dr M Arman Nasution SpPD

Congestive Heart Failure

Classification
Generally classified as the following:
 Left vs right failure

 Systolic vs diastolic dysfunction

 Backward vs forward failure

 Low output vs high output cardiac failure

 The degree of functional impairment

conferred by the abnormality (as in the
NYHA functional classification)
 New York Heart Association Functional Classification

 Class I: No limitation experienced in

any activity and no symptoms from
ordinary activities.

 Class II: Mild limitation of activity and

comfortable at rest or mild exertion

 Class III: Marked limitation of any

activity and comfortable only at rest

 Class IV: Any physical activity brings

discomfort and symptoms appear at
rest
Signs and symptoms
Left Sided Failure-
Symptoms
Backward Failure: Respiratory
compromise

 Dyspnea on exertion
 Dyspnea at rest (severe)
 Orthopnea (on lying flat)
 Paroxysmal nocturnal dyspnea
(cardiac asthma)
 Nocturnal cough
Left Sided Failure-
Symptoms
Forward Failure: Poor systemic
circulation

 Dizziness
 Confusion
 Cool extremities at rest
 Easy fatigueability
 Exercise intolerance
 Right Sided Failure-
Symptoms
Backward Failure: Congestion of systemic capillaries

 Excess fluid accumulation in the body

 Peripheral edema/ anasarca
 Dependent edema (foot, ankle, sacral)
 Nocturia
 Ascites
 Liver congestion (hepatomegaly, jaundice and coagulopathy)

Forward Failure: Hypotension

 Left Sided Failure- Signs
Non specific signs of respiratory distress:
 Tachypnea
 Increased work of breathing
 Decreased vital capacity
Development of pulmonary edema:
 Rales/Crackles – initially at base, throughout the lung
when severe
Extremely severe pulmonary edema:
 Cyanosis (severe hypoxemia)
Left Sided Failure- Signs
 Laterally displaced apex beat (heart enlargement)

 S3 gallop rhythm (increased blood flow/ increased

intra cardiac pressure)

 Heart murmurs- indicative of valvular diseases (Cause

or result of heart failure)
Right Sided Failure- Signs
 Peripheral pitting edema
 Hepatomegaly
 Jugular venous pulse accentuated
by hepatojugular reflux (marker
of fluid status)
 Positive abdominojugular test
 Parasternal heave (increased RV
pressure)
 Ascites (late onset)
Pitting Edema of
Ankle

Ascites
 Pulmonary Edema

Cardiomegaly
Biventricular Failure
 Pleural effusions- more common in
biventricular failures.

 Unilateral failures cause right sided

effusions (large area of right lung)

Signs:
 Dullness of lung fields
 Reduced breath sounds at lung bases
Other signs

 Cardiomegaly

 Weight loss

 Tachycardia (>120 bpm)

 Pink frothy sputum (severe)

Common symptoms of
CCF (overview)

Measuring elevated JVP

 THE HEART
 Normal
 Pathology
 Heart Failure: L, R
 Heart Disease
 Congenital: LR shunts, RL shunts, Obstructive

 Ischemic: Angina, Infarction, Chronic Ischemia, Sudden Death

 Hypertensive: Left sided, Right sided

 Valvular: AS, MVP, Rheumatic, Infective, Non-Infective, Carcinoid,

Artificial Valves
 Cardiomyopathy: Dilated, Hypertrophic, Restrictive, Myocarditis,
Other
 Pericardium: Effusions, Pericarditis

 Tumors: Primary, Effects of Other Primaries

 Transplants
NORMAL Features
 6000 L/day
 250-300 grams
 40% of all deaths (2x cancer)
 Wall thickness ~ pressure
 (i.e., a wall is only as thick as it has to be)
 LV=1.5 cm
 RV= 0.5 cm
 Atria =.2 cm
 Systole/Diastole
 Starling’s Law
TERMS
 CARDIOMEGALY
 DILATATION, any chamber, or all
 HYPERTROPHY, and chamber, or all
S.A. NodeAV NodeBundle of HIS L. Bundle, R. Bundle
Anterior
Lateral
Posterior
Septal
VALVES
AV:
 TRICUSPID 13 cm

 MITRAL 11 cm

SEMILUNAR:
 PULMONIC 8 cm

 AORTIC 6 cm
 CARDIAC AGING
Epicardial Coronary
Chambers Arteries
Increased left atrial cavity size Tortuosity
Decreased left ventricular cavity size Increased cross-sectional luminal area
Sigmoid-shaped ventricular septum Calcific deposits
Atherosclerotic plaque

