AORN Journal
Volume 90, Issue 6 , Pages 874-892, December 2009

Heart Failure Guidelines and Implications for Surgically Treating Heart Failure

  • Janet D. Pierce, DSN, ARNP, CCRN

      Affiliations

    • Janet D. Pierce, DSN, ARNP, CCRN, is a professor at the School of Nursing, University of Kansas, Kansas City. Dr Pierce has no declared affiliation that could be perceived as a potential conflict of interest in publishing this article.
    • ,
  • Kathleen Dalton, RN, MSN, ARNP-C

      Affiliations

    • Kathleen Dalton, RN, MSN, ARNP-C, is a nurse practitioner for Mid-America Cardiology at the University of Kansas Hospital, Kansas City. Ms Dalton has no declared affiliation that could be perceived as a potential conflict of interest in publishing this article.
    • ,
  • Katherine Duke, RN, MSN, FNP-C

      Affiliations

    • Katherine Duke, RN, MSN, FNP-C, is a nurse practitioner at the University of Kansas Medical Center, Kansas City. Ms Duke has no declared affiliation that could be perceived as a potential conflict of interest in publishing this article.
    • ,
  • Joseph R. Spaniol, BS

      Affiliations

    • Joseph R. Spaniol, BS, is a research assistant at the School of Nursing, University of Kansas, Kansas City. Mr Spaniol has no declared affiliation that could be perceived as a potential conflict of interest in publishing this article.

Article Outline

ABSTRACT 

In 2005, the American College of Cardiology and the American Heart Association released updated guidelines for the diagnosis and management of chronic heart failure in the adult, yielding new insights into the progression and treatment of this disease. Perioperative nurses need a working knowledge of these guidelines to provide optimal care when patients require surgical interventions for heart failure. This article provides an overview of the pathophysiology, classifications, and treatments for heart failure. AORN J 90 (December 2009) 874–888. © AORN, Inc, 2009.

Key words:  heart failure , congestive heart failure , implantable cardioverter-defibrillator , cardiac resynchronization therapy

 

Heart failure is a complex, extensive, and expensive clinical problem. The general term heart failure is frequently used to describe a common endpoint of many conditions affecting the cardiovascular system.1, 2 Heart failure occurs because underlying heart injury leads to a progressive deterioration of cardiac function, inadequate tissue perfusion, and possible fluid congestion. In the United States, the lifetime risk of developing heart failure is one in five for both men and women.3 In 2003, there were approximately 5 million documented cases of heart failure in the United States, which contributed to more than 285,000 deaths.4 The cost of heart failure in the United States is estimated at $37.2 billion.5

Heart failure treatments have increased in complexity during the past decade. For this reason, the American College of Cardiology (ACC) and the American Heart Association (AHA) have updated their guidelines for the diagnosis and management of chronic heart failure in adults.6 These guidelines, developed in 1995 and most recently updated in 2005, help health care providers treat heart failure. The purpose of this article is to emphasize portions of these guidelines that are useful for nurses working in both primary care and perioperative settings.

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Pathophysiology of Heart Failure 

Heart failure is a complex clinical syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood.6 Cardiac output is defined as heart rate multiplied by stroke volume.7 Stroke volume is determined by myocardial contractility, preload, and afterload.

Myocardial contractility is used to describe the performance of the heart and is defined as the amount of force applied by a given cardiac muscle fiber length. Preload is the tension in the ventricular wall at the end of the resting phase of the cardiac cycle8 and is measured using end-diastolic pressure.9 Afterload is the tension of the ventricular wall during the contraction phase of the cardiac cycle.7, 10 This is the pressure that the ventricle must generate to eject blood; it is measured by the end-systolic pressure.

Terms Related to Heart Failure

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Afterload1, 2 

The tension of the ventricular wall during the contraction phase of the cardiac cycle; the pressure that the ventricle must generate to eject blood, which is measured by the end-systolic pressure.

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Cardiac output3 

Heart rate multiplied by stroke volume.

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Ejection fraction4 

The amount of blood ejected from the left ventricle with each heartbeat, which is calculated by the stroke volume divided by the end diastolic volume; a normal ejection fraction is approximately 50% to 65%.

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Heart failure2 

A complex clinical syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood.

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Myocardial contractility 

The performance of the heart, which is defined as the amount of force applied by a given cardiac muscle fiber length.

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Preload5 

The tension in the ventricular wall at the end of the resting phase of the cardiac cycle, measured using end-diastolic pressure.

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Stroke volume 

A factor of myocardial contractility, preload, and afterload.

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References 

  1. Abraham WT , Fisher WG , Smith AL , et al.   Cardiac resynchronization in chronic heart failure . N Engl J Med . 2002;346(24):1845–1853
  2. Jessup M , Abraham WT , Casey DE , et al.   2009 focused update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation . Circulation . 2009;119(14):1977–2016
  3. Leung G . In: Blueprints Notes & Cases: Pathophysiology—Cardiovascular, Endocrine, and Reproduction . Malden, MA: Malden/Blackwell; 2004;p. 3–4
  4. Bogaty P , Mure P , Dumesnil JG . New insights into diastolic dysfunction as the cause of acute left-sided heart failure associated with systemic hypertension and/or coronary artery disease . Am J Cardiol . 2002;89(3):341–345
  5. Sodolski T , Kutarski A . Impedance cardiography: a valuable method of evaluating haemodynamic parameters . Cardiol J . 2007;14(2):115–126

As afterload increases, cardiac output usually decreases.11 Systolic and diastolic dysfunction, problems in afterload, and variations in heart rate can contribute to heart failure. Heart failure can be isolated to either the left or right side of the heart or may involve both sides.12 The pathophysiology of heart failure is illustrated in Table 1 and the signs of left- and right-sided heart failure are summarized in Table 2.

Table 1. The Pathophysiology of Heart Failure1
Left-sided heart failureRight-sided heart failure
Systolic dysfunctionDiastolic dysfunctionSystolic dysfunctionDiastolic dysfunction
Decreased left ventricle contractilityStiff left ventricle is less able to relaxDecreased right side contractilityStiff right ventricle is less able to relax
Increased left ventricle dilation to compensateIncreased diastolic filling pressuresDecreased cardiac outputIncreased diastolic filling pressures
Increased preload that causes increased left ventricular filling pressuresIncreased left atrium, pulmonary venous, and pulmonary capillary pressuresIncreased right ventricular filling pressuresIncreased systemic venous pressures
Increased left atrium and pulmonary venous pressures that cause pulmonary congestion and edemaIncreased right-sided heart pressures and pulmonary artery pressuresIncreased right ventricular dilationPeripheral edema and hepatic vein congestion
Decreased oxygenation of the blood Peripheral edema
Pulmonary hypertension that causes increased right-sided heart pressures

1 Alspach JG, ed. Core Curriculum for Critical Care Nursing. 6th ed. St Louis, MO: Saunders Elsevier, Inc; 2006:271–278.

Table 2. Signs of Heart Failure1
Right-sided heart failure
•Peripheral edema

•Ascites (ie, excess peritoneal fluid)

•Hepatomegaly (ie, enlargement of the liver)

•Increased jugular venous pressure

•Presence of a parasternal heave indicating the compensatory increase in contraction strength

•Congestion of the gastrointestinal tract resulting in weight loss

•Impaired liver function

Left-sided heart failure
•Tachypnea (ie, increased respiratory rate)

•Increased work of breathing

•Rales or crackles initially heard in lung bases, but when severe, heard throughout the lung fields

•Pulmonary edema

•Dullness in lung fields to finger percussion

•Pleural effusion detectable by reduced breath sounds at the bases of the lungs

•Cyanosis suggesting hypoxemia

1 Porth C, Matfin G, eds. Pathophysiology: Concepts of Altered Health States. 8th ed. Philadelphia, PA: Wolters Kluwer Health;2009:1688.

