Chronic Cardiac Conditions: Heart Failure & Valves

• Chronic Cardiac Conditions Part 2 addresses Heart Failure and Valvular Disease

Recap of CAD (from Part 1)

• Risk factors, diagnostic tests (EKG, stress tests, angiography), ST segment changes, nurse's role, medications, and CKD management are all topics addressed in Part 1

Learning Objectives: Heart Failure

• Differentiate classifications of heart failure (HF)
• Discuss clinical manifestations
• Select appropriate nursing and collaborative interventions for chronic HF
• Describe low-sodium and weight-control diets for HF treatment

Learning Objectives: Valvular Disease

• Differentiate between stenosis and regurgitation
• Discuss pressure gradient differences
• Highlight valvular disorder symptoms related to right- or left-side involvement
• Describe percutaneous transluminal balloon valvuloplasty
• Discuss advantages/disadvantages of valve repair and replacement

Heart Disease Types

• Categories include obstructive and non-obstructive

Cardiomyopathy vs. Heart Failure

• Cardiomyopathy involves a diseased heart muscle that weakens and limits filling
• Heart failure involves the heart's inability to pump adequate blood and is a pump problem
• Other causes of heart failure include myocardial infarction, valvular disease, atherosclerosis, hypertension, and vascular disease

Systolic Heart Failure described

• The heart can't push blood forward, and blood can go backwards
• Weak myocardium (dilated cardiomyopathy) or dead tissue (secondary to myocardial infarction) can cause
• Systolic Heart Failure is a forward failure stemming from a broken pump

Diastolic Heart Failure described

• The heart can't fill because of a compromised myocardium
• Restrictive cardiomyopathy or a thickened left ventricular wall (hypertrophic cardiomyopathy) can cause
• Diastolic Heart Failure is a filling failure

Heart Failure Classification

• AHA/ACC stages range from high risk without structural disease to refractory heart failure
• New York Heart Association classes range from no physical activity limitation to symptoms at rest

Assessing Heart Failure Risk

• Key questions involve breathing difficulty, sleeping position, nocturnal awakenings, SOB, and ADL tolerance
• Assess history of heart disease, medications, substance use, cancer treatment, and weight

Left- vs. Right-Sided Heart Failure

• Symptoms differ based on where fluid accumulates
• Right-sided HF symptoms include hepatomegaly, JVD, dependent edema, dyspnea on exertion, and ascites
• Left-sided HF symptoms include orthopnea, crackles/rales, dyspnea at rest, pale skin, cool extremities, weak pulse, delayed capillary refill, paroxysmal nocturnal dyspnea, and angina

Red Flags from Example Patient

• Symptoms include a history of myocardial infarction (MI) and systolic heart failure from ischemic cardiomyopathy
• An ejection fraction (EF) of 30%
• Shortness of breath (SOB) that has progressed in severity
• The need to sleep upright, 3+ pitting edema, and an 8-lb weight gain in 3 days

Orthopnea Definition

• Orthopnea is dyspnea that develops when recumbent and is relieved by head elevation

Orthopnea vs. Paroxysmal Nocturnal Dyspnea

• Orthopnea is dyspnea relieved by sitting upright
• Paroxysmal nocturnal dyspnea is characterized as sudden SOB that happens at night, causing anxiety

Red Flags of Heart Failure

• Anxiety indicates increased oxygen demand and workload
• Crackles in all lung fields indicates fluid accumulation, increasing respiratory failure risk
• Pale skin indicates sympathetic nervous system involvement
• Dependent edema may be evasive
• HR greater than 90 is a compensatory mechanism that is not effective
• O2 saturation at or below 92% indicates respiratory depression/distress/failure

Labs to Confirm Diagnosis of Heart Failure

• B-natriuretic peptides (BNP) confirm the diagnosis

B-Type Natriuretic Peptide (BNP) Facts

• BNP is produced in ventricles and helps compensate for HF
• BNP widens blood vessels and encourages kidneys to excrete salt and water
• BNP reduces hormones that narrow blood vessels and increase heart rate
• BNP reduces fluid retention (adrenaline, angiotensin, and aldosterone)

Long-Term Effects of HF Compensation

• Prolonged compensation can tire and weaken the heart, increasing vascular resistance.

