Cardiac Conditions PDF

Cardiac
Conditions
Danielle G. Devilleres, PTRP
Coronary Artery Disease
• A focal, narrowing of the coronary artery which results to
a decrease in blood supply to the heart. There is an
imbalance in myocardial oxygen supply and demand.
definition
• Modifiable Factors
• Cigarette smoking
• Smoking increases Carbon monoxide level in the blood, which
may in turn damage the coronary endothelium.
epidemiology & risk

factors
• Hypertension
• The higher either the systolic or diastolic blood pressure, the
more likely development of CAD.
epidemiology & risk

factors
• Hypercholesterolemia
• The incidence of CAD increase with increasing total serum
cholesterol is carried in the blood by low-density lipoprotein
(LDL) or bad cholesterol and high-density lipoprotein (HDL)
or good cholesterol. The higher the percentage of total
cholesterol carried by LDL in relation to HDL, the higher the
risk of CAD. Patients with LDL to HDL ratios of greater than
2:1 are particularly prone to CAD.
epidemiology & risk

factors
• Sedentary lifestyles of Physical Activitiy
epidemiology & risk

factors
• Non-Modifiable Factors
• Age
• CAD usually occurs after age 40
epidemiology & risk

factors
• Gender
• Male has a higher risk of CAD than females with the same age
during the premenopausal period – younger than 40-50 years
old. During post-menopausal period, both genders will have
equal risk.
epidemiology & risk

factors
• Family history of CAD
epidemiology & risk

factors
• Race
• Caucasians > Blacks > Asians
epidemiology & risk

factors
• Other Contributing Risk Factors
• DM
• Obesity
• Type A personality
• Oral Contraceptives
epidemiology & risk

factors
• Arteriosclerosis
• Hyperplasia of Arterial Muscles
• Coronary Artery Spasm
• Coronary Artery Thrombus
etiology
• Main Pathophysiology of CAD is Arteriosclerosis. It stars
with the Virchow’s Triad:
• Stasis
• Endothelial injury
• Hypercoagulable State
pathophysiology
1
• Injury to the endothelial lining of the coronary arteries
causes platelets and WBC to converge at the injured site.
Macrophages congregate under the damaged lining and
absorbs oxidized cholesterol forming a fatty streak that
narrow the arterial lumen.
pathophysiology
2
• Because the arterial lumen narrows gradually, collateral
circulation develops and helps maintain myocardial
perfusion distal to the obstruction. When myocardial
demand for oxygen is more than the collateral circulation
can supply, myocardial metabolism shifts from aerobic to
anaerobic producing lactic acid which stimulates pain
nerve endings.
pathophysiology
3
• The patient experiences worsening angina that requires
rest and medication for relief. Lacking oxygen, the
myocardial cell die. This decreases contractility, stroke
volume, and blood pressure. Excessive damage to the left
ventricle may impair the ventricle’s ability to pump,
allowing blood back up into the left atrium and eventually
into the pulmonary veins, and capillaries. When this
occurs, the patient may be dyspneic, orthopneic,
tachypneic, and cyanotic.
pathophysiology
TYPE OF VESSEL INVOLVED AND THE EXTENT OF DISEASE
WITHIN THE WALL
1. Type I / Intimal Arteriosclerosis
Arteriosclerosis which affects the innermost layer of the vessels.
2. Type II / Medical Sclerosis

Affects the middle layer of the vessel and results in calcification and
hypertrophy. Individuals with this type of arterioclerosis develop
pipestem or rigid arteries, typically in the medium-sized vessels. Blood
flow is not usually produced.
3. Type III / Arteriolar Sclerosis

