Heart Failure

Objectives
At the end of this presentation the participant will be able to:

Review Heart Failure pathophysiology

Discuss current approaches to the management of

Heart Failure

Recognize the Wagner Care Model

Verbalize how the HF specific plan of care as it relates to

2013 American College of Cardiology Foundation /
American Heart Association guideline for the
management of Heart Failure

Provide patient with HF letter upon admission

 Heart Failure (HF)

• American Heart Association (AHA) definition:

– A progressive condition resulting from structural and/or functional
cardiac disorders that impairs the hearts ability to pump blood to the
body’s cells.

American College of Cardiology & American Heart Association

Four Stages of Heart Failure:

 Stage A: No identifiable disorder or symptoms, but High Risk for HF development

 Stage B: No Symptoms with structural heart disorder
 Stage C: Past/Current symptoms of HF associated with structural heart disease
 Stage D: Refractory HF requiring advanced support
 Comorbidities & Contributing Factors

• Hypertension • Pulmonary Embolism

• Coronary Artery Disease • Infections
• Diabetes Mellitus – Myocarditis
• Myocardial Infarction – Endocarditis
• Anemia – HIV

• Valvular Disease • Arrhythmias

– Aortic Regurgitation • Congenital Septal Defects
– Mitral Regurgitation • Thyrotoxicosis
• Cardiomyopathy • Dyslipidemia
– Substance abuse • Vascular Disease
– Viral infection
– Muscular dystrophy
 Heart Failure Classification

Systolic Dysfunction Diastolic Dysfunction

• Impaired Contractility & Ejection • Impaired Relaxation & Fill
• Ejection Fraction < 40% • Ejection Fraction > 40%
• Pathologies: • Pathologies:
– Myocardial Ischemia – Coronary Artery Disease (CAD)
– Heart Valve Disease – Systemic Hypertension

Compensatory
Mechanism
Activation

Sympathetic Nervous System

Renin-Angiotensin-Aldosterone System (RAAS)
Cardiac Hypertrophy
Natriuretic Peptides
Compensatory Mechanisms
Short Term Benefits Prolonged Activation

• Improves cardiac output • Increases cardiac workload

– Increase heart rate • Accelerates cardiac
– Increase contractility decompensation
– Increase heart size – Dyspnea
– Vasoconstriction – Venous engorgement
– Cyanosis
– Edema
 Clinical Presentation
General Symptoms Advanced Symptoms
• Right-Sided
o Peripheral Edema
• Fatigue o Jugular Vein Distention
o Abdominal fullness
• Dyspnea o Persistent Cough
• Fluid Retention o Cyanosis
o Ascites
o Congestive Hepatomegaly
• Left-Sided
o Exertional Dyspnea
o Paroxysmal Nocturnal Dyspnea
o Tachypnea
o Rales/Rhonchi
o Murmurs
o Extra heart sounds (S3/S4)
Patient Assessment

• Historical Interview
 Comorbidities & Contributing Factors:
 Hypertension, Diabetes Mellitus, Dyslipidemia, Vascular
Disease, and Valvular Disease
 History of Present Illness
 Onset, symptom severity, sleep patterns, physical exertion
tolerance
 Familial History
 Patient Assessment
• Physical Assessment
 Neurological
 Somnolence, confusion, anxiety
 Respiratory
 Crackles, wheezes, moist cough, frothy sputum,
dyspnea, tachypnea, orthopnea
 Cardiovascular
 Tachycardia, S3/S4 heart sounds, dysrhythmias,
delayed capillary refill, peripheral edema, diminished
peripheral pulses
 GI/GU
 Oliguria, ascites
 Integumentary
 Diaphoresis

Reference
Images retrieved from: heart-symptoms.blogspot.com
Diagnostics
 Treatment Options
Lifestyle Modifications Dietary Adjustments

• Smoking Cessation • Fruits & Vegetables

• Limit Alcohol o 4-5 Daily Servings
• Regular Moderate Exercise • Whole-grain Foods
• Healthy Weight Maintenance • Meat - Chicken or Fish
• Stress Reduction • 2-3 G Sodium (No Added Salt)
• Lower Blood Pressure
• Reduce Blood Cholesterol

Retrieved from: American Heart Association Website www.heart.org

Pharmacologic Treatment

Diuretics
Beta-blockers
ACE Inhibitors
Digitalis
Aspirin
Angiotensin-Converting Enzyme (ACE) Inhibitors
 Action:
o Inhibit enzymatic conversion of angiotensin I to angiotensin II
 Therapeutics
o Decreases Afterload
• Blocking production of Angiotensin II
o Decreases Preload
• Inhibiting Aldosterone release by Adrenal Cortex

