HEART FAILURE: CHRONIC
a. Remodeling of the myocardium (as a structural response to
injury) changes the heart from an efficient football shape
to an inefficient basketball shape, making coordinated
i. Ventricular dilation (systolic dysfunction) results in poor
contractility and inadequate emptying of chamber.
ii. Ventricular stiffening (diastolic dysfunction) impairs
ability of chamber to relax and receive and eject blood.
b. Failure of the left and/or right chambers of the heart results
in insufficient output to meet metabolic needs of organ and
c. Cardiac-related elevation of pulmonary or systemic venous
pressures leads to organ congestion.
d. Backward heart failure (HF): passive engorgement of the
veins caused by elevated systemic venous pressure or a
“backward” rise in pressure proximal to the failing cardiac
chambers (right ventricular failure)
e. Forward HF: decreased cardiac output with reduced forward
flow into the aorta, systemic circulation (inadequate renal
blood flow leads to sodium and water retention), and increasing
pulmonary venous pressure results in fluid accumulation
in alveoli (left ventricular failure)
f. Myocardial muscle dysfunction associated with left ventricular
hypertrophy (LVH) causes decreased cardiac output, activating
g. Elevated circulating or tissue levels of neurohormones,
norepinephrine, angiotensin II, aldosterone, endothelin,
vasopressin, and cytokines, causes sodium retention and
peripheral vasoconstriction, increasing hemodynamic
stresses on the ventricle.
a. New York Heart Association Functional Classification
System for HF (9th ed, 1994)
i. Class I—normal physical activity is not limited by
ii. Class II—ordinary physical activity results in fatigue,
dyspnea, or other symptoms.
iii. Class III—marked limitation in normal physical
iv. Class IV—symptoms at rest or with any physical
b. American College of Cardiology/American Heart
Association (ACC/AHA) 2005 Guidelines include specific
recommendations for each stage (Hunt et al, 2005).
i. Stage A—high risk for HF associated with such conditions
as hypertension, diabetes, and obesity. Treatment is
focused on comorbidity.
ii. Stage B—presence of structural heart disease, such as
left ventricular remodeling, LVH, or previous myocardial
infarction (MI), but is asymptomatic. Treatment is
focused on retarding the progression of ventricular
remodeling and delaying the onset of HF symptoms.
iii. Stage C—clients with past or current HF symptoms
associated with structural heart disease, such as
advanced ventricular remodeling. Treatment is focused
on modifying fluid and dietary intake and drug therapies
as well as nonpharmacological measures, such as
biventricular pacing and valvular or revascularization
iv. Stage D—refractory advanced HF symptoms at rest or
with minimal exertion and frequently requiring intervention
in the acute setting. Treatment is focused on promoting
clinical stability including supportive therapy to sustain
life, such as left ventricular assist device, continuous
intravenous (IV) inotropic therapy, experimental surgery
or drugs, a heart transplant, or end-of-life or hospice care.
i. Complex clinical syndrome resulting from any structural
or functional cardiac disorder that impairs the ability of
the ventricle to fill with or eject blood (ACC/AHA 2005
Guidelines; see Hunt et al, 2005).
ii. Risk factors and comorbidities—hypertension; obesity;
diabetes; coronary artery disease (CAD); peripheral and
cerebrovascular disease; valvular heart disease with onset
of atrial fibrillation (AF); sleep disorders such as sleep
apnea; history of exposure to cardiotoxins, for example,
chemotherapy, alcohol, and cocaine; family history of
a. High morbidity and mortality, particularly in clients with
New York Heart Association Class IV symptoms (Hunt et
b. Morbidity: 5.2 million Americans have HF. (National
Heart, Lung and Blood Institute [NHLBI], 2007)
i. Approximately 550,000 new cases reported annually
(Centers for Disease Control and Prevention [CDC],
ii. 1.1 million hospitalizations reported annually (CDC,
c. Mortality: 287,000 deaths reported annually (CDC, 2006b).
d. Cost: $29.6 billion spent in 2006, making HF the most
common reason for hospitalization of Medicare clients
Although generally managed at the community level, an
in-client stay may be required for periodic exacerbation of
failure or development of complications.
Psychosocial aspects of care,
1. Improve myocardial contractility and systemic perfusion.
2. Reduce fluid volume overload.
3. Prevent complications.
4. Provide information about disease and prognosis, therapy
needs, and prevention of recurrences.
1. Cardiac output adequate for individual needs.
2. Complications prevented or resolved.
3. Optimum level of activity and functioning attained.
4. Disease process, prognosis, and therapeutic regimen
5. Plan in place to meet needs after discharge.