Left-sided heart failure 

Left-sided heart failure may be systolic or diastolic in nature. Both systolic and diastolic left-sided failure may lead to decreased cardiac output and increased pressures in the left atrium and pulmonary venous system associated with pulmonary congestion and decreased blood oxygenation.

Left-sided, systolic heart failure occurs when the left ventricle is not effectively pumping blood to the rest of the body and may be caused by factors that initially decrease the contractility of the left ventricle and increase afterload. If unchecked, left ventricular systolic failure causes a progressive enlargement and weakening of the left ventricle with a decrease in the fraction of blood pumped out of the left ventricle with each heart beat (ie, ejection fraction). A normal ejection fraction is approximately 50% to 65%.

Left-sided, diastolic heart failure occurs when the left ventricle is unable to relax and fill properly.8 Diastolic heart failure may occur when the left ventricle's systolic function is preserved or supernormal as reflected by a normal or higher than normal ejection fraction.

Patients with systolic heart failure also may have a component of diastolic failure—problems with both the contraction and relaxation of the heart. Continued, untreated, left-sided failure eventually causes increased right-sided heart pressure associated with signs and symptoms of right-sided failure.

Right-sided heart failure 

Right-sided heart failure may be systolic or diastolic in nature. Patients may have isolated right heart failure or concomitant right- and left-sided heart failure.

Right-sided, systolic heart failure occurs when the right ventricle is not effectively pumping blood into the pulmonary system. Right ventricular failure may be caused by multiple problems, such as pulmonary hypertension or right ventricular myocardial infarction. Right-sided, systolic heart failure is associated with increased right ventricular filling pressures, right ventricular hypertrophy, and gradual dilatation and weakening of the right ventricle.

Right-sided, diastolic heart failure occurs when the right ventricle is unable to relax and fill properly, resulting in increased diastolic filling pressures. Failure of the right side of the heart may lead to peripheral edema, hepatic congestion, impaired liver function, and ascites.13

As a result of the different types of right- and left-sided heart failure, forward heart failure, backward heart failure, and congestive heart failure occur. Forward heart failure refers to the inability of the heart to pump blood at a sufficient rate to meet the oxygen demands of the body at rest or during exercise. Backward heart failure refers to the ability of the heart to pump blood at a sufficient rate only when heart filling pressures are abnormally high. The most common congestive heart failure occurs when inadequate pumping from the heart and high heart-filling and venous pressures cause increased fluid in the lungs or in the body.

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Classifications and Stages of Heart Failure 

Two systems for classifying and staging heart failure are available to help health care providers determine a treatment regimen by describing a patient's clinical status—the New York Heart Association (NYHA) heart failure classification system and the ACC/AHA stages of heart failure (Table 3). The ACC/AHA recommend using the two systems in conjunction with one another.

Table 3. Classes and Stages of Heart Failure
New York Heart Association Functional Class1American College of Cardiologists/American Heart Association Heart Failure Stage2
I.No symptoms present
A.High risk for developing heart failure because of condition(s) associated with heart failure

Cardiac structural/functional abnormalities absent

No history of signs or symptoms of heart failure

II.Symptoms present with “more than normal activity”

No symptoms present with either “normal activity” or “at rest”
B.Cardiac structural/functional abnormality present

No history of signs or symptoms of heart failure

III.Symptoms present with “more than normal activity” and “normal activity”

No symptoms “at rest”
C.Cardiac structural/functional abnormality present as well as current or previous heart failure symptoms

IV.Heart failure symptoms always present with “more than normal activity,” with “normal activity,” and “at rest”
D.Structural heart disease is in advanced state

Signs and symptoms of heart failure present even at rest with best possible medical therapy

1 The Criteria Committee of the New York Heart Association. Diseases of the Heart and Blood Vessels: Nomenclature and Criteria for Diagnosis. 6th ed. Boston, MA: Little Brown; 1964.

2 Hunt SA, Abraham WT, Chin MH, et al; American College of Cardiology; American Heart Association Task Force on Practice Guidelines; American College of Chest Physicians; International Society for Heart and Lung Transplantation; Heart Rhythm Society. ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure): developed in collaboration with the American College of Chest Physicians and the International Society for Heart and Lung Transplantation: endorsed by the Heart Rhythm Society. Circulation. 2005;112:e154-e235.

NYHA Heart Failure Classification System 

The NYHA classification system was first developed in 1928 and has since been updated multiple times. This system is a subjective assessment tool based on how the patient's heart failure symptoms affect his or her daily functional activities. A patient may fluctuate between the four classes (ie, I through IV) in the NYHA classification system from one visit to the next.

•A patient who is diagnosed as having class I heart failure has had heart failure symptoms in the past; however, the patient reports no symptoms with “more than normal activity,” “normal activity,” or “at rest” at the present time.

•A patient with a diagnosis of class II mild heart failure reports symptoms with “more than normal activity,” none with “normal activity,” and none “at rest.”

•A patient with a diagnosis of class III moderate heart failure reports symptoms with both “more than normal activity” and “normal activity” but not “at rest.”

•A patient with class IV heart failure experiences symptoms of heart failure in all three areas.14

ACC/AHA stages of heart failure 

In 2001, the ACC and the AHA introduced guidelines for use of a new four-stage heart failure classification system. These stages (ie, A though D) describe the progression of the patient's heart failure and guide health care providers in choosing appropriate management. Unlike the NYHA functional classification system, the ACC/AHA heart failure stages are “one way.” When a patient has reached a stage, the patient cannot later be classified at a previous stage regardless of his or her response to treatment.

