Congestive Heart Failure

J.O. Medina,RN,MSN,FNP,CCRN

Education Specialist

Nurse Practitioner

Critical Care&EmergencyServices

California Hospital Medical Center

Congestive Heart Failure and Pulmonary Edema Overview

Definition – heart failure is inability of the heart to pump enough blood to meet the metabolic demands of the body

Diagnosed by Manifestations of inadequate tissue perfusion Signs and symptoms of intravascular volume overload

Over 2 million Americans have heart failure 10% will die in one year; 50% in five years America’s highest volume DRG

Congestive Heart Failure and Pulmonary Edema Pathophysiology

Neurohormonal theory Increased TNF – alpha – cachectin Endothelin – vasoconstrictor released by endothelial cells Natriuretic Peptides released by atrial and ventricular

stretch and counterbalance effects of endothelin Common causes

CAD; MI;HTN Dilated cardiomyopathy Aortic stenosis ; Aortic regurgitation Mitral regurgitation

Atrial / Brain Natriuretic Peptides

Congestive Heart Failure and Pulmonary Edema Types

Forward vs. backward failure Forward failure – inadequate tissue perfusion to meet

metabolic demands of the body Backward failure – seen in pulmonary and systemic

congestion Right vs. left failure

May involve RV, LV or both Usually LV failures precedes RV failure, producing

symptoms of pulmonary congestion RV failure is usually result of LV failure but may occur

with primary pulmonary hypertension

Congestive Heart Failure and Pulmonary Edema

Systolic vs. diastolic failure Systolic failure – inability of the ventricles to

eject adequate volume Diastolic failure – inability of ventricles to relax

and fill High output vs. low output failure

Most HF – result of low contractility producing low CO

High output HF occurs when acute metabolic needs are not met even with high CO

Congestive Heart Failure and Pulmonary Edema

Acute vs. chronic failure Acute failure – heart is overwhelmed by abrupt alteration

in cardiac function and unable to bring compensatory mechanisms to play

Chronic failure – compensatory mechanisms have time to partially of completely restore cardiac function

Refractory vs. compensated HF Compensated – body or medical therapies are working

and heart is responding Refractory – heart is not responding to therapies

Congestive Heart Failure and Pulmonary Edema New York Heart Association Classification of

Heart Failure Class I - no limitations with ordinary activity Class II – slight limitations of physical activity Class III – marked limitations of physical activity Class IV – inability to engage in any physical

activity without symptoms

Congestive Heart Failure and Pulmonary Edema Clinical Presentation

Intravascular and interstitial fluid overload SOB; Dyspnea on exertion;Orthopnea Paroxysmal nocturnal dyspnea Non-productive cough; crackles; wheeze Weight gain; S3;sinus tach; atrial dysrhythmias Displaced PMI ; systolic murmur ; GI symptoms

Inadequate tissue perfusion Decreased exercise tolerance Unexplained fatigue Unexplained mental confusion Decreased urine output Arrythmias Peripheral vasoconstriction

JVD / Pitting Edema

Congestive Heart Failure and Pulmonary Edema Diagnosis

CXR – cardiomegaly; pulmonary vascular congestion;pleural effusions

Echocardiogram – dilated cardiac chambers; hypertrophy; vascular insufficiency and/or stenosis; wall motion abnormalities (akinesis, hypokinesis; dyskinesis); low EF

EKG – tachycardia; arrythmias; chamber enlargement; ischemia/infarction

Cardiac Catheterization – increased PA/PCWP; low EF and low CO with high LVEDP; valvular dysfunction and CAD

Congestive Heart Failure and Pulmonary Edema Management

Goals of therapy Reduce Preload

Venodilators NTG ; diuretics ; ace inhibitors

Morphine Dopamine (low dose)

Optimize Heart rate Digoxin

Reduce Afterload Arteriodilators

Ace inhibitors; hydralazine Nitroglycerin ; nitroprusside

Improved contractility Digoxin Dopamine; dobutamine; amrinone

Congestive Heart Failure and Pulmonary Edema

Atrial Natriuretic Peptide (ANP) Adrenergic Blockade Nitric Oxide Synthetase Spirolactone

Congestive Heart Failure and Pulmonary Edema

Pulmonary Edema Severe pulmonary congestion due to

excess fluid in interstitial and/or alveolar spaces

Pathogenesis same as HF Can develop spontaneously; day or night;

at rest; following exercise or stressful event; or in conjunction with HF

Pulmonary Edema Clinical Presentation

Mentation – anxious; restless ; agitation CV signs – tachycardia with increased BP (unless

compensatory mechanisms fail - BP); S3; PAWP >25 mmHg; CI <2.2

Pulmonary Signs – orthopnea; O2 levels; crackles; pink frothy sputum; wheezes

Peripheral signs – skin diaphoretic; cool; pale or cyanotic Diagnosis

CXR – diffuse interstitial edema with cloudy lung fields ABG – hypoxemia; respiratory acidosis

Congestive Heart Failure and Pulmonary Edema

Congestive Heart Failure and Pulmonary EdemaPulmonary Edema

Furosemide Morphine NTG Oxygen Positive inotropes Aminophylline IV : for bronchospasm

Alveoli With Fluid

Questions ?