CHF: 220 test II

• 1. CAD
• 2. advanced age
• 3. HTN
• 4. DM
• 5. smoking
• 6. obesity
• 7. high serum cholesterol

• 1. AA high incidence, mortality, & develops at earlier age than in whites
• 2. AA have more ACE inhibitor angioedema
• 3. Asians have extremely high risk for ACE cough

bidil

• 1. CAD including MI--> kills tissue --> HF
• 2. HTN & hypertensive crisis --> stretches heart tissue --> HF
• 3. rhumatic heart disease
• 4. congenital heart defects
• 5. pulmonary hypertension
• 6. cardiomyopathy:  potpartum, substance abuse
• 7. hyperthyroidism
• 8. valvular disorders
• 9. myocarditis

• 1. anemia
• 2. infection
• 3. dysrhythmias

• 1. thyrotoxicosis
• 2. hypothyroidism
• 3. bacterial endocarditis
• 4. pulmonary disease
• 5. paget's disease
• 6. nutritional deficiencies
• 7. hypervolemia

shows CO, SVR (vasoconstriction/dilation)

used to calculate CO, SVR, pulmonary art wdge pressure, SV, central venous pressure

function of L side of heart

pulmonary artery catheter 

sits in pulmonary artery & shows R-side pressure

can measure with a central line

shows fluid status (overload or dehydration) & gives info about why BP is decreased

blood & fluids or if r/t heart not pumping can Tx with HF meds

volume coming back to heart

it is increased

diuretics & vasodilators/BP meds

dangling legs

can go too far & hit ventricle --> arrhythmias

decrease

decreases preload

• 1. decrease preload
• 2. decrease afterload
• 3. increase CO

SVR

decreases

no - will drown them

volume of blood pumped by heart in one minute

normal -4-8L/min

systemic vascular resistance - afterload

R atrial pressure

indicates preload

Schwann Ganz or pulmonary wedge

fluid status, increased CVP, volume overload or R ventricular failure, decreased CVP, hypovolemia

L ventricle preload (measures pulmonary capillary pressure & R atrial pressure)

heart failure/fluid overload

natriuretic peptides (ANP & BNP) are released by heart muscle & promote vasodilation to reduce afterload & preload

no forward BF, decreased EF & BP

• 1. MI
• 2. htn
• 3. cardiomyopathy
• 4. valvular heart disease

decreased EF

ventricles do not fill during diastole --> decreased SV & CO

CVP & R atrial pressure - shows functioning of the L side of the heart

high filling pressure in ventricles r/t noncompliance/stiffness --> venous engorgement in pulmonary & systemic systems --> pulmonary congestion, pulmonary HTN, ventricular hypertrophy, and normal EF

results from LV hypertrophy r/t chronic systemic HTN, aortic stenosis, or hypertrophic cardiomyopathy

muscles of heart stretch to increase CO & force of contractions --> enlarged heart will start to fail

elevated BNP indicates HF

will drop

poor contractility

responds to decreased CO by releasing catecholemines (EPI & NE) to increase HR & contractility & vasoconstricts (increased preload) --> strains already failing heart

lungs

mannitol - pulls fluid from tissue into BV --> will stress overworked heart r/t increased BF

need IV filter

decreased CO --> renin/angiotensin/aldosterone release --> retention of Na/water & vasoconstriction --> increased BP --> increased stress on heart 

decreased CO also causes release of ADH

L sided

LV dysfunction --> blood backs up through L atrium into pulmonary veins --> increased pulmonary pressure --> fluid from pulmonary capillary bed shifts into interstitum & alveoli --> pulmonary congestion/edema

CAD, HTN, cardiomyopathy, rheumatic heart disease

R-sided HF

CXR will show decreased fluid in the lungs

backflow to R atrium & venous circulation --> venous congestion --> peripheral edema, hepatomegaly, splenomegaly, vascular congestion of GI, JVD

albumin

• 1. L sided dysfunction
• 2. chronic pulmonary HTN/cor pulmonale
• 3. COPD
• 4. pulmonary emboli
• 5. MI

lung alveoli filled with fluid - manifests as pulmonary edema

• 1. agitation
• 2. pale
• 3. may be cyanotic
• 4. skin clammy & cold
• 5. dyspnea
• 6. RR >30
• 7. orthopnea:  feel like drowning when lay flat
• 8. wheezing
• 9. frothy blood-tinged sputum
• 10. bubbling crackles
• 11. pulmonary edema
• 12. enlarged heart on CXR
• 13. paroxysmal nocturnal dyspnea

• usually have biventricular failure
• 1. tachycardia
• 2. edema
• 3 nocturia
• 4. behavioral changes:  r/t hypoxia 
• 5. skin changes
• 6. weight changes
• 7. chest pain
• 8. fatigue
• 9. dyspnea
• 10. orthopnea:  orthopnea X5 - sleep with 5 pillows

dry hacking cough

poor nutrition, renal disease, or durg therapy (ACE)

dyspnea when in supine position

pt wakes in panic with feelings of suffocation & has strong desire to sit up for relief

