Heart Failure: Systolic vs Diastolic

Heart Failure (HF)

• Heart failure is a complex clinical condition with an underlying structural abnormality or dysfunction
• It results in the ventricle's inability to fill with or eject blood
• Heart failure is also referred to as Congestive Cardiac Failure (CCF)
• Can be left sided: systolic heart failure (↓ejection) or diastolic heart failure (filling issue)
• Or right sided

Causes of HF

• CAD can cause decreased blood supply
• Infarction and fibrosis from prolonged ischaemia accounts for 2/3 systolic HF and a reduction in EF
• Other causes are dysrhythmias and valve disease like regurgitation and stenosis
• Further causes include cor pulmonale, congenital heart disease (ASD, VSD), rheumatic fever and cardiomyopathy
• HF can be caused by diabetes mellitus (diastolic HF) and chronic HTN (diastolic HF)

Systolic vs Diastolic Heart Failure

• Systolic heart failure involves a problem with contraction
• This results in decreased force of contraction, contractility, and inotropy
• The stroke volume is also reduced, leading to decreased cardiac output and ejection fraction below 40%
• Systolic failure is indicated by enlarged ventricles and a thinner chamber wall
• Diastolic Heart Failure is a filling problem, leading to decreased preload
• Small ventricles and large chamber walls indicate diastolic heart failure
• Myocardial hypertrophy may be evident
• Patients can have a normal ejection fraction

Clinical Manifestations

• Left-sided heart failure primarily affects the lungs (L=Lungs)
  • Increased pulmonary artery pressure (PAP)
  • Crackles on auscultation
  • Pulmonary oedema (congestion)
  • Dyspnoea/orthopnoea
  • Pink frothy sputum
  • Cough
  • Decreased blood pressure (BP), cardiac output (CO), and cardiac index (CI)
  • S3 heart sounds
  • Fatigue, weakness, lethargy
  • Decreased urine output (UO)
  • Rapid/irregular heart rate (HR)
• Right-sided heart failure affects the rest of the body (R=Rest of Body)
  • Peripheral oedema (+/- pitting)
  • Elevated jugular venous pressure (JVP)
  • Increased central venous pressure (CVP)
  • Hepatosplenomegaly
  • Ascites
  • Weight gain
  • Nocturia
  • Decreased BP, CO, and CI
  • Fatigue, weakness, lethargy
  • Rapid/irregular HR
  • Decreased UO

Physiological Responses to Heart Failure

• The body responds to heart failure through the sympathetic nervous system
• The renin-angiotensin-aldosterone system (RAAS) is activated to compensate
• Frank-Starling response also comes into play

Cardiogenic Shock

• Cardiogenic shock can be stimulated by release of compensatory renin, aldosterone, antidiuretic hormone, and catecholamine
• Adequate blood volume along with increased systemic vascular resistance is resulted

Acute and Chronic HF

• Acute heart failure is a sudden development of symptoms and it's often severe
• Causes include myocardial infarction, ischaemia, inflammatory or toxic insult, acute valve insufficiency, or pericardial tamponade
• Requires urgent evaluation and management and may respond to treatment and improve
• It may occur as a decompensation of chronic heart failure
• Chronic heart failure appears slowly and gets worse as heart function continues to deteriorate
• Frequent assessment and adjustment of the management regimen is required
• A person with chronic heart failure may have acute exacerbations
• Heart function often continues on a slow decline despite intervention

Diagnostic procedures/tests

• ECG: Understand how to interpret the rhythm, and have MO review within 1 hour of taking
• CXRAY: Have a basic level of understanding with the assessment, and show any formal report findings
• CXRAY findings may involve cardiomegaly and pulmonary oedema
• ECHO: Nurses don't generally undertake these but need to be able to interpret the result and report the findings
• ECHO results show Dilation, Hypertrophy, Valves, Contractile force, and EF %

Management of HF

• First treat the underlying cause by performing Fibrinolytic, cath lab, CABG, or valve replacement
• Manage fluid volume overload with ACE inhibitors, diuretics (loop, thiazides), fluid restriction, and salt restriction
• Improve ventricular function by reducing preload and afterload and improving contractility
• Beta blockers like carvedilol, bisoprolol, metoprolol can improve function
• Other drugs that assist are ACE inhibitors, Digoxin, Antiarrhythmic drugs, IV Calcium, and inotropic drugs
• Inotropic therapy options: dobutamine, milrinone, and levosimendan
• Lifestyle modifications: Fluid restriction of 1-1.5L/day, daily weights, reduced dietary sodium, weight loss, smoking cessation, and controlled diabetes

ACE Inhibitors and ARBs

• ACE inhibitors drugs include Captopril, Lisinopril, Enalapril, Ramipril, and Peridopril
• Angiotensin Receptor β-Blocker (ARBs) drugs include Losartan, Valsartan, and Candesartan