Myocardium
Increased mass
Valves
Increased subepicardial fat
Aortic valve calcific deposits
Mitral valve annular calcific deposits Brown atrophy
Lipofuscin deposition
Fibrous thickening of leaflets
Basophilic degeneration (glyc.)
Buckling of mitral leaflets toward the left atrium
Amyloid deposits
CARDIAC AGING
Aorta
Dilated ascending aorta with rightward shift

Elongated (tortuous) thoracic aorta

Sinotubular junction calcific deposits

Elastic fragmentation and collagen accumulation

Atherosclerotic plaque
BROWN
ATROPHY, HEART

LIPOFUCSIN
Pathologic Pump Possibilities
 Primary myocardial failure (MYOPATHY)
 Obstruction to flow (VALVE)
 Regurgitant flow (VALVE)
 Conduction disorders (CONDUCTION SYSTEM)
 Failure to contain blood (WALL INTEGRITY)
 CHF
 DEFINITION
 TRIAD
 1) TACHYCARDIA
 2) DYSPNEA
 3) EDEMA
 FAILURE of Frank Starling mechanism
 HUMORAL FACTORS
 Catecholamines (nor-epinephrine)
 ReninAngiotensionAldosterone
 Atrial Natriuretic Polypeptide (ANP)
 HYPERTROPHY and DILATATION
 HYPERTROPHY
 PRESSURE OVERLOAD (CONCENTRIC)
 VOLUME OVERLOAD (CHF)

 LVH, RVH, atrial, etc.

 2X normal weight ischemia

 3X normal weight HTN
 >3X normal weightMYOPATHY, aortic
regurgitation
CHF: Autopsy Findings
 Cardiomegaly
 Chamber Dilatation
 Hypertrophy of myocardial fibers, BOXCAR
nuclei
Left Sided Failure
 Low output vs. congestion
 Lungs
 pulmonary congestion and edema
 heart failure cells
 Kidneys
 pre-renal azotemia
 salt and fluid retention
 renin-aldosterone activation

 natriuretic peptides

 Brain: Irritability, decreased attention,

stuporcoma
Left Heart Failure Symptoms
 Dyspnea
 on exertion
 at rest
 Orthopnea
 redistribution of peripheral edema fluid
 graded by number of pillows needed
 Paroxysmal Nocturnal Dyspnea (PND)
LEFT Heart Failure
Dyspnea
Orthopnea
PND (Paroxysmal Nocturnal
Dyspnea)
Blood tinged sputum
Cyanosis
Elevated pulmonary “WEDGE”
pressure (PCWP) (nl = 2-15 mm Hg)
Right Sided
 Etiology
Heart Failure
 left heart failure
 cor pulmonale
 Symptoms and signs
 Liver and spleen
 passive congestion (nutmeg liver)

 congestive spleenomegaly

 ascites

 Kidneys
 Pleura/Pericardium
 pleural and pericardial effusions

 transudates

 Peripheral tissues
RIGHT Heart Failure
FATIGUE
“Dependent” edema
JVD
Hepatomegaly (congestion)
ASCITES, PLEURAL EFFUSION
GI
Cyanosis
Increased peripheral venous pressure
(CVP) (nl = 2-6 mm Hg)
HEART DISEASE
CONGENITAL (CHD)
 ISCHEMIC (IHD)
 HYPERTENSIVE (HHD)
 VALVULAR (VHD)
 MYOPATHIC (MHD)
 CONGENITAL HEART
DEFECTS
 Faulty embryogenesis (week 3-8)
 Usually MONO-morphic (i.e., SINGLE
lesion) (ASD, VSD, hypo-RV, hypo-LV)
 May not be evident until adult life
(Coarctation, ASD)
 Overall incidence 1% of USA births
 INCREASED simple early detection via
non invasive methods, e.g., US, MRI, CT,
etc.
 Incidence per Million Live
Malformation Births %
4482 42
Ventricular septal defect
1043 10
Atrial septal defect
Pulmonary stenosis 836 8
781 7
Patent ductus arteriosus
577 5
Tetralogy of Fallot
Coarctation of aorta 492 5
396 4
Atrioventricular septal defect
Aortic stenosis 388 4
388 4
Transposition of great arteries
136 1
Truncus arteriosus
120 1
Total anomalous pulmonary venous connection
Tricuspid atresia
GENETICS
 Gene abnormalities in only 10% of CHD

