Cardio G
primarily in the lungs, to angiotensin 2
Heart Failure
- Is the inability of the heart to pump
sufficient blood to meet the needs of
the tissues for oxygen and nutrients
- May or may not be congestion
- If (+) congestion = congestive heart
failure
Causes
1. Coronary atherosclerosis
- Condition wherein the blood vessel
supplying oxygenated blood to the
heart is obstructed by fats or atheroma,
clot, thrombus or by embolus
Pathophysiology
 Impaired contractile properties of the
heart which (systolic dysfunction)
 Impaired filling of the heart (diastolic
dysfunction)
Result
 Lower than normal cardiac output
Signs and symptoms
 Compensatory mechanisms of the body
- ventricular hypertrophy (enlargement
of ventricle muscles)
- renin-angiotensin-aldosterone system
(activated normally when there’s
insufficient blood flow to the kidneys.
The insufficient blood flow to the
kidneys and decreased sodium to the
kidneys, if detected by the
juxtaglomerular cells , releases enzyme
Renin. Renin splits Angiotensinogen,
protein produced by liver causes the
release of angiotensin 1 which is a mild
vasoconstrictor, then converted by
angiotensin converting enzyme located
in most blood vessels in the body,
which is a potent vasoconstrictor.
Angiotensin 2 further stimulates the
release in the adrenal cortex of
aldosterone, which causes sodium
retention in the kidneys, further
increasing blood pressure. Only
normally released when there’s
reduced in blood flow to the kidneys. In
heart failure, they are stimulated
because of the reduced blood flow to
the kidneys but not because of trauma
like stab wound, but because of the
heart’s inability to pump blood
throughout the organs. As a resultthe
BP is increased, worsening the heart
failure of client)
- sympathetic nervous system stimulation
(organs receiving reduced blood flow
secondary to heart failure)
 increases workload on the heart
 if there’s decompensation: no
contraction, resistance to filling further
worsening of heart failure
a. Left sided heart failure
- most often fails earlier than the right
sided heart failure (Because left heart
does more work)
- Pulmonary congestion
- #1 pathognomonic sign: pulsus aternans
(alternating strong and weak pulse)
b. Right sided heart failure
- Systemic congestion: edema, ascites
(abnormal buildup of fluid in the
abdomen), neck vein distention,
hepatomegaly, splenomegaly
Diagnostic Tests
1. Clinical manifestaions
 Classification of heart failure
a. Class 1 (symptomatic with exertion)
b. Class 2 (symptomatic with less than
Nursing Care
ordinary activities)
c. Class 3 (Symptomatic with less than
ordinary activities)
d. Class 4 (always symptomatic)
2. Echoocardiogram (assess ejection
fraction of ventricles)
3. Chest radiographs (cardiomegaly)
4. ECG
5. Serum levels
 CBC
 Kidney function
- Creatinine clearance:
125ml/min/1.73m2, 25mg/kg/24hrs
- Creatinine: n 0.6-1.2mg/dl (more
accurate)
- BUN: 10-20mg/dl
*kidneys are assessed because they are very
sensitive to lack of blood flow. If the patient has
heart failure, first organ to suffer: kidneys
6. Cardiac catheterization – insertion of
catheter through artery of the leg, catheter is
then driven to the heart to make sure the
pressure in the chambers of the heart
7. Swan-ganz catheter
> 4 lumen catheter
Measures:
a. CVP (central venous pressure: the
pressure of the right side of heart) –
mean 3-6mmHg
Disadvantage: late indicator of
increased fluid volume, it takes a while
before increased fluid volume increases
CVP
b. Pulmonary artery capillary
pressure/pulmonary capillary wedge
pressure
– uses a catheter to measure the pressure
on the pulmonary vein
- Indirect measurement of pressure of
left side of heart
- Mean 12-16 mmHg
a. Patient in Trendelenburg position
- To prevent air embolism (trendelenburg
position helps air embolus be trapped in
the right atrium or right ventricle and
not be lodged in pulmonary capillaries)
- For venous engorgement prevention
b. Use sterile technique
c. MD thread ballon tipped catheter thru
subclavial vein > right atrium and right
ventricle > balloon is inflated (1-2ml of
air but never water, water has more
weight than air and if touches the wall
of the atrium might trigger arrythmias)
(balloon acts as buffer between the
hard part of catheter and wall of
ventricle to prevent ventricular
arrhythmias) > blood guides balloon to
pulmonary capillaries
d. When measuring, make sure that the
zero mark on the
manometer/transducer or stopcock is
at the level of client’s right atrium (level
of 4th ICS, left midaxillary line):
phlebostatic axis (phlebo [ blood ] +
static)
- Phlebostatic axis: Lowest blood
pressure, set to 0 point (0mmHg) of
manometer or transducer
- Normal central venous pressure (CVP):
5-10cm H20 or 3-6mmHg
- Increase: hypervolemia
- Decrease: hypovolemia
 Proximal Lumen
- Rests in the vena cava or the right
atrium
- Reflects the central venous pressure
 Distal Lumen
- Rests in the pulmonary artery
- Reflects the PACP (pulmonary artery
capillary pressure)/PCWP (pulmonary
capillary wedge pressure)
  Thermistor Lumen ballon tip formationing pulmonary wedge
- Measures cardiac output using the pressure
thermal dilution technique
- Fast change indicates increased cardiac
output
- Low change indicates decreased cardiac
output
 Inflation lumen and balloon
- Inject 1-2ml of air to inflate balloon

