Dysrhythmias in Congestive Heart Failure

Ledi Iksarina

and Halimuddin

Nursing Science Program, Faculty of Nursing, Universitas Syiah Kuala Banda Aceh, Indonesia

Department of Emergency and Critical Care Nursing, Faculty of Nursing, Universitas Syiah Kuala Banda Aceh, Indonesia

Keyword: Congestive Heart Failure, Sinus Dysrhythmia, Supraventricular Dysrhythmia, Ventricular Dysrhythmia,

Atrioventricular Block Conduction, Interventricular Block Conduction.

Abstract: Dysrhythmias is a clinical critical event which aggravate congestive heart failure. Dysrhythmia might be

caused the main heart failure nursing diagnose, decreased of cardiac output occurred, then early dysrhythmia

identification will help nurse to determine etiology and planning that will be given. Rhythm identification can

be done by electro-cardiogram (ECG). The study was to aim an illustration on congestive heart failure

dysrhythmia. This descriptive qualitative study was designed with secondary data retrospective study

(medical record) on 282 congestive heart failure patients who were hospitalized in dr. Zainoel Abidin Hospital

Banda Aceh. Data collection used ECG strip in first 24 hours and the result were written in the research sheet.

After whole data collected, it was found that Sinus Dysrhythmia was in 68 respondents (24,10%),

Supraventricular dysrhythmias in 51 respondents (18,10%), Ventricular Dysrhythmias in 10 respondents

(3,60%), Atrioventricular Block Conduction in 14 respondents (5,00%), Interventricular Block Conduction

in 18 respondents (6,40%), whereas 121 respondents (42,90%) had Normal Sinus Rhythm. Dysrhythmia

finding should not be the main indicator on detect problem that caused decrease of cardiac output, so nurse is

recommended to identify another condition that underlying the nursing diagnose has been labeled.

Cardiovascular nurse is suggested not to ignore normal rhythm in heart failure, meanwhile the nurse have to

identify another dysfunction underlying decreased of cardiac output.

1 INTRODUCTION

Cardiovascular diseases are the top cause of death in

the world. Based on data from WHO 2015 which

report in Top Ten Causes of Death 2017, heart disease

is in the top position with 54% of all causes mortality

in the world. Congestive heart failure is a condition

which increase high mortality rate caused by

cardiovascular. The clinical event that worsening

congestive heart failure is dysrhythmia. According to

the study conducted in Prof. Dr. R. Kandou Hospital,

Manado showed that 119 from 376 coronary artery

disease cases are belonging dysrhythmia, and 6 are

congestive heart failure with dysrhythmia. Mortality

rate caused by dysrhythmia also high, 35%

dysrhythmia was among 51-60 years old, 29% in 61-

70 years old, and 1% in 71-80 year old. It shows that

only 1% patient with dysrhythmia can survive up to

80 years old. (Kalangi, Jim and Joseph, 2016, p. 2).

Dysrhythmia is an emergency case as it

conduction disorder can influence cardiac output

which can change every second, then leading on

nutrient and oxygen circulation until critical

condition. An examination that can be done by nurse

to detect dysrhythmia is Electrocardiogram (ECG)

tapping.

Dysrhythmia which influences cardiac output

findings can direct the nurse to establish etiology of

nursing diagnose which has labeled, where the

exchange of heart beat and rhythm is one of criteria

in nursing diagnose, decreasing of cardiac output.

Accuracy in rhythm interpretation is very determined

patient’s live related intervention that will be given.

The dysrhythmia treatment purpose is to return the

rhythm and heart contraction effectivity, decrease of

anxiety, and also reduce high mortality rate caused by

cardiovascular (Smeltzer and Bare, 2003, p. 698;

Solikhah, 2015, p. 36).

The study aimed to identify rhythm illustration

that can occur in congestive heart failure, so the result

can give basic data regarding the possible

dysrhythmia in heart failure, facilitate nurse to

recognize the problem which makes hemodynamics

worse and determine the best treatment. Therefore,

Iksarina, L. and Halimuddin, .