 Trisomies 21, 13, 15, 18, XO

 Mutations of genes which encode for transcription
factorsTBX5ASD,VSD
 NKX2.5ASD
 Region of chromosome 22 important in heart
development, 22q11.2 deletionconotruncus,
branchial arch, face
CARDIOVASCULAR SYSTEM
• Review of Anatomy & Physiology
• Assessment : History and Physical Assessment
• Diagnostics
• Planning
REVIEW OF ANATOMY AND PHYSIOLOGY-
Heart
 Structures

 Blood Supply – LCA, RCA, veins

 Conductive System –Sino-atrial node AV node

Bundle of His Bundle branch Purkinje fibers
HEART
LUNGS

RA LA

RV LV

SYSTEMIC
SYSTEMIC
SYSTEMIC
CIRCULATION
CIRCULATION
CIRCULATION
CONDUCTION PATHWAY
- SA NODE

RA LA
AV NODE-

BUNDLE OF HIS
PURKINJE
RV BUNDLE
BRANCH
LV
PURKINJ
E
REVIEW OF ANATOMY AND PHYSIOLOGY-
Heart
 Nervous System Control

 SYMPATHETIC

 PARASYMPATHETIC
REVIEW OF ANATOMY AND PHYSIOLOGY-
Heart
 Properties of the Heart:
 All or None Principle
 Rhythmicity
 Excitability
 Refractoriness
 Conductivity
 Automaticity
 Extensibility
REVIEW OF ANATOMY AND PHYSIOLOGY-
Heart
STROKE VOLUME (SV) - amount of blood pumped out
with each contraction
HEART RATE (HR)
CARDIAC OUTPUT (CO)– volume of blood pumped out
per minute
=SV x HR
PRELOAD
AFTERLOAD
REVIEW OF ANATOMY AND PHYSIOLOGY –
Blood Vessels

 Arteries
 Microcirculation Layers of the Blood
 Veins Vessels:
 Flow Regulation  Intima
 Pressure gradient  Media
 Flow resistance  Adventitia
 Role of Blood vessels
REVIEW OF ANATOMY AND PHYSIOLOGY
CIRCULATION
 SYSTEMIC

 PULMONARY

 PORTAL
PULMONARY CIRCULATION

LUNGS

RA LA

RV LV

SYSTEMIC
SYSTEMIC
SYSTEMIC
CIRCULATION
CIRCULATION
CIRCULATION
SYSTEMIC CIRCULATION
LUNGS

RA LA

RV LV

SYSTEMIC
SYSTEMIC
SYSTEMIC
CIRCULATION
CIRCULATION
CIRCULATION
HISTORY AND PHYSICAL EXAM
 Check for:
 dyspnea,  abdominal pain and
 jaundice, discomfort,
 edema,  clubbing of fingers,
 hemoptysis,
chest pain,
 palpitations
 fatigue,
 syncope and
fainting,
 cyanosis,
HISTORY AND PHYSICAL EXAM
 Heart –I P P A  Heart Sounds
 aortic area,  S1- AV valve
closure
 pulmonic area,
 S2 semilunar v.
 tricuspid, closure
 mitral  S3 vent. Gallop
 S4 atrial gallop
 Murmurs
 rubs
HISTORY AND PHYSICAL EXAM
 Blood vessels
 Inspection
 color:pallor, rubor, cyanosis
 circulation of extremities
 Palpation
 edema, pulses
 Auscultation
 bruit
Diagnostic Assessment
 NonInvasive
 ECG
 Chest Xray
 Dynamic ECG Stress Test
 Radionuclide Studies
 Treadmill Vector
 Venography
 Cardiogram
 UTZ – DOPPLER
 Phonocardiogram
 Pletysmography
 Echocardiogram
Diagnostic Assessment
Invasive
 Lymphogram
 Cardiac
Catheterization  Bone Marrow
Aspiration:
 Arteriogram  Sternum

 iliac crest
 Angiocardiogram  tibia (infants)

 Venogram
Diagnostic Assessment
 Blood and Urine
Studies
 lipid profile
 CBC
 serum enzymes:
 Hematocrit
SGOT, SGPT, LDH,
 Clotting time
CPK
 PT
 VMA
 PTT
 Renin Test
 APTT
 Schilling’s Test
 ESR
HEMODYNAMICS MONITORING
CVP n= 6 -12 cm water
 Measures:
 cardiac efficiency,
 bld volume,
 peripheral resistance,
 right ventricular pressure
 0-pt be at mid axillary line, 5 cm below the sternum
 dc ventilator with reading
 = fluid overload, = hypovolemia
HEMODYNAMICS MONITORING

