Lecture 9: Heart Failure & Pulmonary Edema

med-surg notes Lecture 9: February 12 Heart Failure & Pulmonary Edema Cardiac Output Heart Failure & Pulmonary Edema Og R Heart rate )H*V P stro=e yolume )f,V HF occurs when the heart muscle is unable to pump evectiyel→ d inaqeCuate Og anq s→stemic conTestion NreloaqA akterloaqA anq contractilit→ contribute to f, 'he heart is unable to maintain circulation to meet tissuesS neeqs ftructure or kunctional anq acute or chronic Pulmonary edema: feyere bac=up ok (uiq in the lunTs que to seyere HF Left-Sided Heart Failure HF ClassiBcation Oauses Dew .or= Heart Mssociation H'DA OMIA L; Class I: Do s→mptoms ,alyular qisease *esult zac= ok korwarq (ow FinqinTs Mcute conkusion )low blooq (owV- katiTue Nulmonar→ conTestion )crac=lesA whee3x inTA couThV fW Tallop R increaseq z, pressure I→spnea on eJertion or at rest- orthopx nea NaroJ→smal nocturnal q→spnea )NDIV Oool eJtremities Right-Sided Heart Failure Diagnostic Assessment of HF Oauses /x'→pe Datriuretic Neptiqe )/DNV zektxsiqeq heart kailure /elow :66 pT9mzj Do HF *iTht yentricular L; :66xW66 pT9mzj HF present Nulmonar→ issues )OgNIV Mboye W66 pT9mzj Lilq HF *esult Mboye X66 pT9mzj Loqerate HF f→stemic conTestion Class II: f→mptoms on maJix mal eJertion Class III: f→mptoms on minix mal eJertion Class IV: f→mptoms at rest MOO9MHM Olassi0cation f→stem Stage A: HiTh ris= kor HF without structural heart qisx ease or s→mptoms Mboye G66 pT9mzj feyere HF FinqinTs 1chocarqioTram )/estV BuTular yein qistention ,iews chambers anq yalyes 1nlarTeq liyer anq spleen Ietermines eKection kraction )1FV *iTht upper Cuaqrant pain OY*A M/UA 1QU Stage B: ftructural heart qisx ease without s→mptoms Stage C: ftructural heart q3 with prior9current s→mptoms Iepenqent eqema )leTsV Eea= peripheral pulses Stage D: *ekractor→ HF rex CuirinT interyention Iistenqeq abqomen MnoreJia anq nausea Stage C HF fwollen hanqs anq 0nTers Stage A HF ftructural heart qisease with prior or current s→mptoms Nol→uria at niTht HiTh ris= kor HF without structure heart qisease or s→mptoms 1arl→ satiet→ )keelinT kullV Natient Nopulations Qnown structural qisease Natient Nopulations HF Reduced EF )ReFI 'herap→ Uoals Oontrol s→mptoms HF siTns anq s→mptoms H'DA ILA obesit→ Natient equcation Stage v HF Mtherosclerotic qisease ftructural heart qisease without siTns or s→mptoms Letabolic s→nqrome ZsinT carqiotoJins HF Preser(ed EF )PeFI 'herap→ Uoals Heart health→ likest→le Nreyent yascular coronar→ qisease Nreyent z, structure abnormalities MO1;s or M*/s in appropriate patients kor yascular qisease or IL Oontrol s→mptoms z, remoqelinT )z,H anq low 1FV ;mproye H*gs measurement zetharT→ Iail→ weiThtsj fame scaleA same time ): =T ok weiTht Tain R : z (uiq oyerloaqV H'D or h→po'D 'emporar→ or permanent LOf OolqA clamm→A c→anotic Mll ;, (uiq on an inkusion pump to preyent bolusinT9 oyerloaq N,Os anq other q→srh→thx mias Iocusate soqium )OolaceV to preyent straininT qurinT /L gliTuria )% W6 mz9hrV 1Jperimental surTer→9qruTs Lonitor ok pt qeyelops fg/A