Heart failure

Heart failure
often referred to as congestive heart failure
(CHF), is the inability of the heart to pump
sufficient blood to meet the needs of the tissues
for oxygen and nutrients.
Heart failure is a clinical syndrome in
which mechanical and biochemical
forces alter the size, shape, and
function of the ventricle's ability to
pump enough blood to meet the
metabolic demands of the body.
Heart failure is a condition in which
the heart can’t pump enough
blood to meet the body’s needs.
 OR
HF is defined as a clinical syndrome
characterized by signs & symptoms of fluid
overload or of inadequate tissue perfusion.

These signs & symptoms result when the heart

is unable to generate a CO sufficient to meet the
body’s demands.
N.B:-

The term CHF is misleading, because it

indicates that patients must experience
pulmonary or peripheral congestion to have
HF, and it implies that patients with
congestion have HF.
The term HF is preferred & indicates
myocardial heart disease in which there
is a problem with contraction of the
heart (systolic dysfunction) or filling of
the heart (diastolic dysfunction) and
which may or may not cause pulmonary
or systemic congestion.
What are lifestyle risk factors for heart
failure. ( Controllable)
Lifestyle risk factors that contribute to heart failure
include:
lack of exercise.
high-fat diet.
emotional stress.
having a "type A" personality (aggressive, impatient,
competitive).
Excessive alcohol consumption
Smoking
Long-term use of steroids
Age Sex
Some of the risk factors for heart disease include smoking,
high blood pressure, high cholesterol, diabetes, and obesity.
Risk factors for congestive heart failure (CHF)
include:
The following medical conditions increase risk for
developing CHF:

Can be classified as shown in table.

 Heart Failure
Chronic Acute
Hypertensive HD Acute MI
Rheumatic Heart Dis Dysrhythmias
Congenital Heart Dis Pulmonary emboli
Cor pulmonale Thyrotixicosis
Cardiomyopathy Hypertensive crisis
Anemia, DM(type 2). Rupture of papillary
Bacterial endocarditis muscle
Valvular disorders Myocarditis
Atherosclerosis of
the larger
coronary arteries

Myocardial Infarction
Classification of heart failure:-

1- Acute Versus Chronic Heart failure.

The terms acute &chronic are used to describe

both the onset of symptoms of heart failure
and the intensity of symptoms.
a) Heart failure of acute onset
refers to the sudden appearance of symptoms, usually
over days or hours.

Acute symptoms of HF have progressed to a point at

which immediate or emergency intervention is
necessary to save the patient’s life.
b)Heart failure of chronic onset
refers to the development of symptoms over months
to years.

Chronic symptoms represent the baseline condition,

the limitations the patient lives with on a daily basis.
N.B:-
If the cause of the acute onset is not reversible, then the
heart failure may become chronic. For example, a patient who
has an acute MI with severe damage to the left ventricle has
acute heart failure with pulmonary edema, causing lasting
damage to the left ventricle.

As a result, the patient has poor contractility (and, therefore,

dyspnea on exertion) after the MI has resolved. The patient’s
acute onset of heart failure has left him with chronic
symptoms.
2- Left-Sided Heart Failure Versus Right-
Sided Heart Failure.

a)Left-sided heart failure

refers to failure of the left ventricle to fill or empty

properly.

This leads to increased pressures inside the ventricle

and congestion in the pulmonary vascular system.
Picturing Left Ventricular
Hypertrophy
Congestive Heart Failure
Pulmonary Edema
N.B:- Left-sided heart failure

may be further classified into systolic and

diastolic dysfunction. Backward failure can be

subdivided into failure of the left atrium, the

left ventricle or both within the left circuit.

•Systolic Dysfunction

Systolic dysfunction is defined as an ejection

fraction of less than 40% and is caused by a
decrease in contractility.

i.e. The ventricle is not emptied adequately

because of poor pumping and the end result is
decreased cardiac output.
Congestive Heart Failure
•Diastolic Dysfunction
Diastolic dysfunction is often referred to as heart
failure with preserved left ventricular function.

Pumping is normal or even increased, with an

ejection fraction as high as 80% at times.
•N.B:- Diastolic dysfunction is caused by
- impaired relaxation & filling.
Left ventricular filling, a complex process that takes place
during diastole, is a combination of passive filling & atrial
contraction. If the ventricle is stiff and poorly compliant
(due to aging, uncontrolled hypertension, or volume overload),
relaxation is slow or incomplete.

- if the patient has atrial fibrillation, there is no organized

atrial contraction.

--These mechanisms reduce filling of the ventricle and

contribute to diastolic dysfunction, therefore
decreasing cardiac output.
b) Right-sided heart failure refers to failure of
the right ventricle pump adequately.

•The most common cause of right- sided heart

failure is left-sided heart failure.

