Sie sind auf Seite 1von 8

LINICAL

Heart failure: Managing systolic dysfunction


SHERILYN A, SERDAHL RN, MS, CNP

24

R N JUNE2C

www.mweb.com

CLINICAL

The effective management of systolic dysfunction includes medication, lifestyie changes, and comprehensive patient education.

Heart failure affects an estimated 5 million Americans, accounting for nearly a million hospitalizations each year.^-^ In addition, almost 500,000 new cases are diagnosed yearly.'" In the United States, the most common causes of heart failure are coronary artery disease and uncontrolled hypertension. The diagnosis of heart failure is a clinical one, distinguished by a constellation of signs and symptoms caused by either systolic or diastolic dysfunction, or both. Here, we'll review heart failure caused by systolic dysfunction, so that you'll be equipped to recognize its manifestations and ready to help your patients manage their disease.

What happens when the heart fails


In heart failure caused by systolic dysfunction, the left ventricular myocardium is weakened, often enlarged, and the ventricles are unable to pump blood efficiently enough to meet the body's demands. Stroke volume, the amount of blood ejected from the ventricles with each contraction, is reduced. The blood that's not expelled remains in the ventricles during relaxation, or diastole, and this can lead to pulmonary congestion.^'* Initially, when cardiac output drops, compensatory neurohormonal mechanisms ensure that perfusion to vital organs remains adequate. Heart rate rises to increase cardiac output, and ventricles enlargehypertrophyallowing more blood to be ejected with each contraction. With these adaptive mechanisms in effect, the individual experiences few or no symptoms in the short
SHERILYN SERDAHL is a nurse practitioner with UriiversiiY of Minnesota Physioians, Fairview, MN, Tine author has no financiai reiationships to disciose. EDiTOR: Kathieen A, Moore. RN, BS

term. However, these compensatory responses require higher energy expenditure and increase the workload of the heart. Damage may continue for yearsundetected. When adaptive mechanisms eventually fail, symptoms appear, indicating that the disease has progressed. The most common presenting signs of heart failure are fatigue and shortness of breath, or dyspnea. Fatigue in the presence of heart failure is often a sign of low cardiac output.'-^ Dyspnea is the result of pulmonary congestion and an indication of fluid overload. Two-thirds ot pallents Dyspnea that occurs when the person lies with systolic dystunction down but lessens when he or she sits up or have coronary ortery stands is called orthopnea. Lying flat increases disease, venous blood return to the heart, which may precipitate pulmonary edemaand hence, Angitensin-converting shortness of breath. Patients with orthopnea enzyme (ACE) inhibitors frequently sleep with their upper body are first-iine agents for propped up on pillows. Shortness of breath systolic dysfunction. that occurs several hours after falling asleep and is eased by sitting upright is called paroxPotienfs with heoti foiiure ysmal nocturnal dyspnea (PND), and is a sign who participate In of severe heart failure.''^ supervised exercise programs report reduced The fluid overload of heart failure may became evident as edemausually in depen- symptoms and improved quaiity ot lite. dent areas such as ankles or feetor as overall weight gain. Fluid may also accumulate in the liver and manifest as ascites and/or hepatomegaly, and in severe cases, cause jaundice. A patient with gastrointestinal congestion from heart failure may report abdominal pain, bloating, ^^

The all-important patient history


A thorough history is invaluable to the diagnosis and work-up of heart failure. Ask if the patient experiences shortness of breath or fatigue, and what and how much activity causes it. Document
www.mweb.com JUNE 2008 R N

25

SYSTOLIC DYSFUNCTION

Classifying heart failure


Once heart failure is diagnosed, its severity is determined using the New York Heart Association (NYHA) Classification of Functional Capacity, summarized below:

