Heart FailureJulie Hutsick

MSN 621Alverno College

Heart Failure Statistics from the Center for Disease Control and Prevention

• 5.8 million Americans have heart failure, with 670,000 new diagnoses each year

• One in every five patients dies from heart failure with in the first year from diagnosis

• This results in costs of 39.2 billion dollars per year for treatments including physician visits, hospitalizations and medications

Outcomes- this tutorial will help the audience develop and understanding of:

• The basic anatomy and physiology of the heart• The effects of the Sympathetic nervous system,

Renin-Angiotensin-Aldosterone Mechanism, Inflammation, Aging and Genetics on Heart Failure

• The different classifications of Heart Failure• Treatments for Heart Failure• Importance of patient teaching and teaching

needs

Before you get started…

• This is an interactive presentation• You will be asked questions, and will need to

pick answers. Feedback will be provided. • If at any time you would like to return to the

navigational page click the home button.• The next arrows (on the right top or bottom of

the page) will automatically take you to the next slide in the presentation.

• Have fun and enjoy your learning experience!

Main Areas- Click the words to go to that part of the presentation

Anatomy and Physiology of the Heart

Compensatory mechanisms

Inflammation

Genetics

Aging

Diagnosing Heart Failure

Risk Factors

Signs and Symptoms

Types of Heart Failure

Stages and Classes of Heart Failure

Medications

Teaching Needs

Nursing Interventions

References

What is Heart Failure?

• Heart failure is the body’s inability to properly circulate blood throughout the body due to decreased pumping ability.

• Slow disease progression. • Can be prevented or can decrease progression

with early diagnosis and intervention. (Porth, 2009).

Anatomy and Pathophysiology of the Heart and the Effects of the

Sympathetic Nervous System, the Renin-Angiotensinogen-Aldosterone Mechanism,

Inflammation and The Role of Genetics and Aging

Blood from the lungs enters into the left

atrium via the pulmonary veins

Blood flows to the left ventricle through the

mitral valve

From the ventricle it enters the body via

the aorta

Blood Flow Through the Heart

Blood returns from the body via the

inferior and superior vena cava

Retrieved from http://www.nhlbi.nih.gov/health/dci/Diseases/hhw/hhw_anatomy.html

Blood enters the Right Atrium

Passes through the tricuspid valve into the

right ventricle

From the ventricle blood flows to the

lungs via the pulmonary arteries

(Porth, 2009).

Physiology

• Cardiac output is the amount of blood pumped from the heart per minute– Based on heart rate and amount of blood

pumped with each beat (stroke volume)

• Preload is the volume of blood in the heart and the end of diastole. When the heart muscle becomes stiff and unable to relax the preload decreases. (Porth, 2009).

Physiology, cont.

• Afterload is the force of contraction needed to eject blood from the heart. When the ventricles become weakened and enlarged the force is diminished

• Myocardial contractility is the ability of the heart to contract independently of preload and afterload. This occurs due the interaction between actin and myosin filaments which results in muscle shortening. (Porth, 2009).

Compensatory Mechanisms

• Sympathetic nervous system (SNS)- initially assists with maintenance of perfusion to body organs.

• Renin-Angiotensin-Aldosterone Mechanism (RAA). When cardiac output is decreased, there is reduced blood flow to the kidneys and decreased glomerular filtration rate resulting in increased sodium and water retention. (Porth, 2009).

SNSDecreased cardiac output and increased

water retention stimulates the SNS

increased release of catecholamines, epinephrine and norepinephrine

tachycardia, vasoconstriction and cardiac arrhythmia

Prolonged activation results in

ischemia due to increased work

load and increased myocardial oxygen

demand

decreased contractility resulting in faster heart

function deterioration

Decreased sensitization to norepinephrine, resulting in increased

systemic vascular resistance, increased after load and decreased

blood flow to skin, muscle and abdominal organs

(Porth, 2009).

RAADecreased cardiac output, resulting in reduction of renal

blood flow and decreased glomerular filtration rate

Sodium and water retention

Increase circulating levels of angiotensin II

Increased renin secretion

Increased vasoconstriction

Facilitate norepinephrine release and prevents reuptake by the SNS

Stimulates aldosterone production which increases

reabsorption of sodium

Increases the level of antidiuretic

hormone

Accumulation of excess fluid leads to ventricular dilation and increased wall tension

(Porth, 2009).

Inflammation and Heart FailureAngiotensin II and aldosterone stimulate inflammatory and repair processes

after tissue damage

Stimulate cytokine production (tumor necrosis factor and interleukin-6)

Neutrophils and macrophages are attracted to the site

Macrophages are activated and stimulate the growth of fibroblasts and synthesis of collagen fibers

Repair results in ventricular hypertrophy and myocardial wall fibrosis (decreased contraction ability)

Progression of ventricular dysfunction

(Porth, 2009).

