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CHF: Definition
Congestive cardiac failure is defined as
“inability of the heart to maintain output at
rest or during stress, necessary for the
metabolic needs of the body (systolic
failure) and inability to receive blood into
the ventricular cavities at low pressure
during diastole (diastolic failure) .
• Thus due to systolic failure it is unable to
propel blood into the aorta and in diastolic
failure it receive in adequate amount of
blood .
Etiology
• Heart failure due to diastolic dysfunction
I. Mitral or tricuspid stenosis
II. Constrictive pericarditis
III. Restrictive cardiomyopathy
IV. Acute volume overload
V. Myocardial ischemia
VI.Marked vetricular hypertrophy
Cause of systolic or mixed failure
leading to CCF
• Infants
i. Congenital heart disease
ii. Myocarditis and primary myocardial dise
iii. Paroxysmal tachycardia
iv. Anemia
v. Miscellaneous causeinfection,hypoglycemia ,hypocalcemia,
neonatal asphyxia, persistent fetal
circulation
.
Children
i. Rheumatic fever and rheumatic heart
disease.
ii. Conginital heart disease complicated by
anemia ,infection,endocarditis
iii. Hypertension ,myocarditis ,upper respi.
Obstruction.
CHF: Classification
New York Heart Association
functional classification
Class I: No limitation of physical activity
Class II: Slight limitation
Class III: Marked limitation
Class IV: Inability to carry out any physical
activity without discomfort.
CHF: Renin angiotensin system
activation
• Increase sympathetic tone
• Decrease parasympathetic tone
• Angiotensinogen
is
converted
into
angiotensin I with the help of renin
• Angiotensin I is converted into angiotensin
II by converting enzyme
CHF: Renin angiotensin system
Angiotensin II
• Stimulates aldosterone from the adrenals
• Aldosterone secretion results in sodium
accumulation & also produces arteriolar
constriction
CHF: Renin angiotensin system
Angiotensin II
• Increases ventricular pre- load & after-load
• Increases peripheral resistance
• Serves as growth factor producing myocardial
hypertrophy.
• Can produce fibrosis & myocyte loss by
enhancing apoptosis.
Symptoms of CCF
1.
2.
3.
4.
Poor weight gain
Difficulty in feeding
Breathes too fast
Breathes better when hold against the
shoulder
5. Persistent cough and wheezing
6. Irritability ,excessive perspiration,
restlessness
7. Pufiness of face ,pedal edema
Sign of CCF in infants
Right sided failure
Left sided failure
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Tachypnea
Tachycardia
Cough
Wheezes
Rales in the chest
• Hepatomegaly
• Facial edema
• Jugular venous engorgement
• Edema on feet
Failure of either side
• Cardiac enlargement
• Gallop rhythm(S3)
• Peripheral cynosis
• Small volume pulse
• Absence of weight gain
CHF: Medical Treatment
Principles of treatment
• Treatment of underlying disease
• Defining the stage of disease: LVEF and by
symptoms
• Intensity of care
CHF: Principles of treatment
• Reduce volume overload
• Reduce pre- load & after load
• Improve ventricular contractility
CHF: treatment of the cause
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•
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Hypertension
Ischaemic Heart Disease
Valvular Heart Disease
Congenital Heart Disease
CHF: precipitating causes
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Anaemia
Infection
Acute arrhythmias - AF
Poor compliance with treatment
Pulmonary embolism
Silent Myocardial infarction
CHF: treatment
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ACE inhibitors
Beta Adrenergic blockade
Spiranolactone
Loop diuretic
Digitalis
Anticoagulation ?
ACE Inhibitors & Betablockers
• Betablocker reverses remodeling
• ACE inhibitors improve vascular process
CHF: ACE inhibitors
• Improvement in vascular endothelial
function
• Stabilizing athero-sclerotic plaques by
reducing smooth muscle growth.
• Maximum tolerable dose is beneficial
CHF: ACE inhibitors
•
•
•
•
Captopril.
Enalapril .
Lisinopril .
Ramipril.
Pharmacological treatment of left
ventricular systolic dysfunction
• ACE inhibitors
• Hydralazine and Isosorbide dinitrate in
patients who can not take ACE inhibitors
• Digoxin not responding to ACEI & diuretic
Digoxin and diuretic dose in children
1. Digoxin
Age
Total digitalizing
dose(mg/kg)
Maintanence
dose(fraction digitalizing
dose /day)
Premature and infants
0.04
¼
1 month to 1 year
0.08
1/3 to ¼
1 to 3 yrs
0.06
1/3 to ¼
Above 3 yrs
0.04
1/3
2. Diuretics (frusemide)
Oral 2-3 mg /kg/day
Intravenous -1 mg/kg/day
3. Potassium chloride
(liq) 1mg/kg/day
Pharmacological treatment of left
ventricular systolic dysfunction
• Digoxin in AF
• Diuretic for patients with fluid overload
• Anticoagulation in AF, previous history of
pulmonary embolism
• Beta-blockers after an acute MI
Pharmacologic Treatment of Left
Ventricular Diastolic Dysfunction
• Diuretic
• Nitrates
• Drugs suppressing AV conduction to
control ventricular rate in patients with AF
• Anticoagulation in patients with AF or
previous systemic or pulmonary embolism
Activity recommendation in CHF
• Regular exercise for all patients with sable
NYHA class I- III heart failure
Diet: CHF
• Diet : sodium 2 gm/ day
• Not more than one drink per day