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Right Sided Heart Failure

Preload and Afterload

Preload is the pressure on the walls of the ventricle when it begins to contract and the end of diastolic filling. Think about preload as filling up a water balloon. The pressure put on the balloon by the water inside of it is preload.

This pressure comes from the atria delivering blood to the ventricles to either be pumped to the lungs or the body. The amount of blood in the ventricle at the end of diastole determines the amount of blood that will get pump out of the ventricles. Increased preload volume will put excessive workload on the heart muscle and cause the heart to demand more oxygen to keep up with the added load.

Decreased preload will cause a hypovolemic state and not perfuse the vital organs with enough oxygenated blood.

After load is pressure, in either the pulmonary arteries or the aorta, that the ventricles must over come to pump the blood out.

Causes of Right Sided Heart Failure:

• Right ventricular infarction

• Pulmonary embolism

• COPD

• Past MI

• Hypertensive Cardiomyopathy (heart disease secondary to high BP)

• Acute myocarditis or endocarditis,

• Drug induced

• Cardiac dysrhythmias: Sustained tachycardia or bradycardia.

Signs and Symptoms of CHF or Heart Failure:

• Swollen Extremities

o Fluid backs up in the veins, leaks out of the capillaries and accumulates in the tissue.

• Angina: Chest pain caused by exertion because the heart muscle is not getting properly perfused.

• Shortness of breath

o Fluid backs up in the lungs

• Hypertension (Caused by many things)

o Excessive preload

o Coronary artery disease, stenosis in the coronary arteries making a restriction so the heart has to pump harder to get oxygen rich blood to the heart muscle.

Signs and Symptoms of Left Side Heart Failure

• Unexplained hypotension, impaired mental status, and pulmonary congestion. (These are should be used as differential diagnosis material, not definite signs of heart failure.)

• Dyspnea

• Tachycardia

• Tachypnea

• Cyanosis

• Peripheral Edema

• Reduced urine output

Treatment for these patients:

• O2- because heart failure basically restricts the flow of blood, O2 will be our first medication administration.

• CPAP- Go over protocol

• Nitro- Go over protocol

• Dopamine- Go over protocol

Right Ventricular Infarction:

• Isolated RVI’s are extremely rare, though RVI’s complicate up to 40% of inferior infarcts.

• Because of poor right ventricle contractility, RVI’s are very sensitive to preload. Nitro can cause sever hypotension in these patients.

• If patients with RVI’s become hypotensive, they are to be treated with fluid bolus.’

• ST elevation in V1- V1 is the only lead that looks directly at the right ventricle

• Greater ST elevation in lead III vs. lead II. Lead III more rightward facing and will pick up more activity in the right ventricle than lead II

• ST elevation in V1>V2

• ST elevation in V1 with ST depression in V2

• ST elevation in V4R

o ST elevation in V4R has a sensitivity of 88%, specificity of 78% and diagnostic accuracy of 83% in the diagnosis of RV MI.

Description of Right Sided Heart Failure from the American Heart Association:

Right-sided or right ventricular (RV) heart failure usually occurs as a result of left-sided failure. When the left ventricle fails, increased fluid pressure is, in effect, transferred back through the lungs, ultimately damaging the heart's right side. When the right side loses pumping power, blood backs up in the body's veins. This usually causes swelling or congestion in the legs, ankles and swelling within the abdomen such as the GI tract and liver (causing ascites).

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