Genetics and Heart Failure

Heart cells have two main functions- – to generate contractile force by sarcomere

proteins– transmitting that force throughout the heart by

intermediate proteins

Scientists have found a genetic link between these components and heart failure. (Morita, Seidman, and Seidman, 2005.)

Further research needs to be performed to learn the direct role of genetics in relation to Heart Failure. (Morita, Seidman, and

Seidman, 2005.)

Gene mutations in the sarcomeres can result in

– hypertrophic cardiomyopathy (wall thickening)– dilated cardiomyopathy (thinned walls,

enlarged chamber)

Gene mutations is the intermediate proteins result in

– Dilated cardiomyopathy – Heart failure

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Aging and Heart Failure• Decreased response to receptor stimulation

reduces the hearts ability to increase heart rate and contractility to maximum level

• Increased vascular stiffness results in increased systolic blood pressure which results in left ventricular hypertrophy and alteration in diastolic filling

• Heart is stiffer and less compliant resulting in decreased cardiac output, elevated diastolic pressure and muscle stretching. (Porth, 2009).

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Commonly used tests to determine a diagnosis of Heart Failure

• Echocardiogram- determine whether there is systolic or diastolic dysfunction

• EKG- conduction changes can indicate heart failure, and previous MI

• Chest x-ray- will show cardiomegaly, pulmonary congestion and pleural effusions

• BNP- secreted by ventricles due to stretching of the muscle cells, the higher the number the more severe the heart failure. (Cunningham, 2006.)

Case study (1)

Mrs. Montgomery is a 72 yr old woman who wasadmitted to your unit directly from the physician’soffice. She went to see her physician this morningbecause she was having increased shortness ofbreath, was waking up breathless three to fourtimes a night, has increased swelling in both lowerlegs and doesn’t have the energy to follow herdaily exercise routine. Her current weight is 157pounds, which is up from 148 seven days ago.

Mrs. Montgomery (2)

She had an echocardiogram done duringher last admission, which was 83 days ago.It showed an ejection fraction of 37%.

What type of heart Failure does Mrs. Montgomery have?

SystolicThat’s right!

DiastolicSorry, that’s incorrect.

Diastolic has a normal EF

Mrs. Montgomery (3)

Mrs. Montgomery is a current smoker andhas been smoking for 50 years. She wasdiagnosed with Heart Failure six monthsago. Before that, she frequently ate frozendinners, canned foods or fast food, as shelives alone. She meets friends for a wateraerobics class at the YMCA, but not on a regularbasis.

Mrs. Montgomery (4)

She has a medical history that includes:• Hypertension• Pneumonia• Depression• Previous MI• Gerd• Glaucoma• Coronary artery disease (CAD)

(American Heart Association, 2011).

Lifestyle and Disease Factors (5)

• What lifestyle factors put her at risk?

• Is she at risk for Heart Failure due to her past medical history?

High salt intakeYes that’s right

Water aerobics at the YSorry, activity is recommended for

people with heart failure

Living aloneSorry, this has no relationship to

heart failure

YesDue to her history of HTN,

previous MI and CAD

NoSorry, she is at risk due to

her history of HTN, previous MI and CAD

SmokerYes, that’s right.

Mrs. Montgomery (6)

You enter the room to assess Mrs.Montgomery. You ask her what symptomsshe has been having. She tells you she isshort of breath, has been waking up duringthe night, has swelling in her legs and ismore fatigued than usual. What signs ofheart failure might you observe during yourassessment?

Mrs. Montgomery (7)

You ask Mrs. Montgomery more about heractivity intolerance. She states that since herlast admission she has been trying toexercise on a regular basis. She says she isusually able to walk a mile around herneighborhood at a moderate pace. Lately,though, she becomes short of breath sooner, andis only able to make it half that distance due toincreased fatigue.

Mrs. Montgomery (8)

Click the question to receive the answer

In what stage of Heart Failure would youclassify Mrs. Montgomery?

She is in stage C, as she has structural heart disease, and is having symptoms.

What class is Mrs. Montgomery in?She is in stage III, as shown by the

increased symptoms and decreased tolerance for activity.

Mrs. Montgomery (9)

• Mrs. Montgomery is currently taking pepcid, zoloft, metoprolol and lasix. Will any of these medications help with her heart failure?

Continue on to see common Heart Failure Medications

PepcidSorry, that medication is for Gerd

ZoloftSorry, that medication is for depression

MetoprololYes, this medication is for Hypertension,

and is prescribed for Heart Failure patients

LasixYes, this medication is used to treat Edema, and is prescribed for Heart

Failure patients

Mrs. Montgomery (10)

Click the question to receive the answer

Are there any other medications that Mrs.Montgomery should be on beforedischarge?

