Heart Failure (Acute Exacerbations, Chronic)

Definition/Etiology:

• Definition
  • HF is a clinical presentation of impaired cardiac function in which one or both ventricles are unable to maintain an output adequate to meet the metabolic demands of the body.
• Types
  • Acute-suddenly (maybe a PE) vs Chronic (slow like HTN)
• Etiology/Cause
  • Left Sided (Systolic (Bad Squeeze/Low EF) or Diastolic (Bad Fill)
    • Pathologies that affect LEFT side of the heart
      • CAD/ACS,
      • Cardiomyopathy
      • Cardiac Tamponade
      • Aorta/Mitral Valve disease
  • Right-Sided
    • Left-Sided Heart Failure left untreated
    • Acute Lung Pathologies
      • Example : Pulmonary Hypertension, Pulm Embolism

Pathophysiology:

• Analogy: Think of a car going uphill. If that car stops, it has to roll backwards. Fluid in the heart and it’s chamber behaves the same way. Symptoms are either going to be pulmonary or peripheral.
• Normal Blood Flow
  • Body → Vena Cava → RA → Tricuspid → RV → Pulm Artery
    → Lungs → Pulmonary Vein → LA → LV → Aorta → Body
• Left-sided HF backs up to lungs
  • Pulmonary Symptoms
• Right-sided HF backs up to body
  • Peripheral Symptoms

Noticing: Assessment & Recognizing Cues:

• Subjective
  • Chest Pain
  • Tired/Fatigued
  • “Activity Intolerance”
• Left Sided Heart Failure -Pulmonary
  • Increased Pulmonary Congestion
  • Pulmonary edema
  • Cough
  • Pink/frothy sputum
• Right-Sided Heart Failure – Periphery
  • Peripheral Edema
  • ↑ JVD
  • ↑ Preload
  • Weight Gain
  • Liver / GI Congestion

Interpreting: Analyzing & Planning:

• Labs
  • BNP (Brain Natriuretic Peptide – stretched ventricles)
    • ↑ 400 = very specific for Heart Failure
    • May Have seen Pro-BNP or BNP-T
      • These are facility specific rather than PCCN test material – focus on traditional BNP levels
  • CRP – marker of inflammation (not specific for HF – helpful)
• Diagnostics
  • ECG
    • Dysrhythmia -Afib & Heart Block
  • Echocardiogram
    • Chamber Size
    • Valve Function
    • Wall Thickness
    • Squeeze/Fill
  • CXR
    • Cardiomegaly
    • Pulm Congestion

Responding: Patient Interventions & Taking Action:

• ABCs + Underlying Cause
  • 02 Support
  • Meds highly effect circulation
    • Fluids or Squeeze of heart/vessels
• Pharmacological Interventions
  • 02 Support
  • Decrease Preload
    • Diuretics – Get Fluid OUT
  • Decrease Afterload
    • Ace-Inhibitors – Decrease Afterload
  • Contractility
    • Beta-Blockers
    • Digoxin
  • + Inotropes/Vasopressors → ICU
• Non-Pharmacological Interventions
  • Sodium Restriction
  • Implanted Pacemakers/DEFIB
  • Valve Replacement
  • Transplant
• Adjunct Medical Therapy
  • Cardiology – Plumbing
  • Electrophysiologist – Electricity

Reflecting: Evaluating Patient Outcomes:

• DR – Identify underlying cause (Treat/remove)
  • Nothing we do will help if not identified!
    • MI?- Cath Lab
    • HTN? – Antihypertensive + Diuretics
    • PE?- Clot busters
• HF Symptoms Relieved
  • Lungs Clear/Sob Relieved
  • Edema Relieved/Kidneys producing urine
• Hemodynamics stabilized
• Prognosis = Compliance
  • Sodium Restriction
  • Fluid Restrictions
  • KCL watch related to diuretics
  • Daily weight monitoring

Linchpins (Key Points):

• Notice -Symptoms
  • Right vs Left sided cues
• Interpret-
  • ECHOCARDIOGRAM
    • Walls, Ventricles, Valves & Output
  • BNP – Severity
• Respond
  • Treating underlying cause
  • Pharm, Non-Pharm
• Reflect
  • Symptomatics Relieved
  • Hemodynamics stabilized
  • Complaint