Heart Failure
- A state in which the heart cannot provide sufficient cardiac output to satisfy the metabolic needs of the body
- Underlining causes include: arteriosclerotic heart disease, MI, HTN, valvular heart disease, dilated cardiomyopathy, congenital heart disease, embolism, angina, arrhythmia, drugs, alcohol, pregnancy, toxins (chemotherapy), thyroid disease, anemia, idiopathic
- Causes of Left Ventricular failure: volume overload; pressure overload; loss of muscle; restricted filling
Symptoms of Heart Failure
- SOB, Orthopnea, Paroxysmal nocturnal dyspnea
- Low cardiac output symptoms
- Abdominal symptoms: Anorexia, N, Abdominal fullness, Rt hypochondrial pain
Clinical Signs & Symptoms of Heart Failure
- High diastolic BP and occasional ↓systolic
- JVD, RALES, Displaced and sustained apical pulse
- 3rd heart sound-heard during rapid filling of ventricles (common in children)
- 4th heart sound-at end of diastole
- Pale, cold sweaty skin
Systolic and Diastolic heart failure
- Systolic HF: failure of the pump
- Systolic HF tests: echo, ejection fraction @ 70; BNP
- Diastolic HR: problem with vessels filling
- Diastolic HR test: ejection fraction will be normal
Other Causes of Heart Failure
- High output failure
- Large MI,
- Aortic valve dysfunction
Right VS Left Heart Failure
Right HF
- Most common cause is Left sided HF
- First see signs in the periphery
- Cor pulmonale (brought on by long-term high blood pressure in the pulmonary arteries and right ventricle of the heart)
Left HF
- most common cause is R sided HF
- The heart cannot pump enough blood to the rest of the body.
- Begins slowly
Diagnostic Lab Tests Used for Diagnosis of Heart Failure
Labs
- BNP (200 early sign)
- Anemia
- Hyperthyroid
- Chronic renal insuff.
- Electrolyte abnormalities
- Pre-renal azotemia
- Hemochromatosis
EKG
- Old MI or recent MI
- Arrhythmia
- Some forms of Cardiomyopathy are tachycardia releated
- LBBB→ may help in management
CXR
- Size and shape of heart
- Evidence of pulmonary venous congestion
- Pleural Effusion
ECHO
- Function of both ventricles
- Wall motion abnormality that may signify CAD
- Valvular abnormality
- Intra-Cardiac shunt
Differential Diagnosis for Heart Failure
- Pericardial Disease, Liver Disease
- Nephrotic Syndrome
- Protein losing enteropathy
Treatment of Heart Failure
- Afterload reducers – drugs that reduce BP
- Diuretics- ↓BP and/or Blood volume
- B-Blockers- ↓HR, SV, and BP
- Positive inotropes- stimulate the heart by ↑contractile force development
- Ace inhibitor or ARB
- B-Blocker
- Diuretic
- Direct Vasodilators: Hydralazine, Isosorbide, nitroprusside
- Inotropic Agents: Digoxin, Digitoxin, Amrinone, Dobutamine, Milrinone
- Aldosterone Antagonists: Spironolactone
Drugs Used in Critical Care for Acute Heart Failure
Positive inotropic Drugs: Dobutamine, Dopamine, Milrinone, Amrinone
- Improves myocardial contractility
- Studies show increase mortality with oral agents
- Must be given IV and in hospital setting
- Used for Acute HF/Cardiogenic shock
Primacor (Milrinone)
- Inovasodilator=causes positive inotropic effects
- Causes peripheral Vasodilation= Afterload reduction
- IV agent for acute to severe HF
- MOA: inhibits phosphodiesterase (PDE)→buildup of C-AMP→ positive inotropic effect and vasodilation
- Adverse Effects: Arrhythmias, CP, hypotension, thrombocytopenia
Afterload reducers
Nitroprusside=severe CHF or HTN Emergency
Cyanide toxicity is a major side effect (smells like almonds)
Nitroglycerine=Vasodilator,
- ↓BP, and unloads fluid
Long acting Dihydropyridines CCB
NATRECOR
- Used for severe HTN = relaxes and dilates blood vessels, lowering blood pressure
- Improves breathing in people with congestive heart failure
References
Harvey, R. A., Clark, M. A., Finkel, R., Rey, J. A., & Whalen, K. (2012). Pharmacology (5th ed.). Baltimore, MD: Lippincott.
JNC8 Guidlines 2014. (2014). JNC 8 Guidlines. Retreived from:
http://jama.jamanetwork.com/article.aspx.articleid=1791497
McCance, K. L., Huether, S. E., Brashers, V. L., & Rote, N. S. (2010). Pathophysiology: The biologic basis for disease in adults and children (6th ed.).
Dunphy, L.M., Winland-Brown, J. E. (2011). Primary Care: The Art and Science of
Advanced Practice Nursing. Philadelphia, PA. F.A. Davis.
Uphold, C.R., & Graham, M.V. (2013). Clinical guidelines in family practice. (5th ed.) Gainesville, Fl.: Barmarrae Books, Inc.