Lecture 22: ADHF AND PULMONARY EDEMA
The goals of therapy for both ADHF and chronic HF are to decrease patient symptoms,
reverse ventricular remodeling, improve quality of life, and decrease mortality and
Treatment strategies should include the following:
o Decreasing intravascular volume with the use of diuretics to reduce venous return
o Decreasing venous return (preload) to reduce the amount of volume returned to
the LV during diastole.
o Decreasing afterload (the resistance against which the LV must pump) improves
CO and decreases pulmonary congestion.
o Gas exchange is improved by the administration of IV morphine sulfate and
o Inotropic therapy and hemodynamic monitoring may be needed in patients who
do not respond to conventional pharmacotherapy (e.g., diuretics, vasodilators,
o Reduction of anxiety is an important nursing function, since anxiety may increase
the SNS response and further increase myocardial workload.
COLLABORATIVE CARE: CHRONIC HEART FAILURE
The main goal in the treatment of chronic HF is to treat the underlying cause and
contributing factors, maximize CO, provide treatment to alleviate symptoms, improve
ventricular function, improve quality of life, preserve target organ function, and improve
mortality and morbidity.
Administration of oxygen improves saturation and assists greatly in meeting tissue
oxygen needs and helps relieve dyspnea and fatigue.
Physical and emotional rest allows the patient to conserve energy and decreases the need
for additional oxygen. The degree of rest recommended depends on the severity of HF.
Nonpharmacologic therapies used in the management of HF patients who are receiving
maximum medical therapy, continue to have NYHA Functional Class III or IV
symptoms, and have a widened QRS interval include the following:
o Cardiac resynchronization therapy (CRT) or biventricular pacing. Involves pacing
both the right and left ventricles to achieve coordination of right and left ventricle
o Cardiac transplantation. Strict criteria are used to select the few patients with
advanced HF who can even hope to receive a transplanted heart.
o Intraaortic balloon pump (IABP) therapy. The IABP can be useful in the
hemodynamically unstable HF patient because it decreases SVR, PAWP, and
PAP as much as 25%, leading to improved CO. However, the limitations of bed
rest, infection, and vascular complications preclude long-term use.
o Ventricular assist devices (VADs). VADs provide highly effective long-term
support for up to 2 years and have become standard care in many heart transplant centers. VADs are used as a bridge to transplantation.
o Destination therapy. The use of a permanent, implantable VAD, known as
destination therapy, is an option for patients with advanced NYHA Functional
Class IV HF who are not candidates for heart transplantation.
General therapeutic objectives for drug management of chronic HF include: (1)
identification of the type of HF and underlying causes, (2) correction of sodium and
water retention and volume overload, (3) reduction of cardiac workload, (4) improvement
of myocardial contractility, and (5) control of precipitating and complicating factors.
o Diuretics are used in HF to mobilize edematous fluid, reduce pulmonary venous
pressure, and reduce preload.
Thiazide diuretics may be the first choice in chronic HF because of their
convenience, safety, low cost, and effectiveness. They are particularly
useful in treating edema secondary to HF and in controlling hypertension.
Loop diuretics are potent diuretics. These drugs act on the ascending loop
of Henle to promote sodium, chloride, and water excretion. Problems in
using loop diuretics include reduction in serum potassium levels,
ototoxicity, and possible allergic reaction in the patient who is sensitive to