Transcript Congestive Heart Failure - Kelly Strine, MS, RN, FNP

Congestive Heart Failure
Jennifer Smith & Kelly Strine
Congestive Heart Failure
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Results from any structural or functional disorder that impairs the ability of
the ventricle to contract and effectively pump blood to meet the metabolic
needs of the tissue.
Affects the cardiovascular and pulmonary system
Associated with a hypercoagulable state
Increased trend of heart failure with preserved ejections fraction of 50% or
higher
Classified as “diastolic”(preserved ejection fraction) or “systolic” (reduced
ejection fraction
Patients may have both diastolic and systolic dysfunction
(Dunphy, Winland-Brown, Porter & Thomas, 2011)
NYHA Functional Classifications
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Class I: No limitation of physical activity; ordinary physical activity does not
cause undue fatigue, palpitations, or dyspnea
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Class II: Slight limitation of physical activity; comfortable at rest, but ordinary
activity results in fatigue, palpitations, or dyspnea
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Class III: Marked limitation of physical activity; comfortable at rest, but less
than ordinary activity results in fatigue, palpitations, or dyspnea
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Class IV: Unable to carry on any physical activity without discomfort;
symptoms present at rest if any activity is undertaken, discomfort is
increased
(McMurray, 2010)
Pathophysiology
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Myocardial injury leads to pathologic remodeling of left ventricle affecting its
size, shape, and function impairing its contraction
Neurohumoral imbalance, increased cytokines, and inflammatory changes
Apoptosis results in energy starvation and oxidative stress
Tissue hypoperfusion
Elevated levels of norepinephrine, angiotensin II, aldosterone, endothelin,
vasopressin, and cytokines
Inadequate delivery of oxygen
Results in pulmonary and systemic venous hypertension
Progressively worse if left untreated
Exacerbated by additional injury (e.g. myocardial infarction)
Sympathetic Stimulation- increased heart rate
Activation of renin-angiotensin-aldosterone system
Hypertrophy
(McMurray, 2010)
Etiology
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Coronary Heart Disease
Myocardioal Infaction
Hypertension
Diabetes
Cardiomyopathy
Valvular Disease
Arrhythmias
Congenital Heart Defects
Thyroid Disorders
Alcohol/Cocaine or other Drug use
(Dunphy, Winland-Brown, Porter & Thomas, 2011)
Pathophysiology
• Systolic Dysfunction
 Forward Heart Failure
• Diastolic Dysfunction
 Backward Heart Failure
• Left Sided Heart Failure
• Right Sided Heart Failure
(Dunphy, Winland-Brown, Porter & Thomas, 2011)
Incidence
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Affects approximately 5 million in U.S.
Over 550,000 diagnosed each year
Primary reason for 12-15 million office visits
6.5 million hospital days per year
80% of hospitalized patients >65
<1% in those less than 50
Most common Medicare diagnoses
More common in males
African Americans have higher risk
(Hunt et al, 2011)
Screening
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Evaluate potential risk factors with thorough history
Assess patient’s ability to perform ADL’s
Assess fluid volume status, orthostatic BP, BMI
Screen for cardiac risk factors
Initial laboratory evaluation
Twelve lead electrocardiogram
Echocardiogram
Coronary arteriography in patients presenting with HF
and angina
• Stress testing
Risk Factors
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Coronary Artery Disease
Myocardial Infarction
Hypertension
Valvular Heart Disease
Diabetes Mellitus
Cardio toxic Medications
Genetics (Familial cardiomyopathy)
Mediastinal Radiation
Obesity/Metabolic Syndrome
Rheumatic Heart Disease
Obstructive Sleep Apnea
HIV
Illicit drugs and ETOH
Congenital Heart Defect
Kidney disease
(Hunt et al, 2011)
Subjective Clinical Findings
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Dyspnea at rest worse with exertion
Fatigue
Generalized weakness
Exercise Intolerance
Fluid Retention, Edema
Abdominal bloating
Nocturnal nonproductive cough
Orthopnea
Paroxysmal nocturnal dyspnea
Wheezing at night with no history of asthma or infection
Anorexia or dull pain right upper quadrant
(Dunphy, Winland-Brown, Porter & Thomas, 2011)
Left vs Right
(Zerwekh, Claborn & Miller, 2007)
Physical Findings
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Rales and sometimes wheezing
Peripheral edema
Cool extremities
Ascites
Elevated JVD
S3 gallop
Pre-sacral edema
Scrotal Edema
Hepatomegaly
Hypoxemia
Pleural effusion and tenderness
Worsening mitral or tricuspid regurgitation
May have an arrhythmia
Altered mental status
(Dunphy, Winland-Brown, Porter & Thomas, 2011)
Clinical Findings
Congestive Heart Disease, N.D.
