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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 • • • • • 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 • • • • Hypertension Ischaemic Heart Disease Valvular Heart Disease Congenital Heart Disease CHF: precipitating causes • • • • • • Anaemia Infection Acute arrhythmias - AF Poor compliance with treatment Pulmonary embolism Silent Myocardial infarction CHF: treatment • • • • • • 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