Affects small blood vessels with characteristic changes in both the
media and intima. Blood flood is reduced and Htn results.
pathophysiology
• Angina Pectoris
• Characteristics:
• The pain usually described as a squeezing pressure sensation.
• The symptoms usually begins at a low intensity, increases over
2-3 minutes, and last a total of less than 15 minutes.
• Radiation of anginal pain to the left arm is well known. Pain
also may radiate to the jaw, teeth or throat.
clinical manifestations
• Angina Pectoris
• Types:
• Stable Angina
• Onset: Chest pain on exertion. Pain that has been present for
some time.
• Method of Relief: Cessation of activity; rest.
• Intensity and duration: The quality, intensity & duration of pain
does not change. Responsive to Nitrates.
• Angina Pectoris
• Types:
• Unstable Angina
• Onset of pain: No definite level of exertion that will trigger
angina in arising. Now onset of angina occuring for the first
time.
• Method of relief: Less responsive to rest and nitrates
• Intensity and duration: The quality, intensity and radiation of
pain is changing.
• Angina Pectoris
• Types:
• Variant Angina
• Onset of pain: Pain often occurs at rest instead of during exercise
and most frequently early morning or on most often at night.
• A variation of unstable angina but its pathophysiology is
different. It results from spasm of coronary arteries.
• Method of relief: Unaffected by exertion, but it may be relieved
by rest and nitrates
• Intensity and duration: The pain is more intense of longer
duration than Angina Stable
• Myocardial Infarction (MI)
• Second manifestation of CAD
• Death or necrosis of some portion of the cardiac muscle
secondary to sustained myocardial ischemia
• Myocardial Infarction (MI)
• Clinical features:
• The pain usually presents with severe, oppressive chest pain or
pressure that persist for more than 30 minutes and is unrelieved
by nitroglycerin.
• The pain is frequently associated with nausea, vomiting or both
as well as diaphoesis and SOB.
• Pain radiation is similar to that of angina pectoris
• The pain usually occurs when the patient is at rest or involved
in minimal activity. Although possible, it is unusual for M.I to
be precipitated by vigorous activity.
• Sudden Cardiac Death
• an unexpected cardiac death occurring in an apparently
healthy individual engaging in his or her normal ADL
without prior symptoms of less than an hour’s duration
• The ventricle quivers rather than contracts. There is no
effective cardiac output. If sustained, death may result
within 4 minutes. Prompt initiation of CPR is the only
proven means of preventing SCD.
• Congestive Heart Failure
• characterized by the inability of the heart to maintain an
adequate cardiac output to meet the demands of the tissue,
one ventricle may fail initially, but soon the other ventricle
becomes affected, leading to total decompensation. Two
frequent situation are left-sided failure and right-sided
failure
• Arrythmias
• Irregular cardiac rhythm
• MC form of arrythmic death in an acute MI is ventricular
fibrillation
• Treatment:
• Prophylactic lidocaine – given intravenously
• Additional antiarrythymic theraphy – ex. Brethylium Tosylate,
Phenytoin Sodium (can be given intravenously with caution)
complications and
management
• Pump failure
• Treatment:
• Diuretics
• Digitalis – reduce both cardiac size and myocardial oxygen
consumption
• Vasodilators – may be useful in reducing cardiac afterload,
allowing increased cardiac output
complications and
management
• Cardiac rupture
• Nearly always fatal
• Results in cardiac tamponade – there is an excessive amount
of fluid in the pericardial space choking the heart and
preventing it from contracting and relaxing
complications and
management
• Shock
• Treatment:
• A swan-ganz catheter is placed to measure left ventricular
filling pressure if less than 18 mmHg
complications and
management
• The prognosis of patients with CAD is primarily
determined by two variables: the extent of coronary
disease in terms of the number of vessels affected by the
disease and the extent of left ventricular damage present
due to previous Ml.
prognosis
• Angina Pectoris
• Nitrates / Nitroglycerine
• Most valuable drug in the treatment of Angina
• Dilate coronary arteries as well as others in the body which
may cause hypotension
medical management
• Angina Pectoris
• Beta-blockers
• Slow down heart rate
• So oxygen demand decreases
medical management
• Angina Pectoris
• Calcium blockers
• Relax smooth muscle in the arteries to prevent spasm
medical management
• Angina Pectoris
• Percutaneous Transluminal Angioplasty (PTCA)