Stage A heart failure describes a patient who is at high risk for heart failure because of factors such as hypertension, coronary artery disease, or diabetes but who has not experienced structural changes to his or her heart. The treatment regimen recommended by the ACC/AHA guidelines for a patient in stage A heart failure focuses on two main areas: lifestyle modifications and medications. Lifestyle modifications include sodium restriction; a moderate, routine exercise program; weight reduction; smoking cessation; alcohol abstinence or limitation; and discontinuation of illicit drug use if applicable.15, 16 Two medication classes that should be considered in this stage, unless contraindicated, are angiotensin-converting enzyme inhibitor and beta blockers.6

A patient in stage B heart failure has evidence of structural changes to his or her heart, such as a decreased ejection fraction from having experienced a myocardial infarction, but is asymptomatic. This corresponds with the NYHA functional class I. In addition to considering all the stage A therapies, health care providers should evaluate patients with stage B heart failure for the risk of sudden cardiac death and the need for an implantable cardioverter-defibrillator (ICD). A patient is eligible for an ICD if, in addition to other criteria, he or she is at least 40 days post-myocardial infarction, at least 90 days post-coronary revascularization, and is expected to survive with “good functional status” for at least one year.6

A patient in stage C heart failure has experienced structural changes to his or her heart associated with a current or prior history of heart failure. All stage A and B treatment modalities should be implemented for patients in stage C heart failure in addition to other treatments. Additional medications that should be considered include:

•an angiotensin receptor blocker if the patient cannot tolerate an angiotensin-converting enzyme,

•an aldosterone antagonist,

•a hydralazine/isosorbide dinitrate combination,

•digoxin, and

•diuretics if the patient is in volume overload.

Stage C patients are encouraged to follow a routine exercise program and to restrict their dietary sodium to prevent volume overload.6, 17 In addition to evaluating the patient for sudden cardiac death, health care providers should evaluate patients with stage C heart failure for cardiac resynchronization therapy.6

Stage D is often called end-stage heart failure and represents severe changes in heart structure associated with severe symptoms of heart failure. Patients with stage D heart failure are treated with the regimens from stages A through C but often require more intensive regimens and treatment by a heart failure specialist. Meticulous fluid control is vital to prevent fluid overload, dehydration, and electrolyte imbalance. This usually involves the close monitoring of daily weights and laboratory values and careful titration of diuretics. Hospitalization involving IV diuretics and inotropes usually is necessary to treat heart failure exacerbations in these patients along with frequent outpatient heart failure visits. Some stage D patients do not improve with these therapies and may be considered for cardiac transplantation.6

ACC/AHA heart failure treatment recommendations 

The ACC/AHA heart failure guidelines describe four main treatment categories to help improve survival in heart failure. These include

•lifestyle modifications,

•medications,

•an implantable cardioverter-defibrillator (ICD), and

•cardiac resynchronization therapy.

Lifestyle modifications 

The first treatment category includes changes that patients can make in their daily lives that may improve heart failure outcomes. Guidelines recommend dietary sodium restriction for patients with heart failure.6 Although sodium restriction has not been directly related to a decreased risk of developing heart failure, it has been shown that an excessive intake of dietary sodium is related to volume overload.17 Volume overload leads to worsening of heart failure, and dietary indiscretions associated with heart failure exacerbation are a common reason for heart failure hospitalizations.17

The guidelines strongly recommend alcohol abstinence since alcohol is cardiotoxic. Although several studies found no correlation between alcohol consumption and the risk of developing heart failure,15, 16 the ACC/AHA guidelines advise alcohol abstinence in any patient with a history of heavy alcohol use or abuse and new-onset heart failure without other obvious causes. Many programs limit patients with heart failure to one alcoholic beverage daily for all patients with left ventricular dysfunction regardless of cause. Furthermore, most heart failure patients are on a variety of medications for which alcohol consumption is contraindicated.

A moderate, routine exercise program is recommended to help reduce heart failure symptoms and increase the patient's quality of life.18, 19 The guidelines suggest 20 to 45 minutes of exercise at least three to five times per week.6

Medications 

Three major classes of medications help improve survival of patients with heart failure:

•angiotensin-converting enzyme inhibitors or angiotensin receptor blockers,

•beta blockers, and

•aldosterone antagonists.6

A fourth combination medication, hydralazine plus isosorbide dinitrate, has been shown to enhance survival in black patients.20

Several angiotensin-converting enzyme inhibitors have been shown to decrease heart failure symptoms and reduce mortality, thus improving the patient's quality of life.21 In a trial comparing enalapril to a placebo, enalapril was found to postpone the onset of heart failure in asymptomatic patients with left ventricular dysfunction.22 Enalapril also was shown to increase survival and improve symptoms in patients with symptomatic heart failure and a decreased ejection fraction.23 When the patient does not tolerate an angiotensin-converting enzyme inhibitor, angiotensin receptor blockers such as candesartan, losarten, or valsartan have decreased mortality and hospitalizations in heart failure patients.21, 24 Furthermore, a combination of an angiotensin-converting enzyme and an angiotensin receptor blocker may decrease the size of the left ventricle more than either medication alone.25 Two studies demonstrated that adding an angiotensin receptor blocker to angiotensin-converting enzyme therapy for treatment of heart failure resulted in a decrease in patient hospitalizations.25, 26 The Valsartan Heart Failure Trial Echocardiographic Substudy evaluated patients with moderate heart failure who were treated with the angiotensin receptor blocker valsartan in combination with an angiotensin-converting enzyme or a beta blocker; study results indicated that left ventricle remodeling was reversed with this regimen.25

Beta blockers are key to enhancing survival and lowering the risk of sudden cardiac death in patients with heart failure.27, 28, 29, 30 Studies comparing the beta blocker carvedilol to a placebo in patients at different stages of heart failure found the mortality rate to be significantly lower with carvedilol.31, 32

Aldosterone antagonists have been shown to decrease the incidence of death in patients with heart failure.33 A long-term study found that administering spironolactone combined with an angiotensin-converting enzyme to recently hospitalized patients with NYHA heart failure class III and IV decreased the risk of death from 46% to 35% in two years. In addition, there was a 35% reduction in hospitalizations.34

Taylor et al20 studied the combination medication hydralazine plus isosorbide dinitrate in the treatment of black patients with heart failure. Results of this study showed that treatment with this medication resulted in a 33% decrease in the rate of first hospitalization as well as an increase in quality of life when compared to a placebo. The study also showed a 43% reduction in total mortality in patients treated with this medication combination in addition to the normal treatment for heart failure.20

Implantable cardioverter-defibrillators 

An ICD is used to treat problems with the heart's rhythm. An ICD system has two main parts: a device and leads. The device has a battery pack and electrical circuitry (ie, the “brains” of the system), and usually is implanted in a pocket of tissue under the skin of the left, upper chest. One or more insulated leads are inserted into the heart and attached to the device. These leads carry electrical signals between the device and the heart. The lead placed in the right ventricle (RV) is often used as both the shock lead and as a pacing lead. In addition to the dual-purpose RV lead (ie, single-lead system), pacing leads can be placed in the right atrium (ie, dual-lead system) and left ventricle (ie, cardiac resynchronization therapy).

All current ICDs contain a pacemaker. An ICD system is able to automatically treat very fast, abnormal heart rhythms coming from the lower chambers of the heart (eg, ventricular tachycardia, ventricular fibrillation) by delivering short periods of rapid pacing (ie, anti-tachycardia pacing) as well as electrical shocks to the heart through its insulated wires. The ICD also can prevent slow heart rates (ie, bradycardia) by pacing to maintain a normal heart rate. This pacing is particularly important to guarantee that a heartbeat occurs after an ICD shock.