•Right-sided heart failure can also result from

pulmonary disease & primary pulmonary artery
hypertension
(where it is referred to as cor pulmonale).

•Acute onset of right-sided heart failure is often

caused by pulmonary embolus.
 Types

 Systolic (pumping problem)—inability of the heart

to contract to provide enough blood flow forward

 Diastolic (filling problem)—inability of the left

ventricle to relax normally, resulting in fluid back
up into the lungs

 Left-sided—inability of the left ventricle to pump

enough blood, causing fluid back up into the lungs

 Right-sided—inefficient pumping of the right side

of the heart, causing fluid buildup in the abdomen,
legs, and feet
 Pathophysiology
- Heart failure is a response to cardiac dysfunction, a
condition in which the heart cannot pump blood at
a volume required to meet the body s needs.

- Any condition that impairs the ability of the

ventricles to fill or eject blood can cause HF.
-Coronary artery disease with resultant necrotic
damage to the left ventricle is the underlying cause of
HF in most patients.

Other major conditions that lead to HF

include :
 valvular dysfunction.
 infection (myocarditis or endocarditis).
Cardiomyopathy.
uncontrolled hypertension.
 Signs and Symptoms of HF

Right heart failure Left heart failure

Pulmonary
Congestion of peripheral Cardiac output
congestion
tissues

Liver congestion  Activity Impaired gas Pulmonary

Edema and
impaired liver
ascites intolerance exchange edema
function

GI tract Impaired Dyspnea 

congestion digestion cyanosis

Cough (w/ frothy

Anorexia, Weight loss, cachexia sputum)
orthopnea
Signs & Symptoms of heart failure

S&S of Left-sided heart failure

1- Respiratory signs:
Cyanosis which suggests severe hypoxemia.
Rales or crackles heard initially in the lung bases, and
when severe, throughout the lung fields .
Tachypnea.
Congestion of the pulmonary vasculature.
dyspnea on exertion and in severe cases, dyspnea at rest.
paroxysmal nocturnal dyspnea.
Cough (produces frothy or blood-tinged mucus)
2- Cardiac signs:

laterally displaced apex beat (which occurs if the

heart is enlarged).

gallop rhythm (additional heart sounds) may be

heard as a marker of increased blood flow, or
increased intra-cardiac pressure.

Heart murmurs may indicate the presence of

valvular heart disease.
"Cardiac asthma" or wheezing may occur.
-Irregular or rapid pulse.
- Sensation of feeling the heartbeat
(palpitations)
3- Symptoms of poor systemic
circulation:

-such as dizziness, confusion and cool

extremities at rest.

-Easy fatigue ability and exercise intolerance.

-Decreased urine production .

-Weight gain from fluid retention

 Clinical Picture
Right Sided Heart Failure
Jugular vein distention.

Anorexia & nausea.

Edematous hands and fingers.

Weight gain.

Increased BP (excess volume) OR

Decreased BP (from failure).
A man with congestive heart failure and marked
jugular venous distension. External jugular vein
marked by an arrow
 Right Sided
Congestive Heart Failure
S& S of Right-sided heart failure

- pitting peripheral edema (legs & sacrum).

- Ascites, and hepato-splenomegaly.
- Jaundice may appear.
- Coagulopathy (problems of decreased blood
clotting) may occur.
- Nocturia (frequent nighttime urination) may
occur when fluid from the legs is returned to the
bloodstream while lying down at night.
A B
Example of pitting edema. (A) The nurse applies finger
pressure to an area near the ankle. (B) When the pressure is
released, an indentation remains in the edematous tissue.
What are the heart disease symptoms in
women, and people with diabetes?

For many women and people with diabetes,

pain is not a symptom of heart disease at all.
Instead of experiencing discomfort, they often
have symptoms of malaise or fatigue.
Biventricular failure
Dullness of the lung fields to finger percussion
and reduced breath sounds at the bases of the
lung may suggest the development of a pleural
effusion (fluid collection in between the lung
and the chest wall).
 Complications of HF

•Pulmonary edema. * impaired liver function

•Renal failure. * Pleural effusion

•Cerebral insufficiency.

•Myocardial infarction.

•Cardiac dysrhythmias.
 Diagnosis
1- History.
2- Physical examination.
3- Diagnostic studies.
 1- History
1- History of a precipitating factor such as MI, recent
open heart surgery, dysrhythmias, or hypertension.

2- Symptoms vary based on the type and severity of

failure.
3- Ask patients if they have experienced any of the
following:

- anxiety, irritability, fatigue, weakness, lethargy, mild

shortness of breath with exertion or at rest, orthopnea
that requires two or more pillows to sleep.

