Heart Failure

Your heart as pumping has resposibillity to provide oxygenated blood to around cells including the heart itself and return deoxygenated blood to the heart, where it travels to the lungs to be reoxygenated. First of all, deoxygenated blood comes from the body, from the venous system, and travels via the inferior or from lower body and superior or from upper body and coming to vena cava to the right atrium.

Blood flows from the right atrium to the right ventricle and out to the lungs through the pulmonary artery. The blood then picks up oxygen in the lungs and travels via the pulmonary vein to the left atrium and down to the left ventricle. From the left ventricle, oxygenated blood is pumped out through the aorta to the body.

The entire heart acts as a pump and likes to move blood in one direction: forward. If blood is not moving forward, it backs up into the venous or arterial system. If the right side of the pump begins to fail, blood backs up into the venous system.When the left side of the heart fails, blood backs up into the lungs, preventing blood from being pumped out to the rest of the body.


Cardiac output

Cardiac output (CO) is defined as the amount of blood ejected from the
left ventricle over one minute. The CO must remain fairly constant to
achieve adequate perfusion to around the body. Normal value for cardiac output is from
4 to 8 liters/minute.

CO is calculated using the estimation:
Heart rate (HR) _ stroke volume (SV) _ cardiac output (CO).


Stroke volume is influenced by three factors:

1. Preload is the amount of blood returning to the right side of the heart. To remember preload, think volume—you can have too much or not enough. Ways to increase preload: increase fluid volume in the vascular space, elevate the legs, and place the client in the Trendelenberg
position.Ways to decrease preload are to sit the client up with the legs down and decrease vascular volume.

2. Afterload is the pressure in the aorta and peripheral arteries that the left ventricle has to work against to get blood out. This pressure is referred to as resistance—how much resistance the ventricle has to overcome to pump blood out to the body.

The aorta is naturally a high-pressure vessel, but we don’t want it to go too high.Ways to increase afterload include making the client’s BP go up. Now the client’s left ventricle will have even more pressure to pump against. As a result, less blood will be pumped out of the heart, and cardiac output will go down. This is not nice! Ways to decrease afterload are to give your client a vasodilator or an antihypertensive. This will decrease the pressure in the aorta and therefore the heart will not have as much pressure to pump against.

Then the left ventricle will say, “Thank you! Now I don’t have to work as
hard against that high pressure to get the blood out.” Then the cardiac
output will go up.

3. Contractility is the heart’s ability to “squeeze” volume out of the ventricle.





What is the heart failure?

Heart failure is a clinical syndrome in which any abnormality of cardiac function causes either a failure of the heart to pump blood at a rate commensurate with the requirement of metabolizing tissues, or a situation in which filling pressures are elevated, or frequently both conditions simultaneously. Patients with impaired cardiac-pumping function experience symptoms related to abnormal perfusion and retention of vascular fluid volume.


Predisposing causes of heart failure.

1. Hypertension
2. Diabetes mellitus
3. Dyslipidemia
4. Valvular heart disease
5. CAD
6. Myopathy
7. Rheumatic fever
8. Mediastinal radiation
9. Sleep apnea disorders
10. Exposure to cardiotoxin agents
11. Alcohol abuse
12. Smoking
13. Collagen vascular disease
14. Thyroid disorder
15. Pheochromocytoma
16. Old age
17. Metabolic syndrome
18. CAD, coronary artery disease.



Classification of Heart Failure patients:

1. Stage A : Patient with high risks for HF
2. Stage B : Asymptomatic patients with LV dysfunction
3. Well compensated Stage C : Patients with minimal symptom treated as outpatient in office
4. Early decompensated Stage C : Patient with first hospitalization because of decompensated HF
5. Recurrent decompensated Stage C : Patients with recurrent hospitalizations because of
frequent relapse of decompensated HF
6. Stable very low EF, Stage C :Patients with multiple previous hospitalizations now
followed-up at a dedicated HF clinic





Left-sided heart failure

The Congestive heart failure is classified as left-sided heart failure or rightsided
heart failure. Left-sided heart failure is happen when the left ventricle fails and cardiac
output falls. The blood backs up into the left atrium and lungs, causing
pulmonary congestion.



What cause the left heart failure ?