According to the Multicenter Automatic Defibrillator Implantation Trial II, survival increases when an ICD is placed in patients with a left ventricular ejection fraction of less than or equal to 30% who have had a previous myocardial infarction.35 This study demonstrated that patients treated with an ICD had a 31% reduced incidence of death versus those treated with conventional medical therapy alone. The Sudden Cardiac Death in Heart Failure Trial compared the outcomes of heart failure patients with ischemic and non-ischemic cardiomyopathies, an ejection fraction of less than 36%, and functional NYHA class II or III.36 Those treated with an ICD had a 23% reduction in mortality compared to patients treated with amiodarone alone.

Cardiac resynchronization therapy (CRT) 

Cardiac resynchronization, previously known as biventricular pacing, is used to treat heart failure that is caused by a variety of heart muscle diseases (eg, cardiomyopathies).37 It is used to re-coordinate ventricular beating, which improves cardiac output. The primary indications for a CRT device is the presence of heart failure symptoms (eg, dyspnea, fatigue, exercise intolerance); an ejection fraction less than 35%; and a QRS duration of greater than 0.12 seconds, which represents an electrical delay between the right and left ventricles (eg, an interventricular conduction delay, bundle branch block). Similar to the ICD, a CRT system consists of a device and three insulated wires or leads (ie, right atrium, right ventricle, left ventricle), however, if the patient is in chronic atrial fibrillation, he or she may not have a right atrial lead. In addition to coordinating the teamwork between the upper and lower chambers of the heart (ie, atria and ventricles) as does a standard, two-lead pacemaker, a CRT device also coordinates the teamwork between the right and left ventricles to help the failing heart beat more efficiently and to improve cardiac output.

A CRT system may consist of a three-lead pacemaker alone (ie, CRTP). More often, because patients with heart failure are at significantly higher risk for sudden cardiac death, they will receive a CRTD, which is a CRT pacemaker combined with an ICD all-in-one device. When added to optimized medical therapy, CRTD therapy has been shown to not only improve ejection fraction for patients with heart failure, NYHA functional class, and quality of life, but it also improves the patient's chance of survival.10, 38, 39, 40, 41

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Perioperative Nursing Implications 

Some procedures performed for heart failure (eg, ICD or CRT implantation) may be performed in an electrophysiology laboratory, cardiac catheterization laboratory, or the OR. Nursing care of the patient undergoing surgical treatment for heart failure must be personalized. Table 4 describes the perioperative nursing care plan for a patient with heart failure who is undergoing surgery.

Table 4. Nursing Care Plan for Patients Undergoing Surgical Treatment for Heart Failure
DiagnosisNursing interventionsInterim outcome criteriaOutcome statement
Cardiac output decreased
•Identifies baseline cardiac status including
•reviewing physiological parameters;

•auscultating for quality and regularity of the heart rhythm; and

•palpating for equality, volume, and rate of pulses.


•Uses monitoring equipment to assess cardiac status (eg, interprets electrocardiogram tracing).

•Evaluates postoperative cardiac status.

The patient's hemodynamic status is within expected range at transfer to the postoperative unit.The patient's cardiovascular status is consistent with or improved from baseline levels established preoperatively.
Impaired gas exchange
•Monitors changes in respiratory status.

•Uses monitoring equipment to assess respiratory status including
•applying and monitoring the pulse oximeter,

•positioning the patient for maximal lung expansion unless contraindicated, and

•interpreting arterial oxygen saturation.


•Recognizes and reports deviation in arterial blood gas studies.

•Evaluates postoperative respiratory status.

The patient's percent arterial oxygen saturation (SaO2) and respiratory rate are within the expected ranges at discharge from the postoperative unit.The patient's respiratory function is consistent with or improved from baseline levels established preoperatively.
Risk for fluid volume deficit
•Identifies baseline tissue perfusion and assesses factors related to ineffective tissue perfusion.

•Identifies factors associated with an increased risk for hemorrhage or fluid and electrolyte loss.

•Monitors physiological parameters for fluid deficit and signs of hypervolemia and hypovolemia.

•Recognizes and reports deviation in diagnostic study results.

•Administers prescribed medications based on arterial blood gas results.

•Establishes IV access and collaborates in fluid and electrolyte management.

•Monitors color and amount of urine output from urinary catheter.

•Administers electrolyte therapy as prescribed.

•Evaluates response to administration of fluids and electrolytes.

•Evaluates postoperative tissue perfusion.

•Implements hemostasis techniques.

•Administers blood product.

•Evaluates progress of wound healing.
The patient's vital signs are stable at time of discharge from the OR.

The patient's urinary output is within the expected range at discharge from the OR.
The patient has wound/tissue perfusion consistent with or improved from baseline levels established preoperatively.

The patient's fluid, electrolyte, and acid-base balances are consistent with or improved from baseline levels established preoperatively.

Anxiety related to deficient knowledge
•Determines knowledge level and assesses readiness to learn.

•Identifies psychosocial status and barriers to communication.

•Assesses coping mechanisms.

•Elicits perceptions of surgery.

•Implements measures to proved psychological support.

•Explains sequence of events and reinforces teaching about treatment options.

•Provides oral instructions and written educational materials for the surgical procedure and discharge based on the patient's identified need.

•Communicates patient concerns to appropriate surgical team members.

•Provides status reports to family members.

•Evaluates response to instruction.
The patient states realistic expectations regarding recovery from the procedure.

The patient verbalizes the sequence of events to expect before and immediately after surgery.

The patient demonstrates knowledge of the expected responses to the operative or invasive procedure.
Risk for imbalanced body temperature
•Assesses risk for inadvertent hypothermia.

•Monitors the patient's body temperature.

•Implements thermoregulatory measures throughout the perioperative period by
•increasing room temperature as needed,

•applying a temperature-regulating blanket or other warming devices when applicable, and

•administering warmed solutions.


The patient's temperature is greater than 36° C (96.8° F) at the time of discharge from the OR.The patient is at or returning to normothermia at the conclusion of the perioperative period.

Preoperative nursing assessment 

During the preoperative nursing assessment, perioperative nurses should address certain precautions relevant to patients with heart failure. For example, peripheral edema and deep vein thrombosis (DVT) are both commonly associated with heart failure.42, 43 Perioperative nurses should be aware of the risks of DVT (eg, recent major surgery, immobility, recent injury, history of prior DVT, age, obesity, smoking). Thus, the perioperative nurse should ensure that thromboembolic disease stockings and sequential compression device leggings have been ordered and applied, if appropriate, before the patient is transferred from the preoperative area to the OR to help improve venous return from the legs, decrease lower extremity edema, and decrease the risk of DVT. Care should be taken when applying thromboembolic disease stockings because of the potential to tear fragile skin.

