Study Notes on Heart Failure and Complications from Heart Disease

Chapter 25: Management of Patients With Complications From Heart Disease

Learning Objectives

  • Recognize the etiology, pathophysiology, and clinical manifestations of the different classifications of heart failure.

  • Describe the medical management, including recommended pharmacologic treatments, for patients with heart failure.

  • Use the nursing process as a framework for care of the patient with heart failure.

  • Identify additional heart disease disorders and medical and nursing management of patients with complications from heart disease.

Heart Failure (HF) Overview

  • Definition: Heart failure is a clinical syndrome resulting from structural or functional cardiac disorders that impair the ability of the ventricles to fill or eject blood.

  • Historical Terminology: Previously referred to as congestive heart failure (CHF) due to associations with pulmonary or peripheral congestion and edema.

  • Characteristics: Clinical syndrome characterized by signs and symptoms of fluid overload or inadequate tissue perfusion.

  • Myocardial Disease: Denotes issues with contraction (systolic failure) or filling (diastolic failure) of the heart.

  • Reversible Cases: Some instances of heart failure may be reversible depending on the underlying causes.

  • Management: Primarily a chronic, progressive condition managed with lifestyle changes and medications.

Types of Heart Failure

Left Sided Heart Failure

  • Description: Ineffective left ventricular contraction.

  • Consequences: May lead to pulmonary congestion or pulmonary edema and decreased cardiac output.

  • Common Causes: Left ventricular myocardial infarction, hypertension, and aortic and mitral valve stenosis or regurgitation.

  • Secondary Outcomes: Can result in pulmonary edema and right-sided heart failure.

Right Sided Heart Failure

  • Description: Resulting from ineffective right ventricular contraction.

  • Common Causes: Acute right ventricular infarction or pulmonary embolus; most often due to profound backward flow from left-sided heart failure.

Chronic Heart Failure - Incidence

  • Age Factor: Incidence of heart failure increases with age.

  • Statistics: Approximately 6 million people in the United States have heart failure; 870,000 new cases are diagnosed each year.

  • Hospitalization Trends: It is the most common reason for hospitalization in those over 65 years old and the second leading cause of physician visits.

  • Readmission Rates: About 20% of patients discharged after HF treatment are readmitted within 30 days, and nearly 50% within 6 months.

Pathophysiology of Heart Failure

  • Underlying Causes: Include myocardial dysfunction, ischemic heart disease, hyperthyroidism, myocardial infarction, valve disease, and lifestyle factors such as alcohol or cocaine abuse and hypertension.

  • Cardiac Output Impact: Affects systemic blood pressure and renal perfusion, which activates baroreceptors.

  • Renin-Angiotensin-Aldosterone System Activation: Initiates series of physiological changes including vasoconstriction and sodium/water retention, contributing to heart failure progression.

Causes of Heart Failure

  • Medical Conditions: Anemia, arrhythmias, atherosclerosis with myocardial infarction, connective tissue disorders (e.g., sarcoidosis), constrictive pericarditis, cor pulmonale (right-sided heart failure), infections, mitral/aortic insufficiencies, myocarditis, and significant nutritional deficiencies.

  • Lifestyle Associations: Nonadherence to medical regimen, excessive salt or water intake, and emotional stress.

Risk Factors for Heart Failure

  • Coronary artery disease, hypertension, myocardial infarction, diabetes, obesity, high-fat high-sodium diet, inactivity, and older age.

  • Psychosocial Factors: Emotional stress, excessive alcohol intake, smoking, and age/ethnic disparities.

Complications of Heart Failure

  • Potential Complications: Pulmonary edema, organ failure (brain and kidneys), myocardial infarction, cardiomyopathy, cardiac arrhythmias, valvular insufficiency, sudden cardiac death, fluid/electrolyte imbalance, malnutrition, and embolism leading to ischemia/infarction.

Assessment of Heart Failure

  • Symptoms: Dyspnea, orthopnea, paroxysmal nocturnal dyspnea, peripheral edema, fatigue, weakness, insomnia, anorexia, nausea, abdominal fullness, decreased exercise tolerance, weight gain, and nocturia.

Clinical Manifestations – Physical Findings

Right Sided Heart Failure Findings

  • Viscera and peripheral congestion, jugular venous distention (JVD), dependent edema, hepatomegaly, ascites, and weight gain.

Left Sided Heart Failure Findings

  • Pulmonary congestion, crackles in lung sounds, S3 or ventricular gallop, dyspnea on exertion (DOE), low oxygen saturation, dry nonproductive cough evolving to pink/frothy sputum, and oliguria.

Diagnostics – Laboratory Tests

  • Key Tests:

    • B-type natriuretic peptide (BNP): Elevated levels assist in dilating blood vessels and aiding heart function.

    • Complete blood count (CBC) & comprehensive metabolic panel (CMP): Check for anemia, infections, and kidney function.

    • Lipid panel: Assess for underlying cardiac disease.

Diagnostics – Procedural/Imaging

  • Electrocardiogram (EKG): Assess electrical activity of the heart.

  • Echocardiogram: Evaluate heart structure and function.

Medical Management of Heart Failure

  • Variability in Treatment: Depends on severity, comorbidities, and cause of heart failure and may include oral and IV medications, lifestyle modifications, supplemental oxygen, and surgical interventions (e.g., ICD and heart transplant).

  • Essential Education: Comprehensive education and counseling to patient and family are vital for effective management.

Pharmacologic Treatments for Heart Failure

Medications Group 1

  • ACE Inhibitors: Cause vasodilation and diuresis, decrease afterload; monitor for hypotension, hyperkalemia, and altered renal function.

