End-Stage

Heart Disease
Presented By:
Cyrille Agnes Tarroja

Heart Failure Is a Condition of

Aging
Almost 75% of those diagnosed with HF are older than
65 years (Heart Disease and Stroke Statistics2009.
HF is the number one hospitalization diagnosis for
older adults with the number of hospitalizations
increasing 150% over the last 20 years
Heart failure (HF) is a terminal disease.

 Inability of the heart to pump the amount of

oxygenated blood necessary to affect venous
return and meet metabolic requirement of body.

Pathophysiology

Causes
Direct damage the heart
Ventricular Overload
Constriction of Vessels

Afterload

Resistance of left ventricle, must overcome to

circulate blood.
Increase in HPN & Vasoconstriction
Increase Afterload = Increase Cardiac
workload.

Preload

Pressure from the volume of the blood in

ventricles at the end of diastole.
Increase in Hypovolemia, Regurgitation of
cardiac calves and Heart Failure.

Clinical Signs of Heart Failure

Presenting Symptoms in
Heart Failure
According to the ACC/AHA guidelines
patients with HF usually present in three ways:
A recent syndrome of decreased exercise
tolerance, usually due to dyspnea and/or
fatigue. In this case, it is important for the
provider to ascertain whether these symptoms
represent HF or another condition such as
pulmonary disease.

Fluid retention with complaints of leg edema or

abdominal bloating
With or without any symptoms of another cardiac
or non cardiac disorder, such as DM, abnormal
heart sounds, abnormal EKG, arrhythmia, HTN/
hypotension, AMI, pulmonary emboli/other systemic
thrombosis, or a chest x-ray that has evidence
of cardiac enlargement.
Dyspnea is the initial manifestation of HF in most Patients.

Manifestation
Right
H-epatomegaly
E-dema
A-scites
D-istended Neck Vein

Left
C-oughing/Dsypnea
H-emoptysis
O-rthopnea
P-ulmonary Congestion

Complication
Right
Tricuspid Valve
Stenosis
Cor Pumonale

Left
Mitral Valve Stenosis

Cardiac Assessment
Assessment of the heart rate and rhythm
are essential to determine whether there are
any dysrhythmias that are compromising the
function of the heart.

Nursing Mgt. HF
Goal: Increase myocardial contraction
Normal CO: 3-6L/min
Normal Stroke Volume: 60-70ml/h2o.

U-pright Position

F-luids

N-itrates

A-fterload

L-asix

S-odium Restrict

O-xygen

T-est Digoxin

A-minophylline
D-igoxin

HEART FAILURE MANAGEMENT

General Medication Guidelines For Patients
With Heart Failure With Reduced Ejection Fraction:

1. Diuretics with salt restriction are the mainstay for

patients with fluid overload. Loop diuretics or
thiazides are most often used.
2. ACEIs, they have been shown to promote disease
regression, symptom improvement, and decreased
mortality.

3. Angiotensin receptor blockers (ARBs) are used when

the patient is not able to take an ACEI. That ARBs
reduce endpoint mortality and morbidity and improve
clinical signs and symptoms.
4. Aldosterone antagonists, such as Spironolactone or
Eplerenone, to decrease mortality though they need to
be used in conjunction with potassium monitoring due
to the risk of hyperkalemia. This potassium-sparing
effect is often beneficial when they are used in
combination with potassium wasting diuretics such as
furosemide.

5. Hydralazine and nitrates, demonstrated improved

mortality and reduced hospitalization rates when added on
with other evidence-based therapies in African Americans.
6. Beta-blockers (BBs) improve mortality and symptoms
and prevent hospitalizations in patients with chronic HF.
However, they may worsen symptoms initially, and their
benefit is long term so they should be initiated and the
dose up-titrated when a patient is stable, rather than
during an episode of decompensation
7. Digoxin is a positive inotropic medication that
improves pump contractility.

Drugs to Avoid in Heart Failure

Three classes of drugs that should be avoided
in most HF patients are the following:
1. Antiarrhythmic agents that may lead to
cardio depression and proarrhythmic effects.
Only amiodarone and dofetilide have been shown
to be safe in patients with HF.
2. Calcium channel blockers should be used with
caution because they may lead to increased risk
of cardiovascular events and decreased survival.

3. Nonsteroidal anti-inflammatory drugs cause

sodium retention and peripheral vasoconstriction,
as well as decrease efficacy and increase
toxicity of diuretics and ACEI.
In addition, they increase the risk of bleeding
when used with anticoagulants such as warfarin,
a drug widely used in this population. Because
this important class of analgesics cannot be
safely used in HF, pain management can be
challenging in this population.

Mind Body Therapies

Spirituality is another mindbody modality used by
patients to cope with the uncertainty of HF.
Spirituality influences the manner in which a patient
adjusts to a chronic illness. Patients with end-stage
heart disease often reflect on their past and attempt
Exercise & Relaxation
Meditation
Acupuncture
Yoga
Tai Chi

Experimental Treatments
1. Cardiovascular Regeneration and

Cell-Based Therapies
. Regeneration of myocardial cells and activation of
myocardial stem cells to replace infarcted myocardial
cells has the potential for a positive effect on HF
patients but is in the experimental stages (Choi & Poss,
2012).
.These therapies show incredible promise as a
treatment to prevent or reverse myocardial remodeling
and to promote cell regeneration in the future
(Suncion, Schulman, & Hare, 2012)

2. Xenotransplantation
Xenotransplantation involves the

transplantation of non human tissues or organs

into human recipients.

