NURS 321: Ch 20, Heart Failure

HOW MANY classifications of HEART FAILURE are there?

4

What is Class I HEART FAILURE?

No limitation of physical activity - ordinary physical

activity does not cause symptoms of heart failure

What is Class II HEART FAILURE?

Slight limitation of physical activity. Comfortable at rest,

but ordinary physical activity results in symptoms of

heart failure

What is Class III HEART FAILURE?

Marked limitation of physical activity. Comfortable at

rest, but less than ordinary activity causes symptoms of heart failure

What is Class IV HEART FAILURE?

Unable to perform any physical activity without

symptoms of heart failure, or there are symptoms of

heart failure at rest

What are the THREE COMPENSATORY MECHANISMS that cause VENTRICULAR FAILURE?

1.) Activation of norepinephrine atrial

natriuretic peptide

2.) Activation of renin-angiotensin-

aldosterone mechanism

3.) Increased myocardial contractility

How does Activation of norepinephrine atrial

natriuretic peptide cause VENTRICULAR FAILURE?

widens blood vessels leading to tachycardia to compensate; more stress on myocardium leads to congestive heart failure

How does Activation of RAAS cause VENTRICULAR FAILURE?

increases sodium and water retention causing further stress on the myocardium resulting in congestive heart failure

How does increased myocardial contractility cause VENTRICULAR FAILURE?

increases cardiac workload so myocardium cells are stretching too much resulting in compensatory hypertrophy and dilation

What is CAD?

plaque that narrows coronary arteries resulting in an insufficient supply of blood to meet the oxygen demands of the myocardium

What will CAD result in?

heart attack

What is the leading cause of HEART FAILURE?

CAD

How does HYPERTENSION affect the heart?

leads to an enlarged cardiac muscle because the

heart must work harder than normal to pump against the high pressure in the arteries

What is PULMONARY EDEMA?

Increased fluid in the lung tissue manifested by rales,

wheezes, blood-tinged sputum, low oxygenation

What sound may DEVELOP in PULMONARY EDEMA?

third heart sounds (S3)

When does HEART FAILURE occur?

results from inadequate pumping of the heart muscle with manifestations caused by the heart's inability to meet the circulation needs of the whole body

What are the RISK FACTORS of HEART FAILURE?

- Uncontrolled hypertension

- Congenital heart defect

- Arrhythmias

- Coronary artery disease

- Damage of the heart muscles

- Dysfunction of heart valve

What is BNP?

peptide that is released when the ventricle stretches

from being filled with too much fluid

What BNP level would demonstrate HEART FAILURE?

< 100 pg/mL

What test helps RULE OUT heart failure?

B-type natriuretic peptide (BNP)

What does CHEST X-RAY reveal?

enlarged heart

What does ECHOCARDIOGRAM reveal?

ejection fraction

What CLIENT EDUCATION should be provided to patients with HEART PROBLEMS?

- s/s of fluid retention

- elevated head of bed

What are SIGNS AND SYMPTOMS of FLUID RETNETION?

edema, weight gain, shortness of breath

How much WEIGHT GAIN is ALARMING?

2-3 lbs over a 24 hour period

What POSITION should a client with HEART FAILURE be in? WHY?

semi-fowler's; When lying flat, fluid in the

lungs (pulmonary congestion) causes shortness of breath, so elevating the head allows easier breathing

What are INDICATIONS of CONGESTIVE HEART FAILURE?

chest pain, dizziness, sudden fatigue, swelling of feet and hands, SOB, sudden weight gain

What does LEFT SIDED HEART FAILURE affect?

weakness of left side ventricle contraction causes blood to back up into lungs because of reduced pump

What does RIGHT SIDED HEART FAILURE affect?

weakness of right side ventricle contraction causes blood to back up into tissues/body because of reduced pump

Where does FLUID BACK UP in LEFT SIDED HEART FAILURE?

LUNGS

Where does FLUID BACK UP in RIGHT SIDED HEART FAILURE?

tissues

When does RIGHT SIDED HEART FAILURE usually occur?

as a result of Left-Sided Heart Failure

What are S/S of LEFT SIDED HEART FAILURE?

- Dyspnea (Shortness of breath)

- Orthopnea (Trouble lying flat)

- Rales (crackles) can be heard

- Cough (sometimes pink, foamy)

What are S/S of RIGHT SIDED HEART FAILURE?

- Swelling of the legs and hands

- Weight gain (2-3 lbs per day)

- Edema (pitting)

- JVD

- Ascites

What is JVD?

