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: LR shunts, RL 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
Starlings Law
TERMS
CARDIOMEGALY
DILATATION, any chamber, or all
HYPERTROPHY, and chamber, or all
S.A. NodeAV NodeBundle 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)
ReninAngiotensionAldosterone
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 weightMYOPATHY, 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,

stuporcoma
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
factorsTBX5ASD,VSD
NKX2.5ASD
Region of chromosome 22 important in heart
development, 22q11.2 deletionconotruncus,
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
Schillings 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,
Allens 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 7. Anticoagulants
Morphine ( +
preload & afterload)
Demerol causes vomiting
2. Oxygen
3. Inotropics
4. Beta Blockers
5. Antiarrhythmics
6. No ice or very hot drinks
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
Cushings Syndrome/steroid Therapy
Pheochromocytoma
Coarctation of the Aorta
dr M Arman Nasution SpPD