experience anginal-type pain, so they may require more detailed evaluation and freClass I: Heart has identifiable structural changes, but individual's quent monitoring.^ physical activity is not limited. Able to perform activities that require 10 metabolic equivalents (METs)' of oxygen As part of the physical exam, assess resconsumption. piratory rate and pattern. Auscultate the Class II: Physical activity slightly limited, but individual comfortable lungs, noting any crackles or other adventiand asymptomatic at rest. Abie to perform 5 or 6 METs of tious sounds. Examine the patient's lower activity. extremities, checking for pitting edema, Class III; Indicates increased severity of heart failure. Minimal physical uneven hair distribution, wounds, proactivity causes fatigue, palpitations, shortness of breath, or longed capillary refill time, and diminished angina. Able to perform 3.6 to 4.2 METs of activity. or absent pedal pulses. Be aware, however, Class IV: Debilitating symptoms. Individual unabie to cany out any that peripheral edema is a nonspecific indiphysical activity without discomfort. Angina, shortness of cator of systolic dysfunction. It can occur breath, fatigue, and palpitations may occur at rest. with diastolic dysfuncHon and with a mulSymptoms increase with activity. Able to perform 2 METs of activity. titude of other conditions as well. Also assess apical rate and heart sounds. *An MET is a measure of physical activity intensity; 1 MET equals energy (oxygen) used by the body as it stts quietly. Tachycardia may indicate that the heart is compensating for a drop in cardiac output. Source: Braunwald, E. (2005). Approach to the patient with cardiovascular disease. In. D. L. Kasper, E. Braunwald, et al. (Eds.). Harrison's principles of interAn S^ heart sound, or ventricular gallop, is a nal medicine 06th e., pp. 1301-1304), New York; McGraw-Hill. specific indicator of systolic dysfunction. It's low-pitched and occurs during diastole, after your findings using objective language. For examS;.' Because life-threatening arrhythmias can occur ple, write: "John Doe is able to walk two blocks in patients with heart failure, be sure to assess before stopping because of shortness of breath." heart rhythm, noting any abnormalities. Ask if the Note whether the patient has to sleep on multiple patient has ever experienced light-headedness or pillows, and whether he or she wakes up at night sudden fainting spells. with breathing difficulty. You can also estimate the size of the heart by Also ask if the patient has gained any weight locating the point of maximal impulse (PMI), recently, and if so, how much and over what period which is normally palpated at the left fifth interof time. A gain of two pounds L 24 hours or five n costal space at the midclavicular line; the pulsation pounds in one week can indicate increased fluid you'll feel is the contraction of the left ventricle. retention. Ask if he or she has experienced swelling As the heart enlarges and dilates, the PMI of the ankles, feet, or legs, or if shoe size or width becomes weaker and is displaced laterally, in has recently increaseda clue that this condition which case you'll note the pulsation below the may exist. fifth intercostal space, lateral to midclavicular line. Since coronary artery disease is one of the leadObserve the jugular veins for distention, a sign ing causes of heart failure, screen for angina. of vascular congestion. Jugular venous pressure Choose your words carefully, however, because greater than 4 cm from the sternal notch suggests not all patients with angina describe it as "pain." fluid overload or right-sided heart failure.' instead, they may report a feeling of "heaviness" Confusion in an elderly patient may be a sign of or "discomfort." heart failure, so be sure to note it. As cardiac outTo evaluate angina, ask if the sensation is presput falls, perfusion to vital organs is comproent at rest or only with activity, and whether it mised. Hypoperfusion of the brain can lead to subsides with rest. Also inquire about risk factors changes in mental status. for coronary artery disease, including hypertension, hyperlipidemia, smoking, obesity, diabetes, A closer look at the failing heart physical inactivity, and family history of heart Heart failure is a cliiucal diagnosis made after a disease. Furthermore, diabetics do not typically detailed history and physical and confirmed with

26

R N JUNE 2008 www.rnweb.com

CLINICAL

CE

SYSTOLIC DYSFUNCTION

Treating systolic dysfunction


The three main classes of drugs for treating systolic dysfunction are listed below. Other drugs may be indicated for specific patients and classes of heart failure, including, for example, digoxin (Lanoxin), the diuretic spironolactone (Aldactone), nitrates, such as nitroglycerin, plus hydralazine. Drug group
Angiotensin-converting enzyme (ACE) inhibitors, such as enaiaprii (Vastoec), captoprii (Capoten), If ACE inhibitors cannot be used, consider angiotensin receptor biockers (ARBs), such as irt>esartan (Avapro), candesartan (Atacand), valsaran (Diovan).