• Inserting a catheter into the coronary artery
• Inflates the balloon tip and widens the diameter of the blood
vessel
medical management
• Angina Pectoris
• Coronary Artery Bypass Graft (CABG)
• Bypassing one or more obstructed arteries either by the
anastomosing of a vein graft form the aorta or by patch grafting
to widen the artery
medical management
• Angina Pectoris
• Indications:
• Severe hypertension
• Moderate or severe aortic stenosis
• Uncontrolled ventricular arrythmias
• Uncontrolled tachycardia
• New York Functional Classification III and IV
medical management
• Angina Pectoris
• New York Functional Classification Class I
• Limits of activity – no limitations; no symptoms with ordinary
activity
• METS : >=7
• O2 Consumption : >=24.5
medical management
• Angina Pectoris
• New York Functional Classification Class II
• Limits of activity – slight limitation; comfortable at rest;
symptomatic with less than ordinary activity
• METS: 5-6
• O2 Consumption: 17.5-21
medical management
• Angina Pectoris
• New York Functional Classification Class III
• Limits of activity: marked limitation; comfortable at rest;
symptomatic with less than ordinary activity
• METS : 3-4
• O2 consumption: 10.4-14
medical management
• Angina Pectoris
• New York Functional Classification Class IV
• Limits of activity – symptomatic at rest; discomfort with any
activity
• METS : 1-2
• O2 consumption : 3.5-7
medical management
• Myocardial infarction
• primary the therapeutic objectives of management of the
patient with Ml are to prevent death from arrythmias and to
minimize the mass of infracted tissue.
• First and foremost, it is mandatory to maintain an optimal
balance bet myocardial O2 supply and demand in order to
salvage as much as possible of the jeopardized zone of
mycoradium surrounding the center of the infract.
medical management
• Therapeutic strategies that help attain this goal include:
• Analgesia
• Morphine
• This is still most effective and remains the drug of choice. It
lowers the arterial pressure and produce a feeling of well-being
associated with the relief of pain.
medical management
• Analgesia
• Demerol or Dilaudid
• This is effective employed in place of morphine.
• It relieves both pain and anxiety.
medical management
• Oxygen
• The use of O2 decrease arterial PO2 in many patients with Ml and
that O2 inhalation reduce infract size.
medical management
• Activity
• Factors which increases the work of the heart may increase the size
of the contractility are increasem should be avoided.
medical management
• Diet
• During the First 5 days, ingestions of food should be kept down
prevent cardiac output increase
• During the 2nd week, increasing amount of food may be introduce
into the diet.
• Willingness to accept dietary restriction and to discontinue cigarette
smoking is usually never greater than it is during this early period
of convalescene.
medical management
• Nitroglycerine
• Aspirin
• Thrombolysis
• PTCA
• CABG
medical management
• Patient Interview
• Determination of Chief complaint.
• Descriptors used to assist in problem identification are:
• Location
• Quality
• Quantity
• Course
• Setting
• Aggravating and alleviating factors.
• Associated symptoms
assessment
• Patient Interview
• Review of pt’s Hx
• Health Hx and Current meds Taken
• Family Hx
• Occupation Hx
• Social habits, including smoking, alcohol consumption, and
drug use.
• Functional and external activity levels
• Medication Hx
• Cough History
• Angina Pattern
• Onset, radiation, and relation to activity
assessment
• Physical Examination
• Temperature
• HR
• RR
• BP
assessment
• Observation
• Observation should begin with a general overview of the pt.
At rest and then during activity.
assessment
• Inspection and Palpation
• Universal precautions should be used when contact with a
pt. or body fluids is necessary.
assessment
• Inspection and Palpation
• Abnormal pulsations - By observing the thorax, abnormal
pulsations can be seen. Palpation of the precordium will
verify observation, thrill, or findings.
• Aortic area – 2nd interspaces of right sternum.
• Demonstrates a pulsation, thrill, or vibration
• Pulmonic area – 2nd and 3rd left interspaces
• Right ventricular area – lower left sternal border following
down to the 5th intercostals space
• Apical Area – 5th intercostals space, medial to midclavicular
line
• Epigastric area – upper central region of the abdomen
assessment
• Auscultation of the heart
• Korotkoff’s Sounds
• S1 : Lub : louder, longer, lower
: closure of AV valve
• S2 : Dub : closure of semulunar valves
• Extra Heart Sounds:
• S3 : Ventricullar Gallop
: Normal in young
