR:
PULMONIC
AORTIC

6 cm

8 cm

CARDIAC AGING
Chambers
Increased left atrial
Decreased
ventricular cavity
cavity left
size
size
Sigmoid-shaped ventricular
septum

Epicardial
Coronary
Tortuosity
Arteries

Increased cross-sectional
luminal
area
Calcific
deposits
Atherosclerotic plaque

Myocardium
Valves

Increased mass

Aortic valve calcific

Mitral valve annular calcific deposits
deposits

Brown atrophy

Fibrous thickening of leaflets

Buckling of mitral leaflets toward the

Increased subepicardial
fat
Lipofuscin deposition

Basophilic degeneration
(glyc.)deposits
Amyloid

CARDIAC AGING
Aorta
Dilated ascending aorta with rightward shift
Elongated (tortuous) thoracic aorta
Sinotubular junction calcific deposits
Elastic fragmentation and collagen
accumulation
Atherosclerotic plaque

BROWN
ATROPHY, HEART

LIPOFUCSIN

Pathologic Pump
Possibilities
Primary myocardial failure (MYOPATHY)
Obstruction to flow (VALVE)
Regurgitant flow (VALVE)
Conduction disorders (CONDUCTION

SYSTEM)
Failure to contain blood (WALL
INTEGRITY)

CHF

DEFINITION
TRIAD

1) TACHYCARDIA
2) DYSPNEA
3) EDEMA
FAILURE of Frank Starling mechanism
HUMORAL FACTORS
Catecholamines (nor-epinephrine)
ReninAngiotensionAldosterone
Atrial Natriuretic Polypeptide (ANP)
HYPERTROPHY and DILATATION

HYPERTROPHY
PRESSURE OVERLOAD (CONCENTRIC)
VOLUME OVERLOAD (CHF)
LVH, RVH, atrial, etc.
2X normal weight ischemia
3X normal weight HTN
>3X normal weightMYOPATHY, aortic

regurgitation

CHF: Autopsy
Findings
Cardiomegaly
Chamber Dilatation
Hypertrophy of myocardial fibers,

BOXCAR nuclei

Left Sided Failure

Low output vs. congestion
Lungs
pulmonary congestion and edema
heart failure cells

Kidneys
pre-renal azotemia
salt and fluid retention
renin-aldosterone activation
natriuretic peptides

Brain: Irritability, decreased

attention, stuporcoma

Left Heart Failure

Symptoms
Dyspnea
on exertion
at rest
Orthopnea
redistribution of peripheral edema fluid
graded by number of pillows needed
Paroxysmal Nocturnal Dyspnea (PND)

LEFT Heart Failure

Dyspnea

Orthopnea
PND (Paroxysmal Nocturnal
Dyspnea)
Blood tinged sputum
Cyanosis
Elevated pulmonary
WEDGE pressure (PCWP)
(nl = 2-15 mm Hg)

Right Sided Heart

Failure
Etiology
left heart failure
cor pulmonale

Symptoms and signs

Liver and spleen
passive congestion (nutmeg liver)
congestive spleenomegaly
ascites
Kidneys
Pleura/Pericardium
pleural and pericardial effusions
transudates

Peripheral tissues

RIGHT Heart
Failure

FATIGUE
Dependent edema
JVD
Hepatomegaly (congestion)
ASCITES, PLEURAL EFFUSION
GI
Cyanosis
Increased peripheral venous
pressure (CVP) (nl = 2-6 mm

Hg)

HEART DISEASE
CONGENITAL

(CHD)
ISCHEMIC (IHD)
HYPERTENSIVE (HHD)
VALVULAR (VHD)
MYOPATHIC (MHD)

CONGENITAL HEART
DEFECTS

Faulty embryogenesis (week 3-

8)
Usually MONO-morphic (i.e.,
SINGLE lesion) (ASD, VSD, hypoRV, hypo-LV)
May not be evident until adult
life (Coarctation, ASD)
Overall incidence 1% of USA
births

Malformation

Incidence per Million

Live Births

Ventricular septal
Atrial septal defect

4482

42

1043

10

836

defect

Pulmonary stenosis
Patent

ductus arteriosus

Tetralogy of Fallot
Coarctation of aorta

Atrioventricular septal
Aortic stenosis

defect

Transposition of great arteries

Truncus arteriosus
Total anomalous pulmonary venous
connection
Tricuspid atresia

781
577
492
396
388
388
136
120

GENETICS
Gene abnormalities in only 10% of CHD
Trisomies

21, 13, 15, 18, XO

Mutations of genes which encode for

transcription factorsTBX5ASD,VSD
NKX2.5ASD
Region of chromosome 22 important in
heart development, 22q11.2
deletionconotruncus, branchial arch,
face

