Jennifer Smith & Kelly Strine - PowerPoint Presentation

Slide1

Jennifer Smith & Kelly Strine

Congestive Heart FailureSlide2

Congestive Heart Failure

Results from any structural or functional disorder that impairs the ability of the ventricle to contract and effectively pump blood to meet the metabolic needs of the tissue.

Affects the cardiovascular and pulmonary system

Associated with a hypercoagulable stateIncreased trend of heart failure with preserved ejections fraction of 50% or higherClassified as “diastolic”(preserved ejection fraction) or “systolic” (reduced ejection fractionPatients may have both diastolic and systolic dysfunction

(

Dunphy

,

Winland

-Brown, Porter & Thomas, 2011)Slide3

NYHA Functional Classifications

Class I: No limitation of physical activity; ordinary physical activity does not cause undue fatigue, palpitations, or dyspnea

Class II: Slight limitation of physical activity; comfortable at rest, but ordinary activity results in fatigue, palpitations, or dyspnea

Class III: Marked limitation of physical activity; comfortable at rest, but less than ordinary activity results in fatigue, palpitations, or dyspneaClass IV: Unable to carry on any physical activity without discomfort; symptoms present at rest if any activity is undertaken, discomfort is increased

(McMurray, 2010)Slide4

Pathophysiology

Myocardial injury leads to pathologic remodeling of left ventricle affecting its size, shape, and function impairing its contraction

Neurohumoral

imbalance, increased cytokines, and inflammatory changesApoptosis results in energy starvation and oxidative stressTissue hypoperfusionElevated levels of norepinephrine, angiotensin II, aldosterone, endothelin, vasopressin, and cytokinesInadequate delivery of oxygenResults in pulmonary and systemic venous hypertension

Progressively worse if left untreated

Exacerbated by additional injury (e.g. myocardial infarction)

Sympathetic Stimulation- increased heart rate

Activation of renin-angiotensin-aldosterone system

Hypertrophy

(McMurray, 2010) Slide5

Etiology

Coronary Heart Disease

Myocardioal

InfactionHypertensionDiabetesCardiomyopathyValvular DiseaseArrhythmiasCongenital Heart DefectsThyroid DisordersAlcohol/Cocaine or other Drug use

(

Dunphy

,

Winland

-Brown, Porter & Thomas, 2011)Slide6

Pathophysiology

Systolic Dysfunction

Forward Heart Failure

Diastolic DysfunctionBackward Heart FailureLeft Sided Heart FailureRight Sided Heart Failure

(

Dunphy

,

Winland

-Brown, Porter & Thomas, 2011)Slide7

Incidence

Affects approximately 5 million in U.S.

Over 550,000 diagnosed each year

Primary reason for 12-15 million office visits6.5 million hospital days per year80% of hospitalized patients >65<1% in those less than 50Most common Medicare diagnosesMore common in malesAfrican Americans have higher risk

(Hunt et al, 2011)Slide8

Screening

Evaluate potential risk factors with thorough history

Assess patient’s ability to perform ADL’s

Assess fluid volume status, orthostatic BP, BMIScreen for cardiac risk factorsInitial laboratory evaluationTwelve lead electrocardiogramEchocardiogramCoronary arteriography in patients presenting with HF and anginaStress testingSlide9

Risk Factors

Coronary Artery Disease

Myocardial Infarction

Hypertension Valvular Heart DiseaseDiabetes MellitusCardio toxic MedicationsGenetics (Familial cardiomyopathy)Mediastinal RadiationObesity/Metabolic SyndromeRheumatic Heart DiseaseObstructive Sleep ApneaHIVIllicit drugs and ETOHCongenital Heart Defect

Kidney disease

(Hunt et al, 2011) Slide10

Subjective Clinical Findings

Dyspnea at rest worse with exertion

Fatigue

Generalized weaknessExercise IntoleranceFluid Retention, EdemaAbdominal bloating Nocturnal nonproductive coughOrthopneaParoxysmal nocturnal dyspneaWheezing at night with no history of asthma or infectionAnorexia or dull pain right upper quadrant

(

Dunphy

,

Winland

-Brown, Porter & Thomas, 2011)Slide11

Left

vs

Right

(

Zerwekh

,

Claborn

& Miller, 2007)Slide12

Physical Findings

Rales and sometimes wheezing

Peripheral edema

Cool extremitiesAscitesElevated JVDS3 gallop Pre-sacral edemaScrotal EdemaHepatomegalyHypoxemiaPleural effusion and tendernessWorsening mitral or tricuspid regurgitationMay have an arrhythmiaAltered mental status

(

Dunphy

,

Winland

-Brown, Porter & Thomas, 2011)Slide13

Clinical Findings

Congestive Heart Disease, N.D.Slide14

Differential Diagnosis

Pulmonary embolism

Exertional asthma

Cardiac ischemiaCOPDConstrictive pericarditisNephrotic syndromeCirrhosisVenous occlusive diseaseAnemiaSepsisHyperthyroidismPeripheral edema

(Domino, 2011)Slide15

Social Considerations

Alcohol consumption should be no more than 1 glass of wine per day.

