Heart failure

1.  Us. Waleed Ameen

5. Classification of Heart Failure
• Onset:
• Acute heart failure
• Chronic heart failure
• Affected side of the heart:
• Left heart failure
• Right heart failure
• Stages of heart failure severity:
• New York Heart Association
• American Heart Association/American College of Cardiology

6. Heart Failure Classification
NYHA Classification of Description
Functional Capacity
NYHA class I Asymptomatic
Table 1
NYHA class II Symptoms with moderate exertion
NYHA class III Symptoms with minimal exertion
NYHA class IV Symptoms at rest
New Classification based on symptoms Corresponding NYHA class
Asymptomatic NYHA class I
Table 2
Symptomatic NYHA class II/ III
Symptomatic with recent history of dyspnea NYHA class IIIB
at rest
Symptomatic with dyspnea at rest. NYHA class IV

7. Myocardial Disease / Injury
Impaired Ventricular Performance
Cardiac Cardiac
Output
Workload
Vicious Cycle
of
Heart Failure
Ventricular ↑ SNS
↑ HR
Remolding ↑ Contractility
Dilation & Vasoconstriction
Hypertrophy
↑ RAAS
Vasoconstriction
Na/H2O
Retention

11. What Are The Symptoms
of Heart Failure?
Think FACES...
• Fatigue
• Activities limited
• Chest congestion
• Edema or ankle swelling
• Shortness of breath
© 2008 Heart Failure Society of America, Inc.

15. Therapy for heart failure
Myocardial
dysfunction
Neurohomonal
Increased load activation
Drug therapy
Cardiomyocyte
dysfunction
Drug therapy Cell
transplantation
Cell death
Gene therapy Heart
transplantation
Heart failure

16. Treatment Considerations
Non-Pharmacologic
•Diet:
1. Salt restriction
2. Fluid restriction
3. Weight loss
4. Lipid control
Pharmacologic
•Alcohol
•Smoking
•Exercise
•Cardiac Rehab
•Palliative Services
•Social Support

17. Pharmacologic Interventions
Good Evidence to use the following exist:
1. ACE-Inhibitors
2. Beta Blockers
3. Spironolactone
4. Diuretics
5. Digoxin

18. Angiotensin Converting Enzyme Inhibitors
• Indication: All HF patients with sDysfunction (symptomatic or
not); [A]
• Goal :Reduce morbidity & Mortality
• Dose: Ideal dose controversial, start low and increase to
common dose
• Precautions:
- Baseline Serum K+ and Cr. at initiation of therapy required.
- Careful monitoring if sBP <100mmHg, or if elevated serum
Cr.
- Titrate as tolerated if administered with b-blockers [C].

19. ß-BLOCKERS
Limit the donkey’s speed, thus saving energy

20. Spironolactone
• Indication: Symptom at rest or new onset of
symptom in last 6mo. Beneficial for moderate to
severe HF.
• Dose: 25mg OD
• Precautions: Monitor kidney function & K+, >25mg
is rarely indicated.

21. Diuretics
• Indication: to control fluid overload (Edema, Ascites, Wt
gain)
• Goal: Improve morbidity
• Dose:
- Usually Furosemide, start @ 20mg/d and incr/decr as
needed
- Diuretics can be stopped if fluid overload resolves.
• Precautions: K+ wasting, typically given with
KCl supplements, Monitor serum K+.

22. ACE-Inhibitors
Evidence for Use:
Systemic reviews & RTCs show that ACE-Inhibitors
• reduced ischemic events
• slow disease progression
• improve exercise capacity
• decrease hospitalization & mortality for heart
failure compared with placebo.

23. DIURETICS, ACE INHIBITORS
Reduce the number of sacks on the wagon

24. Digoxin
• Indication:
1. HF + A.fib [A]
2. Patients still symptomatic despite use of Diuretics, ACEI &
b-Blockers.
3. PRN use to control dyspnea at rest (existing or new onset)
[A].
• Goal: Improve morbidity
• Dose: 0.125 – 0.25mg /d
• Precautions:
-Digoxin levels [when toxicity is suspected].
-Pushed to backburner b/c of recent discovery that it can incr
risk of death from any cause amongst women [not men]
w/HF and decr LVEF.

25. DIGITALIS COMPOUNDS
Like the carrot placed in front of the donkey

26. CARDIAC RESYNCHRONIZATION
THERAPY
Increase the donkey’s (heart) efficiency

37. Heart Failure: Nursing Diagnoses
• Impaired gas exchange related to ventilation perfusion
imbalance.
• Ineffective (cardiopulmonary) tissue perfusion related
to impaired arterial blood flow.

38. Heart Failure: Nursing Diagnoses
• Excess fluid volume related to excess fluid or sodium
intake and retention of fluid secondary to heart failure
and its treatments.
• Anxiety related to breathlessness and / or restlessness
secondary to inadequate oxygenation.
• Powerlessness related to inability to perform usual role
responsibilities.
• Knowledge deficit related to heart failure and its
treatments.

39. Nursing Management: Heat Failure
• Nursing Considerations
• Respiratory
• Supplemental oxygen
• Good lung assessment
• Monitoring
• Hemodynamic Monitoring
• Daily Weights
• I & O’s
• Laboratory Results
• i.e. electrolytes, BNP & digoxin levels
• Maintain
• Small frequent meals; low in salt
• Skin integrity

40. Nursing Management: Heat Failure
• Nursing considerations Cont.,
• Promote rest and avoid fatigue
• Assess for peripheral edema
• Client Education
• Medications
• Lifestyle changes
• i.e. low-sodium diet & activity-rest balance
• Daily weights
• S/Sx of worsening heart failure to report
• Importance of follow-up care

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