Dobutamine

• Dobutamine is a short term inotropic support in acute HF or acute exacerbations of Chronic HF
• Used to treat HF, cardiogenic shock, and sepsis with systolic dysfunction
• The onset of action is 2-10 minutes via continuous IV infusion of 250mg/250mls
• Administer with 2-20mcg/kg/min
• Acts as a Positive inotrope to ↑CO and ↑HR
• Beta (β)1 agonists activates to increase contractility leading to decrease in end systolic volume and increase SV
• Has both Beta 2 and Alpha (α) 1 minimal effects
• Beta 2 - vasodilation - Decreases afterload (SVR) and a drop in BP should gradually improve with the Beta 1 effects
• If ↑SV & ↑HR + ↓SVR = ↑CO, Preserved systemic BP as a result
• Systemic and pulmonary oedema leads to dyspnoea

Haemodynamic Assessment and Monitoring

• Haemodynamics: measures and monitors factors that influence the force and flow of blood
• This monitoring assess cardiovascular function in the critically ill or unstable patient.
• Haemodynamic monitoring is used when vital signs aren't enough to evaluate changes in cardiovascular status
• Haemodynamic monitoring provides the full range of information required to enable individualised goal directed therapy

Non-Invasive Patient Assessment

• Look, Listen, and Feel
• Pathology results
• Decreased Cardiac Output (CO) results in inadequate perfusion to the tissue or organs
• This leads to compensatory mechanisms in place to save vital organs
• Comprehensive assessment of hemodynamics needs to go beyond circulation

Signs of Inadequate Perfusion/Compromised Haemodynamics

• Primary Signs affect Skin and GIT, and are cool and clammy skin, > cap refill, pallor, decreased Bowel sounds, Diarrhoea/constipation and Increased NG output
• Secondary Signs affect Kidneys, Liver and Lungs and are Concentrated urine, Decreased UO, Increase BUN/Cr/Potassium, Increase in ALT/AST/Coags, Increase RR and effort, SOB, and Decreased PaO2 decreased SpO2
• Final Signs affect Brain, and Heart, and are Decreased or altered LOC, Disorientation, Slow reacting pupils,Chest pain, Tachycardia/bradycardic/ectopics, and ST elevation

Continuous Cardiac Monitoring + ECG

• Constant cardiac monitoring to provide rapid assessment
• Constant evaluation from 5 lead continuous cardiac monitoring or 2 lead display
• Nurses skills for interpreting rhythm are needed such as: Sinus Rhythm (SR), Atrial Fibrillation (AF), Supraventricular Tachycardia (SVT), ST elevation, 1st, 2nd, 3rd degree heart blocks, Bundle Branch blocks (BBB), atrial and ventricular ectopics, Ventricular Tachycardia (VT), Ventricular Fibrillation (VF), and asystole)
• Conduct 12 lead ECGs
• Understand Pharmacology knowledge Electrolyte levels

Mean Arterial Blood Pressure (MAP)

• MAP definition: The average arterial pressure throughout one cardiac cycle, systole, & diastole
• Influenced by cardiac output and systemic vascular resistance
• Use as a risk indicator and measures perfusion pressure
• MAP values under 60-65mmHg should be avoided as low perfusion pressure can cause tissue hypoxia and related issues
• Estimation Formula: MAP = DP + 1/3(SP – DP)
  • DP is diastolic blood pressure
  • SP is systolic blood pressure

Invasive Patient Assessment and Monitoring: Arterial Catheters

• Radial artery: Most common/preferred because of Max mobility, Bleeding control and Collateral circulation
• Risks radial artery: Risk to nerves
• Brachial artery: Large and easy to place, Bleeding, Arm mobility is still more restricted, and Limited collateral circulation
• The Brachial artery has more instances of thrombus. It is the 2nd most common artery used
• Femoral Artery: 2nd most common, High risk of infection, Mobility affected, Bleeding control not easy, and Increase risk of thrombus

Arterial Lines

• Arterial lines deliver continuous assessment of systemic arterial BP and a Visual trace of waveform
• Lines offer vital diagnostic info such as arterial compliance and stroke volume.
• Arterial can assessment arterial perfusion to major organs.
• Titration with medication can be assessed through arterial
• Arterial eases blood sampling and is more accurate than manual cuff pressure

Arterial Lines Complications

• Complications such as <5% chance of Thrombosis, Embolisation & Infection Bleeding is another complication that can be common and a safety hazard
• Haematoma Vasospasm - rare

Arterial Line Set Up

• Zero the transducer to atmospheric pressure
• Level accurate to Phlebostatic axis @ 4th intercostal border midaxillary line
• Maintain height if transducer changes

Arterial Line Wave Forms

• In addition to SBP, DBP, MAP and HR also get data from waveforms
• More info is available by watching the arterial line waveform interpret action videos