: Adult - indicative of left ventricular failure
• S4 : atrial gallop
: Before S1
: Indicative - chronic hypertension
assessment
• Auscultation of the heart
• Murmurs:
• Indicative of defecti in the valves (heart)
• Bruits : heard in the peripheral arteries
assessment
• Graded Exercise Testing
• Prior to exercise program GXT (Graded Exercise Training)
may be performed. This is the observation and recording of
the patient’s cardiovascular responses during a measured
exercise stress
assessment
• Goals:
• To observe the electrocardiographic changes representative of
myocardial ischemia and coronary artery disease during known
work loads.
• To determine the functional aerobic capacity of the individual.
assessment
• Goals:
• To observe the electrocardiographic changes representative of
myocardial ischemia and coronary artery disease during known
work loads.
• To determine the functional aerobic capacity of the individual.
assessment
• The test begins with a low-level work load and gradually
increases to the point of cardiovascular limitation. Stages
are usually 2 to 3 minustes in duration, and allow the patient
to each steady state (a work situation in which O2 uptake
equals the O2 requirement of the tissues). Steady state work
can be detected during exercise by observing the heart rate
response, which levels off to a constant rate (usually within
three to four beats of the previous heart rate.) Heart rate,
blood pressure, rating of perceived exertion, and signs and
symptoms of exertional intolerance are closed monitored
throughout the test and during recovery..
assessment
• Cardiac rehabilitation is the restoration of maximum
potential of a patient with cardiac problem. It is the
restoration of a patient with a cardiac disease going back
to his maximum potential.
rehab management
• CHARACTERISTICS OF CARDIAC REHABILITAION:
• Individualize
• Meaning cardiac rehabilitation doesn’t have a protocol
• Supervised
• Cardiac rehabilitation is not a home program therefore it should be
done with a therapist and patient.
• Therapeutic
• Relaxing not stressful
• Dynamic
• The activities done in cardiac rehabilitation should be something
that involves movement
• Aerobic
• Activities are done for a prolong period of time
rehab management
• Enjoyable not stressful
• Educational
• Part of cardiac rehabilitation is to teach patient techniques
• Prolonged or longitudinal
• Preventive
rehab management
• Goals of cardiac rehabilitation
• Increase functional capacity of the patient
• It should alter natural history of the disease in order to reduce
morbidity and mortality by education and exercise that increase
circulation.
rehab management
• CONTRAINDICATIONS FOR PROGRAM ENTRY TO
CRP:
• unstable angina
rehab management
• Cardiac Rehabilitation is divided into three (3) phases:
• In-hospital
• Early post hospitalizaton
• Maintenance
rehab management
• Inpatient Cardiac Rehabilitation (Phase I)
• This begins on admission of the patient to the hospital and
continues until the patient is discharge.
• Education for a healthier lifestyle is an integral part of each phase
of rehabilitation, with individual instruction on identifying and
modifying reversible risk for the prevention of further cardiac
events.
• Graded Exercise Test
• Prior to discharge, a low-level, symptom-limited graded exercise
test should be performed. The purpose of this test is to evaluate the
pt’s functional capacity and to establish a symptom limited HR to
prescribe a safe and effective program for the next phase of cardiac
rehabilitation. The recommended met value during the pre-
discharge exercise stress test should not exceed to 5.
rehab management
• Initial activities include self-care, resumption of upright
sitting, and selected arm and leg exercise designed to
improve flexibility and muscle tone. Supervised ambulatiob
is generally begun 3 to 5 days after the event. Exercise
progression within a pragram generally include:
• passive to active resistive exercise
• Distal to intermediate to proximal joint exercise
• Extremity to trunk exercise
• Lying to sitting to standing exercise
• Progressive increase in ambulation distances and progression to
stair climbing
rehab management
• The metabolic cost of these activities can be increased by:
• Altering the specific type of activity
• Increasing the time (duration) spent on the activity
• Altering the position of the body.
rehab management
• The sessions are brief but as the patients improve, a pattern
of warm-up, endurance aerobic activity, and cool-down
segments should be instituted
rehab management
• The sessions are brief but as the patients improve, a pattern
