Heart Failure

Question 1

Identify the 2 main causes of left heart failure

Answer 1

1. Mitral regurgitation

2. Valve stenosis

Question 2

What are the other causes of LHF?

Answer 2

Aneurysm of LV following MI

Ischaemic heart disease – (Coronary artery disease) Chronic high BP

Question 3

Explain the 2 main causes of left heart failure

Answer 3

• Mitral regurgitation –
  The papillary muscles are damaged by ischaemic heart disease
  Blood therefore flows back through the mitral valve into the LA during systole.
  LV has to work harder to maintain CO, causing LV hypertrophy.
  LV failure - blood not fully expelled from LV in systole, so diastolic pressure doesnt return to 0.
  Pressure needed to fill LV increases, causing a pressure rise in the LA.
  This increases the pressure on the pulmonary veins - fluid is therefore forced out of alveoli as hydrostatic pressure is higher than osmotic pressure
  Oedema occurs in lungs, increasing WOB.
• Valve stenosis –
  Narrowing of the mitral valve
  Less oxygenated blood enters LV from LA = reduced CO.
  LA has to work harder, causing hypertrophy
  Volume and pressure of LA increases, causing increased pressure on pulmonary veins, increasing hydrostatic pressure so pulmonary oedema in lungs occurs.

Question 4

What is left ventricular failure?

Answer 4

In left heart failure, the LV cannot contract properly/is not pumping enough blood to the body.

Blood therefore remains in the LV (forwards failure) so the LV has to work harder to maintain SV and CO. The LV therefore undergoes hypertrophy.

Back pressure into the LA occurs = increased pressure in the pulmonary veins – pulmonary oedema occurs in the lungs – dec sa for ge so TV decreases and RR inc

Question 5

Identify the features of LHF and explain why they occur

Answer 5

Dyspnoea – pulmonary oedema (backwards failure) as caused by the increased hydrostatic pressure in the pulmonary veins and capillaries, occludes the alveoli and therefore impedes gaseous exchange of o2 and co2 across the respiratory membrane due to the decreased sa for ge. This causes hypoxaemia and type 1, 2 respiratory failure. Pt may present with cyanosis, feeling SOB, having a reduced exercise tolerance and brain hypoxia – dizziness and confusion

• Tachychardia – the heart compensates for the decreased CO so the workload of the heart increases. Signalled by the SNS.
• Frothy sputum; sometimes red, cough – backflow of blood from the LV to the LA due to mitral regurgitation, causes and increases hydrostatic pressure in the pulmonary veins and capillaries, this forces fluid out into the alveoli, also get pulmonary hypertension. The capillaries therefore become damaged and air mixes with blood.
• Pallor, cyanosis, hypoxia, fatigue, poor exercise tolerance – occurs due to the pulmonary oedema in the lungs decreasing the sa for ge, therefore less o2 diffuses into the pulmonary capillaries, so hypoxaemia occurs. Therefore less oxygenated blood returning to the left side of the heart, LV inability to pump blood to the body so dec o2 to the peripheries so less aerobic respiration occurs, less glucose produced.
• Cardiogenic shock – MI (later stages)
• Echocardiogram shows LV hypertrophy as L workload increasing due to dec blood vols in the LV/inability of the LV to pump blood to the body via the aorta.
• Paroxysmal nocturnal dsypnoea – occurs due to increased VR in lying

Question 6

What does the physiotherapist need to consider when managing a patient with left sided heart failure?

Answer 6

Manage respiratory symptoms
o SOB/WOB/Reduced exercise tolerance/pulmonary oedema/sleep apnoea
 Positions of ease
 Breathing control
 Pacing
 Fan therapy
 Purse lip breathing
 O2 support
 PEP to get effects of PEEP e.g. CPAP (splinting of airways) (increase V/Q)
 Cardiac rehabilitation
• Reduce hospitalisation
• Increase QOL
- Awareness of increased risk of:
o DVT
o PE
o MI
 Therefore know signs and symptoms and treat appropriately
- Self-management
o Education on diagnosis and how to control symptoms
o Restrict sodium intake
o Regular exercise with pacing
o Self monitoring oedema levels for indication of condition
- Involve patient and family in goal setting
- Address psychological decline if necessary
o Refer on
o Reassure and educate
- Acute e.g. sudden after MI
o Need to try to manage underlying condition
o Using appropriate oxygen thereapy
o Mobility practice
o ?repiratory physio – prevent/creat sputum