Congestive Cardiac Failure

Introduction:

         

           Congestive Cardiac Failure (CCF) is a clinical syndrome that can result from any structural and functional cardiac disorders that impairs the ability of ventricles to fill with and pump sufficient blood to meet the needs of the tissues for oxygen and nutrients.

Factors effecting Pre-Load.

Stroke Volume: It is the amount of blood ejected by the left ventricle in one contraction.

• The left ventricle fills with blood until contraction. The filling time is during diastole and is known as the end diastolic volume or EDV.
• The contraction is during systole. The volume of blood left in the ventricle after contraction is the end systolic volume or ESV.
• Stroke volume is then formulated by EDV minus ESV
• Stroke volume= EDV - ESV.

Factors affecting cardiac output

1. Contractility:

a) It is the ability of the heart muscle to contract.

b) It depends upon the number and status of myocardial cells.

c) Contractility is decreased with:

• Infarcted tissue- no contractile strength.
• Ischemic tissue- reduced contractile strength.
• Negative inotropes ( medications that decrease contractility, such as beta blockers).

d) Contractility is increased with:

• Sympathetic stimulation.
• Positive inotropes ( such as digoxin).

Etiology:

1. Impaired cardiac function.

• Coronary heart disease.
• Cardiomyopathies.
• Rheumatic fever.
• Endocarditis.

2. Increased cardiac workload.

• Hypertension.
• Valvular disorders.
• Anemia.
• Congenital heart defects.

3. Acute non cardiac conditions

• Volume overload.
• Hyperthyroidism.
• Infection.

Types of Heat Failure.

• Left sided heart failure 

           There are two types of left sided heart failure.

            1. Systolic dysfunction.

            2. Diasystolic dysfunction.

• Right sided heart failure.

Left sided heart failure:

SYSTOLE DYSFUNCTION

• The left ventricle loses its ability to contract normally resulting inadequate stroke volume and cardiac output.
• Characterized by decreased ejection fraction less than 40%.
• Pumping problem.
• Due to Coronary Artery Disease, Hypertension or Valvular heart disease.

DIASTOLE DYSFUNCTION

• Impaired ability of ventricles to relax and fill during diastole.
• It results in inadequate stroke volume.
• Not much blood to eject.
• Failure of ventricular relaxation results in elevated end- diastole pressure resulting in pulmonary edema and pulmonary HTN.

Pathophysiology:

Clinical Manifestations:

Right sided heart failure:

• Results due to failure of right ventricle to pump efficiently.
• Blood back flows into right atrium and venous circulation.
• It usually occurs as a result of left sided failure and pulmonary hypertension.

Pathophysiology:

Clinical Manifestations:

Diagnosis:

• Ejection Fraction (EF)

1. It is the fraction of the end- diastolic volume that is ejected with each beat.

2. Normal EF ranges from 55% to 70%.

3. EF is performed to assist in determining the degree of heart failure.

4. EF= SV/EDV

• History taking.
•  Physical examination.
• Echocardiography: visualizes chamber size, ejection fraction, type of heart failure.
• ECG analysis: evidences of infarction or ischemia. Non specific findings may include hypertrophy, chamber enlargement, conduction disturbances.
• Chest X-ray: demonstrates heart size and progression of pulmonary congestion.
• B- type natriuretic peptide: which is a cardiac neuro-hormone secreted by the ventricles in response to volume expansion and pressure overload.

Medical Management:

The main goals of medical management of heart failure are as follows:

1. Reduce Symptoms.
2. Improve quality of life.
3. Reduce hospitalization.
4. Reduce mortality.
5. Prevent sudden cardiac death.

Treating Congestive Heart Failure:

UN LOAD FAST

• Upright position.
• Nitrates.
• Lasix
• Oxygen.
• ACE Inhibitors.
• Digoxin.
• Fluids (decrease)
• Afterload (Decrease)
• Sodium retention.
• Tests ( dig level, ABG, Potassium level).