    • Prototype: Enalapril.

  • Angiotensin II Receptor Blockers (ARBs): Similar effects to ACE inhibitors; prescribed when ACE inhibitors are not tolerated.

    • Prototype: Losartan.

  • Hydralazine and Isosorbide Dinitrate: Alternative vasodilators for patients intolerant to ACE inhibitors.

  • Beta-Blockers: Used alongside ACE inhibitors; full effects may take weeks, with caution for patients with asthma.

Medications Group 2

  • Ivabradine: Slows conduction through the SA node; monitor for decrease in heart rate and blood pressure.

  • Diuretics: Reduce fluid volume and require serum electrolyte monitoring.

    • Prototypes: Furosemide (Lasix).

  • Digitalis: Enhances contractility; closely monitor for toxicity, especially in hypokalemic patients.

  • IV Medications: Indicated for hospitalized patients with acute decompensated heart failure.

    • Examples: Milrinone, Dobutamine, Dopamine, and various vasodilators for symptom relief.

Gerontologic Considerations

  • Atypical Presentation: Older adults may present with atypical symptoms like fatigue and weakness, with decreased renal function affecting diuretic response.

  • Management Tip: Monitoring for bladder distention from prostate enlargement during diuretic administration in older men is crucial.

Nursing Process for Heart Failure

Assessment

  • Evaluate therapy effectiveness and self-management, along with assessing for signs/symptoms of worsening heart failure.

  • Health history and physical examination should focus on cardiac and respiratory functions as well as daily weights.

Diagnoses

  • Common Nursing Diagnoses:

    • Activity Intolerance related to decreased cardiac output.

    • Excess Fluid Volume related to heart failure syndrome.

    • Anxiety related to treatment complexity.

    • Powerlessness associated with chronic illness.

    • Ineffective family management of therapeutic regimen.

Planning Goals

  • Promote activity and reduce fatigue.

  • Relieve fluid overload symptoms.

  • Decrease anxiety and empower self-management.

  • Educate patients/families on therapeutic regimen management.

Activity Intolerance

  • Management Strategies:

    • Bed rest during acute exacerbations.

    • Gradual increase of physical activity, aiming for at least 30 minutes daily.

    • Pacing activities and avoiding extremes in temperature during activity.

    • Positioning to facilitate breathing.

Fluid Volume Excess Management

  • Monitoring: Assess for symptoms of fluid overload and record daily weights. Patients should report significant changes.

  • Measurement Guidelines: Track intake and output; oliguria (<500 mL/24 hr) and anuria (0-100 mL/day) signify serious concerns.

  • Diuretics: Administer according to timing for maximum effect and maintain sodium restriction per physician orders.

Patient Education

  • Core Components: Education on medications, dietary restrictions, monitoring symptoms, exercise regimens, stress management, and infection prevention.

  • Include family involvement in the education process to ensure support.

CheckPoint: Evaluation of Nursing Diagnosis

  • Evaluation Indicators: Maintaining vital signs within targeted ranges is a reliable indicator that patient outcomes have been met.

End of Life Considerations

  • Heart failure being a chronic and progressive condition will necessitate considerations related to end-of-life care, including palliative or hospice interventions.

Pulmonary Edema Overview

  • Description: Accumulation of fluid in the extravascular spaces of the lungs (alveoli and interstitium), impairing gas exchange and potentially causing severe hypoxemia.

  • Contributing Factors: Left-sided heart failure, myocardial infarction, valve disease, as well as non-cardiac causes such as pulmonary embolism.

  • Symptoms: Include shortness of breath, orthopnea, dyspnea, cough, anxiety, cyanosis, and increased respiratory effort.

Diagnosis and Management of Pulmonary Edema

  • Diagnosis: Based on physical examination, vital signs, and chest x-ray.

  • Management: Focus on prevention and early recognition; includes oxygen therapy, diuretics, and positioning to promote circulation.

Complications from Heart Disease

  • Common Complications: Include cardiogenic shock, thromboembolism, pericardial effusion, cardiac tamponade, and cardiac arrest.

Cardiogenic Shock Overview

  • Definition: A life-threatening condition characterized by decreased cardiac output leading to inadequate tissue perfusion.

  • Causes: Include myocardial infarction, heart failure, or valvular disease, among others.

Management of Cardiogenic Shock

  • Goals: Correct underlying issues, reduce cardiac workload, and improve oxygenation and tissue perfusion.

  • Medications: Diuretics, positive inotropic agents, and vasopressors, with the use of circulatory assist devices as necessary.

  • Intra-Aortic Balloon Pump (IABP): A mechanical assist device for severe cardiac dysfunction, enhancing coronary perfusion and aiding in blood flow during systole and diastole.

Thromboembolism Overview

  • Definition: Obstruction of a blood vessel by a dislodged clot, leading to complications such as ischemic stroke or pulmonary embolism.

  • Management: Anticoagulation therapy, including medications such as heparin and warfarin.

Pericardial Effusion and Cardiac Tamponade

  • Overview: Pericardial effusion involves the accumulation of fluid in the pericardial sac, leading to cardiac tamponade, which restricts heart function.

  • Symptoms: Includes ill-defined chest pain, elevated venous pressure, and dyspnea.

  • Management: Procedures like pericardiocentesis or pericardiotomy to relieve pressure.

Sudden Cardiac Death or Cardiac Arrest

  • Emergency Management Protocol: Immediate identification of unresponsiveness and absence of normal breathing.

  • CPR Initiation: High-quality chest compressions, ensuring correct rescue breaths, and using an AED if available are critical for restoring normal heart rhythms.