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HeartFailureChapter35

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

HeartFailure Anabnormalclinicalsyndromeinvolvinginadequatecardiacpumping/filling

Insufficientbloodsupply/oxygentotissues

Usedtobecalledcongestiveheartfailure(CHF)

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

HeartFailure Associatedwithcardiovasculardiseases

inincidenceandprevalence withage Commoncauseforhospitaladmissionandreadmissions

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CaseStudyM.W.isa78yearoldwomanadmittedtothehospitalwithshortnessofbreath.

ShehasahistoryofhypertensionandCAD.

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CaseStudyHerthirdMIwas8monthsago.

Shestatessheranoutofherdrugsaweekagoandhasjustnotgottenaroundtogetthemrefilled.

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CaseStudy WhatfactorsinM.W.shistoryincreaseherriskforheartfailure?

WhatotherfactorsmightyouquestionM.W.about?

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RiskFactors Primaryriskfactors

Hypertension CAD

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

RiskFactors Contributingriskfactors

Advancedage Diabetes Tobaccouse Obesity Highserumcholesterol

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

EtiologyofHeartFailure Anythingthatinterfereswithmechanismsthatregulatecardiacoutput(CO)

Primarycauses Conditionsthatdirectlydamagetheheart

Precipitatingcauses Conditionsthatincreasetheworkloadofventricles

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

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CaseStudyBeforecaringforR.W.,youquicklyreviewthepathophysiologyofheartfailure. Howisheartfailureclassified? Howdoesthebodytryto

compensateforheartfailure?

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ClassificationofHeartFailure Systolicversusdiastolic

Leftsidedversusrightsided

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PathophysiologySystolicHF Inabilitytopumpbloodforward Causedby

Impairedcontractilefunction Increasedafterload Cardiomyopathy Mechanicalabnormalities

Decreasedleftventricularejectionfraction(EF)

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PathophysiologyDiastolicHF Impairedabilityoftheventriclestorelaxandfillduringdiastole,resultingindecreasedstrokevolumeandCO

HeartfailurewithnormalEF Resultofleftventricularhypertrophyfromhypertension,MI,valvedisease,orcardiomyopathy

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

PathophysiologyMixedHeartFailure Mixedsystolicanddiastolicfailure

Seenindiseasestatessuchasdilatedcardiomyopathy(DCM)

PoorEFs(

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CompensatoryMechanisms Sympatheticnervoussystem(SNS)activation Firstandleasteffectivemechanism Releaseofcatecholamines(epinephrineandnorepinephrine) Increasedheartrate Increasedmyocardialcontractility Peripheralvasoconstriction

InitiallyhelpfulbutthenharmfulCopyright 2014 by Mosby, an imprint of Elsevier Inc.

CompensatoryMechanisms Neurohormonalresponses

KidneysreleasereninandinitiatetheRAASsystem

Posteriorpituitaryglandsecretesantidiuretichormone(ADH)

Endothelinreleasedbyvascularendothelialcells

ProinflammatorycytokinesCopyright 2014 by Mosby, an imprint of Elsevier Inc.

CompensatoryMechanisms Ventricularremodeling

ResultsfromSNSactivationandneurohormonalresponses

Hypertrophyofventricularmyocytes Ventricleslargerbutlesseffectiveinpumping

Cancauselifethreateningdysrhythmiasandsuddencardiacdeath

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CompensatoryMechanisms Dilation

Enlargementofchambersoftheheartthatoccurswhenpressureintheleftventricleiselevated

Initiallyeffective EventuallythismechanismbecomesinadequateandCOdecreases

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DilatedHeartChambers

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CompensatoryMechanisms Hypertrophy

Increaseinmusclemassandcardiacwallthickness

Initiallyeffective Overtimeleadstopoorcontractility,increasedO2 needs,poorcoronaryarterycirculation,andriskforventriculardysrhythmias

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HypertrophiedHeartChambers

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Fig. 35-1. A, Dilated heart chambers. B, Hypertrophied heart chambers.