of warm-up, endurance aerobic activity, and cool-down
segments should be instituted
• Duration=initially, 5 to 10 minutes and as tolerance
improves. Can be lengthened to 20 – 30 minutes
• Frequency=initially 1 to 2 times daily and as tolerance
improves. The frequency I decreased to 1 to 2 times daily.
rehab management
• Early Post-hospitalization (Phase II)
• Phase II is the convalescent stage that will start 2wks. Post-
discharge or 6-8 wks. Post M.l.
• Relaxation Training
• Relaxation training is an effective adjunct to exercise training
these exercise are designed to relieve either generalized or
specific muscle tension.
rehab management
• Intensity - Exercise is prescribed by:
• An adequate training intensity falls between 70-85% of pt’s
functional capacity and 70-90% for athletes
• heart rate because a relative linear relationship exist between
work intensity, oxygen consumption (VO2), and heart rate.
• Karvonen Method Target HR = 60 – 80% (Hrmax-RestingHR) +
Resting HR
• *HRmax- the highest HR safety achieved during GXT
• For patient who have not been testing using GXT: Hrmax = 220 –
pt’s age.
• Borgs’ scale is useful in evaluating a subjects perceived response to
exercise intensity during all phases of cardiac rehab.
rehab management
• An adequate training intensity falls between 70-85% of pt’s
functional capacity and 70-90% for athletes
• heart rate because a relative linear relationship exist between
work intensity, oxygen consumption (VO2), and heart rate.
• Karvonen Method Target HR = 60 – 80% (Hrmax-RestingHR) +
Resting HR
• *HRmax- the highest HR safety achieved during GXT
• For patient who have not been testing using GXT: Hrmax = 220 –
pt’s age.
• Borgs’ scale is useful in evaluating a subjects perceived response to
exercise intensity during all phases of cardiac rehab.
rehab management
• Using the original scale, PRE values of
• a.) <12 )light) approximate 40 – 50 % of max. capacity
• b.) 12 to 13 (somewhat hard), approximate 60-70 of max. capacity
• c.) 14 to 16 (hard) approximate 75-95% of max. capacity
• Thus pts. Need to learn to utilize ratings between 12
(somewhat hard) and 16 (hard) to pace the intensity of their
work. Using the 10-point scale, this would correspond to
values between 4 and 6
• Exercise frequency: 3x per week with
• 5-10 min WARM-UP
• 30-40 min. AEROBIC EXERCISE
• 5-10 min. COOL DOWN
rehab management
• Intensity
• Heart Rate cannot be safely used to prescribed safe loads in the
following situations:
• Isometric exercise
• Valsalva maneuver
• Heavy arm work
• Environmental extremes
• Beta-blockers medication
• Pacemakers
rehab management
• Community Exercise Programs (Phase III)
• simply a continuation of phase II but now done by the
patient at home or in the community
rehab management
• Patients entering community exercise programs include
individuals who participated in phase I and II programs
(typically 6 to 12 weeks after discharge), and individual
with no prior involvement in an organized program. Before
beginning the program, a history, medical evaluation and
GXT are required.
• Goals:
• Maintain function
• Promote life long commitment to physical fitness and personal
health management
rehab management
• Potential patients include:
• Acute MI patients
• Post-Coronary Artery Bypass Grafts Surgery patients
• Post-Percutanous Coronary Angioplaty Patients
• Patients with Angina Pectoris.
• Pts. With CHF
rehab management
• Goals
• Return to activities of daily living (ADL’s)
• Offset the deleterious effects of bed rest
• Help allay anxiety and depression
• Provide medical surveillance
• Patients and Family education
rehab management
• Activities are described in METs or subject is awake and in
a sitting position.
• 1 MET is ~ 3.5 to 4.0 ml of O2per kilogram of bodyweight
per minute.
rehab management
• Important MET values to remember
• Sitting in an easy chair with arms and legs fully supported
1.0
• Supine 1.0
• Relaxed standing 1.2
• Eating 1.5
• Descending stairs 5.2
• Ascending stairs 9.0
• Running 7.4
• Sexual activity with spouse 5.0
• Extramarital sexual activity 8.0
• Master two-step climbing test 5.7
• Driving a car 2.8
rehab management
• Note:
• Bowel Movement in a bedpan has higher MET value that
bowel movement in the toilet or bedside commode.
• Taking a hot shower has higher MET that a warm shower
• Only patients who can tolerate at least 6 METs can do isometric
exercise
rehab management
• Participation in phase III programs may last for several
months or indefinitely. Individuals are expected to progress
from supervision to self-regulation of their exercise
programs. Session may be 45or min. III programs focus on