 Adverse Effects
o Hypotension
o Diminished Renal Function
o Hyperkalemia
o Cough
Beta-Blockers
 Action
o Inhibition of the Sympathetic Nervous System to slow AV node
conduction
 Therapeutics
o Prevention of tachyarrhythmia's
o Slow the progression of heart failure
 Adverse Effects
o Potential worsening of dyspnea or edema
o Symptomatic bradycardia w/ or w/o hypotension
o Lightheadedness or dizziness
o Bronchospasm
Digitalis Glycosides

• Digoxin
– Action
• Inhibits sodium-potassium adenosine triphosphatase (ATP-ase)
activity on myocardium
– Therapeutics
• Positive Inotrope
– Adverse Effects
• Ventricular arrhythmias
• Heart block
• GI: Anorexia, nausea, vomiting
• Visual disturbances
Diuretics: Thiazide, Loop, Potassium-sparing

• Action
– Inhibit the reabsorption of sodium & chloride at different sites along
the renal tubules
• Therapeutics
– Reduction of symptoms in fluid overload (dyspnea, edema, etc.)
• Adverse Effects
– Electrolyte Imbalances
– Dehydration
Antiplatelet: Aspirin
Anticoagulant: Warfarin

• Action
– Disruptions of clotting cascade mechanisms
• Therapeutics
– Reduction of ischemic events
• Adverse Effects
– Bruising
– Bleeding
Invasive Treatment
• Cardiac Resynchronization
Therapy
– Placement of electrical leads into
the heart from a device that results
in simultaneous biventricular
contraction
• Ventricular Assist Devices
– Permits a period of myocardial
arrest by redirecting blood volume
from the left ventricle and back to
the aorta for distribution to the
body
Surgical Treatment

• Interventions
– Heart Transplantation
– Valve Replacement (Mitral Regurgitation/Stenosis)
– Coronary Artery Bypass Grafting (CABG)
– Left Ventricular Chamber Reduction
– Endovascular Patchplasty (Dacron Patch)
– Cardiomyoplasty
 Co-morbidities
• Pulmonary Complications
– Dyspnea
– Pulmonary Edema
– Chronic Obstructive Pulmonary
Disease (COPD)
• Renal Impairment
• Cardiovascular
– Atrial Fibrillation
– Coronary Artery Disease
– Hypertension
Chronic Disease Care
• Wagner’s Chronic Care Model: Providing
Evidence-Based Care to People with Chronic
Diseases
Chronic Condition

• Any condition that requires ongoing

adjustments by the affected person and
interactions with the health care system.
Chronic Disease

• Recent data
– More than 145 million people live with a chronic
condition
– Chronically ill population of 171 million projected
by 2030
– Gaps in quality care
– Best practices
• avoid an estimated 41 million sick days and more than $11
billion annually in lost productivity.
System Change Concepts
Why a Chronic Care Model?

• Deficiencies in care delivery were attributed to bad

practitioners who just didn’t do the right thing
• Emphasis needs to be on the system and the care it
delivers
• Research is primarily condition-specific because of
funding sources, but there are commonalities across
chronic conditions
• Compartmentalizing the patient by each chronic
condition is not effective in treating the whole
patient
Chronic Care Model

Community

Resources and
policies
Self-Management
Support

Informed, Prepared,
Activated Proactive
Patient Practice Team
Chronic Care Model
The Community

• Mobilize and utilize Community Resources to help

meet needs of the patient

Examples of current Community Partners with

THSW:
• Faith Community Nursing
• American Heart Association
• United Way
• Med-Star Community Health Partnership
 Health System
Senior Leadership Support
Promote Effective Improvement Strategies
Prepared for Change

Examples of THSW Health System

– Committed to utilizing evidence-based care
– Ongoing efforts to continually improve quality of
care, patient safety and service excellence
 Self-Management Support
Empower and prepare patients to
manage their health and healthcare

Examples of THSW Self-Management Support

– Diabetes self-management education program
– Support groups for Heart Failure

Lorig KR, Sobel DS, Stewart AL, Brown Jr BW, Ritter PL, González VM, Laurent DD, Holman HR. Evidence suggesting that a chronic disease self-management program
can improve health status while reducing utilization and costs: A randomized trial. Medical Care, 1999; 37(1):5-14.
 Essential Elements of Good
Chronic Illness Care

Informed, Prepared
Activated
Productive Practice
Patient Interactions Team

• The essential element of good chronic illness care is a Productive

Interaction
• Productive means that the work of evidence-based chronic disease care
gets done in a systematic way, and patient needs are met.
• An interaction can be a face-to-face visit, a phone call or an email
message.