Yes, she should also be on an ACE or ARB.

Mrs. Montgomery (11)

While Mrs. Montgomery is hospitalized, whatare the important interventions that you asthe nurse should ensure are occurring?

If Mrs. Montgomery awakens during the night, should you make her get back into bed, or are there interventions you should attempt?

Mrs. Montgomery (12)

Mrs. Montgomery was just diagnosed withheart failure six months ago, and admits thatshe still smokes, and did not follow a diet orexercise routine prior to diagnosis. Whatshould Mrs. Montgomery be taught beforeshe is discharged?

Mrs. Montgomery (13)

How will you know if the teaching you didwith Mrs. Montgomery is effective? Whatshould you do to ensure she trulyunderstands the information you gave her?

Teach Back, Teach Back, Teach Back!Yes, this is important to ensure the patient understood the

information provided, and has no further questions.

Just assume the patient understands everythingSorry, that is incorrect. Many patients may become overwhelmed when

provided with a lot of new information, but unwilling to ask for clarification.

Types of Heart Failure• Systolic heart failure is when the heart becomes weak

and the ventricle becomes enlarged. The weakened ventricle is then unable to pump enough blood out during contractions. Due to the decreased ability to pump the ejection fraction is decreased to less than 40%.

• Diastolic heart failure is when the ventricle becomes stiff and does not relax appropriately between contractions. Due to this the ventricles are unable to fully fill with blood so there is less to eject during contractions. Since there is less blood to push out, the ejection fraction for this type of heart failure is usually normal, >40%. (Porth, 2009).

Used with permission from http://www.medmovie.com/index.htm

Left vs. Right• Refers to the ventricle that is primarily affected• Initially heart failure can affect only one side, but

long term heart failure usually affect both ventricles. • Left sided heart failure is when the left ventricle is

unable to move blood from the pulmonary circulation to the arterial circulation. This results in blood pooling in the pulmonary veins.

• Right sided heart failure is when the right ventricle is unable to move un-oxygenated blood from the venous system into the pulmonary system, which results in blood pooling in the systemic vessels. (Porth, 2009).

(Porth, 2009). Picture retrieved from http://www.starsandseas.com/SAS

%20Physiology/Cardiovascular/Cardiovascular.htm

Life Style Factors that Cause Increased Risk

• SMOKING CAUSES INCREASED BLOOD PRESSURE AND HEART RATE

• OBESITY RESULTS IN INCREASED WORK LOAD

• EATING HIGH FAT FOODS CAN RESULT IN CORONARY ARTERY DISEASE

• LACK OF PHYSICAL ACTIVITY IS A RISK FACTOR FOR CORONARY ARTERY DISEASE AND OTHER CARDIOVASCULAR PROBLEMS(American Heart Association, 2011).

Microsoft clip art

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Disease Factors that Increase RiskHypertension- Due to increased pressure the heart has to pump harder which

results in the enlarging and weakening of the chambers.

• Coronary artery disease resulting in high blood pressure and possible heart attack

• Diabetes may result in hypertension and atherosclerosis (American Heart Association, 2011).

Used with permission from http://www.medmovie.com/index.htm

• Previous MI resulting in decreased contractility

Used with permission from http://www.medmovie.com/index.htm

• Sleep apnea is a risk factor for heart failure• Lung disease causes increased work on the

heart to pump the available oxygen• Prolonged arrhythmias- heart pumps

ineffectively (American Heart Association, 2011).

Signs and Symptoms of Heart Failure• Dyspnea, nocturnal and with exertion• Tachypnea• Crackles• Nocturia• Diaphoresis• Capillary refill >3 seconds• Venous distension• Dependent pitting edema• Arrhythmias• Ascites

(Hudson, 2009.)

Stages and Classes of Heart FailureGuidelines for diagnosing and treating Heart Failure have

been developed by the American College of Cardiology and The American Heart Association There are four

stages, A-D. Stages A and B are patients are risk for Heart Failure and stages C and D are patients who have Heart

Failure.

Heart Failure is also classified based upon the patients severity of symptoms. The New York Heart Association has

devised a functional classification chart which divides symptoms into four classes, I-IV. (Cunningham, 2006.)

Stage A and B

A- These patients do not have symptoms or structural heart disease but are considered at high risk These patients have: Hypertension, Coronary artery disease, Diabetes, Obesity and a history of cardiomyopathy within the family.

B- These patients do have symptoms of heart failure, but don’t have. These patients have a history of Left ventricular (LV) dysfunction, previous myocardial infarction, asymptomatic valvular disease. (Cunningham, 2006.)

Stage C and DC- These patients have structural heart diseaseand have or have had symptoms including: dyspnea,fatigue and reduced activity tolerance.