Coronary artery diseases
Reduces oxygen-rich blood flow to the cardiac muscle resulting in ischemia. This decreases cardiac output. As the damaged cells begin to heal, they go through neurohormonal changes called remodeling. Remodeling is a bad thing. The “scarred” or remodeled tissue is not the same as healthy heart tissue. The remodeled cells do not contract as well as healthy heart tissue, and the client is at risk for developing congestive heart failure.

Myocardial infarction
Blockage of coronary artery impedes forward blood flow, resulting in cardiac tissue ischemia. This reduces cardiac contraction and cardiac Output.

Myocarditis or endocarditis
Inflammation of heart muscle caused by bacterial, viral, or other infection. Damages heart
muscle and impairs pumping ability .

Heart valve disorders
Narrowing of heart valves causes backward flow of blood. The heart enlarges and cannot pump effectively,so decreases CO occur.

Arrhythmias
The heart beats abnormally, leading to decreased pumping ability.

Pulmonary hypertension
Damages blood vessels in the lungs, making the heart work harder to pump blood into the arteries that supply the lungs.

Pulmonary embolism
Makes pumping blood into the pulmonary arteries difficult (due to blockage).

Hyperthyroidism
Overstimulates the heart, making it pump too rapidly and not empty completely with each heartbeat (if heart beats too fast, the ventricles do not have time to fill).Hypothyroidism Low thyroid hormones make the cardiac muscle weak, decreasing its pumping ability.

Anemia
Reduction of oxygen the blood carries, so the heart must work harder to supply the same
amount of oxygen to the tissues. The heart is now working harder to pump more oxygen around the body.

Kidney failure
Strains the heart because the kidneys cannot remove the excess fluid from the bloodstream. This leads to decreased CO.




Signs and Symptoms Left Heart Failure

Crackles
Indicates pulmonary congestion. If the left side of the heart is weak and cardiac output drops, there is a decrease in forward flow. A decrease in forward flow causes backward flow right into the lungs.


Dispnea
Excess The fluid interferes with the lungs’ ability to pick up oxygen.

Nonproductive cough
Natural response to get the fluid out of the lungs to improve gas exchange.

Blood tinged, frothy sputum
Blood and fluid are accumulating in lungs. Sputum will be frothy pink due to the presence
of blood.

Restlessness HypoxiaTachycardia
The heart rate increases as a compensatory mechanism (sympathetic stimulation) in an effort
to pick up and transport more oxygen to the cells.

S3
Normally there are two heart sounds. S1 indicates the closing of the mitral and tricuspid
valves. S2 indicates closure of the aortic and pulmonic valves. Well, when the heart fails there
is an extra heart sound, called an S3 gallop. It is described as a “floppy” sort of sound caused by
extra fluid in the ventricles S3 sounds like “Ken-tuc-ky”.

S4
Atrial contraction against the noncompliant ventricle causes an extra heart sound S4 sounds
like “Tenn-ess-ee”.

Orthopnea
The client will probably have to sit up to breathe. Sitting up allows for better chest expansion and may decrease the hypoxia.

Nocturnal dyspnea
The client experiences shortness of breath at night while lying flat. Lying flat causes all the
blood that pools in the extremities to return to the heart (preload increases). This causes CHF or
pulmonary edema.

Cool, pale skin
Peripheral vasoconstriction; the heart can’t work hard enough to pump the blood to the extremities to perfuse the tissues.







Treatments:

- Goal is to decrease workload on the heart.
- Diuretics: decrease fluid volume throughout the body.
- ACE inhibitors: dilate blood vessels decreasing workload of heart.
- Angiotensin II receptor blockers: can be used in place of ACE inhibitors.
- Beta-blockers: slow the heart rate; prevent remodeling.
- Vasodilators: cause blood vessels to dilate.
- Positive inotropic drugs: makes the heart muscle contract more forcefully.
- Anticoagulants: prevent clot formation.
- Opioids: relieve anxiety and decrease the workload on the heart especially in pulmonary hypertension.
- Oxygen therapy: improves oxygenation.
- Lifestyle modification: exercise; weight loss; reduce sodium, alcohol, and fat intake; smoking cessation; stress reduction to reduce symptoms of heart failure.
- Coronary artery bypass surgery (CABS) or angioplasty: for heart failure due to coronary artery disease (CAD).
- Heart transplant: when aggressive medical treatments are not effective.




