end-stage heart disease

7/23/2019 End-Stage Heart Disease

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End-StageHeart Diseas

Presented By:

Cyrille Agnes Tarroja



Heart Failure Is a ConditiAging

Almost 75% of those diagnosed with HF are65 years (Heart Disease and Stroke Statisti

HF is the n#m$er one hositali&ation diagnoolder ad#lts with the n#m$er of hositali&atiincreasing '5% oer the last 2 years

Heart fail#re (HF) is a terminal disease"



*na$ility of the heart to #m the amo+ygenated $lood necessary to affect ret#rn and meet meta$olic re,#iremen



Pathophysiology



Causes

Direct damage the heart

-entric#lar .erload

/onstriction of -essels



Afterload 0esistance of left entricle1 m#st oecirc#late $lood"

*ncrease in H3 4 -asoconstriction

*ncrease Afterload *ncrease /ardia

workload"

Preload ress#re from the ol#me of the $looentricles at the end of diastole"

*ncrease in Hyoolemia1 0eg#rgitatio

cardiac cales and Heart Fail#re"



Clinical Signs of Heart Fa



Presenting Symptoms inHeart Failure

According to the A//AHA g#idelinesatients with HF #s#ally resent in three

A recent syndrome of decreased e+erctolerance1 #s#ally d#e to dysnea andor

fatig#e" *n this case1 it is imortant for roider to ascertain whether these symreresent HF or another condition s#ch #lmonary disease"



Fl#id retention with comlaints of leg edema or

a$dominal $loating

8ith or witho#t any symtoms of another cardiac

or non cardiac disorder1 s#ch as D91 a$normal

heart so#nds1 a$normal :;<1 arrhythmia1 H=3

hyotension1 A9*1 #lmonary em$oliother systemi

throm$osis1 or a chest +>ray that has eidenceof cardiac enlargement"

Dysnea is the initial manifestation of HF in most



Co#pli$ation

!ight =ric#sid -ale

Stenosis

/or #monale

"ef 9itral -ale S



Cardiac Assessmen

Assessment of the heart rate and rhare essential to determine whether theany dysrhythmias that are comromisinf#nction of the heart"



Nursing Mgt. HF

?>right osition

3>itrates

@>asi+

.>+ygen

A>minohylline

D>igo+in

F>l#ids

A>fterload

S>odi#m 0estr

=>est Digo+in

<oal *ncrease myocardial contraction

3ormal /. >6@min3ormal Stroke -ol#me 6>7mlh2o"



HEART FAI!RE MANA"EM

<eneral 9edication <#idelines For ati

8ith Heart Fail#re 8ith 0ed#ced :Bectio

1. Diuretics with salt restriction are the atients with fl#id oerload" @oo di#re

thia&ides are most often #sed"2" ACEIs1 they hae $een shown to romoregression1 symtom imroement1 and demortality"



" Angiotensin recetor $lockers (A0Cs) arthe atient is not a$le to take an A/:*" =hred#ce endoint mortality and mor$idity an

clinical signs and symtoms"

" Aldosterone antagonists1 s#ch as Siron:lerenone1 to decrease mortality tho#gh t$e #sed in conB#nction with otassi#m moni

to the risk of hyerkalemia" =his otassi#meffect is often $eneficial when they are #scom$ination with otassi#m wasting di#retif#rosemide"



5" Hydralazine and nitrates1 demonstrated immortality and red#ced hositali&ation rates whewith other eidence>$ased theraies in African

6" Beta-blockers (CCs) imroe mortality and sand reent hositali&ations in atients with chHoweer1 they may worsen symtoms initially1 a$enefit is long term so they sho#ld $e initiateddose #>titrated when a atient is sta$le1 rathe

d#ring an eisode of decomensation

7" Digoxin is a ositie inotroic medication tha

imroes #m contractility"



Drugs to A%oid in Heart F

Three classes o drugs that should b

in "ost H# $atients are the ollo1. Antiarrhyth"ic agents that may leacardio deression and roarrhythmic ef.nly amiodarone and dofetilide hae $e

to $e safe in atients with HF"

'. Calciu" channel blockers sho#ld $e ca#tion $eca#se they may lead to increaof cardioasc#lar eents and decreased



(. )onsteroidal anti-inla""atory dr#sodi#m retention and eriheral asoconas well as decrease efficacy and increasto+icity of di#retics and A/:*"

*n addition1 they increase the risk of when #sed with anticoag#lants s#ch as

a dr#g widely #sed in this o#lation" Cthis imortant class of analgesics cannsafely #sed in HF1 ain management canchallenging in this o#lation"



ind Body Therapie Sirit#ality is another mindE$ody modality #satients to coe with the #ncertainty of HF"

Sirit#ality infl#ences the manner in which aadB#sts to a chronic illness" atients with endheart disease often reflect on their ast and

:+ercise 4 0ela+ation 9editation

Ac##nct#re

oga

=ai /hi



E&peri#ental Treat#1. Cardio!ascular *egeneration and

Cell-Based Thera$ies

. 0egeneration of myocardial cells and actiamyocardial stem cells to relace infarcted mcells has the otential for a ositie effect atients $#t is in the e+erimental stages (/

2'2)".=hese theraies show incredi$le romise astreatment to reent or reerse myocardial and to romote cell regeneration in the f#t#

(S#ncion1 Sch#lman1 4 Hare1 2'2)



'( )enotransplantati

Genotranslantation inoles the

translantation of non h#man tiss#es or into h#man reciients"

