Management of Patients with Complications from Heart Disease

Heart Failure

• Cardiovascular disease is the leading cause of death in the United States.
• Heart disease is often chronic and progressive, with comorbidities like heart failure (HF).
• Heart failure is a clinical syndrome resulting from structural or functional cardiac disorders. It impairs the ventricle's ability to fill or eject blood, leading to insufficient blood supply to meet the body's metabolic demands.
• Heart failure indicates myocardial disease where there is a problem with the contraction of the heart (systolic dysfunction) or filling of the heart (diastolic dysfunction), possibly causing pulmonary or systemic congestion.
• Some cases are reversible, depending on the cause.
• Most HF is a chronic, progressive condition managed with lifestyle changes and medications.
• The incidence of HF increases with age.
• Approximately 6 million people in the United States have HF, and 870,000 new cases are diagnosed each year.
• It is the most common reason for hospitalization of people older than 65 years and the second most common reason for visits to a provider’s office.
• Approximately 20% of patients discharged after treatment for HF are readmitted to the hospital within 30 days, and nearly 50% are readmitted within 6 months.

Pathophysiology of Heart Failure

• Myocardial dysfunction can result from:
  • Ischemic heart disease
  • Myocardial infarction
  • Valve disease
  • Hypertension
  • Hyperthyroidism
  • Alcohol or cocaine abuse
• The pathophysiology of heart failure involves:
  • Decreased cardiac output.
  • Decreased systemic blood pressure.
  • Decreased perfusion to the kidneys.
  • Activation of baroreceptors in the aortic arch and carotid sinus.
  • Activation of the renin-angiotensin-aldosterone system.
  • Stimulation of vasomotor regulatory centers in the medulla.
  • Activation of the sympathetic nervous system.
  • Release of aldosterone by the adrenal cortex, leading to sodium and water retention.
  • Release of arginine vasopressin.
  • Release of endothelin.
  • Increased levels of angiotensin II, leading to vasoconstriction.
  • Increased levels of catecholamines (epinephrine and norepinephrine), leading to vasoconstriction and increased heart rate.
  • Release of cytokines, such as tumor necrosis factor.
  • Ventricular remodeling, including hypertrophy and dilation of the ventricle, resulting in impaired contractility.

Clinical Manifestations of Heart Failure

• Right-Sided Heart Failure:
  • Viscera and peripheral congestion.
  • Jugular venous distention (JVD).
  • Dependent edema.
  • Hepatomegaly.
  • Ascites.
  • Weight gain.
• Left-Sided Heart Failure:
  • Pulmonary congestion, crackles.
  • S3 or “ventricular gallop”.
  • Dyspnea on exertion (DOE).
  • Low $O_2$ saturation.
  • Dry, nonproductive cough initially.
  • Oliguria.

Medical Management of Heart Failure

• Treatment varies based on the severity of the patient’s condition, comorbidities, and cause.
• Treatment options include:
  • Oral and IV medications.
  • Lifestyle modifications.
  • Supplemental $O_2$.
  • Surgical interventions: ICD and heart transplant.
• Comprehensive education and counseling for the patient and family are needed.

Medications Used to Treat Heart Failure

• Diuretics: Decrease fluid volume; monitor serum electrolytes.
• Angiotensin-converting enzyme (ACE) inhibitors: Vasodilation; diuresis; decrease afterload; monitor for hypotension, hyperkalemia, and altered renal function; may cause cough.
• Angiotensin II receptor blockers: Prescribed as an alternative to ACE inhibitors; work similarly.
• Beta-blockers: Prescribed in addition to ACE inhibitors; effects may take several weeks to appear; use with caution in patients with asthma.
• Ivabradine: Decreases the rate of conduction through the SA node; monitor for decreased heart rate and blood pressure.
• Hydralazine and isosorbide dinitrate: Alternative to ACE inhibitors; monitor for decreased blood pressure.
• Digitalis: Improves contractility; monitor for digitalis toxicity, especially if the patient is hypokalemic.
• IV medications (indicated for hospitalized patients admitted for acute decompensated HF):
  • Dopamine: Vasopressor to increase blood pressure and myocardial contractility; adjunct with loop diuretics.
  • Dobutamine: Used for patients with left ventricular dysfunction; increases cardiac contractility and renal perfusion.
  • Milrinone: Decreases preload and afterload; causes hypotension and increased risk of dysrhythmias.
  • Vasodilators: IV nitro, nitroprusside, nesiritide; enhance symptom relief.

Gerontologic Considerations

• Older adults may present with atypical signs and symptoms, such as fatigue, weakness, and somnolence.
• Decreased renal function can make older patients resistant to diuretics and more sensitive to changes in volume.
• Administration of diuretics to older men requires nursing surveillance for bladder distention caused by urethral obstruction from an enlarged prostate gland.

Assessment of the Patient with Heart Failure

• Focus should be on:
  • Effectiveness of therapy.
  • Patient’s self-management.
  • Signs and symptoms of increased HF.
  • Emotional or psychosocial response.
• Health history.
• Physical examination:
  • Mental status.
  • Lung sounds: crackles and wheezes.
  • Heart sounds: S3.
  • Fluid status or signs of fluid overload.
  • Daily weight and I&O.
  • Assess responses to medications.