A patient who has heart failure may be taking anticoagulation medication preoperatively. Typically, the patient is instructed to stop taking these medications before surgery. The preoperative nurse checks with the patient's physician and reviews the patient's medical record to determine whether the patient was to have discontinued these medications and if so, for how long. The nurse then confirms with the patient that he or she has complied with these instructions. If the patient has undergone preoperative clotting tests, the preoperative nurse confirms whether the patient's laboratory results are within expected limits.

Intraoperative nursing care 

Depending on the severity of the heart failure, many patients are unable to lie flat to sleep. To minimize respiratory difficulties at home, a patient with heart failure may have to use additional pillows, put the head of his or her bed on blocks, or sleep in a recliner. A patient with heart failure, therefore, may not be able to tolerate being in the supine position on the OR bed. The perioperative nurse works with the anesthesia care provider to enable the patient to remain in the lawn chair position during induction if at all possible. After settling the patient on the OR bed, the anesthesia care provider may administer a sedative, although the patient may remain awake during the procedure.

Perioperative nurses are aware of the adverse effect of inadvertent perioperative hypothermia on wound healing in surgical patients. The adverse effects of hypothermia are even more significant for heart failure patients who already have a compromised cardiovascular system:

… cold stress adversely affects the cardiovascular system by triggering myocardial ischemia. … In high-risk surgical patients, a core temperature less than 35° C is associated with a two- to threefold increase in the incidence of early postoperative myocardial ischemia. …44(p64–65)

Initiating thermoregulatory measures for patients undergoing heart failure interventions, therefore, is extremely important. Patients should undergo preoperative warming (eg, forced-air warming, warmed IV solutions), and these interventions should be continued in the OR and during recovery.

What is Heart Failure?1
Patient Education

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What is heart failure? 

The heart is a pump and its job is to receive blood from the body in one side of the heart and pump it out of the other side of the heart through the lungs to the body. When it fails to do its job, which is called heart failure, several things can happen:

•Not enough blood is pumped out of the heart to keep the head, the arms, and the legs satisfied, so you may not have as much energy as you used to and may tire easily with exercise.

•Blood backs up because the heart cannot pump it forward. You may feel short of breath because of increased pressure as fluid fills the lungs. If the pressure backs up enough, fluid can collect in the abdomen and in the feet and ankles.

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What are the signs and symptoms of heart failure? 

You may have one or more of the following problems:

•abdominal bloating;

•appetite loss, nausea, and weight loss or gain;

•chest, arm, shoulder, and stomach pain;

•cough;

•dizziness, lightheadedness, and fainting;

•fatigue, loss of energy, and exercise intolerance;

•palpitations (eg, fast or irregular heartbeats);

•shortness of breath at rest, with exertion, lying flat, or at night while sleeping; and

•swelling of your feet or ankles.

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What causes heart failure? 

Many heart conditions can lead to heart failure. It is important for you to ask your health care provider to explain the cause(s) of your heart failure. Some of the conditions that can lead to heart failure include

•abnormal heart valves;

•an abnormally low number of red blood cells;

•heart defects at birth;

•coronary artery disease or heart attack;

•heart rhythm disorders;

•lifestyle factors that increase the risk of heart disease (eg, smoking, alcohol and drug abuse); and

•some health conditions (eg, diabetes, high blood pressure, hyperthyroidism, viral infections).

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What tests are used to diagnose heart failure? 

You may need one or more of the following tests:

•chest x-ray,

•electrocardiogram or echocardiogram,

•nuclear study,

•computed tomography (CT) scan,

•magnetic resonance imaging (MRI) scan, or

•cardiac catheterization.

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What are my treatment options? 

Following are some treatment options that your doctor may recommend:

•Making lifestyle modifications, such as
•monitoring and controlling your blood pressure, cholesterol, and lipid levels;

•monitoring and controlling your diabetes;

•stopping smoking, if applicable;

•abstaining from alcohol and illicit drug use;

•maintaining optimal body weight;

•weighing yourself daily and reporting if your weight increases by 3 to 5 lbs in 3 to 5 days;

•following a low-sodium diet;

•limiting fluid intake according to your doctor;

•exercising regularly according to your doctor;

•managing your stress (eg, reading, music);

•getting flu vaccine and pneumovax; and

•recognizing worsening symptoms and knowing what to do and when and whom to call.


•Taking medications such as
•a variety of heart pills;

•blood thinners;

•cholesterol-lowering medication;

•diuretics (ie, water pills); or

•potassium.


•Getting an implantable cardioverter-defibrillator (ICD), which can pace and shock your heart. The ICD monitors your heart rhythm 24 hours a day, 7 days a week. If a fast, life-threatening rhythm occurs, the ICD can shock your heart back into a normal rhythm. The pacemaker can prevent your heart from beating too slowly and, in some cases, can stop fast, life-threatening rhythms before a shock is needed.

•Undergoing cardiac resynchronization therapy (CRT). This type of ICD, known as a CRT defibrillator (CRTD), is a 3-wire pacemaker plus an ICD. The 3-wire pacemaker helps your heart beat more efficiently and squeeze more blood out to the rest of the body. This may help to decrease your shortness of breath and fatigue and improve your ability to exercise. This ICD helps prevent sudden death from a lethal heart rhythm.

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Reference 

  1. American Heart Association  . Heart failure . http://www.americanheart.org/presenter.jhtml?identifier=1486 Accessed August 3, 2009.

For ICD implantation, the physician injects local anesthesia then makes the incision, usually in the left upper chest (ie, subclavicular), and inserts an introducer and sheath into one of the major veins, usually the subclavian. He or she advances the lead over a guide wire into the heart. One to three leads may be inserted into the heart depending on the ICD system required by the patient. The physician tests each lead for its ability to pace the heart and sense the heart's intrinsic rhythm (eg, pacing and sensing thresholds). Fluoroscopy may be used to verify each lead's location. The physician then makes a pocket in the tissue of the patient's chest just below the incision in which he or she placed the generator after connecting it to the leads.

The physician performs defibrillation threshold tests (DFTs) before closing the incision, which require a deepening of the level of anesthesia, induction of ventricular fibrillation (VF) through the device, and conversion of VF to a normal rhythm via a shock from the ICD. The external defibrillator or a subcutaneous chest defibrillator patch is used if the ICD is unsuccessful. This confirms that the ICD will be able to rescue the patient after he or she has been discharged from the facility. The physician then closes the pocket with suture and adhesive strips.

Although a CRT implant procedure may be performed via a thoracotomy, sternotomy, or sub-xyphoid approach, the transvenous approach is the most common. The transvenous approach for CRT implantation is similar to ICD implantation with standard lead placement in the right ventricle and right atrium, if indicated. The physician threads the third, left ventricular lead into the right atrium, into the coronary sinus, then into a branch off of the coronary sinus. This lead, sitting in a vein on the exterior surface of the heart, paces the heart through the vein wall.