Dysrhythmias in Congestive Heart Failure.

DOI: 10.5220/0008783200002442

In Proceedings of the Aceh International Nursing Conference (AINC 2018), pages 5-10

ISBN: 978-989-758-413-8

the author is interested in discussing the possible

rhythm in congestive heart failure.

2 METHODS

The study was a descriptive quantitative study with

retrospective design, which total sampling on 282

congestive heart failure patients aged between 57 to

60 years who were hospitalized around July and

December 2017 in the Intensive Cardiovascular Care

Unit and Integrated Cardiac Treatment Ward of dr.

Zainoel Abidin General Hospital, Banda Aceh.

Ethical approval was accepted from the Research

Ethic Committee of Nursing Faculty, Syiah Kuala

University.

3 RESULTS

3.1 Sample Characteristics

Sample characteristics are described in Table 1. The

table shows that male has higher risk of congestive

heart failure (63,80%) than female (36,2%), heart rate

mostly in normal range (66,90%). The sample of this

study are mostly congestive heart failure caused by

hypertension heart disease (32,3%).

Table 1: Characteristics of Congestive heart failure patients

(n=282).

Characteristics f %

Gender

Male 180 63,80

Female 102 36,20

Heart Rate (bpm)

<60 19 6,80

60-100 188 66,90

>100 75 26,70

Causes of Heart Failure

Valvular Heart Disease 54 19,10

Systolic Heart Failure 1 0,40

Diastolic Heart Failure 20 7,10

Coronary Artery Disease 88 31,20

Hypertension Heart Disease 91 32,30

Rheumatic heart Disease 2 0,7

Dilatative Cardiomiophaty 13 4,6

Unidentified 13 4,6

3.2 Rhythm Congestive Heart Failure

Patients

Table 2 shows normal rhythm take 42,90% from

whole samples. In Sinus Dysrhythmia the most

rhythm is tachycardia (16,7 %), than bradycardia

(4,60%) and arrhythmia (2,80%). Atrial fibrillation is

the most rhythm in supraventricular dysrhythmia

(14,20%), while premature ventricle contraction is

the most rhythm in ventricle dysrhythmia. In other

dysrhythmia, first degree AV block is the most

rhythm in AV block conduction (4,60%) and right

bundle branch block is the most rhythm in

interventricle block conduction (3,90%).

Table 2: Congestive heart failure patient based on rhythm

(n=282).

Type of Rhythm f %

Normal Sinus Rhythm 121 42,90

Sinus Dysrhythmia 8 2,80

Arrhythmia sinus

Tachycardia sinus 47 16,70

Bradycardia sinus 13 4,60

Supraventricular Dysrhythmia

Paroxismal Supraventricular

Tachycardia (PSVT)

4 1,40

Premature Atrium Contraction (PAC) 4 1,40

Atrial Fibrillation (AF) 40 14,20

Atrial Flutter 3 1,10

Ventricular Dysrhythmia

Premature Ventricle Contraction

(PVC)

9 3,20

Ventricle Tachycardia (VT) 1 0,40

Ventricle Fibrillation (VF) 0 0

Atrioventricular Block Conduction

1st degree AV Block 13 4,60

2nd degree AV Block, Wenckebach 0 0

2nd degree AV Block, Mobitz Type II 1 0,40

3rd degree AV Block 0 0

Interventricular Block Conduction

Right Bundle Branch Block (RBBB) 1 3,90

Left Bundle Branch Block (LBBB) 7 2,50

4 DISCUSSIONS

The result shows that the higher age makes the higher

risk of congestive heart failure. The result is

supported by an epidemiology study which state that

the average age of congestive heart failure patients in

South East Asia is 60 years old (Sakata and

Shimokawa, 2013, p. 2211). On the study conducted

by Rusinaru et al in France, the average of age from

368 samples were in late elderly group that is 69-85

years old. The range of age on its study is higher

because France has high rate of life expectancy and

the criteria of samples is patients whose low of

ejection fraction significantly (Rusinaru et al., 2008,

p. 568). Higher of age cause heart valvular stiffness

and hypertrophy, decreasing myocardium and blood

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vessels elasticity and worsening calcium and lipid

calcification in the artery and vein. Even function is

maintained in normal condition, cardiovascular

system is unable to survive in responding high of load

on compensating circulation needed for long time.

