Heart Failure
Introduction to Heart Failure
• Heart failure (HF) is a clinical syndrome resulting from structural or functional
cardiac disorders so that the heart is unable to pump enough blood to meet the
body’s metabolic demands or needs.
• The term heart failure indicates myocardial disease in which impaired contraction
of the heart (systolic dysfunction) or filling of the heart (diastolic dysfunction) may
cause pulmonary or systemic congestion.
• Some cases of HF are reversible, depending on the cause. Most often, HF is a
chronic, progressive condition that is managed with lifestyle changes and
medications to prevent episodes of acute decompensated heart failure. These
episodes are characterized by increased symptoms of respiratory distress,
decreased cardiac output (CO), and poor perfusion.
Pathophysiology
• Two types:
o Systolic: weakened muscle — can’t eject
o Diastolic: stiff and noncompliant muscle — can’t fill
• Mismatch of Oxygen Supply (MVO2): Demand (DO2)
• Cardiac Output (CO) decreases
• Compensates to maintain CO
• Myocardial myofibrils lose recoil
• CO further declines
• Downward spiral
Cardiomegaly vs. Cardiomyopathy — What's the Difference?
Feature Cardiomyopathy Cardiomegaly
What
Disease of heart muscle Physical enlargement of the heart
it is
Primary or secondary muscle
Cause Symptom/sign of many heart conditions
dysfunction
Types Dilated, hypertrophic, restrictive No types; just describes size
Diagn
Echo, ECG, biopsy, MRI CXR, echo
osis
Treat Depends on type; treat underlying Treat underlying cause (e.g., HTN, valve
ment cause disease)
Normal Chest X-Ray vs. Enlarged Heart
Precipitating Factors/Diseases
• Coronary Artery Disease
• Hypertension
• Valvular disease
• Infections
• Endocrine imbalances (DM)
• Pregnancy-PIH
• Genetics — Marfan Syndrome
• Dysrhythmias
• Renal Failure
• Musculoskeletal disorders
• Autoimmune disease
• Pulmonary Emboli
• Anemia
• Bacterial endocarditis
Left-sided Heart Failure
• Also referred to as left ventricular failure because of the inability of the left ventricle
to fill or eject sufficient blood into the systemic circulation.
Right-sided Heart Failure
• Also referred to as right ventricular failure because of the inability of the right
ventricle to fill or eject sufficient blood into the pulmonary circulation.
• In chronic HF, particularly congestive heart failure, patients may have signs and
symptoms of both left- and right-sided heart failure.
Common Causes of Left Heart Failure
• Ischemic heart disease (e.g., myocardial infarction)
• Chronic hypertension
• Valvular heart disease (especially aortic and mitral)
• Cardiomyopathy
• Diastolic dysfunction (heart failure with preserved EF)
• Tachyarrhythmias (e.g., atrial fibrillation)
Clinical Manifestations — System Affected / Symptoms-Signs
• Pulmonary: Dyspnea, orthopnea, paroxysmal nocturnal dyspnea (PND), crackles,
cough
• Systemic: Fatigue, weakness, oliguria during the day, nocturia
• Neurological: Confusion, restlessness (↓ cerebral perfusion)
• Cardiac: S3 gallop, tachycardia, displaced PMI
Hemodynamic Changes — Parameter / Change
• Pulmonary capillary wedge pressure (PCWP): ↑ Elevated
• Cardiac output: ↓ Decreased
• Systemic vascular resistance (SVR): ↑ Increased (compensation)
Diagnostic Evaluation
• Echocardiogram: ↓ EF in systolic HF; normal in diastolic HF
• BNP or NT-proBNP: ↑ levels indicate ventricular stretch
• Chest X-ray: pulmonary congestion, cardiomegaly
• 12-lead ECG: look for MI, LV hypertrophy, arrhythmias
• Cardiac catheterization: to assess coronary arteries and pressures
• Serum labs:
o Electrolytes (esp. K⁺, Na⁺, Mg²⁺)
o BUN/Creatinine (renal perfusion)
o Troponins (ischemia/infarction)