katiTueA anq tach→carqia with MIzs Orac=les 'ach→carqia Ohronic inotropes /anaging FatigueWkeaJness Nh→sical assessmentj Lonix tor kor f9f ok worseninT Iisorientation9acute conkux sion )earl→ siTn in olqer aqultsV *equce hospital reaqmissions gptions 'hia3oliqineqiones )'&IsV ;ncreaseq pulmonar→ arter→ occlusion pressure OouTh with kroth→A pin=xtinTeq sputum ;mproye H*gs- monitor LI ok an→ chanTes Actiyit→ Oreate an actiyit→ schequle Oarqiac rehabilitation- =now limits WeiTht Complications of Heart Failure Digozin I→srh→thmiasj Oan cause suqx qen carqiac qeath 1yer→ morninT bekore brea=kast fame scaleA same time Oarqiac Tl→cosiqe- s→mptomatic bene0ts kor chronic HF anq axFib ,xtach or yx0bj ;OI placex ment Iiet zimit qail→ soqium inta=e to 4xW T as prescribeq zimit qail→ (uiq inta=e to 4 z Iecreases q→spneaA improyinT kunctional actiyit→ Mcute pulmonar→ eqema Dotik→ LI 1lqerl→ at Treater ris= que to qecreaseq renal eJcretion fiTns > f→mptoms ;ncreases contractili→A requces H*A slows M, noqe conquctionA anq inhibits s→mpathetic actiyit→ OarqioTenic shoc=j gJ→TenA inx tubationA ;, yasopressors Leasure apical pulse kor one minute prior to aqministrationnotik→ LI % X6 bpm or irreTular S→mptoms *eport qi33inessA liThtheaqeqnessA couThA q→spneaA anTinaA peripheral eqemaA cool eJtremitiesA actiyit→ inx toleranceA chanTe in mental status Digitalis xozicity Surgical /anagement ,alye repair9manaTement *outine labsj Dormal serum leyel is 62 x62G nT9mz Heart transplantation Lonitor Q kor h→po=alemia anq replace ik % ↑26 m1C9z ,entricular assist qeyice ),MIV Zsuall→ nonxspeci0c ;ncreasinT katiTueA conkusion Luscle wea=ness /lurreq yision Oonkusion D9,A anoreJia *h→thm qisturbances N,Os most common Mx0bA braq→carqia Loop Diuretics ACE Nnhibitors Angiotensin Receptor vlocJers )ARvsI LgM LgM LgM Mct on the ascenqinT limb ok the zgH to inhibit Da anq Ol reabsorption d urinar→ output ok Da anq water 1Jamples FurosemiqeA bumetaniqeA torsemiqe ;nqications zoop qiuretics are prekerreq to cretion in HF urinar→ eJx Iose aqKustments ma→ be necessar→ baseq on Da anq (uiq inta=e Mqyerse 1vects Oause yasoqilation in both yenous anq arterial s→sx tems /loc= the action ok anTiotensin ;; at its receptors in the yessels anq aqrenal Tlanqs both preloaq anq akterloaq d blooq (ow to yital orTan s→stems anq improyeq 1F *equceq ris= kor h→per=alemia anq couTh /looq yesselsj ,enous anq arterial qilation to preloaq anq akterloaq Mlso bloc= the en3→me neeqeq to conyert anTiotenx sin ; to ;; MnTiotensin ;; is a stronT yasoconstrictor that raises /NA releases alqosteroneA anq retains Da anq water Mqrenal Tlanqsj alqosterone release d cretion ok soqium anq water 1Jamples 1Jamples ,alsartan anq losartan OaptoprilA enalaprilA lisinopril ;nqications ;nqications 1lectrol→te loss9imbalance Natient 1qucation fubstituteq kor pts who cannot tolerate MO1;s ris= ko qeath9hospitali3ations in pts with HFr1F Mqyerse 1vects Mqyerse 1vects *enal q→skunction Iecrease qietar→ soqium H→per=alemiaA renal kailure MnTioeqema ) V EeiTh themselyes