Cardiac output maximum will reduced up to 20%

since 20 until 80 year old (Smeltzer and Bare, 2003,

p. 191).

Risk of congestive heart failure was higher in

male than female (i.e 63,2% on male and 36,8% on

female). The percentage was widely caused by

cigarette and caffeine consumption in male is higher

than female, especially in Aceh. Similarly with the

study conducted by Maulidta (2014) where male has

63,3% encounter coronary artery disease which

trigger heart failure, this was caused by male not

having estrogen hormone which effect atherosclerotic

formation, meanwhile female had estrogen hormone

that prevent atherosclerotic formation or other harm

condition to the blood vessels (Maulidta, 2014, p. 58).

An epidemiology study by Sakata & Shimokawa

showed that 50-70% congestive heart failure patient

in Asia were male (Sakata and Shimokawa, 2013, p.

2211).

In other ways, based on the study was conducted

by Fachrunnisa, Nurchayati, and Arneliwati (2015)

showed that female was more widely in risk on

congestive heart failure (53,3%). In the study most of

respondents were female whose age more than 45

years old which were dominantly menopause.

Menopause caused the reduction of estrogen hormone

and High Density Lipoprotein (HDL) which leading

atherosclerosis was easier to form in blood vessels.

Moreover female psychological is tend to

maladaptive and makes them easier attack to disease

(Fachrunnisa, Nurchayati and Arneliwati, 2015, p.

1099). In terms of etiology that underlying heart

failure, both coronary artery disease or hypertension,

male was higher on percentage that is 81,9%, so risk

of heart failure is higher than female (Farissa, 2012,

p. 37).

Samples’ heart rate in this study was dominantly

in normal range, that is 192 samples (67,1%). Even

though some kind of dysrhythmia such as

supraventricular dysrhythmia or ventricular

dysrhythmia were frequently happen, the heart rate

was possible in normal range. The result of the study

also showed heart rate can increase over normal rate

(24,8%) or decrease under normal rate (6%).

Normal heart rate is including in compensatory

system to maintain cardiac output in normal levels.

One of compensation system is enhances sympathetic

activity reflexively to the heart which makes

effectivity of heart contractibility increase

(Sherwood, 2013, p. 353). Sympathetic and

epinephrine stimulation will increase heart

contractibility through increased contraction strength

in each end diastolic volume. It makes heart

contraction stronger and eject more blood out of

heart. Furthermore, sympathetic stimulation will

enhance vein back flows where the vein constriction

and let the higher blood volume from vessel to the

heart, then increasing end diastolic volume and

subsequently cardiac output will increase (Sherwood,

2013, p. 351).

Hypertension and coronary artery disease are two

highest causes congestive heart failure. This

statement is supported by some studies that show both

conditions enhance the risk of heart failure. Based on

study which was conducted by Halimuddin (2010),

33,3% congestive heart failure patients from his

samples are caused by hypertension and coronary

artery disease. As a study conducted by Kaneko et al

(2014) in Japan, there was 60% from 17.517 samples

were hypertension and coronary artery disease

(Halimuddin, 2013, p. 98; Kaneko et al., 2014, p.

188). In another study which conducted by Kaneko to

see the relation between clinical characteristics with

morbidity and mortality rate of congestive heart

failure through fraction and ejection shows that

hypertension is one of some factors that aggravate

ejection fraction of congestive heart failure besides

aging, dyslipidemia, and adherent of treatment

(Kaneko et al., 2013, p. 108).

