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Heart Failure: Cardiac Output is insufficient to meet the body's…
Heart Failure: Cardiac Output is insufficient to meet the body's metabolic demands
Epidemiology
Adults living with HF increased from 5.7 to 6.5 million from 2009 - 2012.
newer medications & advanced technologies to increase survival rates
Survival rate <5 years for half of patients diagnosed with HF
Cost per year: $30.7 billion
NYHA Classification
1: Patient with asymptomatic HF
2: Patients with HF symptoms with significant exertion
3: Patients with HF symptoms with minor exertion
4: Patients with HF symptoms at rest
ACC/AHA Staging Criteria
A: Patients at risk for developing left ventricular dysfunction
B: Patients with left ventricular dysfunction who have not developed symptoms
C: Patients with left ventricular dysfunction with symptoms
D: Patient with refractory end-stage HF
Pathophysiology
Results from the hearts inability to pump adequate amounts of blood to meet the oxygen demands of peripheral tissues.
dysfunctional ventricle that is unable to pump an adequate amount of blood (systolic dysfunction)
decreased cardiac output
hypoperfusion of end organs
neurohormonal response from kidneys and adrenals
release vasoactive substances & cytokines
Stimulates the renin-angiotensin aldosterone system to increase blood pressure
net result is hypertrophy of LV and remodeling of the heart
decreased pressure detected by baroreceptors in arterial vessels
stimulate the sympathetic nervous system constrict the arteries to raise the BP
net result is hypertrophy of LV and remodeling of the heart
Inability of the ventricle to fill with a sufficient amount of blood (diastolic dysfunction)
elevated filling pressure in left or right ventricle
backward buildup of hydrostatic pressure in the atria
left atria
pulmonary venous system dysfunction
pulmonary wedge pressure increases
pulmonary edema
right atria
peripheral edema
jugular venous distention
Precipitating Causes
Infection
Anemia
Pulmonary Edema
Pregnancy
Rheumatic Heart Disease
Infective Endocarditis
Systemic HTN
increased mechanical stress on the ventricles leading to structural changes of myocardial hypertrophy & left ventricle dilation
Myocardial Infarction
Ischemic Heart Disease
diminished coronary perfusion of myocardium weakens the strength of contractility of the ventricles
Can occur due to a long-term compensated state of heart
It is responsibility of PCP to identify if there is a long-term cause that has negatively affected the function of their heart
Can occur acutely after a heart attack, or acute problem with the heart
Right Heart Failure
impaired ability of the right heart to perfuse the lungs at normal pressures.
Not always caused by RV dysfunction
Causes:
Most common: result of LVF or failure of forward cardiac output
Cor Pulmonale
Pathologic pulmonary process: pulmonary fibrosis, pulmonary emboli, etc.
pulmonary HTN
chronic hypoxia r/t pulmonary arterial vasoconstriction causing an increased resistance against the RV. The RV hypertrophies and remodels due to increased workload & eventually decompensates and fails
Left Heart Failure
Causes
Most common: Long standing HTN causing LV dysfunction
increases the workload of the LV and eventually the LV decompensates into failure
Vulnerable to CAD
Myocardial Infarction
Common place for arteriosclerosis: left anterior descending artery
Systolic or diastolic dysfunction
Treatment Plan
Pharmacotherapeutics
Vasodilators
Antihypertensives
ACE inhibitors: indicated for LV systolic dysfunction, cornerstone of therapy
counteract neurohormonal changes & decrease mortality
ARBs: if unable to tolerate ACE inhibitors
Combination Therapy: entresto (reduce mortality in HF)
Diuretics
Decrease fluid volume overload
overdiuresis: lead to hypotension, renal insufficency, and interfere with other medications
Mild HF: thiazide
severe HF: furosemide/bumetanide
Beta-Blockers
Carvedilol
slow heart rate and limit peripheral arterial vasoconstriction
Bisoprolol
Metoprolol ER
Digoxin
Lifestyle Modifications
Reduce salt intake to < 2g per day
Fluid restriction: 1.5L per day
Sleep with head of the bed elevated if experiencing PND
Use pillows under feet while sitting/laying to elevate extremities to reduce swelling
encourage aerobic exercise 20-30 minutes per day 3-4 times per week
Assistive Devices
LVAD
HeartMate
Heart Ware
