CONGESTIVE HEART FAILURE

1
CONGESTIVE HEARTFAILURE

• Madeline Gervase RN,MSN,CCRN,FNP
• Advanced Practice Nurse

2
LVF vs. RVF

• LVF Pulmonary Congestion
• S3, cardiomegaly, RR increase
• RVF Systemic congestion
• Hepatomegaly, portal HTN

3
Medications

• ACE Inhibitors (Angiotensin-Converting Enzymes)
• -Reduce pre-load and after load
• - Improved CI and EF
• - Decrease symptoms of HF
• - Given in conjunction with Diuretics and with
  EF less than 35

4
ACE Inhibitor Meds

• Captopril Capoten)Rx.HF/LVD
• Enalapril (Vasotec)Rx.HF/LVD
• Fosinopril (Monopril)Reduce SS
• Lisinopril (Zestril)Rx.HF/LVD
• Quinapril (Accupril) Reduce SS
• Ramipril (Altace) Rx. HF/LVD
• Trandolopril (Mavik) Rx. HF/LVD

5
Goals of Treatment

• Increase ejection fraction and reduce cardiac
  workload.

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Mechanism of Action

• Hypovolemia Hypotension
  Decrease BF
• I
• Renin
  release Angiotensinogen
• I
  I
• Angiotensin Converting Angiotensin I
• Enzyme___________________ I
• Angiotensin
  II
• I
• Aldosterone
  Release
• I I
  I
• Peripheral Na and H2O
  Noeepinephrine
• Vasoconstriction Retention
  Release

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Dosage

• Initiate low doses
• Renal function should be assessed
  routinely.(Within the first two weeks of
  initiating treatment)
• Doses should be increased to those doses that are
  effective and do not present any negative events.

8
Dosage

• Capropril at least 150md/day
• Initiate treatment at 6.25mg tid to 12md tid
  to 25mg tid if tolerated. Can increase to 50mg
  tid as target dose.
• Lisinopril at least 20mg/day
• 5mg initial dose- first 24hr, followed by 10
  mg 48hr/daily maint.
• titrate dosage according to patient
  symptomology.
• Enalapril at least 20mg/day
• 5mg initial dose first 24hr, followed by
  10mg 48hr/daily mainenance titrate according to
  patient

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Contraindications

• Decrease BP lt 80mmHg systolic
• Increase Serum Creatinine gt3mg/dl
• Bilateral renal artery stenosis
• Elevated serum potassium gt5.5mmol/L

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Adverse Effects

• Dizziness
• Headache
• Fatigue
• Diarrhea
• ACE Cough
• Hypotension

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Diuretics

• Taken in conjunction with ACE inhibitors and Beta
  Blockers
• Low dose diuretic therapy
• Lasix 20-40mg/daily
• Titrate according to patient symptoms

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Diuretic Interactions

• NSAIDS (including ASA)
• Blunt the diuretic effect may need to
  increase dosage of diuretic
• Lithium
• Decrease Lithium clearance- levels may be
  increased in blood.
• Diuretics are ototoxic at higher levels

13
Digoxin (Lanoxin)

• Improves HR
• Decreases cardiac workload
• Increase Cardiac Output
• Regulates heart rate and cardiac overall
  performance
• Use in HF patients (LV systolic dysfunction)

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Digoxin Dosage

• .25mg daily
• .125mgdaily for reduced renal function, small and
  elderly
• Therapeutic levels .9 1.2mg/ml
• with levels as high as 2 mg/ml
• Digibind Digoxin Toxicity

15
Beta Blockers

• Originally were contraindicated related to the
  negative inotropic effects bradycardia
• peripheral vaso-constriction
• Use is limited to experiental

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Angiotensin II Type I Receptor Antagonists

• Do not block the degradation of vasoactive
  substances (eg. Bradykinin, enkephalins)
• Decreases the adverse effects associated with ACE
  inhibitors such as cough- related to bradykinin
  accumulation

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ARB or AT1

• Losartan (Cozaar)
• Decrease BP
• Decrease SVR
• Decrease PCWP
• Decrease HR
• Increase Cardiac Index
• Decrease DOE and HF exacerbation

18
Calcium Channel Blockers

• Currently recommended to be avoided with patients
  in HF and LV dysfunction.
• Avoid in HF even when patient also presents with
  angina or hypertension.

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Calcium Channel Dosage

• Amlodipine (Norvasc) and Felodipine (Plendil)
  should be prescribed for treating hypertension or
  angina in the amount of 5 10mg daily.

20
HF Treatment Algorhythm

• Assessment of LV function (Echo)
• I
• Ejection Fraction lt40
• I
• Assessment of Volume Status (SS of
  fluid retention)
• I (Yes)
  I (No)
• Diuretic
  ACE Inhibitor
• (Titrate as necessary)
  I gt Digoxin
• 
  Beta Blocker