After testing each lead's ability to pace the heart and sense the heart's intrinsic rhythm (ie, pacing and sensing thresholds) and confirming each lead's position by fluoroscopy, the physician makes a pocket in the tissue of the chest just below the incision in which he or she placed the CRT generator after connecting it to the leads. In some special cases, ICD and CRT generators can be placed behind the breast or in the abdomen. If the device is a CRTD, the physician performs DFTs. Ultimately, the physician closes the pocket with suture and adhesive strips.

As is true with any implanted electronic devices, perioperative nurses should be knowledgeable about the specific ICD being implanted and associated precautions that should be implemented to protect the patient from injury.45 When caring for a patient with heart failure who is undergoing implantation of a new device, the nurse should ensure that the following steps have been taken. The nurse should

•check the patient's medical record and signed informed consent to verify what type of device the patient will receive (eg, pacemaker, ICD, CRT, CRTD);

•place a printout of the settings for the device (eg, lower rate limit, ICD active or inactive) on the patient's medical record after implantation;

•ensure that the printouts placed on the patient's medical record have the manufacturer's contact information, which allows staff members to contact the manufacturer's representative if problems with the device occur so that the representative can come to the health care facility to help troubleshoot device issues with the physician; and

•ensure that the patient undergoing device implantation receives a wallet card with basic information about his or her device (eg, manufacturer, important telephone numbers, model and serial numbers, implantation date) and that the patient understands the importance of keeping this card with him or her at all times.

When caring for a patient with heart failure who has had an implant previously and is undergoing implantation of a new replacement or updated device, the nurse should

•determine what type of device the patient had inserted previously;

•ask the patient if he or she has the wallet card listing the device information;

•obtain device records from the patient's physician or cardiologist;

•obtain any chest x-rays, which can reveal a code on the device to help identify the manufacturer and possibly the device model if the patient does not have this information; and

•contact the manufacturer's representative who can evaluate the device preoperatively and postoperatively because all the major manufacturers have patient device registries of their implanted devices.

Postoperative nursing care 

Depending on the facility and services available, a patient undergoing surgical therapy for heart failure may recover in the postanesthesia care unit or may be returned to his or her room on the inpatient unit. In either case, the recovery nurse monitors the patient's vital signs and heart rhythm closely. The nurse should remind the patient to alert the nurse if he or she experiences chest pain or tightness or pain at the incision sites. The nurse should assist the patient when he or she gets up for the first time after surgery and should measure the patient's blood pressure while the patient is lying, sitting, and standing to monitor for orthostatic hypotension.

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Conclusion 

Knowledge regarding the pathophysiology and treatment of heart failure continues to increase. The ACC/AHA heart failure guidelines help health care providers treat and more effectively manage patients with heart failure. Using the four classes of the NYHA heart failure classification system and the four stages of the ACC/AHA system is helpful in communicating the severity of the disease, the progression or improvement of heart failure, and the selection of appropriate therapies. Perioperative nurses must be prepared to manage patients with heart failure as they undergo surgery. Understanding surgical therapies for heart failure helps perioperative nurses improve the surgical outcomes for these patients.

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Examination 

Heart Failure Guidelines and Implications for Surgically Treating Heart Failure 

Purpose/Goal 

To educate perioperative nurses about heart failure guidelines and implications for surgically treating patients with heart failure.

Behavioral Objectives 

After reading and studying the article on heart failure treatment guidelines, nurses will be able to

1.describe how heart failure affects normal functioning of the heart,

2.discuss nonsurgical treatment of heart failure,

3.discuss surgical therapies for treating heart failure, and

4.explain nursing care of the patient undergoing surgical treatment for heart failure.

Questions 

1.Heart failure occurs because of underlying heart injury that leads to
1.progressive deterioration of cardiac function.

2.inadequate tissue perfusion.

3.possible fluid congestion.
a.1 and 2

b.1 and 3

c.2 and 3

d.1, 2, and 3



2.Factors that initially decrease the contractility of the left ventricle and increase afterload may result in
a.left-sided, diastolic heart failure.

b.left-sided, systolic heart failure.

c.right-sided, diastolic heart failure.

d.right-sided, systolic heart failure.


3.Dietary sodium restriction has been directly related to a decreased risk of developing heart failure.
a.true

b.false


4.Classes of medications that help to improve the survival of patients with heart failure include
1.aldosterone antagonists.

2.aldosterone protagonists.

3.angiotensin-converting enzyme inhibitors.

4.angiotensin receptor blockers.

5.beta blockers.
a.1 and 3

b.2, 4, and 5

c.1, 3, 4, and 5

d.1, 2, 3, 4, and 5



5.An implantable cardioverter-defibrillator delivers a shock to the heart to convert the patient's heart rhythm to a normal rhythm whenever it detects
1.asystole.

2.bradycardia.

3.ventricular fibrillation.

4.ventricular tachycardia.
a.1 and 2

b.3 and 4

c.1, 3, and 4

d.1, 2, 3, and 4



6.Cardiac resynchronization is biventricular pacing used to re-coordinate ventricular beating, which improves cardiac output.
a.true

b.false


7.Appropriate nursing interventions for a patient undergoing surgical treatment for heart failure include
1.assessing factors related to ineffective tissue perfusion.

2.auscultating for quality and regularity of the heart rhythm.

3.interpreting arterial oxygen saturation readings.

4.interpreting electrocardiogram tracing.

5.palpating for equality, volume, and rate of pulses.

6.positioning patient for maximal lung expansion unless contraindicated.
a.1, 3, and 5

b.2, 4, and 6

c.2, 3, 4, 5, and 6

d.1, 2, 3, 4, 5, and 6



8.The __________ approach is the most common approach through which to perform the cardiac resynchronization procedure.
a.sub-xyphoid

b.transvenous

c.sternotomy

d.thoracotomy


9.Precautions to protect the patient from injury specific to having a new cardioverter-defibrillator device implanted include
1.checking the patient's medical record and signed informed consent to verify what type of device the patient will receive.

2.ensuring that the patient receives a wallet card with basic information about the implanted device.

3.placing a printout with the manufacturer's contact information on the patient's medical record after implantation.

4.placing a printout of the settings for the device on the patient's medical record after implantation.
a.1 and 3

b.2 and 4

c.2, 3, and 4

d.1, 2, 3, and 4



10.The first time the patient gets up after surgery, the postanesthesia care unit nurse should measure the patient's blood pressure while the patient is lying, sitting, and standing to monitor for
a.neurally mediated hypotension.

b.orthostatic hypotension.

c.primary hypertension.

d.secondary hypertension.


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Answer Sheet 

Heart Failure Guidelines and Implications for Surgically Treating Heart Failure 

Event #09291

Session #1225

Please fill out the application and answer form on this page and the evaluation form on the back of this page. Tear the page out of the Journal or make photocopies and mail with appropriate fee to:

AORN Customer Service

c/o AORN Journal Continuing Education

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Denver, CO 80231-5711

or fax with credit card information to (303) 750-3212.

Additionally, please verify by signature that you have reviewed the objectives and read the article, or you will not receive credit.

Signature ______________________________________

1.Record your AORN member identification number in the appropriate section below. (See your member card.)

