CONGESTIVE HEART FAILURE

1. CONGESTIVE HEART FAILURE Presented by: Shankar G

2. Introduction • Heart failure does not mean the heart has stopped working. Rather, it means that the heart's pumping power is weaker than normal. • With heart failure, blood moves through the heart and body at a slower rate, and pressure in the heart increases. As a result, the heart cannot pump enough oxygen and nutrients to meet the body's needs. cne

3. CONGESTIVE HEART FAILURE @Congestive heart failure is not a disease but a condition that occurs when the heart is unable to pump enough blood to meet the needs of the body's tissues. @ When the heart fails, it is unable to pump out all the blood that enters its chambers. @ An ejection fraction, is the percent of the blood pumped out during each heartbeat. @ An ejection fraction of 50% to 75% is normal . @ The ejection fraction in CHF falls below 40%; in severe failure it may drop as low as 5%. cne

4. Definition Heart failure describes the clinical syndrome that develops when the heart cannot maintain an adequate cardiac output. The heart pumps blood inadequately, leading to reduced blood flow, back-up (congestion) of blood in the veins and lungs, and other changes that may further weaken the heart.eart

5. Heart Failure can divided: - Right Sided Heart Failure - Left Sided Heart Failure -Diastolic heart failure (Inability to relax) -Systolic heart failure (Inability to Contract) cne

6. Right Sided Heart Failure • In right-sided heart failure, the right ventricle loses its pumping function, and blood may back up into other areas of the body, producing congestion. cne

7. Left Sided Heart Failure • Inability of the left heart to maintain its circulatory load, with corresponding rise in pressure in the pulmonary circulation usually with pulmonary congestion and ultimately pulmonary edema. cne

8. Diastolic heart failure • Diastolic dysfunction refers to an abnormality in how the heart fills with blood during diastole. The heart muscles do not relax in a normal manner and the heart may fill too slowly, asynchronously or with an elevation in filling pressure only. cne

9. Systolic heart failure • The left ventricle loses its ability to contract normally. The heart can't pump with enough force to push enough blood into circulation. cne

10. CAUSES Damage to the mechanisms that control the input and output of blood from the heart is usually the last stage of one of several heart or circulatory diseases. Heart failure can be a direct result of one of these diseases or it can occur over time as the heart tries to compensate for abnormalities caused by these conditions.

11. Coronary Artery Disease Congestive heart failure may develop slowly from heart damage due to atherosclerosis, Heart failure in such cases most often results from a localized pumping defect in the left side of the heart Damage After a Heart AttackPeople now often survive heart attacks, but eventually many develop heart failure from the physical damage done to the heart muscles by the attack

12. High Blood Pressure In hypertension, the heart muscles thicken to compensate for increased blood pressure, and over time the force of their contractions weaken and they have difficulty relaxing, thereby preventing the normal filling of the heart with blood DiabetesDiabetes contributes to heart failure, not only because of its association with obesity, high blood pressure, and coronary artery disease, but also because specific disease mechanisms that contribute to diabetes may also damage the heart.

13. Valvular Heart DiseaseThe valves of the heart, which control the flow of blood leaving the heart, can narrow, causing a back-up of blood, or they can close improperly, causing blood to leak back into the heart CardiomyopathiesCardiomyopathies are diseases that damage the heart muscles and lead to heart failure. Genetic factors or birth defects may play a role in the development of these conditions. HIV infection and chemotherapies also increase the risk for cardiomyopathies.

14. Other Causes for Heart Failure @ Chronic alcohol abuse @ Severe emphysema @ Excessive salt consumption,@ Hyperthyroidism,@ Thiamin deficiency,@ Pneumonia,@ High fever, @ Kidney & Liver Failure@ Amyloidosis, a disease in which a starchy protein (amyloid) builds up in tissues and organs, can cause congestive heart failure. @ Acute myocarditis, @ Long term use of anabolic steroids

15. PATHOPHYSIOLOGY Systolic Heart Failure Decreased ejection fraction Sympathetic nervous system stimulation Release of epinephrine & norepinephrine Support the failing heart Further damage to the heart Decreased renal perfusion Release of rennin from kidney Combines with Angiotensin I ACE converts Angiotensin I to Angiotensin II Vasoconstrictor & release of aldosterone Retention of Na+ & fluid

16. Increase preload & after load Decrease the contractility of myocardium Change myofibers structure & ventriculodilation Compensated by ventricular hypertrophy Myocardial ischemia Myofibril death

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18. SIGNS & SYMPTOMS Many symptoms of heart failure result from the congestion that develops as fluid backs up into the lungs and leaks into the tissues. Other symptoms result from inadequate delivery of oxygen-rich blood to the body's tissues.

