HF Notes PDF

{Heart Failure}- aka pump failure, inability of heart to work effectively as a pump. Major Type of HF: ❖ Left Sided Heart Failure- (LHF) ❖ Right Sided Heart Failure- (RHF) ❖ High-Output Failure- (HOF) ⬇️ ejection fraction Most HF begins w/ LV failure → fa...

{Heart Failure}- aka pump failure, inability of heart to work effectively as a pump. Major Type of HF: ❖ Left Sided Heart Failure- (LHF) ❖ Right Sided Heart Failure- (RHF) ❖ High-Output Failure- (HOF) ⬇️ ejection fraction Most HF begins w/ LV failure → failure of both ventricles. 💗 can’t contract forcefully enough during systole to eject adequate amt of 🩸 {Systolic Heart Failure}- HF w/ - {Ejection Fraction}- % of 🩸 ejected from 💗 during systole. into circulation. EF drops from a normal of 50%-70% → ⬇️40% w/ ventricular dilation. - - - As it decreases tissue perfusion diminishes → blood accumulates in pulm vessels. ⬇️ - Mani: s/s of inadequate tissue perfusion or pulm & systemic congestion. - Sometimes called forward failure bc CO is & fluid backs up into pulm system. - If EF + 1.8 mg/dL→ notify before admin of potassium. - Venous dilators (nitrates)- Pt w/ HF & persistent dyspnea. Benefits include, returning venous vasculature to more normal capacity, decreasing vol of blood returning to heart, improving LV function. Primarily cause venous , but also a significant amt of arterial vasodilation. Drug Enhancing COntractility: - Digoxin: pt w/ chronic HF w/ sinus rhythm and atrial fibrillation. 💗 Reduces ecacerbations. Potential benefits : Increased contractility, reduce rate, slowing of conduction through the atrioventricular node, inhibition of sym. Activity while enhancing parasym activity. S/s toxicity: anorexia, fatigue, blurred vision. Changes in mental status. - Other Inotropic: Beta adrenergic agonists (dobutamine) short term tx of acute episodes of HF. Milrinone (vasodilator/ inotropic agent) , aka photophodiestrase inhibitor, increases cyclic adenosine monophosphate. Enhances entry of calcium into myocardial cells to increase contractile function. *Do Beta-adrenergic- sodium glucose cotransporter Other Non-Surgical - CPAP: improves obstructive sleep. Improves CO/Ejection Fraction. Sleep apnea directly correlated w/ CAD. - Cardiac Resynchronization Therapy (bioventricular pacing) permenant pacemaker alone or combo w/ implantyable cardioverter/ defibrillator. Electric stim = more synchronous vent. Contractions to improve CO, EF MAP. Indicated for class III/IV.  - CCM- pt who may not meet criteria for CRT. Inserted underskin in chest weall w/ leads in RV. Delivers electrical current, increases contractility w/o increasing need of o2. ❣️ - CardioMEMs - implantable monitoring system inserted into pulm artery, allows pt to take a daily reading of pulm artery pressure. Implanted during right catheterization. Pt provided with a special pillow & antenna, turns it on and sleeps on top of it. Can detect increases in pulm pressure, indicatiog fluid retention befor pt demonstrates symptoms - Gene Therapy: may be indicated for pt w/ gene therapy. SX Management: - Heart transplantation. - Ventricular Assist Devices: mechanical pump implanted to work with pt own heart. Both left and right VAD available. End-Stage kidney disease, severe chronic lung disease, clotting disorder, infections = not candidates. Post -op comps = bleeding, infective endocarditis, ventricular dysrhythmias, stroke. - Other SX: LV Surgical reconstruction, however potential impact/long-tem survival rates have not been established. - Endoventricular Circular Patch Cardioplasty- syrgeon removes portions of the cardiac septum and LV wall & grafts a circular patch into opening. Preventing Pulm Edema: - Monitor for signs of acute pulm edema, MI, Mitral Valve Disease, possibly dysrhythmias. - If pt systolic blood pressure above 100 mg Hg, admin sublingual nitroglycerin every 5 min x 3 doses while establishing IV access. - HCP orders rapid-acting diuretic s/a furosemide/bumetanide. Furosemide 1-2 min push to avoid ototoxicity. - If pt blood pressure is adequate, IV morphine sulfate may be prescribed to reduce venous return. - In severe cases of FOL/ Renal Dys. ultrafiltration may be used. Benefits include: decrease in cardiac filling pressure/ pulm arterial pressure, Increase in cardiac index, reduction in norepinephrine renin, aldosterone. Self-management - “MAWDS” - Medication, Activity, Weight, Diet, Symptoms. Activity Schedule - Regular excessive regimen, no overdoing it. - May need to do 6 weeks to fully participate in the program.3 - If chest pain/severe dyspnea occurs while exercising or the patient has fatigue, pt is probably advancing too quickly. Drug Therapy - Oral, written, video instructions about drug regimen. - Diuretics- take in morning to avoid late night peeing.  - ACEIs/ARBS move slowly when changing position, especially from lying/ sitting. - Serum potassim/ renal monitored every few months for pt taking diuretics and ACE inhibitors, ARBs, Sacubitril/Valsartan, potassium-sparing diuretics. Nutrition Therapy: - Restrict dietary sodium - 3 gm sodium - Avoid milk, cannerd, prepared foods. - Commercial salt substitutes contains potassium→ renal/ serum potassium lvl evaluated. - Suggest lemons, spices, herbs to enhance low-salt food. Advance Directives - 50% of deaths from HF are sudden. - Any written directives? Health Care Resources - Home care nurse, ambulatory care clinic, nurse-led follow up program. - Many large hospitals use follow-up telephone calls - AHA → HF path to help pt manage HF. App includes weight, symptom and medication tracking. Valvular HD - Mitral stenosis/ regurgitation/ valve prolapse, aortic stenosis/ regurgitation. Mitral stenosis - usually results from rheumatic carditis, which can cause valve thickening by fibrosis and calcification. - Rheumatic fever = most common cause of problem. Valve leaflets fuse and become stiff, chordae tendineae contract and shorten. LA pressure rises, LA dilates, pulm artery pressure increases, RV hypertrophies - Pulm congestion & RHF occur first → LV receives insufficient blood volume, preload decreases, CO falls. - Mild=asymptomatic - DOE, orthopnea, paroxysmal noc dys, palpitations ,dry cough. Hemoptysis/pulm edema & pulm hypert as congestion progresses. Mitral Regurgitation - Prevents mitral valve from closing completely during systole. This allows backflow into LA when LV contracts. - Diastole- regurgitant output again glows from LA to LV along w/ normal blood flow. Increased vol must be ejected during next systole. - Causes of prime mitral regurg= mitral valve prolapse, rheumatic HD, ineffective endocarditis, MI, Marfan syndrome, dilated cardiomyopathy. Ischemic and  nonischemic heart diseases that damage valve. Theumatic heart disease # 1 cause. - Progresses slowly. Sym begin when LV fails. - S/S: fatigue, chronic weakness, DOE, orthopnea, anxiety, atypical chest pains, palpitations. - RF Symptoms Mitral Valve Prolapse - Occurs b/c valvular leaflets enlarge and prolapse into the left atrium during systole. Usually benign but may progress to pronounced mitral regurgitatio. - Been associated w/ Marfan syndrome. - Chest pain, palp, exercise intolerance. Aortic Stenosis - Most common cardiac valve dysfunction. - Orifice narrows and obstructs LV outflow during systole. - Increased resistance results in V hypertrophy. - LV eventually fails d/t backed up blood in LA, pulm system becomes congested. - Congenital bicuspid, uncuspid aortic valves = primary causes for aortic stenosis. - Dyspnea, angina, syncope on exertion. When CO falls, marked fatigue, debilitaiton, peri cyanosis. Narrow pulse. A diamond-shaped, systolic crescendo-decrescendo murmur is usually noted on auscultation Aortic Regurgitation: - Valve leaflets dont close properly during diastole, annilus may be dilated, loose, or deformed. Blood flow from aorta back into LV during diastole. - LV compensation, dilates to accommodate more vlood→ hypertrophies. - Usually results frm, nonrheumatic conditions s/a ineffective endocarditis, congenital anatomic aortic valvular abnormalities, hypert, marfan syndrome. - Asymptomatic for years, when LV fails→ exertional dyspnea, orthopnea, paroxysmal noc dys. “Bounding: arterial pulse. Pulse pressure widened, elevated systolic, diminished diastolic. High-pitched blowing, decrescendo diastolic murmur. Recognize Cues - Fam HX, rheumatic fever, ineffective endocarditis. IV Drug misuse? - Phys Assessment: signs of edema, obtain vital signs, palpate/aus lungs/heart. 