Central Line Sites

• Placement of the catheter into large vein close to the heart and Superior Vena Cava (SVC) / Inferior Vena Cava (IVC)
• Internal Jugular Vein CVC: Quick and easy access to SVC Subclavian vein CVC: Terminates in SVC, More difficult to place
• More lumens equal smaller lumens
• Distal lumens take largest fluid admin/ Bld products and Stagger exit at catheter tips Femoral Vein CVC: Terminates in IVC and used in Emerg (24hrs)
• Central Lines advantages: Easy to place & access + Ease of access for blood samples
  • Allows for: medications, fluids and nutrition

Central Lines Advantages

• Central lines ease quick placement and blood samples access; infection is a risk
• These eliminate risks of infiltrating tissue
• Meds that require CVC are central lines that will only give meds and fluid
• Fluids give large volumes of fluids and blood products
• Nutrition (TPN) is available if enteral isn't possible, as well as, Fluids - measurement of CVP and PA catheter
• Central lines feature Faster delivery (direct to heart) and handles Multiple infusions

Central Lines: Complications to CVC

• Bleeding increased by disorders Perforate/puncture vessel (usually during insertion)
• Misplaced/Malpositions (Arterial, Most common with IJ and femoral CVCs)
• Use U/S guided insertion when doing placement, and CXR confirms catheter placement Retrograde Catheter goes wrong direction and can either be JJ head or SC up
• Other complications: Pneumo/Haemothorax Increased risk with subclavian CVC and Embolism (rare) + Infection

Other Types of Central Lines

• PICC Lines, Porta catheters (Chemo), Tunnelled Central lines (Going home or Paediatrics), and VAS Catheters (Haemodialysis)

Central Venous Pressure (CVP) Lines and Waveform Interpretation

• The CVF reflects the right ventricular and diastolic pressure
• The RVEDP reflects the right ventricular end diastolic volume (RVEDV)
• 2 - 6 mmHg is a healthy Normal
• Its unimportant by itself, CVP needs to be read along with other clinical data
• A pt may present 5 for Normal. However periphery checks for coolness and an output shows normal range is 5 inadequate
• Administer 500mills of Colloid and increase CVP level to 8 to heat extremities and administer waste
• A level 8 CVP is adequate

Factor Determining Low or High CVP

• When High -> Hypervolemia; tension pneumothorax;Heart failure; and Pleural
• When Low -> Hypovolemia; shock states

Pulmonary Artery (PA) Catheter

• Pulmonary artery catheters or swan-Ganz catheter and inserted intravascally through a central vein and run through the right side/pulmonary artery
• Catheters utilized to measure RV failure, hypertension, shock and post-cardiac surgery.

Pulmonary Artery Nursing Responsibility

• Nurses monitor and maintain. Nurses helps maintain cleanliness to procedure
• Nurses are asked to monitor PAC with positioning and patient monitoring for catheter placement in PA
• Lumens maintain the placement in the PA

Diagnostics Based on Pathology Results

• RBC, WBC, Hg, Fe
• Liver Function Tests
• Serum Electrolytes: K, Ca and Mag

Summarise

• Follow ECG, monitor rate
• The HR and intra-arterial catheter and MAP rate can be assessed
• Note and access Peripheral warmth and color.
• Assess Preload the P.A
• Lactate and Oxygen and mental status can also be determined

Bradycardia

• Bradycardia is caused by slowed heart rate.
• Administer Atropine, Dopamine, and Adrenaline
• Use Transcutaneous or trans venous pacing

Atrial Dysrhythmias

• Common symptoms of atrial fibrillation of atrial flutter

Cardiac Action Potential

• Stages of cardiac action potential, and factors that influence rate
• There are 4 phases, numbered 0-4, of cardiac action potential from Resting Stage to Rapid Depolarization

Anti-dysrhythmic Medications

• Medications decreasing distance from the SA node and rate to help heart
• Medications are always administered via IV, only if converted can it be administered orally
• Class 1, Class 2, Class 3, and Class 4 medications all exist to treat dysrhythmia
• Class I: Sodium Channel blockers (Quinidine, Flecainide, amlodipine)
• Class II: β-Blockers (propranolol, metoprolol)
• Class III: K+ Channel Blockers (Amioderone, sotalol)
• Class IV: Ca2+ Channel Blockers (verapamil, diltiazem)

Drug Interaction: Digoxin

• Narrow range always check level of administration
• Was once used as used as medicine to threat HF
• Decreases in O Consumption in body
• Decreases heart and rhythm

Unclassified Drug interaction: Adenosine

• Shortens body’s action and reactions
• Is an acute and fast reaction to light
• Monitor to avoid high blood loss nausea and light headed ness

Monitor All Anti-Dysrhythmic Drugs

• Have ECG prior to beginning
• Monitor all signs
• Do not begin of acid imbalance
• Have extra medication for back up

Overview of heart failure, including systolic and diastolic types, causes such as CAD, infarction, valve disease and contributing factors such as diabetes and hypertension. Systolic heart failure involves contraction problems, leading to decreased force and contractility. Diastolic heart failure involves filling problems.