Xenotransplantation between closely related

species, such as baboons or pigs and humans,
offers an alternative to allot transplantation as
a source of human organ replacement, but
problems with rejection remain a major concern

Palliative Care Guidelines

When it is time for hospice care, criterion from the
National Hospice and Palliative Care Organization can help
in determining when a patient is appropriate for hospice.
There are criteria specific to heart disease patients;
these include the following:
Intractable or recurrent symptoms of HF
Optimal medical treatment for HF should be in place
Presence of symptomatic arrhythmias
History of cardiac arrest and resuscitation or syncope
Cardiogenic brain embolism
Co-occurring HIV disease

Communication
In this important document, high-quality

decisions involve medically reasonable care

options, which align with the values, goals,
and preferences of an informed patient.

Shared decision making involving a trusted

clinician will help ensure that the patients
goals and wishes match proposed therapies.

Shared Decision Making

Discussions about prognosis and care
preferences should begin early in the
disease process.
As with all patients in this stage of life,
ongoing communication is the key in
achieving the goal of dying well.

Symptom Management
Aggressive symptom management is a

hallmark of quality PC. The four most

prevalent symptoms in HF are dyspnea,
pain, depression, and fatigue (Adler et
al., 2009)

Deactivation of Devices
in Heart Failure
These deactivation guidelines state that:
Patients or surrogate decision makers should be
fully informed of the consequences to deactivation and
offered alternatives.
An order for a do not resuscitate (DNR) should
accompany the deactivation.
Psychiatric and ethics consultations should be
arranged in the setting of impaired decision making or
disagreement.

 If the clinician has personal beliefs that prohibit

deactivation, the patient should be referred to
another clinician.
Deactivation can occur at the implanting center or
a local site at the patients request.
Implanting clinicians should encourage, at the time
of the implantation, the completion of advanced
directives, which include device management and
deactivation at EOL.

General Pharmacological
Recommendations for Older Adults
The following recommendations should be considered
when prescribing cardiac medications for older adults:
1. Start low and go slow. Always begin with the smallest
effective dose; titrate up in small increments, keeping
in mind the patients comorbid conditions that could
influence the pharmacokinetics of the drug(s).
2. As dose adjustment is made, clinical evaluation should
occur.

3. Review each medication the patient is

currently taking, even over-the-counter
medications and herbal remedies, and be aware
of contraindications or adjustments needed.
4. Avoid empiric treatment of symptoms. Have
a diagnosis before initiating drug therapy.
5. Keep it simple! Adherence decreases as the
number of medications and frequency of dosing
increases.

6. Make sure that the patient can read the labels;

if not, a family member or home care nurse should
set up a weekly pill dispenser. Patients can also
have large print labels on their prescription
bottles.
7. Patient education is key. Make sure that each
patient understands the adverse reactions to
watch for and knows when to call for assistance.

Specific Pharmacological
Recommendations for Older Adults
The following recommendations should be considered when
prescribing cardiac medications for older adults:
1. Alpha-blockers, such as doxazosin, prazosin, and terazosin,
should be avoided as antihypertensives. They create a high
risk for orthostatic hypotension.
2. Central alpha agonists, such as clonidine, reserpine (greater
than 0.1 mg/day), and methyldopa, should be avoided as
antihypertensives. They create a high risk for adverse central
nervous system (CNS) effects, bradyarrhythmias, and
orthostatic hypotension.

3. Class Ia, Ic, III antiarrhythmic drugs, such as

amiodarone, procainamide, and quinidine, should
be avoided. They have been associated with
multiple toxicities. Rate control is recommended
over rhythm control for older adults.
4. Disopyramide is a potent negative inotrope in
older adults and should be used with caution as it
may induce HF.
5. Dronedarone is to be avoided in patients with
HF.

6. Avoid Digoxin (greater than 0.125 mg/day).

Higher doses increase risk of toxicity in the
presence of slow renal clearance common in older
adults.
7. Avoid Nifedipine (immediate release). Increases
the risk of hypotension or myocardial ischemia.
8. Avoid Spironolactone greater than 25 mg/day.
Risk of hyperkalemia. Avoid in CrCl less than 30
mL/min.

Nonpharmacological
Recommendations
For older adults (as well as those younger than 65),
aggressive use of the non pharmacologic measures is
imperative.
Drug therapy can often cause unpleasant side
effects, which often lead to nonadherence.
General measures are recommended as follows:
1. Decreasing more or new cardiac injury by risk
factor reduction.
2. Limiting alcohol use to two glasses/day

3. Maintaining fluid balance by restricted salt intake (2

g/day)
4. Improving physical conditioning
5. Careful management of comorbid conditions
6. Patient education regarding self-care
7. Smoking cessation when appropriate
8. Influenza vaccination every fall
9. Pneumococcal immunizations after diagnosis and
revaccination every 5 years
10. Care of patients with HF across settings and by
Inter professional teams
11. Careful monitoring of fluid status

THANK
YOU !