addressing the specific concerns of compliance with
exercise and behavioral life-style intervention goals using
specific motivational techniques.
rehab management
• Monitoring heart rate responses
• HEART RATE
• Heart rate is recorded before, during, and after each exercise
session two sites are available:
• Radial pulse
• Carotid pulse
rehab management
• BLOOD PRESSURE
• Blood pressures are routinely taken before, during, and after each
exercise session. Pressure taken and recorded during an activity
provides the most clinically useful information since the rate-
pressure product (heart rate x systolic blood pressure) is commonly
accepted index of myocardial oxygen consumption.
• It is Important to take post exercise bp immediately after the
activity; within the first 15 seconds since pressure usually falls
rapidly once the activity is stopped.
rehab management
• ELECTROCADIOGRAMS
• The therapist working with a cardiac patient will need to acquire a
working knowledge of the electrocardiogram and its interpretation.
When assessing cardiac function it is important to assess the ECG
at rest, during, and following exercise during the recovery period.
rehab management
• BORG’S SCALE
• Borg’s scale consist of numbers ranging from 5 to 20, which pts,
use to rate their perceptions of how hard they are working.
Descriptive words accompany the numbers such as hard or very
hard.
rehab management
• BORG’S SCALE
• Scale Rate of Perceived Exertion
6 very, very light
7
8 very light
9
10
11 fairly light
12
13 somewhat hard
14
15 hard
16
17 very hard
18
19 very, very hard
rehab management
• BORG’S SCALE
• A more recent version, also by Borg, is the 10 – point scale.
• Scale New Rating Scale
0 Nothing at all
0.5 very, very weak
1 very weak
2 weak
3 Moderate
4 Somewhat strong
5 Strong
7 very strong
10 very very strong
rehab management
Congestive heart failure
• Congestive Heart Failure (CHF) is the inability of the
heart pump enough blood to supply the oxygen
requirements of the body tissues. CHF should never be
considered a diagnosis. Rather, it is the syndrome
resulting from many diseases that interfere with the
cardiac function
definition
• Affects 1% of the population with an annual incidence of
about 3/1000.
epidemiology
• Portion of the myocardium undergoes necrosis and can no
longer contract. These portions of the myocardium can no
longer generate force, resulting in weakening OG the
ventricles. If the areas of infarction are extensive, CHF
results.
etiology
• Valvular Heart Disease
• Stenosis of the cardiac valves places a pressures or volume
overload on the ventricles. Initially, compensatory
mechanism accommodates these overloads and maintains
normal cardiac output at acceptable filing pressure.
Compensatory mechanism includes FRANK-STERLIGN
Mechanism development of cardiac hypertrophy and
hormonal stimulation, which increase the inotropic state.
Eventually, however, these compensatory mechanism fail
and the myocardium no longer can generate adequate force
to maintain cardiac output
etiology
• Hypertension
• The heart has adapted to high pressure so it will
hypertrophy. As a result, the heart can no longer adapt to
high pressure so it will dilate.
etiology
• Arrhythmias
• Irregularity in cardiac rhythm such as tacharrythmias which
can reduce ventricular filling time; bradycardia which can
reduce cardiac output; and arrhythmias that disrupt the
normal atrial and ventricular filling time.
etiology
• Anemia
• Anemia is a common cause of heart failure. Since there is a
decrease of oxygen supply to the tissues, the heart
compensates by contracting faster to increase cardiac
output; and arrhythmias that disrupt the normal atrial and
ventricular filling synchrony
etiology
• Thyrotoxicosis
• Prolonged thyrotoxicosis or hyperthyroidism leads to heart
failure because of the output increased the demand of
cardiac
etiology
• Physical or Emotional Stress
• Strenuous physical exercise and strong emotions increase
sympathetic nervous tone, myocardial contractility and
blood pressure
etiology
• Pregnancy
• With pregnancy, the metabolic needs of the body is
increased thereby increasing the workload of the heart.
etiology
• Pulmonary Disease
• Increased pressure in the pulmonary system due to chronic
obstructive lung disease can produce sizable resistance to
right ventricular emptying. Such resistance may lead to
right ventricular hypertrophy and failure.
etiology
• Hypervolemia
• Excess in circulating blood volume can result from poor
renal function, cardiac disease, medications (such as
steroids) or excessive intake of sodium (prompting water
retention). A diseased heart may not be able to pump the