Dietary sodium restriction of 2 grams per day or lower is recommended.

Regular exercise should be encouraged as it improves functional status and decreases symptoms. Cardiac rehab is available to assist with this.Abstaining from cigarette smoking and avoidance of second hand smoke is recommended.Immunizations from influenza and pneumococcal vaccine can reduce risk of respiratory infection.Slide16

Laboratory Tests

Complete blood count

Urinalysis

CMP or serum electrolytes to include calcium, magnesium, blood urea nitrogen, serum creatinine, fasting blood glucoseGFRLipid panelLiver Function TestsThyroid Stimulating HormoneSerum natriuretic peptide (BNP)HGA1C Laboratory tests for rheumatologic diseases such as amyloidosis and pheochromocytomaSlide17

Diagnostics

Chest x-ray (PA and lateral)

Two-dimensional echocardiogram is most useful test to determine ejection fraction and valvular abnormalities

Twelve-lead electrocardiogramMaximal Exercise Stress TestingNuclear imaging for estimation of ventricle size, perfusion, and systolic functionCoronary arteriography with angina or ischemiaEndometrial biopsy Holter monitoringElectrophysiology studiesCardiac MRI or transesophageal Doppler 2D echocardiography

Peak flow or

spirometrySlide18

Management

Goal of therapy is to decrease symptoms, hospitalizations, and prevent premature death

Reduce pulmonary venous pressure and congestion

Identify and treat the cause of the heart failure Recognize and treat underlying heart disease or comorbidities such as diabetes hypertension or hyperlipidemiaAdjust diuretics therapy to maintain dry weightRate control for atrial fibrillationEliminate tachycardiaTreat hypertensionPrevent thrombus formation

(

Dunphy

,

Winland

-Brown, Porter & Thomas, 2011)Slide19

Non-Pharmacological

Fluid Restrictions < 2L/day

Low Sodium Diet < 2 g/day

Daily weights after voiding in the morningExercise program and rehabilitation programLifestyle modifications: smoking cessation, alcohol limitations, illicit drug useCoronary RevascularizationValve ReplacementCardiac TransplantResynchronizationImplantable cardioverter-defibrillator (ICD)Biventricular PacingTreat anemia

(McMurray, 2010)Slide20

Pharmacological

Diuretics including loop diuretics, thiazides, potassium-sparing

Angiotensin-converting enzyme (ACE) inhibitors (1

st line with diuretics)Angiotensin-II receptor antagonist- Losartan, ValsartanAldosterone antagonist- (Spironolactone)Hydralazine in combination with nitrateBeta-blockers (1st line therapy in systolic dysfunction)DigoxinCalcium channel blocker (Amlodipine)Vasodilators-nitratesAnticoagulants

Antiplatelets

Inotropic agents (

dobutamine

,

milrinone

)Morphine for acute treatment of associated pulmonary edema

NSAIDS contraindicated

(

Verdecchia

, et al., 2009)Slide21

Complications

Declining functional capacity

Electrolyte disturbances

Acute pulmonary edemaFrequent hospitalizationsAtrial fibrillationLeft ventricular thrombusCerebral embolismSudden death from arrhythmiaRenal failureDeath

(

Owan

et al,

2006)Slide22

Follow Up

Cardiologist Referral is recommend at the onset of symptoms.

The Joint Commission has established mandated core measures for hospitalized patients.

Assessment of left ventricular function with Ejection Fraction (EF) notedIf EF less than 40% patient must be placed on an ACEI or ARBCounseling on smoking cessation must occurDischarge education must include activity level, diet, discharge medications, follw0up appointments, weight monitoring, what to do if symptoms worsen

Upon discharge home, it is recommended that patients have intensive home-care surveillance with home care nurses to decrease the need for hospitalization.

Patients should be seen by their provider within 1 week of discharge and at least every 3 months thereafter.Slide23

Consultation/Referral

Multidisciplinary Team Approach

Refer patients with suspected heart failure and a BNP between 100 and 400

pg/ml to have transthoracic Doppler 2D echocardiography and to see a cardiologist within 2 weeksSeek specialist advise before offering second-line treatment to patients with HF due to left ventricular systolic functionPulmonologistCardiac Rehab ProgramSupport GroupsDieticianHome HealthTransplantHospiceSlide24

References

Aurigemma

, G.P. &

Gaasch, W.H. (2004, September). Diastolic heart failure. The New England Journal of Medicine. 351(11), 1097-1105.Congestive heart disease. (n.d.) Miller-Keane Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health, Seventh Edition. (2003). Retrieved January 25 2014 from

http://

medical-dictionary.thefreedictionary.com/Congestive+heart+disease

Domino, F. (2011).