R sided

if taking beta blockers

peripheral, lungs, liver(hepatomegaly), dependent areas, abd cavity (ascites)

increased pulmonary pressures

daytime UO is decreased by decreased CO & fluid in interstitial areas

at night fluid shifts back into BF

• 1. dusky
• 2. cool & damp/diaphoretic
• 3. LE shiny & swollen with diminished or absent hair growth
• 4. pigment changes r/t chronic selling
• 5. brown or brawny ankles & lower legs

unusual behavior:  restlessness, confusion, decreased att. span or memory 

caused by decreased CO --> decreased BF to brain & hypoxia

decreased CO --> decreased coronary circulation

may initially gain r/t fluid retention

eventually will lose weight b/c of anorexia & N:  loss of muscle & fat

may be masked by fluid retention & edema

• 1. pleural effusions
• 2. arrhythmias:  high risk for fatal 
• 3. L ventricular thrombus
• 4. hepatomegaly
• 5. renal failure

increase pressure in pleural capillaries --> fluid into pleural space

in R lower lobe

ventricualr tachyarrhythmias

tachyarrhythmias & afib

low EF increases risk

lasix & other drugs that alter K

• 1. arrhythmias
• 2. formation of clots in L ventricle r/t blood pooling

may be on heparin

can further decrease CO & can cause embolism

more likely with R-sided failure

can lead to liver failure & cirrhosis

decreased perfusion of the kidneys

• FACES
• Fatigue
• Activity limitation
• Cough
• Edema
• Shortness of breath

based on tolerance of physical activity

no limitation of activity

slight limitation of activity:  no s/s at rest

ordinary activity causes fatigue, dyspnea, palpitations, or pain

marked limitation of activity:  usually comfortable at rest & some s/s with activity

inability to carry on anyphysical activity without discomfort

s/s of cardiac insufficiency or anigna may be present even at rest

• 1. physical exam
• 2. CXR
• 3. ECG
• 4. hemodynamic assessment
• 5. echo
• 6. cardiac cath
• 7. BNP

may have BBB r/t enlarged heart

echo & cardiac cath

cath more accurate

• 1. high folwers
• 2. O2 by mask or BNC
• 3. BiPaP
• 4. ET & mechanical ventilation
• 5. cont ECG & pulse ox monitoring
• 6. hemodynamic monitoring
• 7. VS, UO at least q 1h
• 8. drug therapy
• 9. possible cardioversion (for afib, etc)
• 10. ultrafiltration

• 1. diuretics
• 2. ACEs, ARBs, & aldosterone inhibitors
• 3. vasodilators:  nipride, nitrates, B-type natriuretic peptides, hydralazine, isosorbide dinitrate, & bidil
• 4. Beta blockers
• 5. positive inotropes:  dig, beta agonists: dopamine, dobutamine; phosphodiesterase inhibitors:  inocor, primacor
• 6. antidysrhtyhmic drugs
• 7. anticoagulants

• increase Co without increase work of heart
• 1. decrease intravascular volume
• 2. decrease venous return (preload)
• 3. decrease afterload
• 4. improve gas exchange
• 5. increase CO
• 6. decrease anxiety

morphine

EF

degree of L ventricular dysfunction

remove extracellular & intravascular fluid volume

• 1. written discharge instructions or educational materials including:  activity, d/c meds, follow-up, weight monitoring, & what to do if s/s worsen
• 2. L ventricular function is documented 
• 3. pt EF<40% are prescribed ACE or ARB at discharge
• 4. current smokers are given smoking cessation advice

if not done:  insurance won't pay

• 1. O2 admin
• 2.biventricular pacing or cardiac resynchronization therapy 
• 3. implantable cardioverter/defibrillator with CRT
• 4. mechanical options to sustain pt:  intraaortic balloon pump, ventricualr assist devices (used as bridge to transplant)
• 5. Drugs:  diuretics, ACE/ARB/aldosterone inhibitors, vasodilators, beta blockers, positive ionotropes, 
• 6. nutrition:  low Na diet & weight mgmt

• 1. admin O2 & semi-fowlers & monitor ABG's & pulse ox
• 2. adequate rest to decrease O2 needs
• 3. monitor fluid status:  weight, I&O
• 4. give ice chips, gum, hard candy, or popsicles for pt on fluid restrictions to decrease thirst
• 5. Teach:  weight gain 2lb/day or 5lb/wk - need to call MD
• 6. Monitor electrolytes
• 7. monitor pulses & circulation to det CO
• 8. reduce anxiety to decrease SNS stimulation:  benzos or morphine

anxiety & depression

decrease venous return/preload, increase CO, & decrease pulmonary congestion --> increased gas exchange

