Congestive Heart Failure

Congestive Heart Failure, CHF, LVF/RVF , Nursing Bsc Msc Medicine

1. CONGESTIVE HEART
FAILURE
By :-
BaljinderSingh
M.sc (MSN)

2. C H F
Definition: It is a clinical syndrome
resulting from the inability of heart
to pump enough blood at rest or
during exercise even though the
filling pressures are adequate.

3. Incidence
Major public health problem in
industrialized countries.
Common in elderly.

4. Etiology
Divided in to 3 subgroups
-Abnormal loading conditions
-Abnormal muscle function
-Precipitating factors

5. Etiology (contd..)
Abnormal loading conditions
Increased preload
Refers to the length of the ventricular
myocardial fibers just before ventricular
contraction and EDV
-Valvularregurgitation
-Hypervolemia
-Congenital diseases
(ASD,VSD,PDA)

6. Etiology (contd..)
Increased after load
Correspond to the amount of intra
myocardial wall tension that the heart
must generate to overcome systolic
pressure and allows ventricular emptying.
-Aortic valvularstenosis
-pulmonary valve stenosis
-Systemic and pulmonary hypertension
-Increased PVR
-Increased blood viscosity

7. Etiology (contd.)
Abnormal muscle function
-Conditions that interfere with myocardial
contractibility
MI
Myocarditis
Cardiomyopathy
ventricular aneurism
-External compression
(constrictive pericarditis,cardiac
tamponade)

8. Precipitating factors
Physical and emotional stress
Dysrrhythmias
Infection
Anemia
Thyroid disorders
Pregnancy
Paget disease
Nutritional deficiency
Pulmonary diseases
Hypervolemia

9. Pathophysiology
Diseased Normal
myocardium myocardium
Unable to meet the demands
Activation of compensatory system
(sympathetic stimulation)
Fails
Increased residual volume in left
ventricle

10. Pathophysiology (contd..)
Decreased ability to receive blood
from left atrium
Left atrium work hard to eject blood
dilation and hypertrophy
Pulmonary edema and congestion

11. Pathophysiology (contd…)
Increased pressure in pulmonary
vascular system
Right ventricular dilation&hypertrophy
Fails
Engorgement of systemic venous
system
Congestion in GIT,Liver
viscera,Kidneys,Legs,sacrum

12. Pathophysiology (contd..)
Conditions that causes RVF
-Pulmonary diseases
(PAH,Pulmonary embolism,COPD,cor
pulmonale)
-Constrictive Pericarditis
-Tricuspid and pulmonary valvular
disorders
-RV infarction

13. Pathophysiology (contd..)
Cardiac reserve (Hearts ability to
increase the output in response to
stress(5 the times the normal)
But in the diseased heart, it fails to
respond to body’s increased
demands
Compensatory mechanism will be
initiated

14. Pathophysiology contd..
Compensatory mechanisms are
-Ventricular dilation: Lengthening of
the muscle fibers Increased
volume of heart chambers
Increased preload and cardiac out
put leads to reduced contractibility
when stretched beyond capacity
Increased oxygen demand
hypoxia

15. Pathophysiology (contd..)
Ventricular hypertrophy-Increase in
the diameter of muscle fibers
Size and weight of heart increases
Increased oxygen demand
Hypoxia and reduced contractibility

16. Pathophysiology(contd..)
Increased sympathetic stimulation
Increased heart rate and peripheral
vascular resistance
Reduced renal flow and increased
renal conservation of water and
sodium
Fluid overload and increased workload

17. Forms of heart failure
Systolic versus diastolic failure
Systolic-Inability to contract normally
Diastolic-Inability to relax or fill normally
High output versus low output
Low output-IHD,
HT,cardiomyopathy,pericardial diseases
Highoutput-
Hyperthyroidism,anemia,pregnancy,paget
disease

18. Forms (contd..)
Acute versus chronic
Acute –Acute large MI
Chronic-Dilated cardiomyopathy
multivalvular heart disease
Right sided versus left sided
RVF-PAH,Pulmonary
stenosis,pulmonary embolism,
LVF-Aortic stenosis,Post MI

