Heart failure

Question 1

What is heart failure?

Answer 1

This is a syndrome where pts experience typical symptoms such as sob, ankle swelling and fatigue as well as signs such as elevated jugular pressure, pulmonary crackles and displaced apex beat which results from an abnormality in the cardiac structure or function

Question 2

What are the major criteria when diagnosing HF?

Answer 2

Paroxyzmal noctural dyspnoea
Neck-vein distension
Rales
Cardiomegaly 
Acute pulmonary oedema
S3 gallop
Increased venous pressure
Hepatojugular reflex
Loss of weight more than 4.5kg during 5 days

Question 3

What are the minor criteria when diagnosing HF?

Answer 3

Ankle oedema
Night cough
Dyspnoea on exertion
Hepatomegaly
Pleural effusion
Tachycardia (more than 120b/min)

Question 4

How is HF diagnosed?

Answer 4

Either 2 major criteria

OR 1 major criteria with 2 minor criteria

Question 5

What are the typical symptoms of HF?`

Answer 5

SOB
Orthopnoea 
Paroxysmal nocturnal dyspnoea
Reduced exercise tolerance
Fatigue, tiredness, increased time to recover after exercise
Peripheral oedema

Question 6

What are the NYHA classifications for HF?

Answer 6

Class 1: no limitation of physical activity.
Class 2: slight limitation of physical activity - SOB, fatigue or palpitations
Class 3: comfortable at rest but ordinary physical activity is limited as it results in SOB, fatigue or palpitations
Class 4: symptoms at rest and during exercise are present

Question 7

What are the causes of HF?

Answer 7

CAD/ACS -
Idiopathic dilated cardiomyopathy -
Infection, hypoxia and alcohol abuse - all these reduce contractility

valve disease - as this affects the volume/pressure overload

hypovolemia and constrictive pericarditis - causes insufficient volume

drugs - chemotherapy
electrical disorders - vtach which can cause HF

Question 8

What is the preload?

Answer 8

Volume coming into the ventricles at the end diastolic pressure

Question 9

When is the preload increased?

Answer 9

Hypervolemia

Regurgitation of cardiac values

Question 10

What is the afterload?

Answer 10

the resistance the left ventricle must overcome to circulate blood.

this is increased to minimize the symptoms of HF

Question 11

When is the afterload increased?

Answer 11

hypertension
vasoconstriction

these lead to an increase in the cardiac workload and in the afterload

Question 12

What are the compensatory mechanisms in HF?

Answer 12

Sympathetic NS

RAAS

Question 13

What are the counter-regulatory mechanisms?

Answer 13

the chambers of the heart try to release hormones which try to compensate the negative effects of the other hormonal mechanisms.

Natriuretic peptides (ANP and BNP) promote diuresis (increase urine output) and vasodilation.

these have a negative impact long term

Question 14

What is systolic failure?

Answer 14

the inability of the ventricle to contract normally which leads to a decrease in CO. EF <40%

Question 15

What is diastolic failure?

Answer 15

inability of the ventricle to relax and fill normally causing increasing filling pressure. EF is >50%

Question 16

What are the symptoms of LV failure?

Answer 16

Pulmonary edema 
dyspnoea
poor exercise tolerance
orthopnea fatigue
paroxymal noctural crackles 
frothy pink sputum

Question 17

What are the symptoms of RV failure?

Answer 17

systematic venous congestion
peripheral oedema
pulsation in neck (jugular vein distention)
weight gain +1kg/day
Abdomen distension - hepta, spleno, ascites
pitting oedema

Question 18

What are the nursing interventions for HF?

Answer 18

H - head of bed elevation - high fowler position
O - oxygen therapy
P - push diuretics and morphine
E - end sodium/water - sodium swells.

D- iet limit sodium and fluids (1.5lts/day)
R - isk of falls due to orthostatic hypotension
B - BP/BNP - take and monitor trends
E - elevate head of bed and legs
D - daily weight (Document 1kg/day or 3kg over a week)
S - sex only if you can climb 2 flights of stairs without SOB
S - stockings provide TED stockings but remove daily

Question 19

What are the nursing assessment for HF?

Answer 19

Vital signs - BP, HR, RR, TEMP

I/O

Right sided: peripheral edema MONITOR, monitor weight gain, check for pitting edema, neck J.V.D and measure the abdomen distension

Left sided: monitor SOB, measure 02 saturations, ask for sleeping difficulties, listen for crackles and collect sputum

Question 20

What is the difference between acute and chronic HF?

Answer 20

acute: is used exclusively to mean new onset acute or decompensation of chronic cardiac HF characterized by pulmonary and/or peripheral edema

chronic develops or progresses slowly

Question 21

What are the investigations done to diagnose HF?

Answer 21

ECG
BNP
(if these are normal, an echo is done)

CBC + u+e (as hypovolemia and anaemia can cause HF)

Chest x-ray - cardiomegaly, alveolar shadowing and pleural effusion.

ECHO - indicate the cause (MI or valvular disease) and assess the presence or absence of LV dysfunction

Nuclear imaging

LV angiogram

Question 22

What is the medical management of HF?

Answer 22

Diuretics - relieve symptoms of HF. - loop (Watch for hypokalemia, renal impairment. - potassium-sparing (if potassium is less than 3.2mmol/L)

ACE-I (if not tolerated ARBs are given) - improves symptoms. SE: hyperkalemia

Beta-blockers - decrease mortality in HF.

Spironolactone - use in pts on optimal drug therapy but still symptomatic. risk of hyperkalemia is minimal.

Digoxin - helps with symptoms

Vasodilators - should be used if intolerant to ACE-I or ARBs.

LMWH - given as a DVT prophylaxis

Opiates - help with dyspnea and anxiety.