CHRONIC HEART FAILURE

NORMAL PHYSIOLOGY OF THE HEART

Ah ganun ba sige wait patataasin ko HR mo.

Mababa po ang stroke volume ko! Pahelp!

When stroke volume decreases, the heart sends signal telling the brain to increase heart rate

Stroke volume depends on three factors: Preload the amount of blood presented to the ventricle just before systole. Afterload refers to the amount of resistance to the ejection of blood from the ventricle. Contractility the force of contraction in relation to the status of the myocardium.

ILLUSTRATION OF THE HEART

Preload

Afterload

Contractility

HEART FAILURE - Inability of the heart to pump sufficient blood to meet the needs of the tissues for oxygen and nutrients. - Often referred to as congestive heart failure or CHF because patients experience pulmonary or peripheral congestion.

There are two types of Heart Failure: A. Systolic heart failure B. Diastolic heart failure
Classification of Heart Failure
Table 1: American College of CardiologyAmerican Heart Association Classification of Chronic Heart Failure

Stage A: High risk for developing heart failure B: Asymptomatic heart failure C: Symptomatic heart failure

Description Hypertension, diabetes mellitus, CAD, family history of cardiomyopathy Previous MI, LV dysfunction, valvular heart disease Structural heart disease, dyspnea and fatigue, impaired exercise tolerance Marked symptoms at rest despite maximal medical therapy

D: Refractory end-stage heart failure

Table 2: New York Heart Association (NYHA) Heart Failure Symptom Classification System

NYHA Class I II

Level of Impairment No symptom limitation with ordinary physical activity Ordinary physical activity somewhat limited by dyspnea (e.g., long-distance walking, climbing two flights of stairs) Exercise limited by dyspnea with moderate workload (e.g., shortdistance walking, climbing one flight of stairs) Dyspnea at rest or with very little exertion

III

IV

PATHOPHYSIOLOGY

CLINICAL MANIFESTATIONS
General: Pale, cyanotic skin Dependent edema Decreased activity intolerance Unexplained confusion or altered mental status Apical impulse, enlarged and left lateral displacement. Third heart sound (S3) Murmur Tachycardia Increased jugular venous distention

Cardiovascular:

Cerebrovascular: Lightheadedness Dizziness Confusion Gastrointestinal: Nausea and anorexia Enlarged liver Ascites Increased hepatojugular test Renal: Decreased urinary frequency during the day. Nocturia

Respiratory: Dyspnea Orthopnea Bilateral crackles Cough on exertion or when in supine position Paramyxal nocturnal dyspnea

DIAGNOSTIC EXAMINATIONS
ECHOCARDIOGRAM CHEST X-RAY ELECTROCARDIOGRAM (ECG) LAB. RESULTS FOR SERUM ELECTROLYTE, BUN, CREATININE, THYROID STIMULATING HORMONE, BTYPE NATRIURETIC PEPTIDE (BNP) CBC URINALYSIS

MEDICAL - SURGICAL INTERVENTIONS

SURGICAL INTERVENTIONS: CARDIAC TRANSPLANT RESYNCHRONIZATION THERAPY IMPLANTABLE CARDIAC DEFIBRILLATOR ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITORS ANGIOTENSIN II RECEPTOR BLOCKERS HYDRALAZINE AND ISOSORBIDE DINITRATE BETA-BLOCKERS DIURETICS DIGITALIS CALCIUM CHANNEL BLOCKERS

PHARMACOLOGICAL THERAPY:

 INTRAVENOUS INFUSIONS NESITRITIDE MILRINONE DOBUTAMINE OTHER MEDS: ANTICOAGULANTS ANTIANGINAL NUTRITIONAL THERAPY: A LOW-SODIUM (2 -3g/DAY) DIET DIETARY RESTRICTION OF SODIUM ADDITIONAL THERAPY: SUPPLEMENTAL OXYGEN

NURSING MANAGEMENTS
ADMINISTER MEDICATIONS AND ASSESSING THE PATIENTS RESPONSE TO THE PHARMACOLOGIC REGIMEN. ASSESSING FLUID BALANCE, INCLUDING I &O. WEIGHING PATIENT DAILY AT THE SAME TIME AND ON THE SAME SCALE, USUALLY MORNING AFTER URINATION. AUSCULTATING LUNG ROUNDS TO DETECT AN INCREASE OR DECREASE IN PULMONARY CRACKLES. DETERMINE THE DEGREE OF JUGULAR VEIN DISTENTION (JVD). IDENTIFY AND EVALUATE THE SEVERITY OF DEPENDENT EDEMA. MONITOR PULSE RATE AND BLOOD PRESSURE. EXAMINE SKIN TURGOR AND MUCOUS MEMBRANES FOR SIGNS OF DEHYDRATION. ASSESSING FOR SYMPTOMS OF FLUID OVERLOAD.

RECENT STUDIES
- DESPITE OF THE SIGNIFICANT ADVANCES IN DRUG THERAPY FOR CONGESTIVE HEART FAILURE OVER THE PAST 20 YEARS, MANY DEVELOPMENTS ARE UNDER ACTIVE STUDY. NEW CLASSES OF MEDICATIONS ARE BEING IN CLINICAL TRIALS INCLUDING THE CALCIUM SENSITIZING AGENTS, VASOPEPTIDASE AGENTS.