qail→ Ir→ persistent couTh r9t H→per=alemia ) V 'a=e the qiuretic earl→ in the qa→ )bekore ↑ pmV to preyent nocturia DursinT Noints braq→=inin ;k intolerableA ma→ replace with M*/ H→potension *is= kor anTioeqema DursinT Noints DursinT Noints Lonitor serum Q que to ris= ok h→po=alemia MO1;s anq M*/s not to be useq interchanTeabl→ OouTh is a siqe evect- encouraTe continueq use MO1;s are prekerreq- morbiqit→ anq mortalit→ veta vlocJers Aldosterone Antagonists HydralaVineWNsosorbide Dinitrate LgM LgM LgM fDf stimulationA H*9/N ;mproyes z, kunctionA hemoq→namicsA anq eJercise tolerance Loqerate akterloaq requction evects anq sliTht preloaq requction evects 1Jamples ;nqications /N Notassium sparinT qiuretic 1Jamples fpironolactone or eplerenone Nrimaril→ kor HFr1F- ma→ be bene0cial in HFp1F Mqyerse 1vects flow proTression ok s→mptoms in HFr1F Mllow more time kor yentricular 0llinT prior to eKection in pts with HFp1F Mqyerse 1vects Fluiq retention ;nhibits Q eJcretion anq ma→ d h→per=alemia Natient 1qucation DursinT Noints ;k braq→carqia9h→potension are problematicA qose ma→ be requceq fhoulq not be Tiyen at the same time as MO1;s que to H*9/N qose qurinT acute eJacerx Oombineq into one pill to both preloaq anq akterx loaq yia yenous anq arterial yasoqilation ;nqications mortalit→9hospitali3ations in Mkrican Mmericansless responsiye to MO1;s que to suspecteq qiverx ences in enqothelial kunction Mqyerse 1vects HeaqacheA qi33inessA orthostatic h→potension Natient 1qucation OhanTe position slowl→ to preyent kalls que to posx tural chanTes in /N Myoiq salt substitutesA DfM;IsA anq kooqs hiTh in Q to requce the ris= ok h→per=alemia DursinT Noints FatiTueA braq→carqiaA h→potension Io not start or bations /loc= alqosteroneA a mineralcorticoiq that b→ inqucinT Da anq water retention ;nqications /isoprololA caryeqilolA Y* metoprolol eJx Lonitor serum QA /ZDA OrA anq Or clearance ;k also ta=inT an MO1;A assess kor renal insu x cienc→ SacubitralW alsartan LgM First anTiotensin receptor nepril→sin inhibitor- new class ok HF meqs Oombines an M*/ )yalsartanV anq nepril→sin en3→me inhibitors )sacubitrilV HF Priority Problems ;mpaireq Tas eJchanTe Iecreaseq Og ;nevectiye tissue perkusion 1Jcess (uiq yolume )potential kor pulm eqemaV *is= kor impaireq s=in inteTrit→ Mctiyit→ intolerance- katiTue anq wea=ness QnowleqTe qe0cit- proyiqe meqication teachinT ;nevectiye copinTA careTiyer role strain Depril→sin brea=s qown natriuretic peptiqesA rex sponsible kor soqium anq water loss when yentricles are oyerloaqeq Iela→inT brea=qown lenTthens evects anq remoyes more soqium anq water intrayascular yol anq /N d preloaq anq akterloaq ;nqications *equceq ris= ok hospitali3ation9mortalit→ in pts with chronic HF anq requceq 1F La→ replace MO1;9M*/ in chronicA s→mptomatic class ;; or ;;; HFr1F Mqyerse 1vects Ii33inessA katiTue OouThA h→potensionA h→per=alemia DursinT Noints fhoulq not be Tiyen with an MO1;- wait WX hrs krom the last MO1; qose bekore startinT an M*D; Io not Tiye to pts with a histor→ ok anTioeqema