Action and benefits


Block vasoconstriction and promote vasodilation and sodium excretion. Reduce ieft ventricuiar dysfunction by slowing ventricuiar remodeling. Increase or preserve ejection fraction. Siow progression of heart faiiure and reduce mortality.

Comments and considerations


First-iine agents for heart faiiure. Titrate dose upward as tolerated. May increase potassium. Check potassium level and renal function before start of therapy and periodically. May cause dry cough.

Beta adrenergtc biockers, such as metoproloi (Lopressor, Toprol XL), carvediloi (Coreg).

Reduce blood pressure and heart rate. Slow progression of heart faiiure and reduce moriality.

Do not initiate if patient acutely decompensated. May begin after Ml if patient hemodynamically stable. In eideriy, begin at low dose and titrate up slowly to therapeutic dose. Avoid nonselective beta biockers for patients with COPD. asthma; may precipitate bronchospasm. Paramount in the treatment of systolic dysfunction. Potassium-wasting; typically given with KCI supplements. Monitor potassium levd.

Loop diuretics, such as furosemide (Lasix), torsemide (Demadex),

Enhance sodium and water excretion to reduce symptoms of fiuid overload.

Sources: 1. Hunt. S, A.. Baker, D. W., at al. (2001). ACG/AHA Guidelines for Evaluation and Management of Chronic Heart Failure in the Adult, Executive Summary: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation, 104, 2996. 2. Hunt, S. A., Baker, D. W,. e al. (2005). ACC/AHA Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult: A report of the American College of Cardiology/American Heart Assoctaticn Task Force on Practice Guidelines. Circulation. 112. el 54. 3. Kopecky, S., Festin, R.. et a. "Health care guidelines: Heart failure in adults." 2007. viww.icsi.org/heart_failure_2/ heart_failurejn_adults_.htm! (1 Aug. 2007),

the appropriate testing.^"' Some of these tests will also help determine disease severity. An echocardiogram is the most useful and sensitive noninvasive test for detecting heart failure. It enables the examiner to look at heart wall motion and chamber size, to evaluate valve function, and to determine ejection fraction (EF), which is the percentage of blood pumped out of the left ventricle with each heartbeat. An ejection fraction less than 40% indicates systolic dysfunction.''^ Cardiac catheterization, or coronary angiography, is the gold standard for evaluating heart function. It allows for direct visualization of blood flow through the coronary arteries, and for measurement of EF and heart pressures. It is, however, invasive. Another test used in the diagnosis and management of heart failure is brain natriuretic peptide

(BNP). This blood test measures the level of a protein that's released in response to the stretching of cells in the myocardium. A level greater than 500 pg/ml can be an indicator of heart failure in patients with other signs and symptoms.'' If the BNP level is less than 100, heart failure is unlikely.'-^ Other tests that are ordered as part of the work-up for heart failure include: chest X-ray, which may reveal a hypertrophied heart and pulmonary congestion; EKG, which might show a bundle branch block, or left axis deviation, an indicator of left ventricular hypertrophy,'' and blood tests such as serum creatinine, electrolytes, and liver enzymes, which are helpful in evaluating hepatic and renal function before and during drug treatment.
www.mweb.com JUNE 2008 R H

27

ILINICAL

CE

SYSTOLIC DYSFUNCTION

ACC/AHA 2005 Guidelines


stage A: Patients at high risk for HF due to presence of HTN, diabetes, obesity. Treatment is to control these conditions. Patients with left ventricular hypertrophy and/or history of M! but no symptoms. Treatment is to stop the progression. Might use pharmacological agents. Patients with symptoms. Treatment is more aggressive. Diuretics. ACE inhibitors, beta blockers. Modify fluid and dietary intake. Biventricular pacing. Patients with advanced HF symptoms at rest requiring intervention in the acute care setting. Treatment includes aggressive therapies used in Stage C and possibly heart transplant or left ventricular assist device.