"Jugular vein distension"; large neck veins

What if S/S of LEFT and RIGHT SIDED HEART FAILURE are BOTH PRESENT?

indicates chronic heart failure

What are the EIGHT CATEGORIES of HEART FAILURE MEDS?

1.) RAAS inhibitors

2.) Beta blockers

3.) Diuretics

4.) Vasodilators

5.) Sodium-Glucose Co-Transporter 2 Inhibitors

6.) Inotropic Agents

7.) HCN Channel Blockers

8.) Vasopressors

What are the FOUR TYPES of RAAS INHIBITORS used for HEART FAILURE?

1.) ACE INHIBITORS: "-prils"

2.) ARBs: "-sartans"

3.) Aldosterone Antagonsts: Spironolactone and Eplerenone

4.) ARNI: Sacubitril/Valsartan aka Entresto

What are the THREE TYPES of BETA BLOCKERS used for HEART FAILURE?

1.) Carvedilol: Beta 1, Beta 2, & Alpha 1

2.) Metoprolol succinate: cardioselective - Beta 1

3.) Bisoprolol: cardioselective

What are the THREE types of DIURETICS used for HEART FAILURE?

1.) Loops: Furosemide & Bumetanide

2.) Thiazides: Hydrochlorothiazide and Chlorthalidone

3.) Potassium-sparing: SEAT

What VASODILATOR medication is used for HEART FAILURE?

Hydralazine/Isosorbide Dinitrate (BiDil)

What SODIUM-GLUCOSE CO-TRANSPORTER 2 INHIBITORS are used for HEART FAILURE?

Empagliflozin (Jardiance)

What THREE INOTROPIC AGENTS are used to treat HEART FAILURE?

1.) Cardiac Glycosides: Digoxin

2.) Sympathomimetics: Dobutamine

3.) Phosphodiesterase inhibitors: Milrinone

What TWO VASOPRESSORS are used to treat HEART FAILURE?

1.) Adrenergic Agonists: Epinephrine

2.) Antidiuretic Hormone: Vasopressin

How much time is needed between taking ACE INHIBITORS and ARN INHIBITORS?

36-hour washout period

What are CONTRAINDICATIONS of ACE INHIBITORS?

history of angioedema and pregnancy

What are CONTRAINDICATIONS of ARBs?

history of angioedema

Differences between ARBs vs ACEs?

ARBs block angiotensin II effects, while ACEs prevent the creation of angiotensin II

What are ARNIs?

Inhibitor of the renin angiotensin-aldosterone system; used for patients who have Class II-IV heart failure and reduced ejection fraction to replace an ACE inhibitor or ARB

What are CONTRAINDICATIONS of ARNI medicaitons?

severe hepatic/liver impairment

What should ARNIs NOT be COMBINED with?

ACE inhibitor or an ARB, potassium sparing diuretics, NSAIDs, or lithium

What are examples of BETA BLOCKER MEDICATION?

Carvedilol, Bisoprolol, Metoprolol succinate

What systems do NONSELECTIVE beta blockers affect?

cardiac and respiratory

What is the EFFECT of BETA-BLOCKERS?

inhibited effect of beta stimulation; decreased HR and BP

Are SUCCINATE and TARTRATE interchangeable?

No, they are different salt forms and have different release times

What is METOPROLOL SUCCINATE?

beta blocker; extended-release (ER), designed for slow, consistent absorption over 24 hours

What is METOPROLOL TARTRATE?

"lopressor"; immediate-release (IR), designed for faster absorption and shorter duration of action

When is METOPROLOL SUCCINATE used?

chronic heart failure; preferred for its stable, once-daily dosing

Why is METOPROLOL TARTRATE not usually given for CHRONIC HEART FAILURE?

it is an immediate-release formulation with a short

half-life (3-4 hours), leading to fluctuating, inconsistent blood levels and reduced survival benefits

What is INOTROPIC?

ability to influence the strength of muscle contractions

What is CHRONOTROPIC?

ability to increase or decrease heart rate

What is DROMOTROPIC?

ability to influence the speed of cardiac impulse conduction from the AV node through the rest of the heart

What are the THREE EFFECTS of BETA-BLOCKERS on the HEART?

1.) Negative Chronotropic - decreases

the heart rate

2.) Negative Inotropic - weakens the

heart muscle's contraction force to reduce how hard it beats

3.) Negative Dromotropic - less speed of conduction, reduces the rate at which the electrical signal travels from the atria to the ventricles

How do DIURETICS treat HEART FAILURE?

help the kidneys remove excess fluid from the body reducing volume of fluid which reduces the workload on the heart

What MANIFESTATIONS of HEART FAILURE does DIURETICS help with?

shortness of breath, edema, and fatigue

What are THREE THINGS that need to be MONITORED for DIURETIC use to treat HEART FAILURE?