2.Completely darken the spaces that indicate your answers to examination questions 1 through 10. Use blue or black ink only.

3.Our accrediting body requires that we verify the time you needed to complete this 3.2 continuing education contact hour (192-minute) program. ______

4.Enclose fee if information is mailed.

AORN (ID) # ____________________________________________

Name __________________________________________________

Address ________________________________________________

City ___________________________________________________ State __________ Zip __________

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Fee enclosed ___________________________________________

or bill the credit card indicated MC Visa American Express Discover

Card # ___________________________________ Expiration date _____________________

Signature _______________________________________________________________ (for credit card authorization)

Fee: Members $21 (includes $5 processing fee);

Nonmembers $37 (includes $5 processing fee)

Save time and money by completing this CE activity online.

No processing fees at aorn.org/CE.

Program offered December 2009; The deadline for this program is December 31, 2012.

A score of 70% correct on the examination is required for credit. Participants receive feedback on incorrect answers. Each applicant who successfully completes this program will receive a certificate of completion.

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Learner Evaluation 

Heart Failure Guidelines and Implications for Surgically Treating Heart Failure 

This evaluation is used to determine the extent to which this continuing education program met your learning needs. Rate these items on a scale of 1 to 5.

Purpose/Goal 

To educate perioperative nurses about heart failure guidelines and implications for surgically treating patients with heart failure.

Objectives 

To what extent were the following objectives of this continuing education program achieved?

1.Describe how heart failure affects normal functioning of the heart.

2.Discuss nonsurgical treatment of heart failure.

3.Discuss surgical therapies for treating heart failure.

4.Explain nursing care of the patient undergoing surgical treatment for heart failure.

Content 

To what extent

5.did this article increase your knowledge of the subject matter?

6.was the content clear and organized?

7.did this article facilitate learning?

8.were your individual objectives met?

9.did the objectives relate to the overall purpose/goal?

Test Questions/Answers 

To what extent

10.were they reflective of the content?

11.were they easy to understand?

12.did they address important points?

Learner Input 

13.Will you be able to use the information from this article in your work setting?
a.yes

b.no


14.I learned of this article via
a.the AORN Journal I receive as an AORN member.

b.an AORN Journal I obtained elsewhere.

c.the AORN Journal web site.


15.What factor most affects whether you take an AORN Journal continuing education examination?
a.need for continuing education contact hours

b.price

c.subject matter relevant to current position

d.number of continuing education contact hours offered


What other topics would you like to see addressed in a future continuing education article? Would you be interested or do you know someone who would be interested in writing an article on this topic?

Topic(s): ____________________________________________________________________________________________________________________

Author names and addresses: ________________________________________________________________________________________________________