Right Side Heart Failure

Right-sided heart failure—also known as cor pulmonale—occurs when the right ventricle can not contract effectively. This causes blood to back up into the right atrium and the peripheral circulation, which causes peripheral edema and engorgement of the kidneys and other organs.



What causes The Right Heart Failure

Left-sided heart failure
Left-sided heart failure over time will lead to right-sided heart failure. In left-sided heart failure, fluid backs up into lungs. This fluid creates increased pressures in the lungs, which is abnormal. The right side of the heart eventually becomes tired from pumping against these high pulmonary pressures. Over time the patient will experience rightsided heart failure, known as cor pulmonale.

Hypertension
Heart has to pump harder to force blood into the arteries against higher pressure. The
heart’s walls thicken (hypertrophy) and stiffen. This causes the heart to pump less blood.

Age, infiltration, infections that cause cardiac wall stiffness
Heart walls can stiffen naturally with age. Infiltration of amyloid (unusual protein not normally found in the body) can infiltrate heart walls, causing them to stiffen. Infection caused by parasites in tropical countries can cause cardiac wall stiffness.

Heart valve disorders
Hinder blood flow out of the heart; heart works harder; cardiac walls thicken; diastolic dysfunction develops that leads to systolic dysfunction.

Lung disorders COPD,Pulmonary Embolism
Cause high pressure in the lungs and can lead to right-sided heart failure. Any disease
obstructive pulmonary that causes hypoxia will cause the blood pressure in the lungs to go up . . ., pulmonary hypertension.





Sign and Symptom The Right Heart Failure

Enlarged liver (hepatomegaly) and spleen (splenomegaly)
Blood backs up into the venous system and into the liver and spleen, causing engorgement.


Epigastric tenderness
Liver and spleen have a capsule around them. This capsule does not like to stretch because it is filled with nerves and it hurts when the nerves are stretched out. When the organs become swollen, epigastric discomfort and right upper quadrant (RUQ) tenderness result

Ascites
Increased pressure in the venous system causes fluid to leak out of the vascular space into the abdominal cavity. A second reason for ascites is that the liver can no longer make albumin like it used to. Normally, albumin holds fluid in the vascular space. When albumin is low, fluid leaks out of the vascular space into the peritoneal cavity. Edema Pressure in the venous system causes fluid to leak from the vascular space into the tissues.


Anorexia, fullness, nausea
Congestion of liver and intestines

Jugular venous distension (JVD)
Blood backs up from right side of the heart into the venous system. Or, blood cannot empty into the right atrium, so it backs up into the jugular veins.

Weight
Fluid retention causes an increase in weight

Nocturia
Nocturnal fluid redistribution and resorption causes urge to void at night




Treatments:
- Goal is to decrease workload on the heart.
- Diuretics: decrease fluid volume throughout the body (heart isn’t able to pump as much volume, so we need to get rid of excess volume).
- ACE inhibitors: dilate blood vessels, decreasing workload of heart.
- Angiotensin II receptor blockers: can be used in place of ACE inhibitors.
- Beta-blockers: slow the heart rate; prevent remodeling.
- Vasodilators: cause blood vessels to dilate (this decreases workload on the left ventricle as vasodilators drop the pressure in the aorta; cardiac output will improve as well).
- Positive inotropic drugs: make the heart muscle contract more forcefully, which hopefully will increase cardiac output.
- Anticoagulants: prevent clot formation.
- Opioids: relieve anxiety and workload on the heart especially with pulmonary hypertension.
- Oxygen therapy: treat oxygen deficiency.
- Lifestyle modification: exercise; weight loss; reduced sodium, alcohol, and fat intake; smoking cessation; stress reduction to reduce symptoms of heart failure.
- Heart transplant: when aggressive medical treatments are not effective.
- EKG: shows heart strain, enlargement, ischemia.
- Chest x-ray: reveals pulmonary infiltrates and an enlarged heart
- BNP level: increased.
- Echocardiogram: evaluates pumping ability of the heart and function of the valves.
- Pulmonary artery (PA) pressure monitoring: shows elevated pulmonary artery wedge pressures and increased left ventricular end-diastolic pressure in left-sided heart failure.