HEART FAILURE

Prepared By
Hizbullah Khan
Presented & Modified By
Asghar
 OBJECTIVES
 Define heart failure.
 Differentiate between:
Systolic Versus Diastolic Failure
Right Side Versus Left Side Failure
Acute Vs Chronic Heart Failure
 Describe the pathological mechanism underlying the
manifestation of heart failure.
 Discuss the clinical manifestation of heart failure
 Discuss medical, and nursing management of
patients with heart failure.
 Essential Terms
 Stroke Volume: The amount expelled by each contraction of
the ventricles.
 Cardiac Output: The amount of blood pumped out of the
heart in 1 minute. SV x HR = CO
 Factors Affecting Stroke Volume:
 Preload: The stretch of myocardial fibers at end diastole.
 After load: force that the ventricles must develop during
systole in order to eject the stroke volume.
 Terms
 Frank Starling Law: states that the greater the myocardial
fibers length or stretch, the greater will be its force of
contraction.
larger volume of blood flows into the ventricle, the blood
stretch the walls of the heart, causing a greater expansion
during diastole, which in turn increases the force of the
contraction.
 Ejection Fraction:
percentage of blood pumped out of the ventricles with each
contraction. a normal ejection fraction is about 55% to 70%.
 Heart Failure
 Definition: Complex syndrome resulting from any
functional or structural disorder of the heart that results
in or increases the risk of developing manifestations of low
cardiac output and/or pulmonary or systemic congestion.
 According to the agency for health care policy and
research (AHCPR) HF guidelines panel (1994) HF is a
clinical syndrome characterized by signs and symptoms of
fluid overload or of inadequate tissue perfusion.
 HF is the inability of the heart to pump sufficient blood to
meet the needs of the tissues for oxygen and nutrients.
 Systolic Vs Diastolic Dysfunction

There may be a problem with contraction of the heart

(systolic dysfunction) or filling of the heart (diastolic
dysfunction)
 Systolic Dysfunction
Definition: A decrease in myocardial contractility,
characterized by an ejection fraction of less than
40%.
Causes:
 Ischemic heart disease and cardiomyopathy (impair
the contractility of the heart)
 Valvular insufficiency and anemia (produce a
volume overload)
 Hypertension and valvular stenosis (generate a
pressure overload on the heart).
 Systolic Dysfunction
Pathophysiology
 Decrease in myocardial contractility
 Decrease stroke volume and ejection fraction
 Increase in end-diastolic volume (preload)
 Increase in ventricular dilation, and ventricular wall
tension and a rise in ventricular end-diastolic pressure.
 The increased volume, added to the normal venous
return, leads to an increase in ventricular preload.
 Accumulation of blood in the atria and the venous
system causing pulmonary or peripheral edema.
 Diastolic Dysfunction
Definition: In diastolic dysfunction hearts contract
normally, but relaxation is abnormal.
Causes:
 Pericardial Effusion, Constrictive Pericarditis
(compromises expansion of the ventricle)
 Myocardial Hypertrophy, hypertrophic
cardiomyopathy (Increase wall thickness and reduce
chamber size)
 Aging, ischemic heart disease (delay diastolic
relaxation)
 Diastolic Dysfuction
Pathophysiology
 In diastolic dysfunction, blood is unable to move freely into
the left ventricle
 Causing an increase in intraventricular pressure at any given
volume.
 The elevated pressures are transferred from the left ventricle
into the left atrium and pulmonary venous system, causing a
decrease in lung compliance and symptoms of dyspnea.

 Also low cardiac output because of poor ventricular filling

and therefore less volume available for ejection.
 Right Versus Left Heart Failure

 Heart Failure is also classified according to the side of the

heart (right ventricular or left ventricular).

 Although the initial event that leads to heart failure may be

primarily right or left ventricular in origin, long-term heart
failure usually involves both sides.
RIGHT VERSUS LEFT HEART FAILURE
 Right Ventricular Dysfunction
“Impaired ability of the right ventricle to move
deoxygenated blood from the systemic circulation into the
pulmonary circulation.”
 As the right ventricle cannot move the blood forward, the
left ventricle receives less amount of blood from
pulmonary circulation thus cardiac output is reduced.
 There is accumulation or congestion of blood into the
systemic venous system.
 Right Ventricular Dysfunction
CAUSES
 Stenosis or regurgitation of the tricuspid or pulmonic valves,
right ventricular infarction, and cardiomyopathy
(compromise the pumping effectiveness of the right
ventricle)
 Pulmonary hypertension due to chronic pulmonary disease,
severe pneumonia, pulmonary embolus, or aortic or mitral
stenosis (hampers blood flow into the lungs).
 Congenital heart defects such as tetralogy of fallot and
ventricular septal defect.
 Right ventricular failure can also result from left ventricular
failure, it is the most common cause.
 Right Ventricular Dysfunction.
SIGNS AND SYMPTOMS
 Peripheral edema
 Weight gain
 Liver congestion and hepatomegaly
 Congestion of the portal circulation may lead to
engorgement of the spleen and the development of ascites
 In severe right-sided failure, the external jugular veins
become distended
 Nausea, vomiting and loss of appetite leading to weight loss
Portal Circulation
 Left Ventricular Dysfunction

“Impaired ability of the left ventricle to move blood from the

low-pressure pulmonary circulation into the high-pressure
arterial side of the systemic circulation.”
 There is a decrease in cardiac output to the systemic
circulation.
 Blood accumulates in the left ventricle, left atrium, and
pulmonary circulation
 Development of pulmonary edema
 Left Ventricular Dysfunction

