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Congestive Heart Failure
J.O. Medina,RN,MSN,FNP,CCRN
Education Specialist
Nurse Practitioner
Critical Care&EmergencyServices
California Hospital Medical Center
Congestive Heart Failure and Pulmonary Edema Overview
Definition – heart failure is inability of the heart to pump enough blood to meet the metabolic demands of the body
Diagnosed by Manifestations of inadequate tissue perfusion Signs and symptoms of intravascular volume overload
Over 2 million Americans have heart failure 10% will die in one year; 50% in five years America’s highest volume DRG
Congestive Heart Failure and Pulmonary Edema Pathophysiology
Neurohormonal theory Increased TNF – alpha – cachectin Endothelin – vasoconstrictor released by endothelial cells Natriuretic Peptides released by atrial and ventricular
stretch and counterbalance effects of endothelin Common causes
CAD; MI;HTN Dilated cardiomyopathy Aortic stenosis ; Aortic regurgitation Mitral regurgitation
Atrial / Brain Natriuretic Peptides
Congestive Heart Failure and Pulmonary Edema Types
Forward vs. backward failure Forward failure – inadequate tissue perfusion to meet
metabolic demands of the body Backward failure – seen in pulmonary and systemic
congestion Right vs. left failure
May involve RV, LV or both Usually LV failures precedes RV failure, producing
symptoms of pulmonary congestion RV failure is usually result of LV failure but may occur
with primary pulmonary hypertension
Congestive Heart Failure and Pulmonary Edema
Systolic vs. diastolic failure Systolic failure – inability of the ventricles to
eject adequate volume Diastolic failure – inability of ventricles to relax
and fill High output vs. low output failure
Most HF – result of low contractility producing low CO
High output HF occurs when acute metabolic needs are not met even with high CO
Congestive Heart Failure and Pulmonary Edema
Acute vs. chronic failure Acute failure – heart is overwhelmed by abrupt alteration
in cardiac function and unable to bring compensatory mechanisms to play
Chronic failure – compensatory mechanisms have time to partially of completely restore cardiac function
Refractory vs. compensated HF Compensated – body or medical therapies are working
and heart is responding Refractory – heart is not responding to therapies
Congestive Heart Failure and Pulmonary Edema New York Heart Association Classification of
Heart Failure Class I - no limitations with ordinary activity Class II – slight limitations of physical activity Class III – marked limitations of physical activity Class IV – inability to engage in any physical
activity without symptoms
Congestive Heart Failure and Pulmonary Edema Clinical Presentation
Intravascular and interstitial fluid overload SOB; Dyspnea on exertion;Orthopnea Paroxysmal nocturnal dyspnea Non-productive cough; crackles; wheeze Weight gain; S3;sinus tach; atrial dysrhythmias Displaced PMI ; systolic murmur ; GI symptoms
Inadequate tissue perfusion Decreased exercise tolerance Unexplained fatigue Unexplained mental confusion Decreased urine output Arrythmias Peripheral vasoconstriction
JVD / Pitting Edema
Congestive Heart Failure and Pulmonary Edema Diagnosis
CXR – cardiomegaly; pulmonary vascular congestion;pleural effusions
Echocardiogram – dilated cardiac chambers; hypertrophy; vascular insufficiency and/or stenosis; wall motion abnormalities (akinesis, hypokinesis; dyskinesis); low EF
EKG – tachycardia; arrythmias; chamber enlargement; ischemia/infarction
Cardiac Catheterization – increased PA/PCWP; low EF and low CO with high LVEDP; valvular dysfunction and CAD
Congestive Heart Failure and Pulmonary Edema Management
Goals of therapy Reduce Preload
Venodilators NTG ; diuretics ; ace inhibitors
Morphine Dopamine (low dose)
Optimize Heart rate Digoxin
Reduce Afterload Arteriodilators
Ace inhibitors; hydralazine Nitroglycerin ; nitroprusside
Improved contractility Digoxin Dopamine; dobutamine; amrinone
Congestive Heart Failure and Pulmonary Edema
Atrial Natriuretic Peptide (ANP) Adrenergic Blockade Nitric Oxide Synthetase Spirolactone
Congestive Heart Failure and Pulmonary Edema
Pulmonary Edema Severe pulmonary congestion due to
excess fluid in interstitial and/or alveolar spaces
Pathogenesis same as HF Can develop spontaneously; day or night;
at rest; following exercise or stressful event; or in conjunction with HF
Pulmonary Edema Clinical Presentation
Mentation – anxious; restless ; agitation CV signs – tachycardia with increased BP (unless
compensatory mechanisms fail - BP); S3; PAWP >25 mmHg; CI <2.2
Pulmonary Signs – orthopnea; O2 levels; crackles; pink frothy sputum; wheezes
Peripheral signs – skin diaphoretic; cool; pale or cyanotic Diagnosis
CXR – diffuse interstitial edema with cloudy lung fields ABG – hypoxemia; respiratory acidosis
Congestive Heart Failure and Pulmonary Edema
Congestive Heart Failure and Pulmonary EdemaPulmonary Edema
Furosemide Morphine NTG Oxygen Positive inotropes Aminophylline IV : for bronchospasm
Alveoli With Fluid
Questions ?