CARDIOVASCULAR SYSTEM
Review of Anatomy & Physiology
Assessment : History and Physical Assessment

Diagnostics
Planning

REVIEW OF ANATOMY AND

PHYSIOLOGY- Heart
Structures
Blood Supply LCA, RCA, veins
Conductive System Sino-atrial node

node
Bundle of His
Purkinje fibers

AV
Bundle branch

HEART
LUNGS

RA
RV
SYSTEMIC
SYSTEMIC
SYSTEMIC
CIRCULATION
CIRCULATION
CIRCULATION

LA
LV

CONDUCTION PATHWAY
- SA NODE

RA

LA

AV NODE-

PURKINJE

RVBUNDLE
BRANCH

BUNDLE OF HIS

LV
PURKINJ
E

REVIEW OF ANATOMY AND

PHYSIOLOGY- Heart
Nervous System Control
SYMPATHETIC
PARASYMPATHETIC

REVIEW OF ANATOMY AND

PHYSIOLOGY- Heart
Properties of the Heart:

All or None Principle

Rhythmicity
Excitability
Refractoriness
Conductivity
Automaticity
Extensibility

REVIEW OF ANATOMY AND

PHYSIOLOGY- Heart
STROKE VOLUME (SV) - amount of blood pumped
out with each contraction

HEART RATE (HR)

CARDIAC OUTPUT (CO) volume of blood pumped
out per minute

=SV x HR
PRELOAD
AFTERLOAD

REVIEW OF ANATOMY AND

PHYSIOLOGY Blood Vessels
Arteries
Microcirculation
Veins
Flow Regulation
Layers of the Blood
Pressure gradient
Vessels:
Flow resistance
Role of Blood vessels Intima
Media
Adventitia

REVIEW OF ANATOMY AND

PHYSIOLOGY
CIRCULATION
SYSTEMIC
PULMONARY
PORTAL

PULMONARY CIRCULATION
LUNGS

RA
RV
SYSTEMIC
SYSTEMIC
SYSTEMIC
CIRCULATION
CIRCULATION
CIRCULATION

LA
LV

SYSTEMIC CIRCULATION
LUNGS

RA
RV
SYSTEMIC
SYSTEMIC
SYSTEMIC
CIRCULATION
CIRCULATION
CIRCULATION

LA
LV

HISTORY AND PHYSICAL EXAM

Check for:
dyspnea,
jaundice,
edema,
hemoptysis,
fatigue,
syncope and

fainting,
cyanosis,

abdominal pain

and discomfort,
clubbing of
fingers, chest
pain,
palpitations

HISTORY AND PHYSICAL EXAM

Heart I P P A
aortic area,
pulmonic area,
tricuspid,
mitral

Heart Sounds
S1-

AV valve
closure
S2 semilunar v.
closure
S3 vent. Gallop
S4 atrial gallop
Murmurs
rubs

HISTORY AND PHYSICAL EXAM

Blood vessels
Inspection
color:pallor,

rubor, cyanosis
circulation of extremities
Palpation
edema,

pulses

Auscultation
bruit

Diagnostic Assessment
NonInvasive
ECG

Chest

Dynamic ECG Stress

Test

Treadmill

Vector

Cardiogram
Phonocardiogram
Echocardiogram

Xray

Radionuclide

Studies

Venography

UTZ

DOPPLER

Pletysmography

Diagnostic Assessment
Invasive
Cardiac

Catheterization

Arteriogram
Angiocardiogram
Venogram

Lymphogram

Bone

Marrow
Aspiration:
Sternum
iliac crest
tibia (infants)

Diagnostic Assessment
Blood and Urine

Studies
CBC
Hematocrit
Clotting time
PT
PTT
APTT
ESR

lipid profile
serum enzymes:

SGOT, SGPT, LDH,

CPK
VMA
Renin Test
Schillings Test

HEMODYNAMICS MONITORING
CVP n= 6 -12 cm water
Measures:
cardiac efficiency,

bld volume,
peripheral resistance,
right ventricular pressure

0-pt be at mid axillary line, 5 cm below the

sternum
dc ventilator with reading

= fluid overload, = hypovolemia

HEMODYNAMICS MONITORING
Pulmonary Artery and Pulmonary

Wedge Pressure

Swan Ganz catheter :

floated at the right heart,
measures left side of the heart

Intraarterial Blood Pressure :