Normal Sinus Rhythm (NSR) is the most widely

rhythm in this study, with normal ejection fraction

and heart rate.Most of heart failure especially

congestive heart failure show a normal maintained

condition from any compensatory system

(asymptomatic heart failure). Continuously

compensation episode will cause remodeling

structural of heart and culminate to symptomatic heart

failure. Symptomatic heart failure will arise if it is

followed by precipitations factors such as infection

(bacteria or virus), arrhythmia, infarct, anemia,

hyperthyroid and pregnancy, over of activity,

emotional, imbalance of salt diet, and disease

progressivity (Panggabean, 2014, p. 1132).

Normal rhythm in congestive heart failure shows

compensation system work to maintain cardiac

output. Continuously compensation makes heart

work heavier and leading the changes of cardiac

structure. Normal rhythm findings are not showing a

safe condition because it is temporally. This normal

condition also caused by effect of recent treatment

and medicine consumption. Pharmacological such as

anti-arrhythmias are used as front liner to prevent left

ventricle dysfunction. However considering drug

Dysrhythmias in Congestive Heart Failure

utilization is needed since the side effect makes

patient worsen (Hsu, 2007, p. 46).

Sinus dysrhythmia is a rhythm disorder that

widely happen in congestive heart failure patients.

Rhythm of sinus dysrhythmia is dominantly sinus

tachycardia. Mostly caused by hypertensive heart

disease and coronary artery disease with decreasing

ejection fraction.

Sinus tachycardia signed by heart rate rapidity

over than 100 and reach 180 beat per minute (bpm).

During sinus tachycardia, Sino Atrium Node (SA

Node) release impulse between 100 and 180 beat per

minute, but the rapidity can slower along with aging

and activity. Sinus tachycardia is divided into two,

appropriate tachycardia and inappropriate

tachycardia. Appropriate tachycardia is caused by

body stress response such as activity, anxiety, fever,

thyrotoxicosis, hypovolemia, or drug toxicities to

maintain cardiac output. Meanwhile inappropriate

tachycardia is caused by vagal system dysfunction or

disorder in the SA node (Yamin, Harun and Makmun,

2014, p. 1346).

Sinus tachycardia in congestive heart failure is

supported by some factors such as structural

abnormality, metabolic dysfunction, and medication.

Structural abnormalities for instance myocardium

injury which disturb electricity current impulse

toward ventricles and cardiomegaly which increase

preload and afterload that cause prolonged

repolarization cyclic. Metabolic dysfunction that

underlying tachycardia in congestive heart failure

involves neurohormonal activation which conduce

increasing of adrenaline and noradrenaline hormone

plasm, also be responsible of beta-blocker and

Angiotensin Converting Enzyme (ACE) effect on

sudden death, the study explained that significantly

enhancement of norepinephrine is related to

arrhythmias cases (Masarone et al., 2017, p. 2).

Sinus tachycardia commonly found in heart

failure patients caused by hypertension and coronary

artery disease (Raka, Danes and Supit, 2015, p. 755).

It is supported by a study was conducted by Kalangi,

Jim, and Joseph (2016) where the high risk causes

arrhythmias is hypertension (41%), meanwhile the

study mention that sinus bradycardia rhythm is the

most commonly sinus dysrhythmias in congestive

heart failure (65%) especially heart failure ed causa

coronary artery disease (Kalangi, Jim and Joseph,

2016).

Heart failure as a clinical syndrome regarding

heart inability to supply adequate of blood to systemic

will execute compensation effort to maintain cardiac

output by many ways, one of them is with enhance

heart contractility. By increasing heart contractility,

the heart rate will be accelerated, but this sympathetic

stimulation could not persist since heart no more

responsive to the nor-epinephrine stimulation.

Continuously compensation makes heart works

heavier and will contort heart structure, it be

worsening by aging which causes heart inability to

compensate well, it is showed by even heart rate and

contractility increase but ejection fraction still low. In

other side, bradycardia is commonly happen in

congestive heart failure, it is caused by any

dysfunction on SA node that makes inadequate

amount of impulse to the atrium or caused by obstacle

which makes the impulse cannot reach the ventricles

(Masarone et al., 2017, p. 4).