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References 

  1. Kumar V , Abbas AK , Fausto N , Mitchell R . Robbins Basic Pathology . 8th ed.. Philadelphia, PA: Saunders; 2007;
  2. Mattson Porth C , Matfin G . Pathophysiology: Concepts of Altered Health States . 8th ed.. Philadelphia, PA: Lippincott Williams & Wilkins; 2009;
  3. Lloyd-Jones D , Adams R , Carnethon M , et al. , American Heart Association Statistics Committee and Stroke Statistics Subcommittee    Heart disease and stroke statistics—2009 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee . Circulation . 2009;113(3):480–486
  4. Thom T , Haase N , Rosamond W , et al. , American Heart Association Statistics Committee and Stroke Statistics Subcommittee    Heart disease and stroke statistics—2006 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee . Circulation . 2006;113(6):e85–e151
  5. Lloyd-Jones D , Adams R , Carnethon M , et al. , American Heart Association Statistics Committee and Stroke Statistics Subcommittee    Heart disease and stroke statistics—2009: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee . Circulation . 2009;119(3):e21–e182
  6. Jessup M , Abraham WT , Casey DE , et al.   2009 focused update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation . Circulation . 2009;119(14):1977–2016
  7. Leung G . In: Blueprints Notes & Cases: Pathophysiology—Cardiovascular, Endocrine, and Reproduction . Malden, MA: Malden/Blackwell; 2004;p. 3–4
  8. Bogaty P , Muré P , Dumesnil JG . New insights into diastolic dysfunction as the cause of acute left-sided heart failure associated with systemic hypertension and/or coronary artery disease . Am J Cardiol . 2002;89(3):341–345
  9. Sodolski T , Kutarski A . Impedance cardiography: a valuable method of evaluating haemodynamic parameters . Cardiol J . 2007;14(2):115–126
  10. Abraham WT , Fisher WG , Smith AL , et al. , MIRACLE Study Group    Multicenter InSync Randomized Clinical Evaluation. Cardiac resynchronization in chronic heart failure . N Engl J Med . 2002;346(24):1845–1853
  11. Orban M , Bruce CJ , Pressman GS , et al.   Dynamic changes of left ventricular performance and left atrial volume induced by the Mueller maneuver in healthy young adults and implications for obstructive sleep apnea, atrial fibrillation, and heart failure . Am J Cardiol . 2008;102(11):1557–1561
  12. American Association of Critical Care Nurses  . In: Core Curriculum for Critical Care Nursing . 6th ed.. St Louis, MO: Saunders Elsevier, Inc; 2005;p. 967
  13. Bansal V , Schuchert VD . Jaundice in the intensive care unit . Surg Clin North Am . 2006;86(6):1495–1502
  14. The Criteria Committee of the New York Heart Association  . Diseases of the Heart and Blood Vessels: Nomenclature and Criteria for Diagnosis . 6th ed.. Boston, MA: Little Brown; 1964;
  15. Abramson JL , Williams SA , Krumholz HM , Vaccarino V . Moderate alcohol consumption and risk of heart failure among older persons . JAMA . 2001;285(15):1971–1977
  16. Walsh CR , Larson MG , Evans JC , et al.   Alcohol consumption and risk for congestive heart failure in the Framingham Heart Study . Ann Intern Med . 2002;136(3):181–191
  17. Bentley B . A review of methods to measure dietary sodium intake . J Cardiovasc Nurs . 2006;21(1):63–67
  18. Belardinelli R , Georgiou D , Cianci G , Purcaro A . Randomized, controlled trial of long-term moderate exercise training in chronic heart failure: effects on functional capacity, quality of life, and clinical outcome . Circulation . 1999;99(9):1173–1182
  19. Nilsson BB , Westheim A , Risberg MA . Effects of group-based high-intensity aerobic interval training in patients with chronic heart failure . Am J Cardiol . 2008;102(10):1361–1365
  20. Taylor AL , Ziesche S , Yancy C , et al. , African-American Heart Failure Trial Investigators    Combination of isosorbide dinitrate and hydralazine in blacks with heart failure . N Engl J Med . 2004;351(20):2049–2057
  21. Cohn JN , Tognoni G , Valsartan Heart Failure Trial Investigators  . A randomized trial of the angiotensin-receptor blocker valsartan in chronic heart failure . N Engl J Med . 2001;345(23):1667–1675
  22. Rogers WJ , Johnstone DE , Yusuf S , et al.   Quality of life among 5,025 patients with left ventricular dysfunction randomized between placebo and enalapril: the Studies of Left Ventricular Dysfunction. The SOLVD Investigators . J Am Coll Cardiol . 1994;23(2):393–400
  23. Demers C , McKelvie RS , Negassa A , Yusuf S , RESOLVD Pilot Study Investigators  . Reliability, validity, and responsiveness of the six-minute walk test in patients with heart failure . Am Heart J . 2001;142(4):698–703
  24. Yusuf S , Pfeffer MA , Swedberg K , et al. , CHARM Investigators and Committees    Effects of candesartan in patients with chronic heart failure and preserved left-ventricular ejection fraction: the CHARM-Preserved Trial . Lancet . 2003;362(9386):777–781
  25. Wong M , Staszewsky L , Latini R , et al. , Val-HeFT Heart Failure Trial Investigators    Valsartan benefits left ventricular structure and function in heart failure: Val-HeFT echocardiographic study . J Am Coll Cardiol . 2002;40(5):970–975
  26. McMurray JJ , Ostergren J , Swedberg K , et al.   Effects of candesartan in patients with chronic heart failure and reduced left-ventricular systolic function taking angiotensin-converting-enzyme inhibitors: the CHARM-Added trial . Lancet . 2003;362(9386):767–771
  27. The Cardiac Insufficiency Bisoprolol Study II (CIBIS-II): a randomised trial . Lancet . 1999;353(9146):9–13
  28. Effect of metoprolol CR/XL in chronic heart failure: Metoprolol CR/XL Randomised Intervention Trial in Congestive Heart Failure (MERIT-HF) . Lancet . 1999;353(9169):2001–2007
  29. Packer M , Fowler MB , Roecker EB , et al. , Carvedilol Prospective Randomized Cumulative Survival (COPERNICUS) Study Group    Effect of carvedilol on the morbidity of patients with severe chronic heart failure: results of the carvedilol prospetive randomized cumulative survival (COPERNICUS) study . Circulation . 2002;106(17):2194–2199
  30. Packer M , Coats AJ , Fowler MB , et al. , Carvedilol Prospective Randomized Cumulative Survival Study Group    Effect of carvedilol on survival in severe chronic heart failure . N Engl J Med . 2001;344(22):1651–1658
  31. Packer M , Bristow MR , Cohn JN , et al.   The effect of carvedilol on morbidity and mortality in patients with chronic heart failure. US Carvedilol Heart Failure Study Group . N Engl J Med . 1996;334(21):1349–1355
  32. Fonarow GC , Lukas MA , Robertson M , Colucci WS , Dargie HJ . Effects of carvedilol early after myocardial infarction: analysis of the first 30 days in Carvedilol Post-Infarct Survival Control in Left Ventricular Dysfunction (CAPRICORN) . Am Heart J . 2007;154(4):637–644
  33. Ezekowitz JA , McAlister FA . Aldosterone blockade and left ventricular dysfunction: a systematic review of randomized clinical trials . Eur Heart J . 2009;30(4):469–477
  34. Pitt B , Zannad F , Remme WJ , et al.   The effect of spironolactone on morbidity and mortality in patients with severe heart failure. Randomized Aldactone Evaluation Study Investigators . N Engl J Med . 1999;341(10):709–717
  35. Moss AJ , Zareba W , Hall WJ , et al. , Multicenter Automatic Defibrillator Implantation Trial II Investigators    Prophylactic implantation of a defibrillator in patients with myocardial infarction and reduced ejection fraction . N Engl J Med . 2002;346(12):877–883
  36. Bardy GH , Lee KL , Mark DB , et al. , Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT) Investigators    Amiodarone or an implantable cardioverter-defibrillator for congestive heart failure . N Engl J Med . 2005;352(3):225–237
  37. Abraham WT . Cardiac resynchronization therapy for the management of chronic heart failure . Am Heart Hosp J . 2003;1(1):55–61
  38. Higgins SL , Hummel JD , Niazi IK , et al.   Cardiac resynchronization therapy for the treatment of heart failure in patients with intraventricular conduction delay and malignant ventricular tachyarrhythmias . J Am Coll Cardiol . 2003;42(8):1454–1459
  39. Young JB , Abraham WT , Smith AL , et al. , Multicenter InSync ICD Randomized Clinical Evaluation (MIRACLE ICD) Trial Investigators    Combined cardiac resynchronization and implantable cardioversion defibrillation in advanced chronic heart failure: the MIRACLE ICD Trial . JAMA . 2003;289(20):2685–2694
  40. McAlister F , Ezekowitz J , Wiebe N , et al.   Cardiac resynchronization therapy for congestive heart failure . Evid Rep Technol Assess (Summ) . 2004;106:1–8
  41. Bristow MR , Saxon LA , Boehmer J , et al. , Comparison of Medical Therapy, Pacing, and Defibrillation in Heart Failure (COMPANION) Investigators    Cardiac-resynchronization therapy with or without an implantable defibrillator in advanced chronic heart failure . N Engl J Med . 2004;350(21):2140–2150
  42. Goddard AA , Pierce CS , McLeod KJ . Reversal of lower limb edema by calf muscle pump stimulation . J Cardiopulm Rehabil Prev . 2008;28(3):174–179
  43. Piazza G , Seddighzadeh A , Goldhaber SZ . Heart failure in patients with deep vein thrombosis . Am J Cardiol . 2008;101(7):1056–1059
  44. Frank SM . Pathophysiology and consequences of hypothermia . In: Hypothermia in Trauma: Deliberate or Accidental . Baltimore, MD: The International Trauma Anesthesia and Critical Care Society; 1997;p. 64–67
  45. AORN guidance statement: Care of the perioperative patient with an implanted electronic device . In: Perioperative Standards and Recommended Practices . Denver, CO: AORN, Inc; 2009;p. 207–228

 Complete this CE activity online at aorn.org/CE indicates that continuing education contact hours are available for this activity. Earn the contact hours by reading this article and taking the examination on pages 889–890 and then completing the answer sheet and learner evaluation on pages 891–892. The contact hours for this article expire December 31, 2012.The behavioral objectives and examination for this program were prepared by Rebecca Holm, RN, MSN, CNOR, clinical editor, with consultation from Susan Bakewell, RN, MS, BC, director, Center for Perioperative Education. Ms Holm and Ms Bakewell have no declared affiliations that could be perceived as potential conflicts of interest in publishing this article.This program meets criteria for CNOR and CRNFA recertification, as well as other continuing education requirements.AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.AORN recognizes these activities as continuing education for registered nurses. This recognition does not imply that AORN or the American Nurses Credentialing Center approves or endorses products mentioned in the activity.AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019. Check with your state board of nursing for acceptance of this activity for relicensure.

PII: S0001-2092(09)00550-X

doi:10.1016/j.aorn.2009.06.020

AORN Journal
Volume 90, Issue 6 , Pages 874-892, December 2009

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