Radial Artery,
Allens Test

TERMINOLOGIES
VENTILATION MOVEMENT OF AIR IN & OUT OF THE
LUNGS

RESPIRATION EXCHANGE OF GASES : EXTERNAL &

INTERNAL

EXTERNAL BET. ALVEOLI & PULMONARY CAPILLARIES

INTERNAL BET. SYSTEMIC CAPILLARIES

PERFUSION

AVAILABILITY & MOVEMENT OF CAPILLARY

BLOOD FOR EXCHANGE OF GASES

Planning for Health Promotion

Modification of High Risk Factors
Promotion of Circulation
Prevention of Infection
syphillis,
staph, strep,
german measles
Genetic counselling
Role of nutrition

Modification of High Risk

Factors
dyslipedemia
hypertension

stress

glucose

intolerance,

smoking

alcohol abuse

sedentary

caffeine

lifestyle

obesity

pollution

Planning for Health Maintenance &

Restoration
Basic Life Support
Advanced Life Support
Client With Cardiac Surgery:

Closed Heart surgery

Open Heart Surgery
Heart Transpant

Closed Heart surgery

valvutomy
mitral commisurotomy

Open Heart surgery

(CABG)

COMPLICATIONS :
DYSRHYTHMIAS
THROMBOSIS

PULMONARY
EMBOLISM

AND

CARDIOGENIC

BLEEDING
WOUND
RENAL

INFECTION

FAILURE

SHOCK ELECTROLYTE
IMBALANCE
POST-OP

PSYCHOSIS

HEART TRANSPLANT
CRITERIA
1.
2.
3.
4.
5.

End Stage of Disease

Freedom from Chronic Disease
Family Support
Age < 50 yo
No psychological problem

IMPORTANT
1. Immunosuppressant & Steroids 4 hrs prior
2. Donor-Recipient Compatibility size,
crossmatching
3. Donor Heart saline solution 4C up to 4 hrs

CARDIOVASCULAR DISTURBANCES
CORONARY / ISCHEMIC HEART DISEASE
Arteriosclerotic Heart Disease
Angina Pectoris
Coronary Insufficiency
Myocardial Infarction

CONGESTIVE HEART FAILURE

HYPERTENSION
PERIPHERAL VASCULAR DISEASE
DISORDERS OF THE BLOOD

ARTERIOSCLEROTIC HEART DISEASE

Plaque formation
formation and
and internal
internal thickening
thickening
Plaque
(intima)
(intima)
Fibrosis and
and calcification
calcification (media)
(media)
Fibrosis

Narrowing and
and constriction
constriction of
of coronary
coronary arterie
arterie
Narrowing
S/sx of
of ISCHEMIA
ISCHEMIA
S/sx

ANGINA PECTORIS
1.
2.
3.
4.
5.

STABLE
UNSTABLE
PRINZMETAL coronary artery spasm
NOCTURNAL
DECUBITUS

ISCHEMIA VS INFARCTION
ISCHEMIA

INFARCTION

PAIN

SUBSTERNAL
PRESSURE/
HEAVINESS
SQUEEZING

SUBSTERNAL
CONSTRICTIVE (+ SX
OF SHOCK)

DURATION

3-5 MIN

> 5 MIN

PRECIPITANTS

STRESS/ EXERTION

NO

REST
RELIEVED
NITROGLYCERINE

NOT RELIEVED

CARDIAC TISSUE
DAMAGE

PERMANENT

NO PERMANENT

ANGINA PECTORIS
DIAGNOSIS:

Nitro Test 0.4mg

NURSING GOALS:

1.

O2 to myocardium

2.

O2 demand

3. Prevent future episodes of angina

O2 to Myocardium:
Antiplatelets
Calcium Blockers
Beta blockers
Whisky/Brandy

Nitrates :

RAPID-ACTING :
Nitroglycerine
Nitrostat
AmylNitrate
LONG-ACTING:
ISDN,ISMN,
Nitroglycerine
ointment,
Transdermal,
IV

O2 Demand
Limit activities CBR
Moderate Exercise
Sedatives
Warmth

Prevent Future Episodes

DIET low calorie, low saturated fat
No tobacco
Stress Reduction (Anger Management)

Coronary Insufficiency
IMBALANCE BETWEEN :

OXYGEN SUPPLY
OXYGEN DEMAND

MYOCARDIAL INFARCTION
IRREVERSIBLE CARDIAC DAMAGE FROM OCCLUSION OF 1 OR
MORE CORONARY ARTERY

REVIEW OF ANATOMY AND PHYSIOLOGY

E.C.G.
Recent M.I. ST elevation (injury)
T wave inversion (ischemia)
Previous M.I. Q wave (necrosis / old infarct)

BLOOD STUDIES
Troponin T & I
LDH
CPK MB

Q
S

E.C.G.

ST SEGMENT
ELEVATION

S
P

E.C.G.

INVERTED
T - WAVE

T
P

Q
S

E.C.G.

Q wave

Q
P

T
S

E.C.G.