Differential Diagnosis
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Pulmonary embolism
Exertional asthma
Cardiac ischemia
COPD
Constrictive pericarditis
Nephrotic syndrome
Cirrhosis
Venous occlusive disease
Anemia
Sepsis
Hyperthyroidism
Peripheral edema
(Domino, 2011)
Social Considerations
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Alcohol consumption should be no more than 1 glass of wine per day.
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Dietary sodium restriction of 2 grams per day or lower is recommended.
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Regular exercise should be encouraged as it improves functional status and
decreases symptoms. Cardiac rehab is available to assist with this.
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Abstaining from cigarette smoking and avoidance of second hand smoke is
recommended.
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Immunizations from influenza and pneumococcal vaccine can reduce risk of
respiratory infection.
Laboratory Tests
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Complete blood count
Urinalysis
CMP or serum electrolytes to include calcium, magnesium, blood urea
nitrogen, serum creatinine, fasting blood glucose
GFR
Lipid panel
Liver Function Tests
Thyroid Stimulating Hormone
Serum natriuretic peptide (BNP)
HGA1C
Laboratory tests for rheumatologic diseases such as amyloidosis and
pheochromocytoma
Diagnostics
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Chest x-ray (PA and lateral)
Two-dimensional echocardiogram is most useful test to determine ejection
fraction and valvular abnormalities
Twelve-lead electrocardiogram
Maximal Exercise Stress Testing
Nuclear imaging for estimation of ventricle size, perfusion, and systolic
function
Coronary arteriography with angina or ischemia
Endometrial biopsy
Holter monitoring
Electrophysiology studies
Cardiac MRI or transesophageal Doppler 2D echocardiography
Peak flow or spirometry
Management
• Goal of therapy is to decrease symptoms, hospitalizations, and
prevent premature death
• Reduce pulmonary venous pressure and congestion
• Identify and treat the cause of the heart failure
• Recognize and treat underlying heart disease or comorbidities such
as diabetes hypertension or hyperlipidemia
• Adjust diuretics therapy to maintain dry weight
• Rate control for atrial fibrillation
• Eliminate tachycardia
• Treat hypertension
• Prevent thrombus formation
(Dunphy, Winland-Brown, Porter & Thomas, 2011)
Non-Pharmacological
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Fluid Restrictions < 2L/day
Low Sodium Diet < 2 g/day
Daily weights after voiding in the morning
Exercise program and rehabilitation program
Lifestyle modifications: smoking cessation, alcohol limitations, illicit drug use
Coronary Revascularization
Valve Replacement
Cardiac Transplant
Resynchronization
Implantable cardioverter-defibrillator (ICD)
Biventricular Pacing
Treat anemia
(McMurray, 2010)
Pharmacological
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Diuretics including loop diuretics, thiazides, potassium-sparing
Angiotensin-converting enzyme (ACE) inhibitors (1st line with diuretics)
Angiotensin-II receptor antagonist- Losartan, Valsartan
Aldosterone antagonist- (Spironolactone)
Hydralazine in combination with nitrate
Beta-blockers (1st line therapy in systolic dysfunction)
Digoxin
Calcium channel blocker (Amlodipine)
Vasodilators-nitrates
Anticoagulants
Antiplatelets
Inotropic agents (dobutamine, milrinone)
Morphine for acute treatment of associated pulmonary edema
NSAIDS contraindicated
(Verdecchia, et al., 2009)
Complications
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Declining functional capacity
Electrolyte disturbances
Acute pulmonary edema
Frequent hospitalizations
Atrial fibrillation
Left ventricular thrombus
Cerebral embolism
Sudden death from arrhythmia
Renal failure
Death
(Owan et al, 2006)
Follow Up
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Cardiologist Referral is recommend at the onset of symptoms.
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The Joint Commission has established mandated core measures for
hospitalized patients.
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Assessment of left ventricular function with Ejection Fraction (EF) noted
If EF less than 40% patient must be placed on an ACEI or ARB
Counseling on smoking cessation must occur
Discharge education must include activity level, diet, discharge medications, follw0up
appointments, weight monitoring, what to do if symptoms worsen
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Upon discharge home, it is recommended that patients have intensive
home-care surveillance with home care nurses to decrease the need for
hospitalization.
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Patients should be seen by their provider within 1 week of discharge and at
least every 3 months thereafter.
Consultation/Referral
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Multidisciplinary Team Approach
Refer patients with suspected heart failure and a BNP between 100 and 400
pg/ml to have transthoracic Doppler 2D echocardiography and to see a
cardiologist within 2 weeks
Seek specialist advise before offering second-line treatment to patients with
HF due to left ventricular systolic function
Pulmonologist
Cardiac Rehab Program
Support Groups
Dietician
Home Health
Transplant
Hospice
References
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Aurigemma, G.P. & Gaasch, W.H. (2004, September). Diastolic heart failure. The New England
Journal of Medicine. 351(11), 1097-1105.