- nocturnal dyspnea, cough with frothy sputum,

nocturia, weight gain, anorexia, or nausea and
vomiting.
4- Take a complete medication history.

5- Determine if the patient has been on any

dietary restrictions.

6-Determine if the patient regularly participates

in a planned exercise program.
 2-Physical assessment
--It is an essential part of the patient assessment
helps to determine changes.

Including carotid bruits, diminished pulses in the

lower extremities and systolic murmur.

-- assessment of the pain (onset ,site,

quality ,severity, time radiation, reliving &
aggravating factor).
The nurse should measure vital signs and
measure the blood pressure in both arms
of the patient.

--If neurological changes are present, they

can range from minor confusion and
memory impairment to more obvious
confusion.
--signs and symptoms of RT ventricular failure
they including
(Neck vein distention, hepatojugular reflux, and
increasing peripheral edema along with
hypotension).

-- Assessment for dyspnea & orthopnea.

--Also assessment for peripheral pitting edema

A B
Example of pitting edema. (A) The nurse applies finger
pressure to an area near the ankle. (B) When the pressure is
released, an indentation remains in the edematous tissue.
 3- Diagnostic studies
1- ECG. Is obtained to assist in the diagnosis and to
determine the underlying cause of HF.

2- Chest x-ray.

3- An echocardiogram assist in the identification of

the underlying cause & patient’s ejection fraction that
help in identification of the type and severity of HF.
Congestive Heart Failure
This chest radiograph shows an enlarged cardiac and
edema at the lung bases, signs of acute heart failure.
N.B:-
This information may also be obtained noninvasively
by radionuclide ventriculography or invasively by
ventriculogram as part of a cardiac catheterization
procedure.
 Halter monitoring

A portable ECG monitor is connected to the

patient to evaluate chest pain during
performance of daily activities.
4- Computerized tomography tests (CT
scans)
take detailed images of blood vessels to show whether they
have narrowed. In general, this test is used to show that
heart disease is not present.

5- coronary angiography a superior test

compared to the others.
-Angiographic images accurately reveal the extent and
severity of all coronary arterial blockages.
Coronary angiogram
6- Exercise testing or cardiac
catheterization
may be performed to determine whether
coronary artery disease & cardiac
ischemia are causing the HF.
stress test
stress tests require the patient to perform a strenuous
activity under a doctor s supervision, such as walking or
running on a treadmill. An EKG is taken of the person before,
during, and after the stress tests. Stress tests help in
detecting blockages in the coronary arteries. If a patient is
unable to walk on a treadmill, a stress test can be used with
medication that mimics the physiology of exercise without
the patient needing to walk, and the heart can be imaged
with nuclear techniques or ultrasound, and this is as good as
exercise.
7- cardiac MRI

Creating detailed images of body tissue. (it is noninvasive).

 Allowing clearly to see the size and shape of the chambers,
the movement of the muscle wall, and the flow of blood.
It may also be used to assess the ejection fraction.

delayed-enhancement cardiac MRI

A special MRI technique using contrast dye detects damaged
or scarred areas of the heart muscle that can impair the
heart s ability to pump and lead to heart failure.
delayed-enhancement cardiac MRI this technique
uses a dye that cannot enter healthy heart muscle cells but is
absorbed by damaged cells, which show up as bright,
motionless areas on the MR image. This technique is used to
evaluate heart damage that may have been caused by heart
attack, coronary artery disease, or disease of the heart
muscle itself
Laboratory studies include

1- serum electrolytes.

2- blood urea nitrogen (BUN), creatinine.

3- B-type natriuretic peptide (BNP).

4- thyroid-stimulating hormone(TSH).

5- a complete blood cell count (CBC), and routine

urinalysis.
 Management of HF

1-Medical treatment

2-Surgical treatment

3- Nursing intervention
 Medical Management
The goals of the medical management of heart
failure are to :

Relieve heart failure symptoms.

Enhance cardiac performance.
Correct known precipitating causes of acute
heart failure.
There is no single treatment method for
heart disease

Each person experiences heart disease differently,

and no one treatment method works for everyone. A
multi-faceted approach of dietary changes, lifestyle
changes, exercise, and medications may be
combined,, depending on the patient s individual
situation and needs.
1. Drug management
- Angiotensin-converting enzyme inhibitors (ACE)
(Lowered BP).
- vasodilators (nitroglycerin)
- Angiotensin Receptor Blockers
- Diuretics (Decrease excess extracellular fluids and
decreases edema).
- Positive inotropic agents: as Digoxin (lanoxin)
which increase the force of myocardial contraction
and slow the heart rate).
Digoxin Toxicity
Fatigue, mental depression, malaise, anorexia,
nausea, and vomiting (early effects of digitalis
toxicity).
Bradycardia , Blurred , yellow or green vision.
Weakness, drowsiness

 Changes in heart rhythm: new onset of regular

rhythm or new onset of irregular rhythm
Other medications used to treat heart failure.

