Heart Failure and Valvular Heart Disease Lecture Flashcards

Overview of Heart Failure (HF)

• Definition: Heart failure is a condition where the heart cannot pump enough blood to meet the body's metabolic needs.

• Metabolic Needs: It is critical to understand that when metabolic needs are not met, less blood reaches the organs.

• Pathophysiology: As a result of inadequate pumping, fluids back up into the system. The patient subsequently develops congestion and edema.

• Keywords: New, Sudden, Worsening, Rapid.

Risk Factors and Etiology of Heart Failure

• Primary Risk Factors:

  • Hypertension (HTN): This is a modifiable risk factor. If HTN is aggressively treated and managed, the incidence of HF can be reduced by $50\%$. If blood pressure stays high, the heart "gets tired," enlarges, and eventually fails because it has to work harder.

  • Coronary Artery Disease (CAD): Characterized by plaque build-up which prevents oxygen from reaches the heart muscle.

• Co-morbidities: Several conditions contribute to the development of HF, including:

  • Chronic Kidney Disease (CKD).

  • Diabetes (Diabetes is a major contributor to kidney failure and HTN).

• Etiological Categories:

  • Primary Causes: Conditions that directly damage the heart.

  • Precipitating Causes: Conditions that increase the workload of the heart.

Classifications of Heart Failure

• Left-Sided Heart Failure:

  • The most common form of HF.

  • Results from the inability of the Left Ventricle (LV) to either empty adequately during systole or fill adequately during diastole.

  • Mechanism: Blood backs up into the Left Atrium (LA). This increases pulmonary hydrostatic pressure, causing fluid leakage from the pulmonary capillary bed into the interstitium and then the alveoli.

  • Outcome: This results in pulmonary symptoms (Lung-related).

• Right-Sided Heart Failure:

  • The Right Ventricle (RV) does not pump effectively.

  • Mechanism: Fluid backs up in the venous system and moves into tissues and organs.

  • Clinical Presentation: Results in peripheral edema, Jugular Vein Distention (JVD), and ascites (fluid in the belly).

  • Causes: Left-sided HF is the most common cause of right-sided HF. Other causes include RV infarction, Pulmonary Embolism (PE), and Cor Pulmonale (RV dilation and hypertrophy caused by pulmonary disease).

• Systolic vs. Diastolic Failure:

  • HFrEF (Heart Failure with Reduced Ejection Fraction): Also known as systolic failure. It is the inability to pump blood effectively caused by impaired contractile function, increased afterload, or mechanical abnormalities. The heart "can't squeeze well."

  • HFpEF (Heart Failure with Preserved Ejection Fraction): Also known as diastolic failure. It is the inability of the ventricles to relax and fill during diastole, resulting in decreased stroke volume and Cardiac Output (CO).

  • HFpEF Primary Cause: HTN is the primary cause, resulting in Left Ventricular Hypertrophy. Correlates with older age, female gender, diabetes, and obesity.

Clinical Manifestations

• Left-Sided HF (Lungs):

  • Pulmonary congestion.

  • Crackles: Fluid in the air sacs.

  • Dyspnea: Shortness of breath (SOB).

  • Orthopnea: Inability to sleep flat; patients often use multiple pillows to stay elevated. Ask the patient: "How many pillows do you use to sleep?"

  • Paroxysmal Nocturnal Dyspnea (PND): Nighttime difficulty breathing where fluid redistributes into the lungs while lying down, causing the patient to wake up gasping for air.

  • Physical Signs: Lungs may produce pink frothy sputum in severe cases.

• Right-Sided HF (Body):

  • Systemic congestion.

  • Edema: Swelling, particularly in the lower legs.

  • JVD: Jugular Vein Distention; bulging veins in the neck.

  • Ascites: Fluid accumulation in the stomach/abdominal cavity.

  • Hepatomegaly: Enlarged liver due to fluid congestion.

  • Weight Gain: A primary indicator of fluid retention.

Diagnostics and Laboratory Findings

• Ejection Fraction (EF): The percentage of blood pumped out of the heart with each beat.

  • Normal EF: $50 - 70\%$.

• BNP (Brain Natriuretic Peptide): The "Gold Standard" lab for HF. It tells how overloaded the heart is with fluid.

  • Normal Level: < 100\,pg/mL.