Nursing Management
1. Improve Oxygenation
a. High Fowler’s position
b. Administer O₂ if indicated
c. Monitor respiratory status closely
2. Reduce Preload
a. Diuretics (e.g., furosemide)
b. Sodium and fluid restriction
3. Reduce Afterload
a. ACE inhibitors/ARBs
b. Nitrates
c. Monitor BP and renal function
4. Improve Contractility
a. Positive inotropes (e.g., digoxin, dobutamine for acute cases)
b. Monitor HR, rhythm, and digoxin toxicity
5. Control Heart Rate and Rhythm
a. Beta-blockers to slow HR, reduce O₂ demand
Patient Education
• Daily weights: report gain >2 lbs/day or >5 lbs/week
• Low sodium diet
• Medication adherence
• Activity pacing: alternate rest with activity
• Recognizing signs of decompensation: worsening dyspnea, edema, fatigue
• Smoking cessation, alcohol moderation
Right-sided Heart Failure — Manifestations
• Congestion in the peripheral tissues and organs:
o JVD
o Dependent edema
o Hepatomegaly and Splenomegaly
o Ascites
o Weight gain
o Pitting edema extremities
o Bounding pulses
o Dysrhythmias
o Elevated CVP/RAP
Common Causes of Right Heart Failure
• Left-sided heart failure (most common)
• Pulmonary hypertension
• Right Ventricular Infarction
• Chronic Lung Disease – (Cor Pulmonale)
• Tricuspid or pulmonic valve disease
Diagnostic Evaluation (Right-sided HF)
• History & physical exam
• Echocardiogram: evaluates chamber size and function
• BNP or NT-proBNP: elevated levels suggest HF
• Chest X-ray: may show cardiomegaly or pleural effusions
• ECG: assess for arrhythmias or ischemia
• Right heart catheterization: assesses pressures and cardiac output
• Liver function tests: may be elevated due to hepatic congestion
Hemodynamic Parameters (RHF)
• Right atrial pressure (RAP/CVP): ↑ Elevated
• Pulmonary artery pressure: Normal or ↑
• Cardiac output: ↓ Decreased
Nursing Interventions
1. Fluid Management
a. Diuretics (e.g., furosemide)
b. Fluid/sodium restriction
c. Monitor electrolytes
2. Optimize Cardiac Output
a. Use of ACE inhibitors, ARBs, or beta-blockers
b. Monitor for hypotension
3. Reduce Venous Congestion
a. Elevate legs
b. Avoid prolonged standing
c. Compression stockings
4. Respiratory Support
a. O₂ if hypoxic
b. Monitor for pulmonary edema if left HF develops
5. Skin Integrity
a. Edema increases risk for breakdown
b. Turn and position frequently
Clinical Manifestations Summary
• Dyspnea
• Fatigue with limited exercise tolerance
• Fluid retention leading to pulmonary congestion and peripheral edema
• These signs and symptoms are related to the ventricle most affected
Pulmonary Edema
• When the left ventricle begins to fail, blood backs up into the pulmonary circulation,
causing pulmonary interstitial edema preventing gas exchange
• Flash Pulmonary Edema — sudden onset
• Life threatening pump failure
o Extreme anxiety and dyspnea
o Tachypnea, diaphoresis, audible rales
o Respiratory acidosis
o Frothy pink sputum
Heart Failure Management and Treatment
Pharmacologic
• ACE inhibitors
• Beta Blockers
• Diuretics — Furosemide, Bumetanide
• Vasodilators — NTG
• Inotropic agents — Dobutamine, Milrinone, Digoxin (positive inotrope and
chronotrope)
• Dysrhythmics — Amiodarone, Lidocaine, Cardizem
Non-pharmacologic
• Lifestyle management
o Sodium restriction
o Fluid management
o Exercise therapy
• Surgical Intervention
o AICD
o Biventricular pacemaker
o Ventricular Assist Devices
o Heart transplant
o Revascularization — CABG, LV myotomy
Complications of Heart Failure
• Kidney damage or failure — may require dialysis
• Liver damage — fluid backup can lead to scarring
• Other heart changes — valve damage, arrhythmias
• Sudden cardiac death — from dangerous irregular rhythms
