Heart Failure Overview

This chapter covers the management of patients with heart disease complications, specifically focusing on heart failure (HF).
Heart failure (HF) is the inability of the heart to pump enough blood to meet the tissues' needs for oxygen and nutrients.
It's a syndrome characterized by fluid overload or inadequate tissue perfusion.
Heart failure indicates myocardial disease, a problem with heart contraction (systolic failure) or filling (diastolic failure).
Some cases of heart failure are reversible.
Most cases are progressive and lifelong, managed with lifestyle changes and medications.

Myocardial dysfunction can be caused by various factors including ischemic heart disease, hyperthyroidism, myocardial infarction, valve disease, alcohol and/or cocaine abuse, and hypertension.
Activation of renin-angiotensin-aldosterone system: This system leads to vasoconstriction, increasing afterload, blood pressure, and heart rate. This also causes sodium and water retention.
Activation of baroreceptors: This leads to stimulation of vasomotor centers in the medulla.
Activation of sympathetic nervous system: Catecholamines (epinephrine and norepinephrine) are released, leading to vasoconstriction.

Right-sided: Visceral and peripheral congestion, jugular venous distention (JVD), dependent edema, hepatomegaly, ascites, and weight gain.
Left-sided: Pulmonary congestion, crackles, S3 or "ventricular gallop," dyspnea on exertion (DOE), orthopnea, dry, nonproductive cough, and oliguria.

Focus: Effectiveness of therapy, patient self-management, symptoms if HF increases, emotional/psychosocial response, health history, physical exam.
Physical exam: Mental status, lung sounds (crackles, wheezes), heart sounds (S3), fluid status, daily weight, I&O, assess response to medications.

Activity intolerance: Related to decreased cardiac output (CO)
Excess fluid volume: Related to the HF syndrome
Anxiety-related symptoms: Related to the complexity of the therapeutic regimen.
Powerlessness: Related to chronic illness and hospitalizations.
Ineffective family therapeutic regimen management.

Goals: Promote activity and reduce fatigue, relieve fluid overload symptoms, decrease anxiety, encourage patient to verbalize ability to make decisions and influence outcomes, educate patient and family about therapeutic regimen management.

Medications.
Diet: low-sodium, fluid restriction.
Monitor for signs of excess fluid, hypotension, disease exacerbation, daily weight.
Exercise and activity program.
Stress management.
Infection prevention.
Know how and when to contact healthcare provider.
Include family in education.

ACE inhibitors: For vasodilation, diuresis, decreased afterload, monitor for hypotension, hyperkalemia, and altered renal function, and cough.
Angiotensin II receptor blockers: Alternative to ACE inhibitors, work similarly.
Hydralazine and isosorbide dinitrate: Alternative to ACE inhibitors.
Beta-blockers: Prescribed in addition to ACE inhibitors, may take several weeks before effects are seen. Use with caution in patients with asthma.
Diuretics: Decrease fluid volume; monitor serum electrolytes.
Digitalis: Improves contractility; monitor for digitalis toxicity, especially if patient is hypokalemic.
IV medications (e.g., milrinone): For hospitalized patients admitted for acute decompensated HF; decreases preload and afterload, causes hypotension, and increased risk of dysrhythmias.
Dobutamine: For patients with left ventricular dysfunction; increases cardiac contractility and renal perfusion.

May present with atypical signs/symptoms (fatigue, weakness, somnolence).
Decreased renal function can make older patients resistant to diuretics and more sensitive to volume changes.
Administration of diuretics in older men requires surveillance for bladder distention caused by prostatic enlargement.

Emergency management: Cardiopulmonary resuscitation (CPR); A: airway; B: breathing; C: circulation; D: defibrillation for VT & VF.

Acute event where the left ventricle cannot handle blood volume overload. This causes increased pressure in the pulmonary vasculature and fluid moves out of pulmonary capillaries into interstitial space of the lungs and alveoli.
Results in hypoxemia.
Symptoms include restlessness, anxiety, dyspnea, cool/clammy skin, cyanosis, weak and rapid pulse, cough, and noisy, moist respirations, increased sputum production, frothy/blood tinged sputum, and decreased level of consciousness.
Management: Monitor lung sounds, signs of activity intolerance, place patient upright/dangle legs, minimize exertion/stress, administer oxygen, and diuretics (e.g. furosemide), vasodilators (e.g. nitroglycerin).

Decreased mobility and decreased circulation increase the risk of thromboembolism, especially with cardiac disorders, including HF.
Pulmonary embolism: blood clot that originates in legs and travels to obstruct pulmonary vessels.
Management: Anticoagulant therapy.

Pericardial effusion: Accumulation of fluid in the pericardial sac.
Cardiac tamponade: Restriction of heart function due to fluid in pericardial sac, resulting in decreased venous return and decreased CO.
Symptoms include ill-defined chest pain or fullness, pulsus paradoxus, engorged neck veins, and labile or low BP, shortness of breath. Falling systolic BP, narrowing pulse pressure, and rising venous pressure may also occur.
Management: Pericardiocentesis, Pericardiotomy.

Heart Failure Question: The correct answer to identify optimal management of activity intolerance with decreased CO related to HF is maintaining heart rate, blood pressure, respiratory rate, and pulse oximetry within the targeted range.
Cardiac arrest: The most reliable sign of an adult or child's cardiac arrest is the absence of a carotid pulse. In an infant, the brachial pulse is assessed.