D- These patients are in end stage heartfailure. They have severe symptoms, evenduring rest despite maximum medical treatment,and have frequent hospitalizations or needspecialized interventions at home. (Cunningham, 2006.)

Classes of Heart Failure• Class I- No Symptoms or limitations during a

normal level of physical activity• Class II- Mild symptoms, with slight difficulty

during activity (long-distance walking or climbing more two or more flights of stairs).

• Class III- Increased symptoms resulting in a increased limitation in activity. (walking only short distances, minimal stair climbing) Symptoms decreased only at rest.

• Class IV- Severe symptoms even during rest. Unable to tolerate activity. (Cunningham, 2006.)

Angiotensin-converting enzyme inhibitors (ACE)

• Increase vasodilation by blocking conversion of angiotensin I to angiotensin II

• Blocks aldosterone and ADH which decreases fluid retention.

• Increased cardiac output due to decreased preload and left ventricular filling pressure American Heart Association, 2011).

Used with permission from http://www.medmovie.com/index.htm

Angiotensin receptor blockers (ARBs)• Blocks angiotensin II receptor sites to

prevent vasoconstriction and preventing hypertension (American Heart Association, 2011).

Used with permission from http://www.medmovie.com/index.htm

Beta Blocker• Block epinephrine and norepinephrine resulting

in decreased heart rate , and increased vessel dilation which results in decreased blood pressure

• Decreased aldosterone levels resulting in decreased sodium and water retention( American Heart Association, 2011).

Diuretics• Increase sodium and water excretion due to

inhibition of sodium, potassium, and chloride reabsorption in kidneys

• Reduction of preload• Adverse effects include hypokalemia,

hypotension, and dizziness. (American Heart Association, 2011).

Used with permission from http://www.medmovie.com/index.htm

Calcium Channel Blockers• Decrease pumping strength by blocking

the calcium needed for the heart to contract (American Heart Association, 2011).

Used with permission from http://www.medmovie.com/index.htm

Nursing Interventions for the Hospitalized Patient

– Fluid restriction and low salt diet– Strict recording of intake and output– Daily weights, with re-weight and Physician notification if

weight increase is more than two pounds in a day– Encourage smoking cessation and obtain order for nicotine

patch for patients who smoke as needed– Assess medication adherence, and what prevents patients

from taking medications, make referrals as needed– Elevate edematous extremities– During night, assess patient’s needs when awake, and help

patient sit up to improve breathing, or use the bathroom as needed. (Hudson, 2009.)

Microsoft clip art

Microsoft clip art

Patient Teaching NeedsPatients need teaching reinforced during every admission to ensure understanding of self care needs. It is beneficial to the patient to teach when family is present so they can reinforce information after discharge and provide a support system for

the patient. Needs Include:

– Weigh themselves daily, call the physician if they have a weight gain of three pounds in one day or five pounds in one week

– Low salt diet with 2L fluid restriction (the amount of fluid in a juice pitcher)

– Quit smoking- offer resources if needed– Take all medications as prescribed. (Hudson, 2009.)

Teaching cont.– Always carry of list of current medications – Importance of exercise– Importance of keeping physician appointments – Self-monitoring (when to call their physician)

• Weight gain, Increased edema, Dyspnea during rest, Loss of appetite, Increased fatigue, Trouble sleeping (Hudson, 2009.)

Teach Back, Teach Back, Teach BackNeeds to be done to ensure that the patient understands the

information provided to them, and provides them with opportunity to ask questions or receive clarification.

Reference

American Heart Assosiation. (2011). Heart Failure. Retrieved from

http://www.heart.org/HEARTORG/Conditions/HeartFailure/Heart-Failure_UCM_002019_SubHomePage.js

p

Centers for Disease Control and Prevention. (2010). Heart Failure Death Rates Among Adults Aged 65 Years and

Older, by State, 2006. Retrieved from

http://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_heart_failure.htm

Cunningham, C. (2006). Managing Hospitalized Patients with Heart Failure. American Nurse Today. Retrieved

from http://www.nursingworld.org/mods/mod990/heartfailure.pdf.

Hiroyuki Morita, Jonathan Seidman, and Christine E. Seidman. (2005). Genetic Causes of Human Heart Failure.

American Society for Clinical Investigation, 115(3). Retrieved from

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1052010/.

Reference

Hudson, K. (2009). Congestive Heart Failure. Retrieved from

http://dynamicnursingeducation.com/class.php?class_id=130&pid=23.

Krames. (2011). Heart Failure Diagrams. Retrieved from Retrived from

https://www.kramesondemand.com/HealthSheet.aspx?id=82055&ContentTypeId=3.

MedMovie. (2007).Cardiovascular Media Library. Retrieved from http://www.medmovie.com/#.

Porth, C.M. (2009). Pathophysiology: Concepts of Altered Health States. Philadelphia, PA: Lippincott Williams

and Wilkins.