Medical Management:

1. Improve ventricular pump performance.

• Oxygen.
• Digoxin.
• Inotropes.

2. Reduce workload.

• Reduce preload.
• Reduce afterload.

3. Reduce fluid retention.

1. Improve ventricular contraction.

• Supplemental oxygen.
• Digitalis: Digoxin increases the force of myocardial contraction, slows conduction through the AV node.

2. Reduce Preload.

• Diuretics: Thiazide, loop diuretics, potassium sparing diuretics.
• Angiotensin converting enzyme inhibitors. (Ace Inhibitors) eg;enalapril, captopril.
• Hydralazine and isosonide dinitrate.
• Angiotensin II receptor blockers (ARBs) eg: losarton.

2. Reduce Afterload.

• Nitroglycerine.
• ACE inhibitors.
• Beta blockers (Propanolol).
• Calcium Channel blockers. (amlodidipine).

3. Reduce Fluid Retention.

• Sodium restriction. (< or equal to 2-3/day).
• Restrict fluid intake.

Surgical Intervention for Heart Failure.

1. Intra-aortic Balloon Pump. (IABP).
2. Cardiac Resynchronization Therapy. (CRT).
3. Left Ventricular Assist Device. (LAVD).
4. Heart Transplantation.

1. Intra- aortic Balloon Pump

Used to stabilize a person, for a short period of time. It reduces the workload of heart.

• It is to improve heart's ability to pump.
•  It increases the stroke volume.
• Improves coronary artery perfusion.
• Decreases cardiac workload.
• Decrease myocardial oxygen demand.

Cardiac Resynchronization Therapy

It resynchronizes the contractions of the heart's ventricles which can help the heart pump blood throughout the body more efficiently. 

Used in severe HF and intra- ventricular conduction delay, improve ventricular co-ordination and hemodynamics.

Left Ventricular Assist Device (LVAD) 

Heart Transplantation

Complications

1. Cardiogenic shock.
2. Dysarrhythmias.
3. Thromboembolism.
4. Pericardial effusion and cardiac temponade.
5. Pulmonary edema.
6. Pleural effusion.

Nursing Management:

1. Impaired gas exchange related to pulmonary edema.

• Auscultate breath sounds; crackles, wheezes.
• Assess for alteration in lung functions like hypoxemia, atelectasis.
• Oxygen therapy.
• Position for maximum lung expansion and support arms with pillows. (semi fowler's position.)
• Schedule activities to conserve energy.
• Teach deep breathing and coughing exercises.

2. Fluid volume excess related to decreased cardiac output and altered renal hemodynamics.

• Assess daily weight, ascites, abdominal girth, edema.
• Monitor intake- output, noting amount and color of urine.
• Ascultate breath sound.
• Restrict sodium and fluid as prescribed.
• Administer drug as prescribed.

3. Alteration in electrolyte balance related to increased total body fluid, diuretic therapy.

• Monitorr serum electrolytes, fluid losses and gains.
• Assess for ECG changes.
• Monitor the signs of electrolyte imbalance.
• Institute specific interventions for specific electrolyte imbalances.
• Replacement of electrolytes.

4. Decreased activity tolerance related to decreased cardiac output.

• Assess patient's current level of activity.
• Assess potential for physical injury with activity.
• Evaluate need for oxygen during physical activity,
•  Restrict strenuous activities.
• Use slow progression of patient activity to prevent sudden increase in cardiac workload.
• Assist patient with range of motion exercises.

5. Altered nutritional status related to decreased appetite, GI irritability.

• Assess eating habits and calorie intake.
• Assess compliance with drugs, weight, skin turgor, GI status.
• If patient is experiencing decreased appetite encourage the patient and offer small frequent meals.
• Assist family and individual in adjustment to dietary regimen.
• If patient is having GI irritability then give medicine after food.
• Provide emotional support.

Prepared By:

RN Anusha Shrestha.