Understanding Heart Failure: Diagnostics and Concepts

• The notes below are a summary of Module 5, and part of Module 6 & 7

Heart Failure (HF)

• Cardiac output is the amount of blood pumped by the ventricle in liters per minute
• Ejection fraction represents the percentage of end-diastolic volume ejected with each heartbeat from the left ventricle
• Cardiac output is calculated as stroke volume multiplied by heart rate (CO = SV x HR)
• Preload refers to the degree of stretch of cardiac muscle fibers at the end of diastole
• Afterload is the resistance to the ejection of blood from the ventricle
• Contractility is the ability of the cardiac muscle to shorten its fibers in response to an electrical impulse

HF Diagnostics (BNP & Echocardiogram)

• Brain Natriuretic Peptide (BNP) is a neurohormone that helps regulate BP and fluid volume
• BNP is secreted from the ventricles in response to increased preload, indicating elevated ventricular pressure
• Increased BNP in the blood occurs when ventricular walls expand
• BNP is monitored for heart failure
• Elevated BNP levels may be seen in conditions such as heart failure, pulmonary embolus, myocardial infarction (MI), and ventricular hypertrophy
• BNP level higher than 100 pg/mL suggests heart failure

Echocardiogram

• A noninvasive ultrasound measures the ejection fraction, size, shape, and motion of cardiac structures
• Echocardiograms are useful for diagnosing pericardial effusion, chamber size, heart murmurs, heart valve function, and ventricular wall motion
• An echocardiogram can be performed during an exercise or pharmacological stress test, and images are obtained at rest and after reaching the target heart rate
• Nursing interventions during an echocardiogram include applying gel to help transmit sound waves, asking the patient to turn on their left side or hold their breath; procedure is painless

Transesophageal Echo

• A transesophageal echo lasts about 30-45 minutes
• Provides clearer images of the heart and is an important first-line diagnostic tool for people with CVD, HF, valve disorders, and arrhythmias
• Is frequently used during heart surgeries
• During a transesophageal echocardiogram, a topical anesthetic agent & sedation are given, with the patient asked to swallow several times
• Discomfort may occur due to the placement of the probe in the esophagus; complications are uncommon but can be serious, including respiratory sedation, aspiration, and esophageal perforation
• Nursing interventions include NPO status for 6 hours prior, signed consent, IV line insertion, denture removal, monitoring LOC, BP, ECG, respirations, O2 saturation, bed rest with head elevated to 45 degrees, and gradual water intake after 2 hours if the gag reflex is intact; a sore throat is normal, but persistent sore throat, SOB, or difficulty swallowing should be reported

Heart Valves

• The tricuspid valve has 3 leaflets and separates the right atrium and right ventricle
• The mitral valve has 2 leaflets and separates the left atrium and left ventricle
• Mitral valve prolapse involves one or both leaflets ballooning back into the atrium during systole, causing blood regurgitation from the left ventricle back into the left atrium
• Mitral valve prolapse can result in mitral regurgitation due to heart enlargement, atrial fibrillation, pulmonary hypertension, or heart failure
• Clinical manifestations of mitral valve prolapse can include fatigue, shortness of breath, lightheadedness, dizziness, syncope, palpitations, chest pain, and anxiety

Mitral Valve Assessment/Medical/Nursing Management

• Assessment findings of Mitral Valve include an extra heart sound: mitral click, systolic click, and murmurs along with the the s/s of HF
• An echocardiogram is used in the diagnosis and monitoring of the progression.
• Medical management of Mitral Valve includes controlling symptoms by eliminating caffeine, alcohol, and tobacco, in addition to medications as needed (Nitro, CCB, BB)
• Nursing management of Mitral Valve includes education, screening of siblings, counseling the patient on diet and exercise, and close monitoring during pregnancy

Mitral Regurgitation Etiology

• In Mitral Regurgitation, blood flows from the left ventricle back into the left atrium during systole
• Mitral valve leaflets and chordae tendineae become thickened and fibrotic, preventing proper closure
• Rheumatic heart disease is a common cause of Mitral Regurgitation
• Other conditions that cause Mitral Regurgitation include infective endocarditis, systemic lupus, cardiomyopathy, and ischemic heart disease
• The mitral valve leaflet and chordae tendinea may shorten, tear, or elongate
• Mitral Regurgitation volume increases ventricular hypertrophy and can lead to systolic heart failure and back flow of blood into lungs