Wagner EH, Davis C, Schaefer J, Von Korff M, Austin B. A survey of leading chronic disease management programs: Are
they consistent with the literature? Managed Care Quarterly. 1999; 7(3):56-66
 Chronic Care Model
Results
Improvement in process and outcome measures
compared to controls
Improved patient empowerment and education scores
decreased cost of care
Improved patient compliance with treatment regimen
with decreased ED visits or hospitalizations
Improved cost-effectiveness with a decrease in overall
cost of care
Improved quality of life for patients

www.rand.org/health/projects/icice/ for details

Delivery System Design
Key Components
Clinical involvement of the non-physician care team members.
– Increase involvement of non-physician care team members
– Teams discuss the work they do, how they are going to do it,
and how to improve on it.

Have an Agenda
– Determine the agenda for planned interactions (like a routine physical or a
prenatal visit) to assure that critical parts of the care are not overlooked.
– Planned visits can be either 1:1 or in groups.

Intensive Attention
– The use of a clinical case manager for patients with complex needs, or
engaged in an acute transition or exacerbation has been shown to be effective.
 Self Management
Support
The 5A’s Technique
• The best tested strategy to support self-management employs the
5A’s.
1. Assessment includes not only knowledge but beliefs and
behavior.
2. Advice needs to be linked to scientific evidence, not provider
biases.
3. Agree on goals that are important to patients and actions to
reach them.
4. Assist by identifying barriers and problem-solving to deal with
them.
5. Arrange a specific follow-up plan including utilizing internal
and community resources to provide ongoing self-management
support to patients.
Lorig KR, Sobel DS, Stewart AL, Brown Jr BW, Ritter PL, González VM, Laurent DD, Holman HR. Evidence suggesting
that a chronic disease self-management program can improve health status while reducing utilization and costs: A
randomized trial. Medical Care, 1999; 37(1):5-14.
 Delivery System Design
Key Components
Clinical involvement of the non-physician care team members.
– Increase involvement of non-physician care team members
– Teams discuss the work they do, how they are going to do it,
and how to improve on it.

Have an Agenda
– Determine the agenda for planned interactions (like a routine physical or a
prenatal visit) to assure that critical parts of the care are not overlooked.
– Planned visits can be either 1:1 or in groups.

Intensive Attention
– The use of a clinical case manager for patients with complex needs, or
engaged in an acute transition or exacerbation has been shown to be effective.
Nursing Plan of Care
Information
This letter should be given to
each CHF patient upon
admission. This will help
patients understand their plan
of care and what to expect
while hospitalized,
Nursing Checklist
Nursing Checklist
Continued
 References
• American Heart Association (2013). About Heart Failure. Retrieved from:
http://www.heart.org/HEARTORG/Conditions/HeartFailure/AboutHeartFailure/About-Heart-
Failure_UCM_002044_Article.jsp
• ACCF/AHA Guidelines for the Management of Heart Failure: A Report of the American College of Cardiology
Circulation: Published on-line June 5, 2013
• Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness: the
chronic care model, Part 2. JAMA 2002 Oct 16; 288(15):1909-14.
• Fletcher, L., & Thomas, D. (2001). Congestive heart failure: Understanding the pathology and management.
Journal of American Academy of Nurse Practitioners. 13(6). 249-257.
• Heart Failure: Systolic Dysfunction By: Schub E, Caple C, Pravikoff D, CINAHL Nursing Guide, July 22, 2011
• Heart Failure: Diastolic Dysfunction By: Schub E, Schub T, CINAHL Nursing Guide April 20, 2012
• Heart Failure : An Overview By: Kellicker P, Schub T, CINAHL Nursing Guide August 3, 2012
• Diagnosis of Congestive Heart Failure By: Badash M, Fucci MJ, EBSCO Publishing September 2012
• Medications for Congestive Heart Failure By: Badash, M., Fucci, M. J., CINAHL AN: September 2012
• Heart Failure and Lung Disease By: Schub, T., Buckley, L., CINAHL Nursing Guide June 2013
• Heart Failure and Kidney Disease By: Schub, T., Gilgerto, C., CINAHL Nursing Guide August 2012
• Heart Failure and Atrial Fibrillation By: Schub, T., Gilgerto, C., CINAHL Nursing Guide November 2012
• Heart Failure: Surgical Treatment – an Overview By: Cabrera, G., Buckley, L., CINAHL Nursing Guide May
2013.
• Heart Failure: Ventricular Assist Devices By: Caple, C., Schub, T., CINAHL Nursing Guide June 2013
• Lorig KR, Sobel DS, Stewart AL, Brown Jr BW, Ritter PL, González VM, Laurent DD, Holman HR. Evidence
suggesting that a chronic disease self-management program can improve health status while reducing utilization
and costs: A randomized trial. Medical Care, 1999; 37(1):5-14.
• Wagner EH, Davis C, Schaefer J, Von Korff M, Austin B. A survey of leading chronic disease management
programs: Are they consistent with the literature? Managed Care Quarterly. 1999; 7(3):56-66