Griffith’s 5 Minute Clinical Consult.

19

th

Ed. Lippincott Williams & Wilkins.

Dunphy

, L. M.,

Winland

-Brown, J. E., Porter, B. O., & Thomas, D. J. (2011).

Primary care: The art

and

science of advanced practice nursing

. (3 ed.). Philadelphia, PA: F.A. Davis Company

.

Hunt, S.A., Abraham, W.T., Chin, M.H., Feldman, A.M., Francis, G.S.,

Ganiats

, T.G., Jessup, M

.,

Konstam

, M.A., ACC/AHA 2005 Guideline update for the diagnosis and treatment of heart failure

adult

: A report of the American College of Cardiology/American Heart Association Task Force

on practice

guidelines: Developed in collaboration with the American College of Chest

Physician and

the

International

Society for heart and lung transplantation. Circulation, 2005, 112, 154-235.

doi

://10.1161/CIRCULATIONAHA.105.167586

.

Homma, S., Thompson, J.L.,

Pullicino

, P.M., Levin, B.,

Freudenberger

, R.S.,

Teerlink

, J.R., Ammon, S

Graham, S., Sacco, R.L., Mann, D.L., Mohr, J.P., Massie, B.M.,

Labovitz

, A.J., Anker, S.D.,

Lok

,

D.J.,

Ponikowski

, P.,

Estol

, C.J., Lip, G., Di

Tullio

, M.R., Sanford, A.R., Mejia, V., Gabriel, A.P.,

Valle, M.L., &

Buchsbaum

, R. (2012, May). Warfarin and aspirin in patients with heart failure and

sinus rhythm.

The New England Journal of Medicine.

366(20), 1859-1869.

McMurray, J.V. (2010). Systolic heart failure.

The New England Journal of Medicine.

362(3), 228-38.Slide25

References

Owan

, T.E., Hodge, D.O.,

Herges, R.M., Jacobsen, S.J., Roger, V.L., & Redfield, M.M. (2006, June). Trends in prevalence and outcome of heart failure with preserved ejection fraction. The New England Journal of Medicine. 355(3). 251-259.Verdecchia, P., Angeli, F., Cavallini, C., Gattobigio

, R., Gentile, G.,

Staessen

, J. A., et al. (2009). Blood pressure reduction and renin-angiotensin system inhibition for prevention of congestive heart failure: A meta-analysis.

European Heart Journal

, 679-688

.

Zerwekh

, J.,

Claborn

, J. C., & Miller, C. J. (2007).

Memory notebook of nursing

. (4 ed., Vol. 2).

New York

, NY: Nursing Education Consultants.Slide26

Questions

1

. The treatment goals for HF include:

Improve symptoms Optimize fluid volume statusRestore normal oxygenationIdentify and treat etiologyE. All the above2. The practitioner should pay particular attention to the presence of which of the following findings that suggest HF on the physical exam:

Elevated JVD

Peripheral edema

Third heart beat

Diminished lung sounds

Both A and C

All of the aboveSlide27

Questions

Patients that have heart failure with an ejection fraction >50% are classified as:

Systolic heart failure

Diastolic heart failureHow would a patient that has dyspnea on less-than ordinary exertion would be classified according to the NYHA NYHA Class INYHA Class IINYHA Class IIINYHA Class IV

5. The most useful diagnostic test to evaluate patients with heart failure is:

CXR

Stress Test

2-D echocardiogramSlide28

6.

The following would be a contraindication in ACEI except:

Angioedema

HypernatremiaSerum creatinine > 3.0Hyperkalemia >5.57. Which medication classification can be substituted for ACEI:Beta-blockersVasodilatorAngiotensin II Receptor BlockerAldosterone antagonists

8. Patients taking aldosterone antagonists require frequent monitoring for:

Increased edema

Worsening HF

Hyperkalemia

Hypotension

QuestionsSlide29

Questions

Patients taking diuretics should be monitored frequently for:

Renal dysfunction

Electrolyte abnormalitiesSymptomatic hypotensionGoutAll of the above10. Diuretics should be administered at doses high enough to:Allow the patient to eat and drink whatever they want

Improve signs and symptoms of congestion

Reduce blood pressure enough that a ACEI will not be required