💗 - Endocardiography- noninvasive diagnostic procedure ,visualize the structure/ movement. - Transesophageal Endocardiography/Transthoracic Endocardiography: assesses most valve problems - Exercise Tolerance Test: done to eval symptomatic response/assess functional capacity. Nonsurgical Management - Diuretics, beta blockers, ACEIs, Digoxin, 02  - Prophylactic Antibitoic therapy b4 any dental surgery - Majoe concern in valvular heart disease= maintaining CO. When Atrial Fibrillation develops –. CO can decrease, HF may occur. - Low-dose amiodarone to slow vent rate. - Atrial fibrillation+valvular heart disease = usually warfarin to prevent thrombus. - Assess neuro status. - Ruvaroxaba, dabigatran, apixaban, edoxavan not recommended to anticoagulant pt w/ atrial fibrillation r/t valvular disease. - Rest+exercise Nonsurgical Heart Valve Reparative Procedures - “Turn back the clock” → more functional valve/ improvement. - Balloon Valvuloplasty- invasive non-surgical procedure, possible for stenotic mitral & aortic valves. - Aortic Valv- usually older & @ high risk for surgical complications. Rarely lasting 3 m, s/s RHF, elevated systemic venus pressure w/ jugular distention, hepatic engorgement, dependent edema. Interventions - NSAIDS to relieve pain - Corticosteroid Therapy - Pain not relieved in 24-48 hrs → contant HCP - Colchicine can be used as adjnt to NSAIDS → reduce symptoms and decrease rate of recurrence.  - Pericarditis → short term 2-6 weeks, episodes may recur, - Chronic pericarditis → chemo/ radiation - Uremic peri→ hemodialysis - Definitive tx = sx excision (pericardectomy) - Monitor all pt for pericardial effusion- when space b/t parietal/visceral layers if the pericardium fills w/ fluid. - Emergency Care: - Cardiac tamponade- small vol of fluid accumulate rapidly in peri, cause sudden decrease in CO. - Peri may stretch to accommodate. - Findings include: JVD, paradoxical pulse, tachycardia, muffled heart sound, hypoT - Cardiac tamponade is an emergency - Pericardiocentesis- remove fluid and relieve pressure on the heart. Rheumatic Carditis - Sensitivity response that dev after URI w/ group A beta-hemolytic streptococci. - Characterized by formation of Aschoff bodies. Diffude cellular infiltrate also develops and may be responsible for HF. Peri covered w/ exudate. Recognize Cues: - Tachycardia - Cardiomegalyu - New Murmur - Periardial friction rub - Precordial pain - ECG changes - Indications of HF - Evidence of an existing streptococcal infection. Needs antibiotics if: - Mod- high fever - Abrupt onset of sore throat - Reddened throat w/ exudat - Enlarged and tender lymph nodes Take Action: - Penicillin = choice - Erythromycin alternative Cardiomyopathy: - subacute/ chronic disease of cardiac muscle,. - X4 categories dilated, hypertrophic, restrictie, arrythmogenic right ventricular. - Dilated- extensive damage to myofibrils, interference w/ myocardial metabolism, both ventricles dilated, systolic function i impaired. (alcohol misuse, chemo, infection, inflammation, poor nutrition.  - Hypertrophic CardioM- asymmetric ventricular hypertophry and disarray of myocardial fibers, LVH l/t stiff LV, → diastolic filling abnormalities. Obstruction in LV OF. - Restrictive CardioM- rarest, stiff V that restrict during diastole. Symptoms similiar to RHF/LHF or both, can be primary or c/n ndocardial / myocardial disease. - Arrhythmogenic Right Ventricular Cardiomyopathy: replacement of myocardial tissue w/ fibrous & fatty tissue. Famial association. Recognize Cues: - Depend on structural and functional abnormalities. - DCM (dilated cardiomyopathy) - asymptomatic for months-years. - Others have sudden, pronounced symptoms of LVF - HCM results from hypertrophied septum causing reduced stroke volume, cardiac output. Chest pain at rest, no relation to exertion, not relieved by nitrates. Non SX: - Diuretics, vasodilating agents, cardiac glycosides. - Negative inotropic agents s/a beta-adgernic blocking agents and calcium antagonists. Decrease outflow obstruction. Decrease HR. - Vasodilators, diuretics, nitrates, cardiac glycosides contraindicated in pt w/ obstructive HCM. - Strenuous exercise prohibited. SX Management: - Myectomy and Ablation: - Common tx of obstructive HCM involves excising a portion of the hypertrophoied ventricular septum to create a wider outflow tract. - Procedure results in longterm improvement - Percutaneous Alcohol Septal Ablation- HCM. Anslte alcool injected into target septal branch of the left anterior descending coronary artery to produce septla infarction. Overtime, results in remodeling of the area, reducing the obstruction. - Arrythomogenic Right Ventricular Cardiomyopathy who does not respond to drug therapy may have a radiofrequency. Heart Transplantation: - Tx of choice for DCM. End stage HD c/b CAD, alveolar disease, CHD. Preop: Criteria: - Life expectency 300 mOsm/L are hypertonic. - Fluids