Causes
 Hypertension
 Myocardial infarction and myocardial ischemia
 Stenosis or regurgitation of the aortic or mitral valve
 Left Ventricular Dysfunction.
Signs And Symptoms
 Dyspnea/ Orthopnea
 Paroxysmal Nocturnal Dyspnea
 Cough (Crackles)
 Low Oxygen Saturation
 Oliguria
 Slow Capillary Refill
 Dizziness Lightheadedness Confusion, Restlessness
 Altered Digestion
 Increase Heart Rate
 Weak Thready Pulse
 Third Heart Sound
 Acute Vs Chronic Heart

Acute—An emergency situation in which a patient remain

completely asymptomatic before the onset of heart
failure; seen in acute heart injury such as MI.
Chronic—Long-term syndrome in which a patient
exhibits symptoms over a long period of time, usually as
a result of a preexisting cardiac condition.
 Acute Heart Failure Syndrome

The Acute Heart Failure Syndromes (AHFS) are defined

as
“ gradual or rapid change in heart failure signs and
symptoms resulting in a need for urgent therapy.
 It may be an exacerbation of chronic heart failure
 Symptoms are mainly those that are associated with
pulmonary edema.
 Assessment And Diagnostic Findings
 Medical History And Physical Exam
 Echocardiography
 Radionuclide Ventriculography / Ventriculogram
 Electrocardiography (ECG)
 Pulmonary Function Tests
 Chest X-ray
 Assessment And Diagnostic Findings
 Na & K, CBC, Renal Function, C-reactive Protein,
Thyroid Function Test.
 BNP (Brain Or B- Type Natriuretic Peptide)
 Angiography
 Exercise Testing
 I/O, V/S, Body Weight
 MANAGEMENT OF ACUTE HEART
FAILURE
 The patient may become hypotensive and could develop rhythm
abnormalities. This is likely to be tachycardia as the heart struggles to
maintain cardiac output. Therefore patients need cardiovascular
monitoring including cardiac monitoring, blood pressure, respiratory
rate, spo2 and in some cases central venous pressure monitoring.
 Patients should be nursed upright.
 Supplemental oxygen is given to maintain the SpO2 above 95%.
 May require non-invasive ventilation either via continuous positive
airway pressure or bilevel positive airway pressure.
 The aim of pharmacological care is to reduce both preload and
afterload using a combination of intravenous vasodilators and
diuretics.
 Other therapies that may be indicated include cardiac
resynchronisation therapy (pacing of both ventricles), inotropes or
even the insertion of an intra-aortic balloon pump.
 MANAGEMENT

Treat underlying causes of Heart Failure such as

 Atrial Fibrillation with digitalis
 Coronary Artery Disease with Percutaneous Transluminal
Coronary Angioplasty (PTCA) OR CABG
 Electrical conduction defects e.g. left bundle branch
block (LBBB), SA Or AV blocks, etc. with pulse
generator or pacemaker.
 Management
 Pharmacological management
Once heart failure is moderate to severe, polypharmacy
becomes a management standard and often includes diuretics,
digoxin, angiotensin converting enzyme (ACE) inhibitors, and
β-adrenergic–blocking agents.
 Life style Modification (low salt, low fat diet, & exercise)
 DIURETICS
 Most frequently prescribed medications for heart failure.
 They promote the excretion of edema fluid and help to
sustain cardiac output and tissue perfusion by reducing
preload.
 Thiazide and loop diuretics are used.
 In emergencies, such as acute pulmonary edema, loop
diuretics such as furosemide can be administered
intravenously.
 DIGITALIS
 Recognized treatment for CHF for more than 200 years.
 Improve cardiac function by increasing the force and
strength of ventricular contraction.
 By decreasing sinoatrial node activity and decreasing
conduction through the atrioventricular node, they also
slow the heart rate and increase diastolic filling time.
 ACE INHIBITORS
 Prevent the conversion of Angiotensin I to angiotensin II,
have been effectively used in the treatment of heart
failure.
 The newer angiotensin II receptor blockers (ARBS) have
the advantage of not causing a cough, which is a
troublesome side effect of the ACE inhibitors for many
persons.
 Nursing Management

Role of a nurse
 Administering the medications and for assessing their
beneficial and detrimental effects to the patient.
 Hemodynamic monitoring
 Weighing the patient daily
 Auscultation of lung sounds at least daily to detect an
increase or decrease in pulmonary crackles
 Diet plan
 I/O monitoring
 Nursing Diagnosis
• Activity intolerance related to imbalance between
oxygen supply and demand because of decreased CO.
• Excess fluid volume related to excess fluid or sodium
intake and retention of fluid because of HF and its
medical therapy.
• Anxiety related to breathlessness and restlessness from
inadequate oxygenation.
• Powerlessness related to inability to perform role
responsibilities because of chronic illness and
hospitalizations.
• Noncompliance related to lack of knowledge
 HEALTH PROMOTION
Patients with heart failure should be given advice on:
 Smoking cessation
 Abstaining from alcohol
 Reducing salt intake
 Having a yearly flu vaccination and pneumonia
vaccination.
 Exercise and rehabilitation
 Medication compliance.
THANK YOU
• STENOSIS OF THE PULMONARY ARTERY AT ITS POINT OF ORIGIN,
• WHICH INCREASES RIGHT VENTRICULAR WORKLOAD
• • VENTRICULAR SEPTAL DEFECT, I.E. AN ABNORMAL
• COMMUNICATING HOLE BETWEEN THE TWO VENTRICLES, JUST
• BELOW THE ATRIOVENTRICULAR VALVES
• • AORTIC MISPLACEMENT, I.E. THE ORIGIN OF THE AORTA IS
• DISPLACED TO THE RIGHT SO THAT IT IS IMMEDIATELY ABOVE
• THE SEPTAL DEFECT
• • RIGHT VENTRICULAR HYPERTROPHY TO COUNTERACT THE
• PULMONARY STENOSIS.