Congestive Heart

Failure
PMH 125

T. M. SONGOLO
Congestive heart failure (CHF)
• complex, progressive disorder in which the heart is unable to
pump sufficient blood to meet the needs of the body
• HF is due to an impaired ability of the heart to adequately fill
with and/or eject blood
• accompanied by abnormal increases in blood volume and
interstitial fluid, hence the term congestive HF
CAUSES OF HEART FAILURE
• Coronary Artery Disease
• Untreated High Blood Pressure
• Faulty Heart Valves
• Cardiomyopathy
• Lung Disease
• Diabetes
• Infections
• Alcoholism
Types of Heart Failure
1. Systolic Dysfunction (Contraction) 2/3 of Patients
• The heart becomes weak and enlarged
• The weakened heart muscle can’t contract
• Not enough blood is pumped from the chambers
2. Diastolic Dysfunction (Relaxation)1/3

• Stiff heart muscle can’t relax

• Not enough blood fills the chambers
• so less blood goes to the lungs and body
SYMPTOMS AND SIGN OF HEART FAILURE
Symptoms are:
• shortness of breath (indicates lung congestion and therefore left-
sided heart failure)
• tiredness/lethergy (+ only able to walk limited distance)
• swelling of ankles and pitting to the knees (indicates right-sided
heart failure).
Signs are:
• increasing weight due to increased fluid retention
• cardiomegaly on CXR
• basal crackles in both lungs (indicate fluid retention in the lungs due
to left sided heart failure)
• increased JVP
New York Heart Association classification of heart failure

• I No symptoms with ordinary physical activity

• II Slight limitation with dyspnoea on moderate to severe
exertion
• III Marked limitation of activity: less than ordinary activity
causes dyspnoea
• IV Severe disability, dyspnoea at rest
MANAGEMENT OF HEART
FAILURE
• Lifestyle modifications
• Pharmacotherapy
Lifestyle modifications
• Restrict salt and water
• Restrict physical activities
• No smoking, drinking alcohol
• Nutrition
PHARMACOTHERAPY MANAGEMENT OF
CHF
Goals of intervention;
• To alleviate symptoms.
• Slow disease progression, and improve survival
1. Angiotensin-converting enzyme (ACE) inhibitors
• are the agents of choice in HF
• Early use of ACE inhibitors is indicated in patients with all stages of
left ventricular failure
• Adverse effects: These include postural hypotension, renal
insufficiency, hyperkalemia, angioedema, and a persistent dry
cough.
• ACE inhibitors should not be used in pregnant women, because
they are fetotoxic.
Angiotensin-receptor blockers;
e.g losartan, candesartan, valsartan
• have the advantage of more complete blockade of angiotensin action
• do not affect bradykinin levels
• substitute for ACE inhibitors in those patients with severe cough or
angioedema.
• A/E: postural hypotension, renal insufficiency, hyperkalemia
• Contraindicated in pregnancy
Beta-blockers
e.g metoprolol, carvedilol
• Beneficial effect on morbidity and mortality in all grades of heart
failure as an adjunct to ACEIs
• Treatment should be started at low doses and gradually titrated to
effective doses based on patient tolerance
• A/E; bradycardia, fatigue and loss of libido
Diuretics
• Control of sodium and water retention they by reducing symptoms of
heart failure (e.g dypsnoea and oedema)
• Loop diuretics e.g bumetanide ,furosemide and thiazide diuretics can
also be used
• Diuretics decrease plasma volume and, subsequently, decrease
venous return to the heart. This decreases the cardiac workload and
the oxygen demand.
• Diuretics may also decrease afterload by reducing plasma volume,
thus decreasing blood pressure
• Vasodilator
• Hydralazine in combination with isosorbide dinitrate has been
associated with significant improvement in morbidity and mortality.
• The combination of hydralazine plus nitrate has mainly been
Alternative for patients who show intolerance to an ACEI and ARB
• Side effects; postural hypotension, headache or dizziness. Systemic
lupus erythematosus: appearance of a rash on the face (shaped like
a butterfly) or neck.
Aldosterone antagonist
• Spironolactone is a direct antagonist of aldosterone, thereby
preventing salt retention, myocardial hypertrophy, and hypokalemia.
• Spironolactone therapy should be reserved for the most advanced
cases of HF
• Have beneficial effect on morbidity and mortality in patients with
heart failure.
• A/E; gastric disturbances, such as gastritis and peptic ulcer; cns
effects, such as lethargy and confusion; and endocrine
abnormalities, such as gynecomastia, decreased libido, and
menstrual irregularities.
DIGOXIN
• Has a neutral effect on mortality, but is associated with a reduction
in hospital readmission rate
• It also improves cardiac output in HF with atrial fibrillation
• Increasing contraction of the atrial and ventricular myocardium
(positive inotropic action)
• A/E: digoxin toxicity causing arrhythmia, headache, fatigue,
confusion, blurred vision
TREATMENT OF HEART FAILURE
Functional status Drug therapy indicated
of patient (NYHA)

Class I Asymptomatic Mostly lifestyle modifications

Class II Captopril 12.5mg to 25mg bd or
Lisinopril 5-10mg po od or
Enalapril 5-20mg daily orally
Hydroclorothiazide 25mg daily or
Furosemidde 20-40mg daily
Carvedilol 3.125mg bd po then increase
dose every 2 weeks to 25mg twice daily
Class III Captopril 25mg bd or tds or
Lisinopril 10mg to 20mg od or
Enalapril 5mg to 20mg od po
Furosemide 40-80mg bd
Digoxin 0.125mg- 0.25mg daily
Isosorbide dinitrate 5-10mg bd +
hydralazine 25-50mg bd if patient cant
tolerate ACE inhibitors
Acetylsalicylic acid 75mg od
Functional status Drug therapy indicated
of patient (NYHA)

Class IV As indicated for class III plus the following;

Furosemide I.V 40-80mg od or bd
Spironolactone 25mg- 50mg once or twice
daily po
Beta blockers should not be used.