Mitral Regurgitation Assessment and Management

• Mitral Regurgitation can manifest as dyspnea, weakness, fatigue, palpitations, SOB on exertion, and cough from pulmonary congestion
• Assessment for Mitral Regurgitation includes auscultation of the lungs for a systolic murmur at the apex; echocardiogram is used for diagnosis and monitoring
• Pulses may be regular or irregular
• Medical management could include medications for HF if pulmonary congestion develops; ACE inhibitors, ARBs, and beta-blockers, as well as surgical valve repairs

Mitral Stenosis

• Mitral Stenosis is characterized by reduced blood flow from the left atrium into the left ventricle
• It is usually caused by Rheumatic Fever, which thickens mitral valve leaflets and chordae, causing them to fuse together, leading to narrowing, which obstructs blood flow
• Over time, Mitral Stenosis causes pulmonary pressure to increase as the right ventricle fails

Mitral Stenosis Assessment and Management

• Assessment findings of the lungs include a low-pitched, rumbling diastolic murmur heard at the apex, along with a weak and irregular pulse; echocardiogram is used to manage the issue.
• Management of Mitral Stenosis includes prevention (decreasing the risk of bacterial infection), medical management with anticoagulants, beta-blockers, digoxin, and CCBs, and, surgical interventions

Aortic Valve Stenosis

• Aortic valve stenosis is the narrowing of the orifice between the left ventricle and aorta
• It is usually caused by degenerative calcification, progresses gradually, and increases pressure on the left ventricle, leading to hypertrophy.
• Aortic valve stenosis has clinical manifestations that include Syncope and s/s HF
• Risk factors that need to be controlled include Diabetes, HTN, Hypercholesterolemia, Elevated triglycerides, and smoking

Aortic Regurgitation

• Aortic regurgitation is the backward flow of blood into the left ventricle during diastole; caused by congenital valve disorder (bicuspid aortic valve), inflammatory lesion
• Increased systolic BP in the LV is a clinical manifestation
• Visible or palpable arterial pulsations are assessment and diagnosis
• In some patients, medical management can include ACE inhibitors, CCB, and/or restrict sodium

Pulmonary Valve Issues

• Pulmonary valve regurgitation occurs when valves do not close completely & blood flows backward through the valve
• Pulmonary valve Stenosis occurs when the valve does not open completely and blood flow if reduced

Clinical Manifestations of Heart Failure

• Left-sided heart failure is often the result of aortic & mitral valve heart disease and the development of right ventricular failure
• Cardinal sign- dyspnea and fatigue are clinical manifestations of heart failure, along with, nocturnal dyspnea, or pulmonary edema
• Left sided heart failure = lungs = pulmonary congestion, pulmonary crackles, & Orthopnea

Risk Factors of HF (Left & Right Sided)

• HTN, coronary artery disease and Mitral regurgitation are risk factors for Left sided heart failure
• Left sided heart failure, Right ventricular MI and Pulmonary problems are risk factors for right sided heart failure such as COPD
• Congestive heart failure often occurs due to Left sided heart failure. This results in swelling or congestion in the legs, ankles and abdomen

Classifications of HF

• Class I HF: No limitation of physical activity, and ordinary activity does not cause fatigue, palpitation, or dyspnea
• Class II HF: Slight limitation of physical activity, comfortable at rest, and ordinary physical activity causes fatigue, palpitation, or dyspnea
• Class III HF: Marked limitation of physical activity and comfortable at rest
• Class IV HF: Unable to carry out any physical activity without discomfort, experiences symptoms of cardiac insufficiency at rest, and discomfort increases with any physical activity

AHA Stages of Heart Failure

• Stage A HF includes patients at high risk for developing LV dysfunction without structural heart disease or symptoms of HF; treatment focuses on a heart-healthy lifestyle and risk factor control of HTN, lipids, DM, and obesity
• Stage B HF includes patients with LV dysfunction or structural disease but who have not developed symptoms of HF; treatment involves implementing Stage A plus ACE inhibitors or ARBs, beta-blockers, and statins
• Stage C HF includes patients with LV dysfunction or structural heart disease with current or prior symptoms of heart disease; treatment involves implementing Stages A and B plus diuretics, aldosterone antagonists, sodium restriction, implantable defibrillators, and cardiac resynchronization therapy
• Stage D HF includes patients with refractory end-stage HF requiring specialized interventions; treatment involves implementing Stages A, B, and C plus fluid restriction, end-of-life care, extraordinary measures, inotropes, cardiac transplantation,and mechanical support