 Pulmonary Artery and Pulmonary

Wedge Pressure
 Swan Ganz catheter :
 floated at the right heart,
 measures left side of the heart

 Intraarterial Blood Pressure :

 Radial Artery,
 Allen’s Test
TERMINOLOGIES
VENTILATION – MOVEMENT OF AIR IN & OUT OF THE
LUNGS

RESPIRATION – EXCHANGE OF GASES : EXTERNAL &

INTERNAL
EXTERNAL – BET. ALVEOLI & PULMONARY CAPILLARIES
INTERNAL – BET. SYSTEMIC CAPILLARIES

PERFUSION – AVAILABILITY & MOVEMENT OF CAPILLARY

BLOOD FOR EXCHANGE OF GASES
Planning for Health Promotion
 Modification of High Risk Factors

 Promotion of Circulation

 Prevention of Infection
 syphillis,
 staph, strep,
 german measles
 Genetic counselling

 Role of nutrition
Modification of High Risk Factors
dyslipedemia stress

hypertension glucose
intolerance,
smoking
 alcohol abuse
sedentary lifestyle
caffeine
obesity
pollution
Planning for Health Maintenance &
Restoration
 Basic Life Support
 Advanced Life Support

 Client With Cardiac Surgery:

 Closed Heart surgery
 Open Heart Surgery
 Heart Transpant
Closed Heart surgery
 valvutomy

 mitral commisurotomy
Open Heart surgery (CABG)
COMPLICATIONS :
 DYSRHYTHMIAS  BLEEDING

 THROMBOSIS AND  WOUND INFECTION

PULMONARY
EMBOLISM  RENAL FAILURE

 CARDIOGENIC SHOCK  ELECTROLYTE

IMBALANCE

 POST-OP PSYCHOSIS
HEART TRANSPLANT
CRITERIA
1. End Stage of Disease
2. Freedom from Chronic Disease
3. Family Support
4. Age < 50 yo
5. No psychological problem

IMPORTANT
1. Immunosuppressant & Steroids – 4 hrs prior
2. Donor-Recipient Compatibility – size, crossmatching
3. Donor Heart – saline solution 4C up to 4 hrs
CARDIOVASCULAR DISTURBANCES
 CORONARY / ISCHEMIC HEART DISEASE
 Arteriosclerotic Heart Disease
 Angina Pectoris
 Coronary Insufficiency
 Myocardial Infarction
 CONGESTIVE HEART FAILURE
 HYPERTENSION
 PERIPHERAL VASCULAR DISEASE
 DISORDERS OF THE BLOOD
 ARTERIOSCLEROTIC HEART DISEASE

Plaque formation and internal thickening

(intima)

Fibrosis and calcification (media)

Narrowing and constriction of coronary arteries

S/sx of ISCHEMIA
ANGINA PECTORIS

1. STABLE
2. UNSTABLE
3. PRINZMETAL – coronary artery spasm
4. NOCTURNAL
5. DECUBITUS
ISCHEMIA VS INFARCTION
ISCHEMIA INFARCTION

PAIN SUBSTERNAL SUBSTERNAL

PRESSURE/ HEAVINESS CONSTRICTIVE (+ SX
SQUEEZING OF SHOCK)

DURATION 3-5 MIN > 5 MIN

PRECIPITANTS STRESS/ EXERTION NO

REST RELIEVED NOT RELIEVED

NITROGLYCERINE

CARDIAC TISSUE NO PERMANENT PERMANENT

DAMAGE
Coronary Insufficiency
IMBALANCE BETWEEN :

 OXYGEN SUPPLY

 OXYGEN DEMAND
MYOCARDIAL INFARCTION
IRREVERSIBLE CARDIAC DAMAGE FROM OCCLUSION OF 1 OR
MORE CORONARY ARTERY

 REVIEW OF ANATOMY AND PHYSIOLOGY

E.C.G.
Recent M.I. – ST elevation (injury)
T wave inversion (ischemia)
Previous M.I. – Q wave (necrosis / old infarct)