• 1. low Na diet & lifestyle
• 2.should get vaccinations against flu & pneumonia
• 3.s/s of exacerbations
• 4. s/s of drug toxicity & how to take pulse & home BP monitoring
• 5. s/s of hypokalemia & hyperkalemia

thiazides

• 1. hypokalemia
• 2. ototoxicity
• 3. allergy in pt allergic to sulfa drugs

lasix, demadex, bumex

• 1. decrease hypertrophy
• 2. decrease BP
• 3. increase CO
• 4. increase diuresis

• 1. hypotension 
• 2. hyperkalemia
• 3. rebound hypertension if d/c
• 4. angioedema - can develop suddenly & may be life-threatening

decreased renal efficiency  could cause increased drug levels

may also occur in renal failure

decrease Na & fluid retention - K sparing diuretics

spironolactone & inspra

• 1. hyperkalemia
• 2. can decrease dig effects if hyperkalemia occurs
• 3. Teach pt to avoid high K foods:  oranges, bananas, apricots
• 4 assess male pt for gynecomastia with long-term use

nitrates & bidil

decreased BP - must monitor

adheres to plastic - must waste 50-100mL before running med

may take nitrate combined with hydralazine

• 1. tolerance
• 2. ED - ED meds are CI

combo of isosorbide dinitrate & hydralazine

for AA already being Tx with standard therapy 

isosorbide - relaxes vessels & releases nitric oxide 

hydralazine - relaxes arteries & decreases work of heart

block SNS stimulation on failing heart

may be r/t HF or ACE inhibitor

• 1. edema
• 2. worsening HF
• 3. hypotension
• 4. fatigue
• 5. bradycardia

extreme hypotension & bradycardia, bronchospasm, & cardiogenic shock

assess standing BP 1h after dose

sweating, palpitations, & HA

• GI:  anorexia, NV
• Visual:  blurred vision, yellow tinge, visual halos around dark objects
• CNS:  fatigue, drowsiness, HA, depression
• CV:  dysrhythmias, bradycardia, tachycardia, apical-radial pulse deficit, HF

afib, PVC, Vfib, heart block

K wasting diuretics & hypokalemia

elderly, renal & liver dysfunction

withhold the med and/or digibind

moderate to severe HF & renal insufficiency

high flowlers with feet dangling or horizontal  - pools blood in extremeities & improves ventilation

should check CO & CHF exacerbation before giving beta blocker:  any s/s of exacerbation or decreased CO --> should hold beta blocker

if give too many BP meds and BP gets too low it cannot be increased with fluids

nipride decreases afterload & preload

potent vasodilator

need to monitor BP

put in paper bag- light sensitive

decrease afterload & SVR

may be given with thiazide diuretic b/c ACE holds K & thiazides get rid of it

cozaar & diovan

beta blockers - will decrease CO too much

• 1. morphine - decreases O2 demand
• 2. sats decreased may need mask or nonrebreather
• 3. severe pulm edma may need vent
• 4. monitor ABG, pulse ox, 
• 5. rest
• 6. may use BiPaP to deliver O2

nipride

• 1. dig 
• 2. dobutrex, inocor, primacor, natrecor - peripheral vasodilation

can die if stop taking these meds abruptly:  when d/c must monitor for CHF exacerbation

• 1. ID underlying cause:  HTN, valvular defects, etc
• 2. ventricular tachyarrhythmias - implantable cardioverter (ICD)
• 3. Swan-Ganz 
• 4. intra-aortic balloon pumps (IABP) - balloon inflates during diastole so heart doesn't have to pump as hard to pump blood out during systole
• 5. ventricular assist devices (VAD) - longer-term support to wait for heart transplant

may or may not have pulse

• 1. if balloon moves can block aorta & BF to areas of body
• 2. dislodging plaque
• 3. aortic dissection
• 4. thrombocytopenia
• 5. infection

sepsis & death

hypotension - monitor BP, cyanide poisoning after 48h

need to keep MAP>60

pulses, UO, bowel sounds (ischemia & embolism)

CV checks, neuro, & hemodynamic assessments q15-60 minutes

• 1. relatively immobile in sidelying or supine positions with HOB elevated <45 degrees
• 2. sedation, pain relief, skin care & comfort measures
• 3. weaning pt off of IABP

clots & sepsis

augment or replace ventricular action when heart is failing and needs to recover or when waiting for transplant

• 1. low Na diet:  mild CHF <2g, severe <500-1000mg
• 2. fluid restrictions with no more than 2L/day
• 3. daily weight before breakfast:  gain of 3lb in 2 days or 3-5lb in a week:  need to call
• 4. no alcohol- cardiotoxic

percentage of total ventricular volume ejected during each contraction

normal is >55% & usually is 65%

pulls off fluid but doesn't affect electrolytes