Stage B:

Stage C:

Stage D:

A complementary set of guidelines was established by the American College of Cardiology (ACC) together with the American Heart Association (AHA). These ACC/AHA Guidelines offer a way to evaluate and manage chronic heart failure by classifying symptoms into Stages A through D. (The stages are described in detail in the box at the left.) They range from Stage A for individuals at risk for heart failure through Stage D for those with advanced heart failure s)miptoms at rest requiring inter\'ention in the acute care setting.^ This classification system is intended to complement but not replace the NYHA funchonal classification, which primarily gauges the severity of symptoms in patients who are in Stage C or D.

iyianaging heart failure requires lifestyle changes


In addition to utilizing drug therapy and/or interventional devices, most patients with heart failure will need to make lifestyle changes. Since coronary artery disease and hypertension can cause or contribute to heart failure, patient teaching should also address these conditions and their risk factors. Remind smokers that they face a significantly greater risk of heart attack than individuals who've never smoked, and encourage them to stop. If a patient is ready to quit, help implement an appropriate plan. Success is more likely when pharmacotherapy, such as nicotine replacement, is used.^ Teach patients that even a small decrease in dietary sodiumsay, from 10 to 5 grams a d a y can significantly decrease blood pressure.** Tell them to watch their intake of sodium and to refrain from adding salt to their food. Make sure they know how to look for the sodium content of food on package labels. The ACC and AHA recommend that people with heart failure limit their daily sodium intake to 2 to 3 grams.'" If hyperkalemia is a concern, patients should avoid salt substitutes, since they're often high in potassium. Instruct patients to weigh themselves and record their weight daily, and to report a weight gain that could signify fluid retention. Most patients with heart failure won't need to restrict their fluid intake, but they should avoid drinking excessive amounts. Candidates for fluid restriction include patients with severe heart failure.

Source: Hunt, S. A,, Baker. D. W.. et al. {2005). ACC/AHA Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult: A report of the American College of Cardiofogy/American Heart Association Task Force on Practice Guidelines Qrcu/af/on, 772,6154.

Common treatment options


The treatment depends on the cause; therefore, determiniag the cause is very important. If heart failure is due to valvular heart disease, a heart valve replacement can be done. If it's due to coronary artery disease or hypertension, the goal is to slow the progression of heart failure. Furthermore, because systolic and diastolic heart failure result from different mechanisms, the two require distinctly different treatment. Tlie medications commonly used to treat systolic dysfunction are discussed in the table on page 27. Arrhythmias and sudden cardiac death are potential sequelae to heart failure; therefore, it's not surprising that the use of interventional devices in the treatment of heart failure is rapidly evolving. Implantable cardioverter defibrilla tors, for example, are recommended for the prevention of life-threatening ventricular arrhythmias in heart failure patients with ischmie or nonischemic cardiomyopathy, EF of 35% or less, and New York Heart Association (NYHA) class II or in functional status.^ (The classes of heart failure are discussed in the box on page 26).

28

R N JUNE 2008 www.rnweb.com

CLINICAL

CE

SYSTOLIC DYSFUNCTION

extreme edema, or hyponatremia. Sucking on hard candy or mints may help abate thirst. Make sure patients know that nonsteroidal antiinflammatory drugs (NSAIDs) can decrease the effectiveness of certain antihypertensive drugs and can lead to fluid retention''" Advise them to check with their physician before using NSAIDs. Patients who take aspirin for coronary artery disease, however, should continue to do so.' Some research suggests a link between social alcohol use and decreased left ventricular function. Because the role of alcohol in heart failure is unclear, encourage patients who drirc to do so sparingly, perhaps limiting themselves to one drink per day. Patients with severe heart failure and those with alcoholic cardiomyopathy should not drink alcohol at all.'" Supervised exercise decreases symptoms and increases function and quality of life in people with heart failure. Encourage patients with newly diagnosed heart failure to participate in a cardiac rehabilitation program once symptoms have stabilized. Parcipation in cardiac rehab decreases mortality and hospitalization rates in heart failure patients.'^