Types of Left-Side HF

• Heart failure with reduced ejection fraction which Systolic heart failure
• Heart failure with preserved ejected fraction which is Diastolic heart failure
• Heart failure with midrange ejection fraction, Efs between 40-49%

Management Goals for Heart Failure

• Goals for management of heart failure include reporting new symptoms or changes in symptoms, patient education, measuring HR, BP, and RR, and the use of Pulses

ACE Inhibitors for HF

• Angiotensin-converting enzyme (ACE) inhibitors ends in -pril
• ACE inhibitors relieve clinical manifestations of HF, slow the progression of HF, and impove exercise tolerance, promote vasodilation & diuresis
• Monitor for hypotension
• Monitor for Angioedema and stop immediately if occurs

ARBS (Losartan) for HF

• Angiotensin receptor blocker
• Monitor for hypotension, dizziness, and lightheadedness

Loop Diuretics for HF

• Furosemide (Lasix) is a loop diuretic
• Loop diuretics inhibit sodium and chloride reabsorption leading to extensive diuresis
• Monitor for dehydration and increased urination

Managing Heart Failure with Diuretics

• Hydrochlorothiazide (HydroDIURIL) which is potassium wasting and Spironolactone (Aldactone) which is potassium-sparing are both diuretics
• Monitor I & O, and daily weight with diuretics
• Monitor potassium levels and report electrolyte abnormalities

Administering and Monitoring Diuretic Therapy in HF

• Monitor urine output during the day and administer diuretic therapy in the daytime to avoid nocturia
• Administer a diuretic, also check labs for electrolyte depletion prior.
• Monitor for elevated uric acid levels, gout, and assess lung sounds and edema to evaluate therapy

Inotropic Agents in HF

• Digitalis glycosides (digoxin) improve contractility
• Digitalis glycosides (digoxin) - Monitor for toxicity
• Monitor potassium level as well as Pulse/HR rate and rhythm before administration

Adrenergic Agonists in HF

• Adrenergic agonists increase the force of myocardial contractions
• Used for patients with Pulmonary edema, Severe ventricular dysfunction, and Low blood perfusion
• Dopamine is a vasopressor that Increases BP & myocardial contractility

What to Avoid & Nursing Care related to HF

• Nursing care related to HF is monitoring for hyperlipidemia and anemia
• Anemia is independently associated with HF disease severity
• Avoid NSAIDS. These can decrease renal perfusion
• Supplemental oxygen is needed and management of sleep disorder by providing CPAP

Nutrition and HF

• Low sodium diet restrictions of no more than 2g/day is recommended
• Supplements with Omega 3 fatty acid due to its decreased cardiovascular events is recommended

Pulmonary Edema and Interventions

• A life threat and common result of HF
• Often requires IV administration for loop diuretics
• Interventions should result in clear lungs, reducing respiratory distress/Anxiety.

Nursing Interventions, Rheumatic & Inflammatory Heart Disorders

• Nursing Interventions includes high fowlers, lean forward with oxygen support
• Rheumatic Fever can be prevented, through antibiotics, with Penicillin being the first line
• Endocarditis is usually developing from the toxic effects of the infection.

Myocarditis Facts

• Myocarditis is triggered by viral infections, bacterial infections, or autoimmune conditions
• Bed rest is needed
• Anti-embolism (or compression) stockings are put on so that patient does not get blood clots

Pericarditis Facts

• Pericarditis is triggered by infections, autoimmune diseases, MI or pneumonia
• Sitting up, leaning forward relieves pain
• NSAIDS and steroids decrease inflammation

Cardiomyopathy Facts

• Symptoms vary, depending on what type of cardiomyopathy is affected
• Three Types: dilated, restrictive, and hypertrophic
• All types of cardiomyopathies negatively impact the heart's ability to pump blood, which impairs circulation to the lungs

Classifications of Headaches

• Primary headache involves no organic cause
• Secondary headache is caused by an outside factor like brain tumor or stroke

Ischemic and Hemmorrhagic Stroke

• Thrombolytic therapy is best used 4.5 hours within having the stroke to have the best results
• Hemiplegia is paralysis of one side, while Hemiparesis is weakness of one side of the body

Nursing Intervention for Stroke Patients

• Safety should be a high priority of care for stroke patients, monitor blood and glucose
• The acronym NIHSS tool is used to assess stroke
• Rehabilitation is a must, set realistic goals
• Disclaimer: Please note that my responses should not be used as a substitute for professional medical device. Always consult with a qualified healthcare provider for diagnosis and treatment.*