BLOOD STUDIES
Troponin T & I
LDH
CPK MB
MYOCARDIAL INFARCTION
NURSING CARE
1. Pain relief –
Morphine ( +
preload & afterload)
Demerol causes vomiting
2. Oxygen
3. Inotropics
4. Beta Blockers
5. Antiarrhythmics
6. No ice or very hot drinks
7. Anticoagulants
8. ECG and CVP
monitoring
9. Laxatives – Lactulose
10. PTCA
11. Thrombolytic Therapy
BEFORE CELLULAR
DEATH, US. 6 HRS AFTER
THE ATTACK
CARDIAC ARRHYTHMIA
 Review Conduction Pathway

 Review the Basics of Normal ECG

CONDUCTION PATHWAY
- SA NODE

RA LA
AV NODE-

BUNDLE OF HIS
PURKINJE
RV BUNDLE
BRANCH
LV
PURKINJ
E
CARDIAC ARRHYTHMIA
 Sinus Tachycardia – P wave precede each QRS >100 bpm

 Sinus Bradycardia – P wave precede each QRS <60 bpm

 Atrial Fibrillation: P wave = f waves; QRS = normal

CONDUCTION PATHWAY
- SA NODE

RA LA
AV NODE-

BUNDLE OF HIS
PURKINJE
RV BUNDLE
BRANCH
LV
PURKINJ
E
CARDIAC ARRHYTHMIA
 Premature Ventricular Contraction: P wave normal:
early QRS

 Ventricular Tachycardia : 3 or more PVCs

 Asystole – no cardiac activity

CONDUCTION PATHWAY
- SA NODE

RA LA
AV NODE-

BUNDLE OF HIS
PURKINJE
RV BUNDLE
BRANCH
LV
PURKINJ
E
CARDIAC ARRHYTHMIA
 Nursing Management
 Oxygen
 Complete Bed Rest
 Cardioversion/ defibrillation
 Administer antiarrhythmics as prescribed:
 Atropine
 Beta blocker- propanolol
 Lidocaine
 Epinephrine
CONGESTIVE
 Backward Failure
HEART FAILURE
 Forward Failure
 Review of Anatomy and Physiology
 Left-Sided
 Right Sided
 Hypermetabolic Failure
 Clinical Manifestations according to:
 Tissue Anoxia
 Pulmonary Hypertension
 Systemic congestion
CONGESTIVE HEART FAILURE
 Review of Anatomy and Physiology
 Backward Failure
 Forward Failure
 Left-Sided
 Right Sided
 Hypermetabolic Failure
 Clinical Manifestations according to:
 Tissue Anoxia
 Pulmonary Hypertension
 Systemic congestion
CONGESTIVE HEART FAILURE
 Diagnostics
 Nursing Management
 Goals :
1. CARDIAC LOAD
– REST AND SEDATION
2. CARDIAC CONTRACTILITY
– CHRONOTROPICS – DIGITALIS
 Increase in force of contraction
 monitor serum K,
 C/I if HR </= 60 bpm,
 DIGITALIS TOXICITY
CONGESTIVE HEART FAILURE
3. SODIUM REABSORPTION AND FLUID
RETENTION

-DIURETICS ( Thiazide, Loop, K-sparing)

-measure UO
-weigh patient
-watch for s/sx of electrolyte imbalance
-DIET : Sodium Restricted (0.5gm/day)
CONGESTIVE HEART FAILURE
4. PREVENTION OF COMPLICATIONS:
 Intractable HF
 Pulmonary edema
 Pulmonary Infarction
 Myocardial Infarction
 Digitalis Toxicity
 Cardiac Arrhythmia
 Pneumonia
PULMONARY EDEMA
 Emergency!
 Fluid into the alveoli, bronchi & bronchioles

S/SX:
 …of CHF
 Dyspnea
 Cough with pink frothy sputum
PULMONARY EDEMA
 MANAGEMENT:
 Oxygenation

 Assist in Intubation

 Rotating tourniquet

 Phlebotomy

 CVP monitoring
HYPERTENSION
CATEGORY SBP mmHg DBP mmHg

Normal <120 and <180

PreHPN 120-139 or 80-89

HPN, Stage 1 140-159 or 90-99

HPN, Stage 2 >=160 or >=100

HYPERTENSION
 Assess for Major CVD Risk Factors
 Assess for Identifiable Causes of Hypertension:
 Sleep apnea
 Drug-Induced related
 Chronic Kidney Disease
 Primary Aldosteronism
 Renovascular Disease
 Cushing’s Syndrome/steroid Therapy
 Pheochromocytoma
 Coarctation of the Aorta
dr M Arman Nasution SpPD