1.) Electrolyte balance, especially potassium as it can quickly become life threatening

2.) Creatinine and BUN due to risk of decreased kidney perfusion

3.) BP and hydration status

What part of the NEPHRON does LOOP DIURETICS act on?

ascending part of loop of Henle

What RISK FACTOR is associated with FUROSEMIDE?

hypokalemia

What part of the NEPHRON does THIAZIDE DIURETICS act on?

proximal portion of the distal convoluted tubule

What RISK FACTOR is associated with HYDROCHLOROTHIAZIDE?

hypokalemia

What part of the NEPHRON does POTASSIUM-SPARING DIURETICS act on?

distal portion of the distal convoluted tubule/collecting duct

What RISK FACTOR is associated with SPIRONOLACTONE?

hyperkalemia

What is BiDil?

"Isosorbide Dinitrate and Hydralazine"; vasodilator used to decrease preload and afterload to improve perfusion and cardiac function in clients with hypertension or heart failure

What is the ACTION of ISOSORBIDE?

Release of nitric oxide leads to vasodilation; most effect on veins

What is the ACTION of HYDRALAZINE?

Selective dilation of arteries

What is the THERAPEUTIC USE of BiDil?

decrease preload and after load to improve perfusion and cardiac function

What is BiDil used to treat?

hypertension and heart failure

What should be ASSESSED by the NURSE before administering BiDil?

numbness and paresthesia

What are side effects of VASODILATOR/BiDil?

Tachycardia, nausea, diarrhea, headache, orthostatic hypotension, numbness, paresthesia

What CLIENT EDUCATION should be provided about BiDil?

3x a day schedule, orthostatic hypotension precautions, avoid alcohol, maintain hydration, side/adverse effects

What are MEDICATION OUTCOMES of BiDil?

Decreased HF manifestations, improved survival and length of time before hospitalization

What is an EXAMPLE of a SODIUM-GLUCOSE CO-TRANSPORTER 2 INHIBITOR?

Empagliflozin (Jardiance)

What MEDICATION CLASS is Empagliflozin (Jardiance)?

Antidiabetic

What is the ACTION of Empagliflozin (Jardiance)?

inhibits SGLT2 protein for reduced glucose absorption by excretion; causes increased diuresis and natriuresis as well resulting in improved cardiac function

What is the THERAPEUTIC USE for Empagliflozin (Jardiance)?

Lower cardiovascular events, death risk, and number of hospitalizations for clients who have HF

What NURSING ASSESSMENT is appropriate for Empagliflozin (Jardiance)?

Monitor fluid volume, BP, renal function, CBC, lipids, electrolytes, daily weight, glucose, HbA1c, manifestations of UTI

What are SIDE EFFECTS of Empagliflozin (Jardiance)?

UTI, yeast infection

What are ADVERSE EFFECTS of Empagliflozin (Jardiance)?

DKA, renal dysfunction

What are INTERACTIONS need caution for Empagliflozin (Jardiance)? WHY?

insulin; hypoglycemia risk

What are PRECAUTIONS of Empagliflozin (Jardiance)?

Frequent UTI

Why does Empagliflozin (Jardiance) pose a UTI RISK?

causes your body to flush excess glucose

(sugar) out through your urine creating a sugar-rich environment serving as a breeding ground for bacteria

and yeast to thrive

What is the SA NODE?

"sinoatrial node"; heart's natural pacemaker

What are MEDICATION EXAMPLES for CARDIAC GLYCOSIDES?

digoxin

Does DIGOXIN affect BP?

No, affects rate and quality of contractions

What INOTROPIC EFFECT does DIGOXIN have?

Positive inotropic effects so heart beats harder; improves effective pump for SV and CO

What CHRONOTROPIC EFFECT does DIGOXIN have?

Negative chronotropic effects so heart to beats slower; more time for ventricles to fill with blood for increased SV and CO

What is the THERAPEUTIC LEVEL for DIGOXIN?

0.8-2.0 ng/mL

What is the TOXICITY LEVEL for DIGOXIN?

greater than 2.0 ng/mL

What are the TOXICITY S/S for DIGOXIN?

fatigue, weakness, vision changes, anorexia (loss of appetite), GI effects

What can INCREASE RISK for DIGOXIN TOXICITY?

Hypokalemia