• Echocardiogram: An ultrasound of the heart that provides information on LVEF, heart valves, and the presence of effusion (fluid around the heart) or thrombus.

• Other Tests: ECG, ambulatory heart monitors, chest x-ray (CXR), MRI, cardiopulmonary exercise stress test, and cardiac catheterization/angiogram.

• 6-Minute Walk Test: Used to determine if a patient needs oxygen ($O_2$) at home.

Drug Therapy

• RAAS Inhibitors:

  • ACE Inhibitors: Common side effect is a dry cough.

  • Angiotensin II Receptor Blockers (ARBs).

  • Neprilysin-angiotensin receptor inhibitors (ARNIs).

  • Aldosterone Antagonists: e.g., Spironolactone (a potassium-sparing diuretic). Monitor $K^+$ levels.

• Vasodilators: Reduce preload and afterload.

  • Nitrates: e.g., Nitroglycerin. Monitor Blood Pressure (BP) and Heart Rate (HR) as it can cause hypotension.

• Diuretics: Reduce edema, pulmonary venous pressure, and preload by promoting sodium ($Na$) and water excretion.

  • Loop Diuretics: e.g., Furosemide (Lasix). Watch for hypokalemia (low $K^+$) and hypomagnesemia.

  • Thiazide Diuretics: e.g., Hydrochlorothiazide.

• Positive Inotropic Agents: Increase contractility to improve CO.

  • Digitalis (Digoxin): Check Digoxin levels. Watch for Dig Toxicity. Early signs include anorexia ("I am not hungry anymore") and nausea/vomiting (N/V).

Interprofessional and Nursing Care

• Oxygen Therapy: Relieves dyspnea and fatigue.

• Physical/Emotional Rest: To conserve energy and decrease $O_2$ needs.

• Exercise: Structured program; ideally $30\,minutes$ a day, $3$ days a week.

• Nutritional Therapy:

  • Low Sodium Diet: Usually restricted to $2\,g/day$. Avoid canned foods and read labels carefully.

  • Fluid Restriction: For Stage D / IV HF patients.

• Weight Monitoring: Daily weights are essential. Perform at the same time every morning using the same scale and similar clothing, after urinating.

  • Reportable Weight Gain: A gain of $3\,lbs$ ($1.4\,kg$) over $2\,days$ or a $3-5\,lbs$ ($2.3\,kg$) gain over a week should be reported to the Health Care Provider (HCP).

• Positioning: Head of Bed (HOB) should be at $45^{\circ} - 90^{\circ}$.

Cardiomyopathy

• Definition: A disease of the heart muscle that makes it harder for the heart to pump blood.

• Dilated Cardiomyopathy:

  • Most common type ($25-40\%$ of HF cases).

  • Characteristics: Systolic dysfunction; enlargement of all cardiac chambers; weak contraction.

  • Causes: Infectious myocarditis, alcohol, cocaine.

  • Clinical Manifestations: Fatigue, dyspnea at rest, PND, orthopnea.

  • Early Signs of Low CO: Restlessness and agitation.

  • Physical Signs: S3 and/or S4 heart sounds, crackles, weak peripheral pulses (PP), pallor, and hepatomegaly.

• Hypertrophic Cardiomyopathy:

  • Characteristics: Massive ventricular hypertrophy (thickening of the left ventricular wall); diastolic dysfunction.

  • Risk: High risk of sudden death in young athletes.

  • Clinical Manifestations: Fatigue, angina, exertional dyspnea, and syncope (fainting).

  • Care: Use Beta-blockers, Nifedipine, or Diltiazem. Avoid Nitrates and Digoxin as dilators can worsen the condition.

• Restrictive Cardiomyopathy:

  • Least common type.

  • Characteristics: Ventricular walls are rigid (like a "brick wall"), resulting in diastolic dysfunction (filling problems).

  • Causes: Amyloidosis, cancer.

  • Result: Less blood in results in less CO to the body.

Valvular Heart Disease

• Anatomy:

  • Atrioventricular Valves: Mitral (Left side, between LA and LV) and Tricuspid (Right side).

  • Semilunar Valves: Aortic (Between LV and Aorta) and Pulmonic (Right side).

• Types of Dysfunction:

  • Stenosis: Constriction/narrowing. The valve opening is smaller, impeding forward blood flow.