19. Symptoms of Left-Side Heart Failure @Fatigue @ Shortness of breath @ Asthma-like wheezing @ Dry hacking cough & later cough that produces a pinkish froth. @ Loss of muscle weight due to low cardiac output.@ Central sleep apnea, in which the brain fails to signal the muscles to breathe during sleep, is a common condition associated with heart failure. @ Sleep apnea @ pulmonary edema @ the skin is clammy and pale

20. Symptoms of Right-Side Heart Failure @ Fatigue @ Shortness of breath or difficulty breathing, at first during exercise, and later with any activity @ Episodes of awaking at night with difficulty breathing or difficulty in lying flat in bed• @ A dry cough that lasts a long time @ Swollen ankles and feet, along with weight gain due to too much fluid in the body• @ Loss of appetite.

21. RHF • H- hepatomegaly • E- edema • A- ascitis • D- distended neck veins cne

22. LHF • C- cough • H- hemoptysis • O- orthpnea • P- pulmonary congestion cne

23. DIAGNOSTIC EVALUATION @ History @ Physical examination.@ Stress test@ Electrocardiogram @Echocardiography @ Angiography @ X-ray * Laboratory Tests@ Hematology@ Biochemistry

24. Exercise Stress Test Measuring heart rate, blood pressure, and oxygen consumption while patient is exercising. Appears to be a more accurate method for determining the degree of heart impairment than taking such measurements while the patient is at rest.

25. Electrocardiogram An electrocardiogram (ECG) cannot diagnose heart failure, but it is simple and painless to perform and can indicate underlying heart disease by suggesting enlargement of the heart muscle, coronary artery disease, or abnormal cardiac rhythms. It may be effective in determining patients who do not need a more accurate (but moreexpensive) echocardiogram.

26. Echocardiography The best diagnostic test for congestive heart failure is echocardiography coupled with studies known as Doppler flow . Cardiac ultrasounds provide accurate indications of valve function and the flow of blood through the heart's chambers. They can reveal whether the failure is on the left, the right side, or both. Echocardiograms also indicate the ejection fraction, the percent of the blood pumped out during each heart beat.

27. X-Rays X-rays, can reveal cardiac enlargement or evidence of fluid accumulation around the heart and lungs. X-rays are helpful to both diagnose congestive heart failure and confirm the effectiveness of treatment.

28. Angiography Angiograms, help locate problems in the heart's pumping action or blockage in the arteries. Major complications of angiography include stroke, heart attacks, and kidney damage, but these risks are very low (about 0.1%).

29. PROGNOSIS Women have a better survival rate than men do when heart failure is caused by valvular heart disease, high blood pressure, or alcohol abuse. (Some studies indicate that this is because men may be more susceptible to the process of heart muscle-cell remodeling, a damaging effect of hypertension). The survival rates of women and men are more equal, however, when heart failure is caused by coronary artery disease or heart attack.

30. Classification of Severity A classification system was developed by the New York Heart Association to grade congestive heart failure by severity of symptoms. NYHA Classification System for Heart Failure

31. Class I: @ No limitation of physical activity. @ No shortness of breath, fatigue, or heart palpitations with ordinary physical activity.

32. Class II. @ Slight limitation of physical activity. @ Shortness of breath, fatigue, or heart palpitations with ordinary physical activity, but patients are comfortable at rest.

33. Class III. @ Marked limitation of activity. @ Shortness of breath, fatigue, or heart palpitations with less than ordinary physical activity, but patients are comfortable at rest.

34. Class IV. @ Severe to complete limitation of activity. @ Shortness of breath, fatigue, or heart palpitations with any physical exertion and symptoms appear even at rest.

35. Complications The most serious complications of heart failure are arrhythmias (irregular beatings of the heart). Acute pulmonary edema (fluid in the lungs), which is strongly associated with heart failure, can also be life-threatening.

36. COMPLICATION • Pulmonary Edema • Pulmonary Hypertension • Pleural Effusion • Cardiogenic shock • Portal Hypertension • Arrhythmias.