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Congestive heart disease. (n.d.) Miller-Keane Encyclopedia and Dictionary of Medicine, Nursing,
and Allied Health, Seventh Edition. (2003). Retrieved January 25 2014 from http://medicaldictionary.thefreedictionary.com/Congestive+heart+disease
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Domino, F. (2011). Griffith’s 5 Minute Clinical Consult. 19th Ed. Lippincott Williams & Wilkins.
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Dunphy, L. M., Winland-Brown, J. E., Porter, B. O., & Thomas, D. J. (2011). Primary care: The art
and science of advanced practice nursing. (3 ed.). Philadelphia, PA: F.A. Davis Company.
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Hunt, S.A., Abraham, W.T., Chin, M.H., Feldman, A.M., Francis, G.S., Ganiats, T.G., Jessup, M.,
Konstam, M.A., ACC/AHA 2005 Guideline update for the diagnosis and treatment of heart failure
adult: A report of the American College of Cardiology/American Heart Association Task Force on
practice guidelines: Developed in collaboration with the American College of Chest Physician and
the
International Society for heart and lung transplantation. Circulation, 2005, 112, 154-235.
doi://10.1161/CIRCULATIONAHA.105.167586.
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Homma, S., Thompson, J.L., Pullicino, P.M., Levin, B., Freudenberger, R.S., Teerlink, J.R.,
Ammon, S
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Graham, S., Sacco, R.L., Mann, D.L., Mohr, J.P., Massie, B.M., Labovitz, A.J., Anker, S.D., Lok,
D.J., Ponikowski, P., Estol, C.J., Lip, G., Di Tullio, M.R., Sanford, A.R., Mejia, V., Gabriel, A.P.,
Valle, M.L., & Buchsbaum, R. (2012, May). Warfarin and aspirin in patients with heart failure and
sinus rhythm. The New England Journal of Medicine. 366(20), 1859-1869.
McMurray, J.V. (2010). Systolic heart failure. The New England Journal of Medicine. 362(3), 228-38.
References
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Owan, T.E., Hodge, D.O., Herges, R.M., Jacobsen, S.J., Roger, V.L., & Redfield, M.M. (2006,
June). Trends in prevalence and outcome of heart failure with preserved ejection fraction. The
New England Journal of Medicine. 355(3). 251-259.
Verdecchia, P., Angeli, F., Cavallini, C., Gattobigio, R., Gentile, G., Staessen, J. A., et al. (2009).
Blood pressure reduction and renin-angiotensin system inhibition for prevention of congestive
heart failure: A meta-analysis. European Heart Journal, 679-688.
Zerwekh, J., Claborn, J. C., & Miller, C. J. (2007). Memory notebook of nursing. (4 ed., Vol. 2).
New York, NY: Nursing Education Consultants.
Questions
1. The treatment goals for HF include:
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Improve symptoms
Optimize fluid volume status
Restore normal oxygenation
Identify and treat etiology
All the above
2. The practitioner should pay particular attention to the presence of which of the
following findings that suggest HF on the physical exam:
A. Elevated JVD
B. Peripheral edema
C. Third heart beat
D. Diminished lung sounds
E. Both A and C
F. All of the above
Questions
3. Patients that have heart failure with an ejection fraction >50% are classified as:
A. Systolic heart failure
B. Diastolic heart failure
4. How would a patient that has dyspnea on less-than ordinary exertion would be
classified according to the NYHA
A. NYHA Class I
B. NYHA Class II
C. NYHA Class III
D. NYHA Class IV
5. The most useful diagnostic test to evaluate patients with heart failure is:
A. CXR
B. Stress Test
C. 2-D echocardiogram
Questions
6. The following would be a contraindication in ACEI except:
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Angioedema
Hypernatremia
Serum creatinine > 3.0
Hyperkalemia >5.5
7. Which medication classification can be substituted for ACEI:
A. Beta-blockers
B. Vasodilator
C. Angiotensin II Receptor Blocker
D. Aldosterone antagonists
8. Patients taking aldosterone antagonists require frequent monitoring for:
A. Increased edema
B. Worsening HF
C. Hyperkalemia
D. Hypotension
Questions
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Patients taking diuretics should be monitored frequently for:
Renal dysfunction
Electrolyte abnormalities
Symptomatic hypotension
Gout
All of the above
10. Diuretics should be administered at doses high enough to:
A. Allow the patient to eat and drink whatever they want
B. Improve signs and symptoms of congestion
C. Reduce blood pressure enough that a ACEI will not be required