DilatedandHypertrophiedHeartChambers

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Fig. 35-1. A, Dilated heart chambers. B, Hypertrophied heart chambers.

CounterregulatoryMechanisms Natriureticpeptides

Atrialnatriureticpeptide(ANP),btypenatriureticpeptide(BNP)

Releasedinresponsetoincreasedbloodvolumeinheart

Causesdiuresis,vasodilation,andloweredBP

CounteractseffectsofSNSandRAASCopyright 2014 by Mosby, an imprint of Elsevier Inc.

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CounterregulatoryMechanisms Nitricoxide(NO)

Releasedfromthevascularendotheliuminresponsetocompensatorymechanisms

NOrelaxesarterialsmoothmuscle,resultinginvasodilationanddecreasedafterload

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

CaseStudyM.W.sadmissionassessmentrevealsthefollowing:

Alertandorientedtoperson,place,andtime

Finecracklesbilaterallowerlobes Shortnessofbreathonminimalexertion O2saturation89%,roomair

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CaseStudyM.W.sadmissionassessmentrevealsthefollowing:

S1 andS2withoutmurmurorextraheartsounds

BP100/60,HR84,RR28,Temp36.1 C Capillaryrefillsluggishinlowerextremities,normalinupperextremities

2+edemabilaterallowerextremitiesCopyright 2014 by Mosby, an imprint of Elsevier Inc.

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CaseStudy Basedupontheseassessmentfindings,whattypeofheartfailureisM.W.displaying?

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

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LeftSidedHeartFailure Mostcommonform Resultsfromleftventriculardysfunction

Bloodbacksupintoleftatriumandpulmonaryveins

Increasedpulmonarypressurecausesfluidleakage pulmonarycongestionandedema

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

RightSidedHeartFailure Rightventriculardysfunction Bloodbacksupintotherightatriumandvenouscirculation Jugularvenousdistention Hepatomegaly,splenomegaly VascularcongestionofGItract Peripheraledema

MostcommonlycausedbyleftsidedHF

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

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CaseStudy ForwhatotherclinicalmanifestationsofheartfailurewouldyouassessM.W.?

DoyouthinkherHFisacuteorchronic?Explainyouranswer.

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AcuteDecompensatedHeartFailure(ADHF)ClinicalManifestations

Early increasedpulmonaryvenouspressure Increaseintherespiratoryrate DecreaseinPaO2

Later interstitialedema Tachypnea

Furtherprogression alveolaredema Respiratoryacidemia

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

AcuteDecompensatedHeartFailure(ADHF)ClinicalManifestations Canmanifestaspulmonaryedema Lifethreateningsituation alveolifillwithfluid

MostcommonlyassociatedwithleftsidedHF

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PulmonaryEdemaClinicalManifestations

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Anxious,pale,cyanotic

Coolandclammyskin

Dyspnea Orthopnea Tachypnea Useofaccessorymuscles

Coughwithfrothy,bloodtingedsputum

Crackles,wheezes,rhonchi

Tachycardia Hypotensionorhypertension

ADHFCollaborativeManagement Ultrafiltration(aquapheresis)forpatientswithvolumeoverloadandresistancetodiuretics

CirculatoryassistdevicesforpatientswithdeterioratingHF Intraaorticballoonpump(IABP) Ventricularassistdevices(VADs)

Treatanyanxietyand/ordepression

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

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ADHFDrugTherapy Diuretics

Decreasevolumeoverload(preload) Furosemide(Lasix),bumetanide(Bumex)

Vasodilators Reducecirculatingbloodvolumeandimprovecoronaryarterycirculation IVnitroglycerin Sodiumnitroprusside(Nipride)Nesiritide(Natrecor)

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

ADHFDrugTherapy Morphine

Reducespreloadandafterload Relievesdyspneaandanxiety

Positiveinotropes adrenergicagonists(dopamine[Intropin],dobutamine[Dobutrex])

Phosphodiesteraseinhibitors(inamrinone[Inocor],milrinone[Primacor])

DigitalisCopyright 2014 by Mosby, an imprint of Elsevier Inc.