Supraventricular dysrhythmias in congestive

heart failure is most widely Atrial Fibrillation (AF)

rhythm that is 40 respondents (14,2%). The

dysrhythmia is mostly caused by valvular heart

disease (20 respondents) and have low ejection

fraction on 28 respondents who were examined their

echocardiography.

Impulse deliver synchronization is the most

important to create an effective heart blood pump. In

fibrillation, heart cells contraction and excitation are

randomly and unsynchronized. Atrial fibrillation is

signed with rapid, irregular, and uncoordinated atrial

depolarization (unclear P wave) which leading

disruption of atrium contraction. The irregularity of

atrial contraction induces the irregularity impulse to

the AV node and causes ventricles rhythm is

irregular. Some ventricle pulsation will be closer and

also elongate, when two ventricle pulsations are

closer than the ventricle preload will getting shorter

and the product of preload decrease, if the preload

decrease so the next contraction will be weak.

Sometimes, the ventricle contractions is too weak to

pump out blood from heart and causes brachialis vein

is impalpable (Sherwood, 2013, p. 335,340).

Atrial fibrillation findings in congestive heart

failure patients is also reported in study conducted by

Velderrabano et al (2016), there were 20 respondents

(33,3%) from 60 samples with supraventricular

dysrhythmia were atrial fibrillation and closely

related to high risk of chronic kidney disease. They

also explained that AF will impact on long of stay

especially in intensive care unit (Valderrábano et al.,

2016, p. 7). Hsu (2007) and Kaneko et al (2014)

mentioned that AF is highly responsible to congestive

heart failure and the hospitalization duration, but it is

not as main factor the high of mortality rate in

congestive heart failure. AF also influence the left

ventricle dysfunction and its ejection fraction,

specifically on AF with Rapid Ventricular Response

(AF RVR) which the pulse is over than 100 bpm. Low

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ejection fraction on AF RVR is caused by left

ventricle dysfunction as impact of atrial contractility

dysfunction which is leading Atrioventricular

desynchronizing or the irregularity of ventricles (Hsu,

2007, p. 46; Kaneko et al., 2014, p.

187).Desynchronizing impulse deliver from SA node

causes impulse deliver to the ventricles worse. It will

make ventricle pump moves randomly, signed by

irregular QRS waves, leading the blood volume is not

sufficient to fulfill body circulation need.

Premature Ventricle Contraction (PVC) is most

ventricular dysrhythmia which occur in congestive

heart failure. Ventricular dysrhythmia dominantly on

congestive heart failure which caused by coronary

artery disease and valvular heart disease and have low

ejection fraction level.

Ventricular extrasystole/premature ventricle

contraction/PVC is mostly caused by ischemia, acute

myocardial infarction, heart failure, prolonged QT

syndrome, digitalis toxicity, hypokalemia,

myocarditis, cardiomyopathy or mitral valve relapse.

Emergence of this rhythm should threated based on

the etiology, even it is asymptomatic, because this

rhythm aggravation cause ventricular fibrillation

(VF) or ventricular tachycardia (VT) (Yamin, Harun

and Makmun, 2014, p. 1360). The worsening of PVC

dysrhythmias becomes VT / VF is significantly

influences cardiac output because of fast heart rate

and loss of synchronization mechanism between

atrial and ventricle contraction. Not only that,

ventricle fibrillation causes effective contraction stop

spontaneously and ventricle will vibrating

uncoordinatedly. (DeBeasi, 2003, p. 598).

Recent study which is conducted by Kalangi, Jim,

and Joseph proves that premature ventricle

contraction could happen in almost all coronary artery

disease such as stabled angina pectoris (SAP) 21%,

old myocardial infarction (OMI) 33%, unstable

angina pectoris (UAP) 25%, and NSTEMI (15%), it

is dominantly on male in above 50 year old. (Kalangi

et al., 2016, p. 4 – 5).