increased load and cardiac decompensation occurs.
etiology
• By the site of heart failure
• LEFT-SIDED FAILURE
• Left sided failure is more common that right-sided failure. It
frequently leads to right sided failure. Failure of the left
ventricle to pump blood to the vital organs and periphery is
usually caused by myocardial infaction. Decreased left
ventricular output caused fluid to accumulate in the lungs,
precipitating dyspnea, orthopnea, and paroxysmal nocturnal
dyspnea.
classification
• By the site of heart failure
• RIGHT-SIDED FAILURE
• Resulting from failure of the right ventricle to pump sufficient
blood to the lungs, this type can result from congenital heart
problems or chronic obstructive pulmonary heart disease. The
most common cause of right ventricular heart failure, however, is
left ventricular failure. Right ventricular failure follows left
ventricular failure when the increased of pressure through the
pulmonary circulation overloads the right ventricle. In some
occasion, there is an isolated R-sided heart failure. Any condition
that increase pressure in pulmonary vessels, it may lead to right-
sided failure. This condition is called COR PULMONALE. Right
ventricular failure produces congestive hepatomegaly, ascites and
edema.
classification
• Level of cardiac output and direction
• HIGH OUTPUT FAILURE
• Failure with an elevated cardiac output occurs when tissue
demands for oxygenated blood exceed the heart’s ability to
supply it. High-output failure occurs in hyperthyroidism and
anemia.
classification
• LOW OUTPUT FAILURE
• Failure with decreased cardiac output is caused by decreased
pumping ability of the myocardium. Low-output failure occurs
in coronary artery disease, hypertension, primary myocardial
disease and valvular disease
classification
• FORWARD FAILURE
• The heart fails to expel enough blood in the arterial system.
classification
• BACKWARD FAILURE
• When backward heart failure occurs, one ventricle fails to
empty its content normally, and end-diastolic ventricular
pressure. Arises. The pressure and volume in the atrium and
venous system behind the failing ventricles also rise.
classification
• LEFT VENTRICULAR FAILURE
• Increased workload and end-diastolic volume enlarge the left
ventricle.
• Because of the lack of oxygen, however, the ventricle enlarges
with stretched tissue rather than functional tissues.
• Diminished left ventricular function allows blood to pool into the
ventricle and the atrium and eventually back up into the
pulmonary veins and capillaries.
• As the pulmonary circulation becomes engorged, rising capillary
pressure pushes sodium and water into the interstitial space,
causing pulmonary edema.
• When the patient lies down, fluid in the extremities moves into
systemic circulation. Because the left ventricle can’t handle the
increased venous return, fluid pools in the ventricle may now
become stressed because it’s pumping against greater pulmonary
vascular resistance and left ventricular pressure.
pathophysiology
• RIGHT VENTRICULAR FAILURE
• The stressed right ventricle hypertrophies with the formation of
stretched tissues. Blood pools in the right ventricle and right
atrium. The backed-up blood causes pressure and congestion in
the vena cava and systemic circulation. The patient will have
elevated central venous pressure, jugular veins distention and
hepatojugular reflux. Backed-up blood also distends the visceral
veins especially the hepatic vein.
• As the liver and spleen becomes engorged their function is
impaired. Rising capillary pressure forces excess fluid from the
capillaries into the intestinal space. This causes tissue edema
especially in the lower extremities and abdomen. The patient may
experience weight gain, pitting edema, and nocturia.
pathophysiology
• Left ventricular failure
• Dyspnea
• This is the most frequently encountered symptom of CHF. The
feeling of breathlessness is due to vascular congestion, which
reduces pulmonary oxygenation. In addition, the vascular
congestion diminished lung compliance, increasing the work of
breathing and thus adding to the feeling of breathlessness.
• Orthopnea
• Orthopnea refers to dyspnea in the recumbent position and is
relieved by elevation of the head. This result from volume
pooling in the central vasculature during recumbency increased
cardiac volume result, which in turn increased left ventricular
filling pressure and leads to pulmonary congestion and the
feeling of dispel. Orthopnea often is gauged by the number of
pillows the patient sleeps on.
• Paroxysmal Nocturnal Dyspnea
• This is the occurrence of sudden dyspnea that awakens the