Swan Ganz catheter

Illustration of where phlebostatic axis is, where

the stop cup (?) should be leveled to maintain
adequate measurement

4 lumens of swan ganz catheter, where the

catheter will go through the heart
Management - For fluid retention in heart failure
- Diuretics decreases fluid retention
Goal: To return heart to normal function  Loop diuretics
- Furosemide
Medications - Torsemide
1. Inotropic agents (drugs meant to : inhibit the reacsorption of Na, K and CI
increase strength of cardiac in thick ascending limb of loop of henle
contraction) (basic unit of kidney)
a. Dobutamine 5. Vasodilators
- A1, B1, B2  Angiotensin-converting enzyime
- #1 inotropic agent in heart failure inhibitors
- Given as continuous infusion: 1- - ‘pril’
2ug/kg/min - Acts as vasodilators
b. Digoxin - Also diuretics, because they inhibit the
- Action: inhibits the Na-K-pump (Na-K- production of aldosterone that saves
ATPase) > increases influx of calcium sodium from the body and eliminates
into cell > depolarizes cells > creates potassium
action potential > slow HR, inc cardiac - ACE inhibitor increases potassium level
contractility and decreases sodium level
- Therapeutic dose: 0.5 – 2mg/dl - Captopril
- Toxicity: anorexia – earlist sign - Enalapril (s/e: nonproductive cough)
- Digibind: antidote  Angiotensin Receptor blocker
- Contraindication - ‘sartan’
*Hypercalcemia – calcium potentiates - Vasodilator
digoxin may lead to arrhythmias - Losartan
*Hypokalemia – less potassium, less - Valsartan
resistance to calcium influx may lead to  Beta blockers
arrhythmias - ‘olol’
- Give high in potassium foods: apple, - Decrease HR and cardiac demand
banana, carrots - Beta 1 antagonist
- Metoprolol
2. Vasodilators - Propranolol
- If cause if vasoconstriction (e.g - Contraindication: asthmatics (also
myocardial infarction) blocks beta2 receptors that’s
a. Nitroglycerin responsible for bronchodilation, may
b. Nesiritide lead to bronchoconstriction)
c. Na nitroprusside  Calcium Channel Blockers
- Amlodipine, nicardipine
3. Vasoconstrictors - s/e: erectile dysfunction
- If cause of vasodilation or lack of fluids
in blood vessels (e.g shock) 6. surgery
a. Dopamine a. PTCA (percutaneous transluminal
- Stimulates A1, B1receptors coronary angioplasty
b. Vasopressin - For 1-2 affected vessels
c. Epinephrine b. Coronary artery bypass graft
- For 3 affected vessels
4. Lower BP c. Carotid endarderectomy
 Diuretics d. Mechanical assist device
 Intraaortic balloon pump
- Assist heart in pumping sufficient blood
to the body
- deflates with systole
- inflates with diastole
- Increases cardiac output
 Left ventricular assist device
 Heart transplantation
Summary
 Left sided heart failure tends to produce
pulmonary manifestations
 Right sided heart failure tends to
produce systemic manifestations
 Ultimately, both left sided and right
sided failure tend to occur together