ethical and legal implications of end-of-life care. In the meantime, urge families to review the patient's advanced directives regularly to be sure they reflect his or her current wishes. Suggest that they keep a copy in a designated place in the home. Heart failure is a chronic, progressive disease with an uncertain prognosis. Still, there's a lot we can offer patients with respect to treatment, symptom management, and lifestyle modification. In all of these areas, the nurse's role is vital. R N
REFERENCES 1. Braunwald, E. (2005). Approach to the patient with cardiovascuiar disease, in. D. L. Kasper, E. Braunwald, et al. (Eds.), Harrison's principles of internal medicine (16th ed., pp. 1301-1304). New Yori<: McGraw-Hiii. 2. Braunwaid, E. (2005). Normai and abnormai myocardial function, in. D. L. Kasper, E. Braunwald, et al. (Eds.). Harrison's principies of internal medicine (16th ed., pp. 1358-1367). New Yori<: McGraw-iHill. 3. Rodgers, J. M.. & Reeder, S. R. (2001). Managing heart faiiureiPart i.Cr/Wca/Care, 37(11), 1. 4. Rodgers, J. M., & Reeder, S. R. (2001). Managing heart faiiure: Part 2. Critical Care, 3^^2), 1. 5. Tabibiazar. R., & Edeiman, S. V. (2003). Siient ischemia in peopie with diabetes: A condition that must be heard. Clin Diabetes, 21, 5. http://ciinicai.diabetesjournais.org/cgi/content /fuii/21/1/5. 6. Beyerbach, D, M. "Impiantabie cardioverter-defibriiiators." (2006). www.emedicine.com/med/topic3386.htm (10 May 2008). 7. Hunt, S. A.. Baiter, D. W.. et a!. (2005). ACC/AHA Guideiine Update for the Diagnosis and Management of Chronic iHeart Faiiure in the Aduit: A report of the American Coiiege of Cardioiogy/American Heart Association Task Force on Practice Guideiines, Circulation, T12. el 54. 8. Okuyemi, K. S., Noilen, N, L, and Ahiuwalia, J. S. (2006). interventions to faciiitate smoking cessation. Am Fam Physician. 74(2), 262. 9. iHe, f. J., Markandu, N, D.. & MacGregor. G. A. (2005). Modest sait reduction iowers btood pressure in isoiated systoiic hypertension and combined hypertension. Circulation. 46(1), 66. 10. Kopecky. S., Festin, R., e al. "Health care guidelines: iHeart faiiure in adults." 2007. www.icsi.org/heart_faiiurs_2 /heartJailure_in_adufs_.html (1 Aug, 2007), 11 - iHuerta, C, Varas-Lorenzo, C, et ai. (2006). Non-steroidal anti-inflammatory drugs and risk of first hospitai admission for heart faiiure in the gnerai popuiation. Heart, 92(11), 1610. 12. Mears. S. (2006). The importance of exercise training in patients with chronic heart faiiure. Nurs Stand, 20(31), 41. 13. Steinke, E. E. (2005). Intimacy needs and chronic illness: Strategies for sexual counseling and self-management. J Gerontol Nurs, 3T(5), 40.

Addressing the more sensitive issues


The need for intimacy continues throughout the life span, and sexuality is part of intimacy. Reassure patients and their partners that sexual activity is safe in all but the most severely decompensated individuals. Those who can climb two flights of stairs without symptoms should be able to tolerate sexual intercourse,'^ but should do so at a level that's safe and comfortable, inform patients with cardiac defibrillators that the device may fire during intercourse, in response to an elevated heart rate or an arrhythmia; if that happens, their partners may feel a tingling but will not be harmed." Dealing with a chronic, debilitating disease often leads to anxiety and depression. Encourage patients and their loved ones to discuss their fears and concems openly. As heart failure progresses, treatment may become less effective and symptoms more burdensome, at which point palliative care may be necessary. Specialists in palliative care are experts at managing pain, shortness of breath, and anorexia, and at helping patients and families explore the