Genotranslantation $etween closely resecies1 s#ch as $a$oons or igs and h#m

offers an alternatie to allot translantaa so#rce of h#man organ relacement1 $#ro$lems with reBection remain a maBor



Palliati%e Care *uidel8hen it is time for hosice care1 criterion fro

3ational Hosice and alliatie /are .rgani&ation

in determining when a atient is aroriate for =here are criteria secific to heart disease a

these incl#de the following

*ntracta$le or rec#rrent symtoms of HF

.timal medical treatment for HF sho#ld $e in resence of symtomatic arrhythmias

History of cardiac arrest and res#scitation or s

/ardiogenic $rain em$olism

/o>occ#rring H*- disease



Co##uni$ation

*n this imortant doc#ment1 high>,decisions inole medically reasona$otions1 which align with the al#es1 and references of an informed ati

Shared decision making inoling a tclinician will hel ens#re that the atgoals and wishes match roosed the



Shared De$ision a+

Disc#ssions a$o#t rognosis and careferences sho#ld $egin early in thdisease rocess"

As with all atients in this stage ofongoing comm#nication is the key inachieing the goal of dying well"



Sy#pto# anage#e

Aggressie symtom managemenhallmark of ,#ality /" =he fo#r realent symtoms in HF are dyain1 deression1 and fatig#e (Ad

al"1 2!)

D ti ti f D i



Dea$ti%ation of De%i$in Heart Failure

These deacti!ation guidelines state that&

# atients or s#rrogate decision makers shof#lly informed of the conse,#ences to deactoffered alternaties"

# An order for a do not res#scitate (D30) saccomany the deactiation"

# sychiatric and ethics cons#ltations sho#larranged in the setting of imaired decision disagreement"



# *f the clinician has ersonal $eliefs that r

deactiation1 the atient sho#ld $e referred t

another clinician"

# Deactiation can occ#r at the imlanting ce

a local site at the atientIs re,#est"

# *mlanting clinicians sho#ld enco#rage1 at tof the imlantation1 the comletion of adance

directies1 which incl#de deice management a

deactiation at :.@"

* l Ph l i



*eneral Phar#a$ologi$!e$o##endations for ,lder

=he following recommendations sho#ld $e conswhen rescri$ing cardiac medications for older a

'" Start low and go slow" Always $egin with the seffectie dose titrate # in small increments1

in mind the atientIs comor$id conditions thatinfl#ence the harmacokinetics of the dr#g(s)

2" As dose adB#stment is made1 clinical eal#ationocc#r"



" 0eiew each medication the atient c#rrently taking1 een oer>the>co#ntemedications and her$al remedies1 and of contraindications or adB#stments ne

" Aoid emiric treatment of symtoma diagnosis $efore initiating dr#g ther

5" ;ee it simleJ Adherence decreasen#m$er of medications and fre,#ency increases"



6" 9ake s#re that the atient can read thif not1 a family mem$er or home care n#rsset # a weekly ill disenser" atients can

hae large rint la$els on their rescritio$ottles"

7" atient ed#cation is key" 9ake s#re that

atient #nderstands the aderse reactionswatch for and knows when to call for assis



S i Ph l i



Spe$i$ Phar#a$ologi!e$o##endations for ,lde

=he following recommendations sho#ld $e considerrescri$ing cardiac medications for older ad#lts

'" Alha>$lockers1 s#ch as do+a&osin1 ra&osin1 and tsho#ld $e aoided as antihyertensies" =hey crearisk for orthostatic hyotension"

2" /entral alha agonists1 s#ch as clonidine1 reserinethan "' mgday)1 and methyldoa1 sho#ld $e aoided antihyertensies" =hey create a high risk for adersnero#s system (/3S) effects1 $radyarrhythmias1 anorthostatic hyotension"



" /lass *a1 *c1 *** antiarrhythmic dr#gs1 samiodarone1 rocainamide1 and ,#inidine1 s$e aoided" =hey hae $een associated wit

m#ltile to+icities" 0ate control is recommoer rhythm control for older ad#lts"

" Disoyramide is a otent negatie inotroolder ad#lts and sho#ld $e #sed with ca#tio

may ind#ce HF"5" Dronedarone is to $e aoided in atientsHF"



6" Aoid Digo+in (greater than "'25 mgdaHigher doses increase risk of to+icity in thresence of slow renal clearance common in

ad#lts"

7" Aoid 3ifediine (immediate release)" *n

the risk of hyotension or myocardial ische

K" Aoid Sironolactone greater than 25 m0isk of hyerkalemia" Aoid in /r/l less tham@min"

.onphar#a$ologi$



.onphar#a$ologi$!e$o##endation

For older ad#lts (as well as those yo#nger taggressie #se of the non harmacologic measimeratie"

Dr#g theray can often ca#se #nleasant seffects1 which often lead to nonadherence"

+eneral "easures are reco""ended as o1. Decreasing more or new cardiac inB#ry $y rfactor red#ction"

2" @imiting alcohol #se to two glassesday

9aintaining fl#id $alance $y restricted s



" 9aintaining fl#id $alance $y restricted sgday)

" *mroing hysical conditioning

5" /aref#l management of comor$id conditi6" atient ed#cation regarding self>care

7" Smoking cessation when aroriate

K" *nfl#en&a accination eery fall

!" ne#mococcal imm#ni&ations after diagnoreaccination eery 5 years

'" /are of atients with HF across setting

*nter rofessional teams

'' /aref#l monitoring of fl#id stat#s



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end-stage heart disease

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