patient from sleep. Like orthopnea, it occurs during the
recumbency as a result of pooling in the patient awakens from
sleep and feels the need sit upright or to go to an open window
for increased ventilation. The symptom usually subsides after
the patient has been in the upright position for 5-20 minutes.
• Nocturia
• This occurs in CHF due to increased renal blood flow in
recumbency during sleep.
• Pulmonary Edema
• Accumulation of fluid in the lungs, more blood is supplied to
the pulmonary circulation is then removed.
• Cough
• A common symptom of left ventricular failure. The cough
(hacking) may produce large amount of frothy, blood-thinge
sputum.
• Right ventricular failure
• Neck Vein Distention
• The veins can be considered manometers attached to the right
atrium and reflect right atrial pressure.
• Cyanosis
• Due to poor cardiac output
• Liver Distention
• Ascites
• Transudation of fluid into peritoneal space also may occur due
to increased systemic venous pressure.
• Bipedal Edema
• Etiologic Therapy
• It is important, when possible, to direct therapy at the
etiologic agent responsible for the CHF. For example, if
aortic stenosis is the cause of CHF, aortic valve replacement
is the most effective therapy.
medical/surgical
management
• Symptomatic Therapy
• If the etiologic agent cannot be found, or if the patient’s
condition does not permit direct intervention, or if the
patient refuses to consider corrective surgery even of
indicated, therapy must be aimed at relieving the symptom
of heart failure.
medical/surgical
management
• Cardiac glycosides increase the contractile state by
impeding the sodium-potassium-ATPase controlled
intracellular pump. This result in the net influx of
calcium into the myocardium, which contractile
strength.
medical/surgical
management
• Digitalis to reduce fluid volume.
• Vasodilators to increased cardiac output, transferring
central volume to the periphery.
• Diuretics to reduce total blood volume and circulatory
congestion.
medical/surgical
management
• Oxygen administration to increase oxygen delivery to
the myocardium and other vital organ tissues.
• Antiembolism stocking to prevent venostasis and
possible thromboembolism formation.
medical/surgical
management
• Restrict fluid and salt.
• Cardiac transplantation may offer an improved quality of
life to selected patients in whom control of CHF is not
possible and prognosis is poor
medical/surgical
management
• The prognosis for persons with CHF depends on the (1)
the degree of cardiac hyperthrophy, (2) the amount of
cardiac reserve, and (3) the presence of tother heart or
associated disorders.
prognosis
• can be predicted by the person’s response to therapeutic
measures. A very slow or inadequate response of
prescribed medications, special diets, activity limitations,
and so forth signals a poor prognosis. Nevertheless,
thorough ongoing assessment, early interventions
therapeutic compliance and prevention of complications
can control this disorder.
prognosis
• Same with CAD
assessment
• Patients with CHF are often incapacitated as a result of
significant ventricular dysfunction and decreased cardiac
output. Performance is also limited by increased
pulmonary pressures and impairments in peripheral
muscle function associated with chronic activity and
changes in vasomotor capacity.
management
• Patients who exhibit low functional work capacities:
• Patients with mild or moderate CHF are generally limited to
activities of 3 to 4 METs or Class II or III (refer to CAD –
New York Heart Association Functional Classification)
• Patients with severe CHF have Sx of ischemic or dyspnea at
rest and during ADLs despite the use of cardiac meds.
(Class IV)
management
• Patient with CHF who are medically stable can safely
participate in low-level exercises as well as enegery-
conservation methods (Phase I). Chest PT and O2 support
are admitted as supplements to tx when indicated.
However, unstable patients who demonstrate
uncompensated failure are not considered safe candidates
to Phase I.
management
• Exercise protocol allow for every initial workloads and
more gradual increments in exercise intensity. An
interval-training regime with frequent rest periods is
necessary. Other aspects or programming are similar like
the use of warm-up period, a dynamic exercise, and cool
down. Close supervision is necessary throughout the
session. The therapist should be supportive and
instructive.
management

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epidemiology & risk

epidemiology & risk

epidemiology & risk

epidemiology & risk

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