Nitroglycerin: which dilates the coronary arteries, making it

easier for blood to flow.

calcium channel blockers:which help slow the heart rate,

allowing the heart to beat more efficiently.

Statins:which reduce the number of lipids (found in

cholesterol) in the blood to reduce the likelihood of plaque
forming on the arteries.
 Surgical management
The following are common procedures used to treat
heart disease.

1- Coronary (balloon) angioplasty: it is expanded to

keep the artery open so blood can flow more freely,
and the catheter is removed.
2- Stents: The insertion of a stent is similar to
coronary angioplasty except that over the balloon is a
small metallic tube (a stent) that stays in place to
keep the artery open while the catheter & the balloon
are removed.
Atheroectomy: A drill-like device or laser cuts
away the plaque covering the arteries.

Brachytherapy: Radiation is applied to the

blockages to remove them from recurring after
angioplasty.
Coronary (balloon) angioplasty
 Procedure, part 4

A device called a stent may be placed. A stent is a latticed,

metal scaffold that is placed within the coronary artery to
keep the vessel open.
Nursing intervention:-
1-Initially, assess discomfort or symptoms, every 4
hours& with document,
and report to the physician abnormal heart sounds,
abnormal breath sounds (particularly crackles), and
patient intolerance to specific activities.

2- Administer bronchodilators as prescribed:

a. Inhalation is the preferred route.
b. Observe for side effects: tachycardia, dysrhythmias,
central nervous system excitation, nausea, and vomiting.
3- Teach patient:
a. To adhere to the diet prescribed (for example,
explain low-sodium, low calorie diet).

b. To adhere to activity prescription congestion from

increased left heart Pressures.

The association of symptoms and activity can be used

as a guide for activity prescription and a basis for
patient teaching.
Nursing intervention:-
1- Initially, every 4 hours, and with chest discomfort,
assess, document, and report to the physician the
following:

a. Hypotension.

b. Tachycardia and other dysrhythmia.

c. Activity intolerance.

d. Mental changes (use family input).

e. Reduced urine output (less than 200 mL per 8 hours).
f. Cool, moist, cyanotic extremities.

2- Give IV fluids.

3- Administer oxygen by the method as prescribed.

a. Explain rationale and importance to patient.

b. Evaluate effectiveness; observe for signs of
hypoxemia. Notify physician if restlessness, anxiety,
somnolence, cyanosis, or tachycardia is present.

4-ensure that patient eating normal balanced diet with

little amount of fat.
Nursing intervention:-
1. Support patient in establishing a regular regimen of
exercise using treadmill & exercycle, walking, or other
appropriate exercises, such as mall walking.

a. Assess the patient’s current level of functioning and

develop exercise plan based on baseline functional
status.
b. Suggest consultation with a physical therapist
or pulmonary rehabilitation program to determine
an exercise program specific to the patient’s
capability.

c. Have portable oxygen unit available if Oxygen

is prescribed for exercise.
Nursing intervention:-
1. Assess, document, and report to the physician the
patient’s and family’s
level of anxiety and coping mechanisms.

2. Assess the need for spiritual counseling and refer

as appropriate.

3. Allow patient (and family) to express anxiety and

fear:
a. By showing genuine interest and concern.
b. By facilitating communication (listening, reflecting,
guiding).
c. By answering questions.

4. Use of flexible visiting hours allows the

presence of a supportive family to assist in
reducing the patient’s level of anxiety.

5. Encourage active participation in a cardiac

rehabilitation program.

6. Teach stress reduction techniques.

 Health education

1- Regular medication intake as prescribed.

2- Diet.
-Low salt intake.
- Limit intake of fats& cholesterol.
- Small frequent meals.
- moderate amount of fluid intake according to pt condition.
- Avoid gas forming food.
Example.

-A heart-healthy diet includes lots of whole grains,

vegetables, and fruits. beans, can help lower your
cholesterol as well as olive oil, garlic, and avocados.
Nuts, can boost "good" cholesterol. Incorporate fish
and seafood into your meals a few times a week. Also,
try to avoid sweets.
Exercises&
medication
Stop
smoking &
alcohol
intake
Eat a
healthy diet
3- Stop smoking.

4- Stop alcohol intake.

5- Regular exercise. Regular exercise strengthens

the heart, lowers bad cholesterol (LDL), raises good
cholesterol (HDL), and lowers blood pressure.
6- controlling high blood pressure & diabetes.
-Patient must maintain normal blood sugar level.
- Also control & keep it within normal range.
-To achieve this(DM&B.pressure) follow instruction of
DM&hypertension control programs.

7- Follow up.