Heart Failure Overview and Classification

Heart Failure Definition

• Heart failure is the heart's inability to pump enough blood to meet tissue needs for oxygen and nutrients.

Learning Objectives

• Students will be able to define heart failure (HF).
• Understand the mechanisms controlling HF symptoms.
• Classify HF using the NYHA system.
• List different types of HF.
• Identify risk factors and causes of HF.
• Describe clinical manifestations of HF.
• Predict complications of HF.
• Identify diagnostic tests for HF.
• Understand appropriate nursing processes for HF.

Etiology of Heart Failure

• Loss of functional myocardial cells after heart injury due to:
  • Ischemic heart disease
  • Hypertension
  • Idiopathic cardiomyopathy
  • Infections (e.g., viral myocarditis)
  • Toxins (e.g., alcohol, cytotoxic drugs)
  • Valvular diseases
  • Prolonged arrhythmias

Classification of Heart Failure

• Onset:
  • Acute heart failure
  • Chronic heart failure
• Affected side of the heart:
  • Left heart failure
  • Right heart failure
• Stages of heart failure severity:
  • New York Heart Association (NYHA)
  • American Heart Association/American College of Cardiology

Physical Examination

• Auscultate heart rate and palpate peripheral pulses.
• Auscultate the chest for crackles and wheezes.
• Examine the heart for enlargement.
• Assess patient mentation (memory and concentration).

NYHA Classification of Functional Capacity

• NYHA Class I: Asymptomatic
• NYHA Class II: Symptoms with moderate exertion
• NYHA Class III: Symptoms with minimal exertion
• NYHA Class IV: Symptoms at rest

New Classification Based on Symptoms

• Asymptomatic: NYHA Class I
• Symptomatic: NYHA Class II/III
• Symptomatic with recent history of dyspnea at rest: NYHA Class IIIB
• Symptomatic with dyspnea at rest: NYHA Class IV

Vicious Cycle of Heart Failure

• Myocardial disease/injury
• Impaired ventricular performance (increased cardiac workload)
• Increased SNS response
  • Heart rate increase
  • Contractility reduced
  • Vasoconstriction
• Increased RAAS activity
  • Vasoconstriction
  • Sodium/water retention
• Vicious cycle of heart failure (the cycle continues)

Clinical Manifestations

• Signs and symptoms of heart failure (HF) are often described by the effect on the ventricles.

Right-sided heart failure

• Abdominal pain
• Anorexia
• Nausea
• Bloating
• Swelling

Left-sided heart failure

• Dyspnea on exertion
• Paroxysmal nocturnal dyspnea
• Tachycardia
• Cough
• Hemoptysis

Think FACES...

• Fatigue
• Activities limited
• Chest congestion (pulmonary edema)
• Edema (ankle swelling)
• Shortness of breath

Diagnosis

• Response to treatment
• Electrocardiogram (ECG)
• Chest X-ray (CXR)
• Echocardiography (ECHO)
• Angiography

Treatment (General)

• Goals to reduce respiratory and cardiac workload and patient agitation.
• Induce diuresis and vasodilatation.
• Reduce respiratory and heart rates.
• Establish the cause and treat.

Nursing Management

• Respiratory considerations (supplemental oxygen, lung assessment)
• Monitoring (hemodynamic monitoring, daily weights, intake and output)
• Laboratory results (electrolytes, BNP, digoxin levels)
• Diet (small frequent meals, low in salt)
• Skin integrity

Therapy for Heart Failure

• Increased workload
• Drug therapy
• Gene therapy
• Cardiomyocyte dysfunction
• Cell death
• Cell transplantation
• Heart transplantation

Treatment Considerations

Non-pharmacologic

• Diet (salt restriction, fluid restriction, weight loss, lipid control)
• Alcohol moderation
• Tobacco cessation
• Exercise
• Cardiac rehab
• Palliative services
• Social support

Pharmacologic

• ACE inhibitors
• Beta blockers
• Spironolactone
• Diuretics

ACE Inhibitors

• Indication: All HF patients with systolic dysfunction (symptomatic or not)
• Goal: Reduce morbidity and mortality
• Dose: Ideal dose is controversial; start low and increase
• Precautions: Baseline serum potassium (K+) and creatinine (Cr) are needed at the start of therapy. Monitor if systolic blood pressure (SBP) is <100 mmHg or serum creatinine (Cr) is elevated. Titrate as tolerated if administered with beta-blockers.

Beta-Blockers

• Limit heart rate, thus saving energy.

Spironolactone

• Indication: Symptoms at rest or new onset of symptoms in last 6 months. Beneficial for moderate to severe HF.
• Dose: 25 mg once daily (OD)
• Precautions: Monitor kidney function and potassium (K+).

Diuretics

• Indication: To control fluid overload (edema, ascites, weight gain)
• Goal: Improve morbidity
• Dose: Usually furosemide, start at 20 mg/day and increase/decrease as needed. Diuretics can be stopped if fluid overload resolves.
• Precautions: Monitor serum potassium (K+).

Digoxin

• Indication: Heart failure with atrial fibrillation (A.fib), patients still symptomatic despite diuretics, ACE inhibitors, and beta-blockers, or to control dyspnea at rest (existing or new onset).
• Goal: Improve morbidity
• Dose: 0.125-0.25 mg/day (varies)
• Precautions: Digoxin levels need to be monitored closely, especially if toxicity is suspected. In some circumstances (i.e., women with heart failure), digoxin can be associated with an increased risk of death.

Cardiac Resynchronization Therapy

• Increase the efficiency of the heart's function

Complications of Heart Failure

1. Intractable heart failure: Patient becomes progressively refractory to therapy.
2. Cardiac dysrhythmias
3. Digitalis toxicity (from decreased renal function)
4. Pulmonary embolism, pneumonia
5. Cardiogenic shock

This quiz delves into the definition, etiology, and classification of heart failure. Students will explore the mechanisms of symptoms, identify risk factors, and predict complications associated with heart failure, enhancing their understanding of this critical cardiac condition.