37. PHARMACOLOGY General GuidelinesThe primary conditions causing heart failure should be treated first, including coronary artery disease, valvular abnormalities, high blood pressure, arrhythmias, anemia, and thyroid dysfunction. Treating heart failure itself at as early a stage as possible offers the best chance for a longer and better quality life.

38. Four classes of medications are used to treat heart failure: @ Diuretics (drugs to reduce fluid),@ Vasodilators, particularly ACE inhibitors (drugs that dilate blood vessels),@ Inotropics, usually digoxin (drugs that increase the heart's ability to contract), and more recently,@ beta blockers (drugs that block activities of stress hormones on the failing heart).

39. Diuretics Diuretics act on the kidneys to rid the body of excess salt and water. They reduce the accumulation of fluid in the legs, abdomen, and lungs, lower blood pressure, and improve the efficiency of the circulation. Side Effects.Side effects of diuretics include low blood pressure, dehydration, and kidney dysfunction;

40. ACE Inhibitors These drugs block the formation of angiotensin II, a powerful enzyme that raises blood pressure, constricts blood vessels, and leads to salt retention. Commonly used ACE inhibitors are captopril (Capoten), enalapril (Vasotec). The primary adverse effect of ACE inhibitors is low blood pressure, kidney failure,dry cough , excessive potassium levels;

41. Beta Blockers Beta blockers prevent norepinephrine (adrenaline) from binding to heart cells, which affects the frequency and force of heart beats. Elevated levels of norepinephrine, a stress hormone, can over stimulate the failing heart and are associated with severe heart failure. Beta blockers must be carefully monitored and the dosages regulated very carefully, since heart failure may actually worsen in the early stages of treatment. It should not be used in people with asthma, bradycardia, low blood pressure, or people with certain heart conduction disorders.

42. Digitalis Digitalis is referred to as an inotropic drug; it increases the strength of the heart's contractions, reduces heart size, and reduces certain arrhythmias. Derived from the foxglove plant. Digitalis may be useful for patients with systolic dysfunction characterized by low ejection fractions and is helpful in heart failure patients with atrial fibrillation. Digitalis may even be harmful in some patients with heart failure, particularly when caused by diastolic dysfunction characterized by normal to high ejection fraction.

43. The most serious side effects are arrhythmias. Factors which increase the risk of toxicity include advanced age, low blood potassium levels (which can be caused by diuretics), hypothyroidism, anemia, valvular heart disease, and impaired kidney function. Early signs of toxicity may be irregular heart beat, nausea and vomiting, stomach pain, fatigue, visual disturbances, and emotional and mental disturbances. Toxic side effects used to be experienced by nearly 25% of patients taking digitalis, but now that a blood test can be used to monitor the level of the drug in the blood, toxicity is down to 2%.

44. NSAIDs: A Special Warning Recent use of NSAIDs has been associated with a higher risk of hospitalization in heart failure patients, particularly if they are also taking diuretics or ACE inhibitors. In fact, one study suggested that anyone with a history of heart disease who is taking NSAIDs may be at higher risk for heart failure

45. NURSING MANAGEMENT OBJECTIVES • To maintain adequate ventilation • To increase cardiac output. • To provide physical & emotional rest. • To reduce / eliminate edema. • To provide health teaching.

46. INTERVENTIONS • Monitor respiratory status & provide adequate ventilation: • O2 therapy • Semi or high fowler position. • Monitor ABGs. • Assess for breath sounds. • Provide physical & emotional support.

47. Increase Cardiac Output. • Digitalis as ordered. • Electrolytes level (K+) monitoring. • ECG • Vital Signs. • S. Digoxin Level

48. Reduce / eliminate edema • Diuretics • I/O monitoring • Daily weight & abdominal girth • Monitor CVP & electrolytes levels • Low salt & fat diet. • Skin care

49. LIFESTYLE RECOMMENDATIONS Between 30% to 47% of patients who require hospitalization for heart failure are back in the hospital again within six months. Many people return because of lifestyle factors, such as poor diet, failure to comply with medications, and social isolation.

50. Home Support and Rehabilitation Elderly people who had no emotional support at home had triple the risk of a heart attack after hospitalization for heart failure than those who did have such support. In another study, the greatest risk factor for death and readmission to the hospital after a first hospitalization for heart failure was being single, regardless of the health of the patient at discharge.Programs that offer intensive follow-up to ensure that the patient complies with lifestyle changes and medication regimens at home are reducing rehospitalization and costs and improving survival.