Collaborative Problems and Potential Complications of Heart Failure

• Pulmonary edema.
• Hypotension, poor perfusion, and cardiogenic shock.
• Arrhythmias.
• Thromboembolism.
• Pericardial effusion.

Planning and Goals for the Patient with Heart Failure

• Goals:
  • Promote activity and reduce fatigue.
  • Relieve fluid overload symptoms.
  • Decrease anxiety or increase the patient’s ability to manage anxiety.
  • Encourage the patient to verbalize his or her ability to make decisions and influence outcomes.
  • Educate the patient and family about management of the therapeutic regimen.

Nursing Interventions for the Patient with Heart Failure

• Promote activity tolerance:
  • Bed rest for acute exacerbations.
  • Encourage regular physical activity; build up to about 30 minutes daily.
  • Exercise training.
  • Pacing of activities; wait 2 hours after eating for physical activity.
  • Avoid activities in extreme hot, cold, or humid weather.
  • Modify activities to conserve energy.
  • Positioning; elevation of the head of bed to facilitate breathing and rest, support of arms.
• Manage fluid volume:
  • Assess for symptoms of fluid overload.
  • Daily weight.
  • I&O.
  • Diuretic therapy; timing of meds.
  • Fluid intake; fluid restriction.
  • Maintenance of sodium restriction.

Patient Education for the Patient with Heart Failure

• Medications.
• Diet: low-sodium diet and fluid restriction.
• Monitor for signs of excess fluid, hypotension, and symptoms of disease exacerbation, including daily weight.
• Exercise and activity program.
• Stress management.
• Prevention of infection.
• Know how and when to contact health care provider.
• Include family in education.

Pulmonary Edema

• Acute event reflecting a breakdown of physiologic compensatory mechanisms.
• As the left ventricle begins to fail, blood backs up into the pulmonary circulation, causing pulmonary interstitial edema.
• Results in hypoxemia, often severe.
• Clinical manifestations: restlessness, anxiety, tachypnea, dyspnea, cool and clammy skin, cyanosis, weak and rapid pulse, cough, lung congestion (moist, noisy respirations), increased sputum production (sputum may be frothy and blood tinged), decreased level of consciousness.

Management of Pulmonary Edema

• Easier to prevent than to treat.
• Early recognition: monitor lung sounds and for signs of decreased activity tolerance and increased fluid retention.
• Minimize exertion and stress.
• Oxygen; nonrebreather.
• Medications:
  • Diuretics (furosemide).
  • Vasodilators (nitroglycerin).

Nursing Interventions for the Patient with Pulmonary Edema

• Positioning the patient to promote circulation:
  • Positioned upright with legs dangling.
• Providing psychological support:
  • Reassure patient and provide anticipatory care.
• Monitoring medications:
  • I&O.

End-of-Life Considerations

• HF is a chronic and often progressive condition.
• Need to consider issues related to the end of life.
• Consider when palliative or hospice care should be considered.

Cardiogenic Shock

• A life-threatening condition with a high mortality rate.
• Decreased cardiac output leads to inadequate tissue perfusion and initiation of shock syndrome.
• Commonly occurs following acute MI when a large area of the myocardium becomes ischemic and hypokinetic.
• Can occur as a result of end-stage HF, cardiac tamponade, pulmonary embolism (PE), cardiomyopathy, and arrhythmias.

Thromboembolism

• Patients with cardiovascular disorders are at risk for the development of arterial and venous thromboemboli (VTE).
• Decreased mobility and circulation increase the risk for thromboembolism in patients with cardiac disorders, including those with HF.
• Intracardiac thrombi can form in patients with atrial fibrillation because the atria do not contract forcefully, increasing the likelihood of thrombus formation.
• Pulmonary embolism: a blood clot from the legs moves to obstruct the pulmonary vessels.

Pericardial Effusion and Cardiac Tamponade

• Pericardial effusion is the accumulation of fluid in the pericardial sac.
• Cardiac tamponade is the restriction of heart function due to this fluid, resulting in decreased venous return and decreased cardiac output.
• Clinical manifestations: ill-defined chest pain or fullness, pulsus paradoxus, engorged neck veins, labile or low BP, shortness of breath.
• Cardinal signs of cardiac tamponade: falling systolic BP, narrowing pulse pressure, rising venous pressure, distant heart sounds.

Medical Management of Pericardial Effusion and Cardiac Tamponade

• Pericardiocentesis:
  • Puncture of the pericardial sac to aspirate pericardial fluid.
• Pericardiotomy:
  • Under general anesthesia, a portion of the pericardium is excised to permit the exudative pericardial fluid to drain into the lymphatic system.

Sudden Cardiac Death or Cardiac Arrest

• Emergency management: cardiopulmonary resuscitation
  • A: airway
  • B: breathing
  • C: circulation
  • D: defibrillation for VT and VF