Common Orders for Heart Failure

• Diuretics decrease fluid overload but also require careful monitoring of electrolytes
• Transdermal Nitro patch and ACE Inhibitors decrease preload through vasodilation
• Calcium channel blockers/beta blockers decrease heart rate and blood pressure, reducing myocardial workload
• A low-sodium diet decreases fluid overload

Chronic Heart Failure Management

• Heart failure is managed, not cured, with medication and education.

Heart Failure: Client Education

• Diet, activity, and weight changes
• Salt intake must be specific for each client and requires reading food labels
• Fluid restrictions are needed in advanced stages (less than 2 liters a day)
• Adequate intake of K+ if taking loop diuretic

Notify Provider if:

• There is a weight gain of 2-3 pounds in one day
• Or a weight gain of 1 pound per day for 5 day

Valvular Heart Disease

• Includes stenosis and regurgitation

Assessment for 19-Year-Old Patient

• The female patient has had "fluttering" in her chest and occasional shortness of breath
• Symptoms impact her work
• Perform subjective and objective assessments

Assess Subjective

• Assess family history
• Assess COLSPA of fluttering/discomfort and fatigue impacting ADL's (Activities of daily living)
• Assess prior living conditions
• Assess if she remebers having any prior sore throats
• Assess any history of fevers, jerky movements etc

Assess Objecitve

• Head-to-toe body assessmen
• Focus on heart and lungs
• Evaluate chest pain and use PQRST method

Common signs of patient after further valuation

• Patient has a mild edema
• Heart auscultation shows a "harsh" Pansystolic murmur
• Lung auscultation shows a crackles in all areas

Common Vital Sign findings with patient

• Room air saturation of 92%
• HR 102 bpm and regular
• RR 12 bpm at rest, 30 with movement

Hypotheses for Example Patient

• The patient clinical shows heart failure & signs of valvular disease
• The Mitral valve is likely affected on the left-side, causing SOB (Shortness of breath)

Common orders for Patient

• Cardiac Enzymes
• Echo
• Chest Xray
• Cardiac Monitoring & EKG
• Pregnancy Test

Common Test Results Analysis

• After performing the Cardiac Enzymes test; the results will probably be pending
• 12-lead EKG reveals a; Sinus tachycardia with prominent P waves
• Chest X-Ray & Transthoracic Echocardiogram test will likely be pending
• The team may suspect Rheumatic heart disease

Rheumatic Heart Disease

• Is found most commonly in rural poor, and marginalized communities
• Causes a rheumatic fever, and valve and heart failure

Valvular Disease: Causes

• Infective endocarditis
• Infection on the valves, vegetation
• Rheumatic heart disease
• Untreated strep A infection
• Atherosclerosis

Valvular Problems Summary

• Problems affect flow/closing
• Stenosis, "STiffen", the opening is considered narrow

Mitral and Aortic Valve Disease: Overview

• Mitral and aortic valve diseases are common and often treated via surgery
• The left-side of the heart is called the workhorse

The Right vs Left Side

• Pulmonic & Tricuspid with Right-sided failure symptoms
• Mitral & Aortic with Left-sided failure symptoms

Echo is an Ultrasound

• Echo assesses blood flow through the valves and chambers
• Echo is never the arteries

Recognizing Cues Related to rheumatic heart disease

• Assess personal risk factors
• Living conditions could be indicative
• Assess if she has any acess to private care

After EKG change of P Wave

• Check patient, assess for chest pain, negative enzymes

Prioritizing Patient Hypothesis

• Could be Premature Atrial Contractions (PAC)

Chest x-ray and Echocardiogram Results Indicate

• Cardiomegaly
• Mild interstitial pulmonary edema
• Mitral regurgitation
• Thickened mitral leaflets
• Dilated left atrium and ventricle

Analyzing Diagnoses

• XR: Interstitial Pulmonary Edema is fluid backup due to valve malfunction
• XR: Cardiomegaly is heart enlargement from chronic valve problems or Rheumatic Fever
• Echo: Mitral Regurgitation = consistent enlargement/thickening due to Rheumatic heart disease

Potential Plan for patient

• Consult for cardiology

Treatment Options

• Cardiac Cathetherization
• Heart valve replacement

Common discharged medications

• Spironolactone 50 mg
• Aspirin 81 mg
• Enalapril 2.5 mg