Ventricular dysrhythmia presents in congestive

heart failure belonging kidney disorder can increase

the glomerulus filtration rate (GFR) and hemoglobin

amount in blood. In cardiac structure, this condition

causes left ventricle mass index and coronary calcium

enhancement which leading diastolic dysfunction,

ventricular hypertrophy, also coronary artery

calcification. The increasing hemoglobin and

decrease of ejection fraction such condition above is

need to identify the relations between clinical data,

laboratory, and another cardiovascular parameters

(Bonato, Lemos, Cassiolato, & Canziani, 2013, p. 3 -

4). PVC presents can asymptomatic so control the

balances of electrolyte and exposure of infection

agents, and pharmacological optimization are very

suggested (Masarone et al., 2017, p. 8).

Ventricular dysrhythmia is a rhythm disorder

which the impulse source possibility from ventricular

ectopic pulse and produce the premature pulsation or

irregular high rapidity. High rate of ventricle pulse

(ventricle tachycardia) in long time can ending with

ventricle fibrillation, therefore filling and emptying

ventricle episode will be ineffective.

In this study, atrioventricular block conduction

(AV) dysrhythmia is dominantly with first degree

atrioventricular block conduction that is 13

respondents or 4,6% from sample. AV block

conduction is widely experienced by congestive heart

failure with coronary artery disease and low ejection

fraction. This dysrhythmia is very important because

can leading severer block heart conduction (Smeltzer

and Bare, 2002, p. 762). Meanwhile Yamin in Sudoyo

(2014) explained that first degree AV block is not

need early treatment and have a good prognosis. In

another study shows that the patient with UAP,

NSTEMI, and STEMI have first degree AV block

(Kalangi et al., 2016, p. 5 – 6). First degree AV block

also experienced by inferior myocardial infarct.

Electrically, conduction line obstacles from sinus

node to AV node causes impulse cannot separately

well to the next conduction line.

Interventricular block conduction in congestive

heart failure is dominantly with Right Bundle Branch

Block (RBBB). Samples are mostly caused by valvular

heart disease and have low of ejection fraction.

Conduction block on RBBB is a conduction disorder

condition in right branch conduction system. Patients

with RBBB commonly asymptomatic, but if it find the

syncope and other conduction disorder like AV block,

so additional pacemaker is need to considered (Yamin

et al., 2014, p.1362).

Conduction deceleration which caused by

obstacles in bundle his branch makes ventricle

muscles unable to pump out the blood effectively,

sometimes the deceleration also causes the ventricle

pacemaker take over the role to produce its own

impulse and makes premature contraction or

vibrating of ventricle.

5 CONCLUSIONS

Based on the result of this study, we can conclude that

congestive heart failures are dominantly on male;

mostly caused by hypertension and coronary artery

disease, have sinus rhythm with heart rate, and

Dysrhythmias in Congestive Heart Failure

ejection fraction in normal range. The rhythm finding

in congestive heart failure are as follows:

a. Sinus dysrhythmias is the most widely

dysrhythmia in congestive heart failure. The

dominant rhythm is sinus tachycardia,

b. Supraventricular dysrhythmia is dominantly with

atrial fibrillation

c. Rhythm of ventricular dysrhythmia is premature

ventricle contraction (PVC)

d. Rhythm of atrioventricular block conduction is

dominantly with first degree atrioventricular

block conduction, and

e. Rhythm of interventricular block conduction is

dominantly with Right Bundle Branch Block

(RBBB)

It is recommended to nurses that not to make a

rhythm as a main indicator to determine the etiology

decrease of cardiac output, in addition nurses are

expected not to ignore the normal rhythm and more

assess the underlying causing the cardiac output

decrease. For further research is expected to study

further regarding dysrhythmia in congestive heart

failure and the effective nursing interventions to

return heart pump effectively.

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