19. Types (contd..)
Backward versus forward H F
backward-ventricles fail to fill
normally Increased pressure in
the atrium and venous system
sodium and water retention edema
Forward-Inadequate discharge of
blood in to the arterial system

20. Clinical features
LVF-Dyspnea(PND)
Orthopnea
cough(frothy&bloodtinged
sputum)
chynestoke respiration
pulmonary edema (extreme
breathlessness,anxiety,frothy
sputum, nasal flarring)

21. C/F Contd
Cardiovascular signs –
Enlarged left laterally displaced
apical impulse, Heart gallop(S
3 & S
4)
pulses alternas
Cerebral hypoxia-
Anxiety,Irritability,Restlesness,confu
sion,Impaired memory, Insomnia
Renal changes-Oliguria,fatigue and
muscular weakness

22. C/F Contd
RVF-Peripherledema and venous
congestion,
Hepatomegaly and abdominal pain
Cardiac cirrhosis and ascitis
Anorexia,nauseaand bloating
cardiac cachexia
Pitting edema
Jugular vein distention, Increased CVP
Anxiety and depression

26. Complications
Acute pulmonary edema
Refractory heart failure

27. Diagnosis
PND
Neck vein distention
Cardiomegaly
Pulmonary edema
Gallop
Increased CV
Hepatojugularreflex
Framingham criteria
Major criteria Minor criteria
Peripheral edema
Night cough
Dyspnea on exertion
Pleural effusion
Hepatomegaley
Reduced vital capacity
Tachycardia(>120bpm)
Presence of one major or 2 minor criteria confirms the diagnosis

28. Diagnosis(contd..)
Chest radiography
ABG analysis
Liver enzymes
BUN and creatinine
ECG

29. Medical management
Removal of precipitating factors
Correction of underlying causes
Prevention of deterioration of cardiac
function
Control of CHF state

30. Immediate management
Positioning –high fowlers position
0xygen administration(8–10 Lts,)

31. Management contd
Digitalis-Incresesventricular emptying,
slow conduction of impulses through AV
node, Increases stroke volume and
cardiac output
-effective in systolic heart failure
-0.25 6 hourly for adults, for elderly o.125
mg 6 hourly
-Reduce dose in renal impairement
-Should not be given in heart failure with
high output
-Digitalis toxicity should be monitered

32. Management contd
Dopamine and dobutamine
Low output failure
Dopamine-2-10 microgram/kg/mt
Dobutamine-2.5-10 microgram/kg/mt
Anticoagulants
Antiarrythmics
ACEI
Aldosterone antagonist;spironolactone25mg /day
Beta adrenergic blockers

33. CHF: Diuretics
Reduce volume overload
Reduce sodium overload
Preload reduction

34. Diuretics
Thiazide Diuretics
Chlorthalidone
Metolazone
Loop Diuretics
Furosemide
Torsemide
Potassium Sparing
Diuretics
Spironolactone
Amiloride

35. CHF: ACE Inhibitors
Improve hemodynamic status
Improve symptoms
Reduce incidence of hospitization
Slow progression of disease
Reduce mortality

36. ACE Inhibitors
Captopril
Enalapril
Lisinopril
Quinapril
Trandolapril
Fosinopril

37. Management contd
Reduction of cardiac workload
Reducing the physical activity
Emotional rest and reduction of
anxiety
Diet: sodium 1 gm/ day
Water 1000 ml / day
potassium supplements
vasodilators –sodium nitroprussideand
Isosorbiddinitrate
Aminophylline 240-480 mg IV

38. Surgical management
Surgical correction of valvulardisorders
Heart transplantation
Cardiopulmonary bypass
Intra aortic balloon pump

39. Nursing management
Impaired gas exchange related to to fluid
in the alveoli
Decreased cardiac output related to heart
failure and Dysrrhythmias
Fluid volume excess related to reduced
cardiac output and Na and water retention
Decreased peripheral tissue perfusion
related to reduced cardiac output
Activity intolerance related to reduced
cardiac output

40. Nursing management
High risk for impaired skin integrity
related to reduced peripheral tissue
perfusion
High risk for digitalis toxicity related
to impaired excretion
Anxiety and fear of death related to
reduced cardiac output and hypoxia