MYOCARDIAL INFARCTION
NURSING CARE
1. Pain relief
Morphine ( +
preload & afterload)
Demerol causes vomiting

2. Oxygen
3. Inotropics
4. Beta Blockers
5. Antiarrhythmics

6. No ice or very hot

drinks
7. Anticoagulants
8. ECG and CVP
monitoring
9. Laxatives Lactulose
10. PTCA
11. Thrombolytic
Therapy
BEFORE CELLULAR

CARDIAC ARRHYTHMIA
Review Conduction Pathway

Review the Basics of Normal ECG

CONDUCTION PATHWAY
- SA NODE

RA

LA

AV NODE-

PURKINJE

RVBUNDLE
BRANCH

BUNDLE OF HIS

LV
PURKINJ
E

Q
S

E.C.G.

CARDIAC ARRHYTHMIA
Sinus Tachycardia P wave precede each QRS
>100 bpm
Sinus Bradycardia P wave precede each QRS
<60 bpm
Atrial Fibrillation: P wave = f waves; QRS =
normal

Q
S

E.C.G.

CONDUCTION PATHWAY
- SA NODE

RA

LA

AV NODE-

PURKINJE

RVBUNDLE
BRANCH

BUNDLE OF HIS

LV
PURKINJ
E

CARDIAC ARRHYTHMIA
Premature Ventricular Contraction: P wave
normal: early QRS
Ventricular Tachycardia : 3 or more PVCs
Asystole no cardiac activity

Q
S

E.C.G.

CONDUCTION PATHWAY
- SA NODE

RA

LA

AV NODE-

PURKINJE

RVBUNDLE
BRANCH

BUNDLE OF HIS

LV
PURKINJ
E

CARDIAC ARRHYTHMIA
Nursing Management
Oxygen
Complete Bed Rest
Cardioversion/ defibrillation
Administer antiarrhythmics as prescribed:
Atropine
Beta blocker- propanolol
Lidocaine
Epinephrine

CONGESTIVE
HEART
FAILURE
Backward Failure
Forward Failure
Review of Anatomy and Physiology
Left-Sided
Right Sided
Hypermetabolic Failure
Clinical Manifestations according to:
Tissue Anoxia
Pulmonary Hypertension
Systemic congestion

C.H.F.
LUNGS
LUNGS

RA
RV
SYSTEMIC
SYSTEMIC
SYSTEMIC
CIRCULATION
CIRCULATION
CIRCULATION

LA
LVLV

CONGESTIVE HEART FAILURE

Review of Anatomy and Physiology
Backward Failure
Forward Failure
Left-Sided
Right Sided
Hypermetabolic Failure
Clinical Manifestations according to:
Tissue Anoxia
Pulmonary Hypertension
Systemic congestion

CONGESTIVE HEART FAILURE

Diagnostics
Nursing Management
Goals :
1.
CARDIAC LOAD

2.

REST AND SEDATION

CARDIAC CONTRACTILITY

CHRONOTROPICS DIGITALIS
Increase in force of contraction
monitor serum K,
C/I if HR </= 60 bpm,
DIGITALIS TOXICITY

CONGESTIVE HEART FAILURE

3. SODIUM REABSORPTION AND FLUID

RETENTION

-DIURETICS ( Thiazide, Loop, K-sparing)

-measure UO
-weigh patient
-watch for s/sx of electrolyte imbalance
-DIET : Sodium Restricted (0.5gm/day)

CONGESTIVE HEART FAILURE

4. PREVENTION OF COMPLICATIONS:
Intractable HF
Pulmonary edema
Pulmonary Infarction
Myocardial Infarction
Digitalis Toxicity
Cardiac Arrhythmia
Pneumonia

PULMONARY EDEMA
Emergency!
Fluid into the alveoli, bronchi & bronchioles

S/SX:
of CHF
Dyspnea
Cough with pink frothy sputum

PULMONARY EDEMA
MANAGEMENT:
Oxygenation
Assist in Intubation
Rotating tourniquet
Phlebotomy
CVP monitoring

HYPERTENSION
CATEGORY

SBP mmHg

DBP mmHg

Normal

<120

and <180

PreHPN

120-139

or

HPN, Stage 1

140-159

or 90-99

HPN, Stage 2

>=160

or >=100

80-89

HYPERTENSION
Assess for Major CVD Risk Factors
Assess for Identifiable Causes of

Hypertension:
Sleep apnea
Drug-Induced related
Chronic Kidney Disease
Primary Aldosteronism
Renovascular Disease
Cushings Syndrome/steroid Therapy
Pheochromocytoma
Coarctation of the Aorta

Terima kasih
dr M Arman Nasution SpPD