Implantable Defibrillator
Biventricular pacing
Cardiac resynchronization
Treatment of Symptoms & underlying causes
decrease cardiac workload
Rest until baseline weight is achieved
Vasodilators
encourage weight loss
control HTN
decrease volume overload
optimize LV function
correct ventricular dyssynchrony
reduce mortality
control the ventricular rate
Presentation of Disease
Pulmonary System: common in LVHF
Cough
Dyspnea
at rest
with exertion
orthopnea
paroxysmal nocturnal dyspnea
awake in the middle of the night due to nightmare, feeling breathless, or dry cough
hypoxic
Central Nervous System
confusion
difficulty concentration
impaired memory
delirium
insomnia
anxiety
headache
hallucinations
lightheadedness/syncope
Specific End Organs
Renal system
Decreased urine output due to decreased blood flow to kidneys and renal filtration of sodium and water
Nocturia: excessive diuresis in the nighttime
results from enhanced renal filtration
Gastrointestinal: related to congestion of liver, spleen or intestines
Ascites
abdominal fullness
nausea
vomiting
constipation
anorexia
Generalized Systemic
fatigue due to low cardiac output
weakness due to low cardiac output
Peripheral edema
Cardiovascular System
Chest Pain
Assessment & Diagnosis
Physical Assessment
Pulmonary System
crackles on auscultation
elevated pulmonary capillary wedge pressure
pulmonary edema
pink frothy sputum
wheezing: pleural effusion
Ejection Fraction
< 50 % of total ventricular volume in systolic dysfunction
normal or increased in diastolic dysfunction because of compensation for reduced diastolic filling
Jugular Venous distention
most commonly seen in R. sided heart failure
GI System (most common in R. sided HF
hepatomegaly
jaundice
splenomegaly
ascites (peritoneal edema)
Peripheral Extremities
sacral edema
ankle edema
pallor of extremities
peripheral cyanosis
anasarca: full body edema
Vital Signs
Heart Rate
Tachycardic
pulsus alternans: weak pulse alternating with a strong pulse
atrial fibrillation
Respirations
rapid and shallow with minimal exertion
Cheyne - Stokes
Cardiovascular System:
lateral and downward shift in PMI
S3 sound in adults > 40 yo.
murmurs
mitral/tricuspid regurgitation
Diagnostic Tests
Echocardiogram
identify abnormalities of systolic and diastolic function
Cardiac catheterization
measure intracardiac pressures, identify underlying causes of HF
Laboratory Test:
Natriuretic Peptides
ANP
secreted in response to atrial stretch
BNP
abundant in the heart and rapidly rises in the presence of heart failure
useful for degree of HF
can also be elevated in pulmonary edema, COPD, pulmonary embolism, renal disease and other condition.
CBC
anemia with severe HF
UA
proteinuria
RBCs / casts due to glomerulonephritis
ESR
decreased due to impaired fibrinogen synthesis and decreased fibrinogen concentration in patients with HF
Creatinine & BUN
elevated due to fluid volume overload
Electrolyte panel
LFTs
abnormal due to hepatic congestion with R. sided heart failure
Chest X-ray: cardiac silhouette
ECG
used to detect underlying causes of HF
Health Promotion & Education
Regular Exercise to improve functional status and decrease congestive symptoms
Cardiac rehab program
discourage alcohol consumption
Record daily weights
record daily vital signs at the same time each day
follow up with immunizations: flu and pneumococcal
Remove barriers for medication adherence
costs
complexity of regimen
include family or support system on schedule
adverse reactions including polypharmacy
psychosocial support: provide community support groups for the patient
Counsel the patient on prognosis of disease and the plans for the future
Complete an advance directive
smoking cessation
use elastic stocking to reduce peripheral edema
ensure emotional rest and adequate relaxation
advise your PCP when there are symptoms of HF or worsening symptoms leading to an exacerbation
Risk Factors
Modifiable
infection
obesity
anemia
pregnancy
alcohol use
substance abuse
Nonmodifiable
diabetes mellitus
chronic kidney disease
cardiomyopathies
valvular disorders
dysrhythmias
pulmonary embolis
sleep apnea
Referral
The patient should have a cardiologist that they regularly follow up with to manage their disease condition
Nutritionist
This can help with making dietary changes
PCP
follow up every 3 months on condition of the disease
Home care: decrease hospitalization and improve overall functional status