www.rnweb.com JiJNE 2008 R N

29

Continuing Education Test #1137


"Heart failure: Managing systolic dysfunction"
OBJECTIVES After reading the article you should be able to: 1. Identify signs and symptoms of systolic dysfunction. 2. Discuss nursing and medical management for a patient with systolic dystunction, 3. Develop a plan of care for o patient with systolic dysfunction, Circle the one best answer for eoch question below, Transfer your answers to the card that follows page 24. Save this sheet to compare your answers with the explanations you'll receive. Or, take the test online at www.rnweb.com.
1. Heart failure affects an estimated how many million Americans? a. 2 million, b. 3 million. c. 4 million. d. 5 million. 7. Aweight gain of how many pounds may indicate to the nurse that the patient has an increase in fluid retention? a Two pounds in 24 hours. b. Two pounds in five days, c. One pound in 48 hours, d. TTiree pounds in one week. 13. The American College of Cardiology and American Heart Association recommend that patients with heart failure limit their daily sodium intake to how many grams? a, 1 - 2 . b, 2 - 3. C, 3 - 4 . d. 4 - 5.

2. Which of the following categories of drugs are first-line agents for systolic dysfunction? a. Angiotensin-converting enzyme (ACE) inhibitors, b. Aipha adrenergic blockere. c. Beta adrenergic biockers. d. Calcium channel blockers.

8. One of the leading causes of heart failure is: a- Buerger's disease. b. Cerebral vascular accident, c. Coronary artery disease (CAD). d. Raynaud's disease.

3. Which of the following heart sounds is a specific indicator of systolic dysfunction? a. S,. b.Sj, C.S3.

d.s..
Of the following, which pathological changes occur in heart failure caused by systolic dysfunction? a. The heart size remains unchanged. b. Stroke volume increases, c. Pulmonary congestion may occur. d. The ventricles are able to relax and fill property.

9. Which classification of heart failure describes a patient with slightly limited physical activity who is comfortable and asymptomatic at rest? a. Class I, b. Class II, c. Class lit. d. Class IV,

14. The nurse is aware that ICDs are recommended for ejection fractions less than what percentage? a, 35%, b. 45%, 0, 55%, d.65%.

15. Of the following, which is the gold standard for evaluating heart function? a. Cardiac catheterization, b. Cardiac MRI, c. EKG. d. Echocardiogram.

10. Of the following, which group of drugs should be avoided in patients with COPD or asthma? a. ACE inhibitors. b. Beta adrenergic blockers, c. Calcium channel blockers. d. Loop diuretics.

Which of the following actions should the nurse instruct a patient with an implantable cardioverter defibrillator (ICD) to take if the ICD fires during intercourse? a. immediateiy contact the health care provider, b. Teli the partner that he or she may feel a tingling, c. Stop intercourse. d. Take a nitroglycerin taWet.

16. Of the following, which will the nurse include in a teaching plan for a patient with heart failure? a. Drink alcohol at bedtime. b. Use nonsteroidal anti-inflammatoiv drugs for CAD, 0. Weigh self weekly, d, Exercise under supervison.

11. All of the following may be symptoms of heart failure EXCEPT: a. Confusion, b. Jugular vein distention, c. Peripheral edema, d. Point of maximal impulse at the middavicular line,

17. Of the following, which is the most common presenting sign of heart failure? a. Bradycardia. b. Fatigue. c. Urinary frequency. d. Vision chuiges.

6. Of the following, which is a symptom of severe heart failure? a. Blurred vision, b. Insomnia, c. Paroxysmal nocturnal dyspnea. d. Tingling.

12. Which of the following tests is the most useful and sensitive noninvasive test for detecting heart failure? a. Cardiac ultrasound, b. Echocardiogram, c. Electrocardiogram (EKG). d. Treadmill test.

18. Which of the fallowing are risk factors for CAD? a. Diabetes insidipus, b. Hyperthyroidism. c. Hypotension. d. Physical inactivity.

This continuing education offering is co-provided by AHC Media LLC and R N , AHC Media LLC is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation. This program has been approved by the ,fnerican Association of Critical-Care Nurses [AACM) tor 1 Contact Hour, Category A, file number 10852, Provider approved by the Caiilomia Board ol Registered Nursing. Provider 14749, for 1 Contact Hour, This activity is approved (or 1 nursing contact hour using a 60-minute contact hour. Credit will be granted tor this unit through Juns 2010, It was preparad by Marilyn Hertier-Ashton, RN, BC, MS.

www.rnweb.com

Das könnte Ihnen auch gefallen