  • Regurgitation: Incomplete valve closure resulting in the backward flow of blood ("leaking").

Specific Valve Disorders

• Mitral Valve Stenosis:

  • Primary cause is Rheumatic Heart Disease.

  • Manifestations: Exertional dyspnea, loud S1, diastolic murmur, hemoptysis (coughing up blood), and a high risk for Atrial Fibrillation (A-fib) and subsequent stroke.

• Mitral Valve Regurgitation (MR):

  • Blood leaks backward from LV to LA.

  • Acute MR: Causes pulmonary edema and is a medical emergency.

  • Chronic MR: May be asymptomatic for years; progresses to weakness, S3, and peripheral edema.

• Mitral Valve Prolapse (MVP):

  • Leaflets prolapse back into the LA during systole. Usually benign.

  • Symptoms: Chest pain unresponsive to nitrates. Managed with Beta-blockers. Advise patients to avoid caffeine and OTC stimulants.

• Aortic Valve Stenosis (AS):

  • Obstruction of flow from LV to Aorta.

  • Triad of Symptoms (SAD): Syncope, Angina, exertional Dyspnea.

  • Caution: Use Nitroglycerin cautiously as it reduces preload and can worsen chest pain.

• Aortic Valve Regurgitation (AR):

  • Acute AR: Life-threatening emergency; severe dyspnea, chest pain, hypotension.

  • Chronic AR: May present with a "Water-hammer" pulse (strong/bounding pulse).

Interprofessional Care for Valvular Disease

• Echocardiogram: Used for diagnosis.

• Surgical Therapy:

  • Valve Repair: Preferred; lower mortality rate.

  • Mechanical Valve Replacement: Artificial valves. More durable and last longer but require long-term anticoagulation (e.g., Warfarin) due to the risk of thromboembolism. Monitor INR.

  • Biologic Valve Replacement: Bovine (cow), porcine (pig), or human tissue. No anticoagulation required, but they are less durable.

• Nursing Management:

  • Prophylactic antibiotics are required before dental or invasive work for patients with a history of Rheumatic Fever or IE to prevent recurrent infection.

  • Patients should wear a medical-alert bracelet.

Ch. 34 Chronic Heart Failure

• Role of the Nurse: In the prevention, detection, and diagnosis of heart failure, nurses play a crucial role in monitoring symptoms, educating patients about risk factors, and providing ongoing assessments. They help establish care plans that focus on lifestyle changes and medication adherence.

• Precipitating Factors: Identify risk factors such as hypertension, coronary artery disease, and diabetes that can lead to chronic heart failure.

• Clinical Manifestations: Recognize key symptoms including dyspnea, fatigue, edema, and orthopnea. Nursing management includes symptom assessment and adjustment of care plans accordingly.

• Inter-professional Management: Engage with healthcare professionals to create comprehensive management plans, including medications and lifestyle interventions.

• Patient Education: Involve patients and families in understanding the condition, management strategies, and when to seek help.

• Complications Prevention: Key elements include monitoring weight, promoting physical activity, and education regarding medication side effects.

Ch. 36 Cardiomyopathy

• Role of the Nurse: Nurses assist in early detection through regular assessments and patient education about symptoms and lifestyle changes.

• Precipitating Factors: Recognizing risks such as genetic predisposition and previous heart conditions.

• Clinical Manifestations: Identify signs like fatigue, shortness of breath, and arrhythmias. Management includes supportive care and strict monitoring for worsening symptoms.

• Inter-professional Management: Collaborate with physicians and specialists for optimal patient outcomes.

• Patient Education: Ensure patients and families understand the disease process and management options.

• Complications Prevention: Focus on adherence to treatment regimens and regular follow-ups.

Valvular Heart Disease

• Role of the Nurse: Nurses play a significant role in recognizing symptoms and in the early detection of valvular disorders.

• Precipitating Factors: Identify underlying causes like rheumatic fever or degenerative diseases.

• Clinical Manifestations: Understand symptoms including exertional dyspnea and signs of heart failure.

• Inter-professional Management: Work closely with cardiac specialists and surgical teams for valve repair or replacement considerations.

• Patient Education: Educate patients and families regarding lifestyle modifications and the importance of monitoring their symptoms.

• Complications Prevention: Highlight the need for regular cardiac evaluations and patient vigilance for symptom changes.