Congestive Heart Failure (CHF)

Definition

• Coronary artery disease or myocardial infarction
• Long-standing hypertension
• Valvular heart disease
• Cardiomyopathy
• Arrhythmias, especially atrial fibrillation
• Congenital heart disease

Pathophysiology of CHF

Basic mechanism

1. Myocardial dysfunction or excessive cardiac workload reduces the heart’s pumping ability.
2. This causes decreased cardiac output and inadequate tissue perfusion.
3. The body activates compensatory mechanisms:
   • Sympathetic nervous system activation increases heart rate and vasoconstriction.
   • Renin-angiotensin-aldosterone system activation causes sodium and water retention.
   • ADH secretion causes further water retention.
4. Retained salt and water increase blood volume, venous return, and cardiac filling pressure.
5. The failing heart cannot handle the added volume. Pressure rises behind the affected ventricle, leading to congestion.

Left-sided heart failure

• Blood backs up into the left atrium and pulmonary veins.
• Pulmonary capillary hydrostatic pressure rises.
• Fluid moves into the lung interstitium and alveoli.
• This produces pulmonary congestion and pulmonary edema.

Right-sided heart failure

• Blood backs up into the systemic veins.
• Venous pressure rises.
• Fluid accumulates in dependent tissues and abdominal organs.

Clinical Manifestations of CHF

Symptoms

• Dyspnea on exertion
• Orthopnea, breathlessness when lying flat
• Paroxysmal nocturnal dyspnea, sudden nighttime breathlessness
• Fatigue, weakness, reduced exercise tolerance
• Nocturnal cough or wheeze
• Palpitations
• Rapid weight gain due to fluid retention
• Reduced urine output during the day, nocturia at night
• Loss of appetite, nausea, abdominal fullness, early satiety
• Confusion, dizziness, or drowsiness in severe low-output states

Signs of left-sided CHF

• Tachycardia
• Tachypnea
• Basal lung crackles/crepitations
• Low oxygen saturation or cyanosis
• Cough, sometimes pink frothy sputum in acute pulmonary edema
• S3 gallop rhythm
• Cool extremities and weak peripheral pulses
• Displaced apex beat in cardiomegaly

Signs of right-sided CHF

• Pitting edema of feet, ankles, legs, or sacrum
• Raised jugular venous pressure
• Hepatomegaly and tender liver
• Ascites
• Abdominal distension
• Weight gain
• Pleural effusion
• Positive hepatojugular reflux

Surgical and Device Management of CHF

1. Coronary revascularization

• Percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) may be indicated in patients with significant coronary artery disease and viable myocardium.
• It improves myocardial blood supply and may improve ventricular function and symptoms.

2. Valve repair or valve replacement

• Mitral valve repair/replacement
• Aortic valve replacement
• Transcatheter valve procedures in selected high-risk patients
• Tricuspid valve repair in selected cases

3. Cardiac resynchronization therapy (CRT)

• A biventricular pacemaker coordinates contraction of the right and left ventricles.
• Used in selected patients with reduced ejection fraction, persistent symptoms, and electrical dyssynchrony such as a broad QRS complex with left bundle branch block.
• May improve symptoms, exercise capacity, ventricular function, and survival.

4. Implantable cardioverter-defibrillator (ICD)

• Prevents sudden cardiac death from life-threatening ventricular tachyarrhythmias.
• It does not remove congestion directly, but protects eligible patients with significantly reduced ejection fraction.

5. Ventricular assist device

• A left ventricular assist device (LVAD) mechanically supports systemic blood flow.
• Used in advanced end-stage HF:
  • As a bridge to heart transplantation
  • As destination therapy when transplantation is unsuitable

6. Heart transplantation

• Considered for selected patients with refractory end-stage HF despite maximal medical, device, and surgical treatment.
• Requires lifelong immunosuppression and close follow-up.

Nursing Management of CHF

A. Assessment and monitoring

1. Assess severity of dyspnea, orthopnea, fatigue, cough, edema, chest pain, and palpitations.
2. Monitor:
   • Respiratory rate, oxygen saturation, heart rate, BP, temperature
   • Lung sounds for crackles
   • Heart sounds, especially S3
   • Level of consciousness and signs of poor perfusion
3. Check for peripheral edema, sacral edema, JVP, hepatomegaly, and ascites.
4. Record daily body weight at the same time, using the same scale and similar clothing.
5. Maintain accurate intake and output charting.
6. Monitor urine output. Report oliguria.
7. Observe laboratory values as ordered:
   • Electrolytes, especially potassium and sodium
   • Renal function
   • BNP/NT-proBNP where used
8. Monitor ECG or telemetry for arrhythmias.

B. Improve breathing and oxygenation

1. Position patient in high Fowler's or semi-Fowler's position with legs dependent if appropriate.
   • This reduces venous return and improves lung expansion.
2. Administer oxygen as prescribed.
3. Encourage rest and reduce unnecessary activity during acute dyspnea.
4. Monitor for acute pulmonary edema:
   • Severe breathlessness
   • Falling oxygen saturation
   • Widespread crackles
   • Cyanosis
   • Pink frothy sputum
     This requires urgent escalation.

C. Fluid and edema management

1. Restrict fluid intake if prescribed.
2. Implement sodium restriction as prescribed.
3. Measure and document all oral and IV fluid intake and urine output.
4. Weigh daily and compare with baseline.
5. Elevate swollen legs when resting, if not contraindicated by severe dyspnea.
6. Provide skin care and reposition regularly to prevent skin breakdown in edematous areas.
7. Administer diuretics as prescribed and assess response:
   • Urine output
   • Reduction of edema and breathlessness
   • BP
   • Electrolytes and renal function

D. Medication-related nursing care

• Diuretics: dehydration, hypotension, hypokalemia or other electrolyte disturbances
• ACE inhibitors/ARBs/ARNI: hypotension, renal dysfunction, hyperkalemia
• Beta-blockers: bradycardia, hypotension, worsening symptoms during initiation or dose increase
• Mineralocorticoid receptor antagonists: hyperkalemia
• Digoxin, when prescribed: nausea, vomiting, visual disturbance, bradycardia, arrhythmias, and toxicity risk

E. Promote rest, activity, and rehabilitation

1. Provide periods of rest during acute symptoms.
2. Assist with activities of daily living when fatigue is severe.
3. Gradually increase activity after stabilization.
4. Teach energy-conservation methods:
   • Sit while bathing or dressing
   • Divide activities into smaller steps
   • Rest before becoming exhausted
5. Encourage supervised cardiac rehabilitation when available.

F. Diet and lifestyle education

• Follow a low-sodium diet.
• Avoid adding table salt and limit highly processed foods.
• Follow the prescribed fluid limit.
• Weigh daily and keep a written record.
• Avoid smoking and limit or avoid alcohol as advised.
• Maintain regular physical activity within individual tolerance after stabilization.
• Keep follow-up appointments and take medicines regularly.
• Receive recommended vaccines, including influenza and pneumococcal vaccination when appropriate.

G. Discharge teaching: when to seek help

• Weight gain of about 2-3 lb (1-1.5 kg) in one day or 5 lb (2-3 kg) in a week, or the threshold individually prescribed
• Increasing ankle or abdominal swelling
• Increased breathlessness, new orthopnea, or waking at night short of breath
• Reduced exercise tolerance
• Persistent cough or wheeze
• Dizziness, fainting, palpitations, or chest pain
• Reduced urine output