Congestive heart failure

Done by: group A

Presented by : Ramlah Al-khalifah
2062040008
 The case

70 years old man presented with a two months
A
history of progressive dyspnea on exertion. In the
past two weeks, he has observed paroxysmal
nocturnal dyspnea and three pillow orthopnea. His
feet have been swollen for about a week and he
also has swelling of his abdomen.
 On examination he was breathless at rest, JVP
was raised 12cm, pulse rate was 110/min and it
was irregularly irregular. Blood pressure was
130/90 mmHg .
 The case (cont.)
 apex beat was in the 6th left intercostal space 2cm
outside the mid-clavicular line. Heart sounds 1st
and 2nd were heard and there was a 3rd heart
sound. There were crepitations in both lung bases.
The liver was palpable 4cm below the costal
margin and it was tender. There was peripheral
edema and minimal ascites. Chest x-ray showed a
large heart and opacities in both lung bases. An
ECG confined atrial fibrillation.
Problem list
:History
month progressive dypsnoea on exertion 2 ♦
Last 2 wk PND ♦
Three pillow orthopnea ♦
.Swelling of feet & abdomen for 1 week ♦
Problem list (cont.)
: O/E
Breathless at rest
JVP = 12 cm
Pulse =110/min
Apex beat= 6th lt. intercostals space , 2 cm outside mid-clavicular
.line
Crepitation on both lung bases
Tender palpable liver 4 cm below the coastal margin
Peripheral edema & minimal ascites
Chest X-ray showed a large heart &opacity in both lung bases
ECG confined atrial fibrillation
 Diagnosis
Congestive heart failure

left Right
Excertional dyspnea - Jugular venous distention-
Orthopnea - Hepatomegally -
Paroxismal nocturnal - Edema (pitting) -
dyspnea Ascitis -
Cardiomegally - S3-
Displaced sustained -
Tachycardia -
Basal lung crackles -
Pulmonary edema -
The pathophysiology
:Definition
Congestive heart failure (CHF) is a condition when
abnormality of cardiac function is responsible for
inability of heart to pump blood at a rate required by
.tissues
:Etiology
cardiomyopathy
 The pathophysiology (cont.)
Reduce Cardiac output
 low renal perfusion  increase renin production  increase
angiotensin 
stimulation of aldosterne  Na and fluid retention  -1
increase in venous return  increase in pre-load
peripheral vasoconstriction ( increase in after load and -2
pre-load)

 low carotid sinus flow  increase in the sympathetic activity to

maintain ventricular contractility  tachycardia and increase
in total peripheral resistance
Therapeutic objectives
: Control heart failure
.reverse effect of RAS -
Control of excessive fluid retention -
.- Enhancement of myocardial infarction
 treat fluid retention (Diuretics )

total cost suitability safety efficacy drugs

12 ++ +++ +++ ++++ Loop

diuretics

8 ++ ++ ++ ++ Thiazide

6 + + ++ ++ K-sparing

p-group is: Loop diuretics

 Diuretics (Loop diuretics)

total cost suitability safety efficacy drugs

12 +++ ++++ ++ +++ Furosemide

10 ++ +++ ++ +++ Bumetanide

8 ++ ++ ++ ++ Torasemide

p-drug: furosomide
reverse effect of RAS (ACEI)
total cost suitability safety efficacy drugs

11 +++ +++ ++ +++ Captopril

9 ++ ++ ++ +++ Enalapril

10 +++ +++ ++ ++ Lisinopril

-captopril: drug is P
due to it is fast onset & reach to steady state very rapidly
 Digoxin
:Mechanism of action
inhibit Na-k ATPase pump on cardiac cell membrane ---increase intracellular Na----
reduce electrochemical gradient ---extrusion of intracellular Ca by Na/Ca
exchange---Ca is stored in sarcoplasmic reticulum &when release lead to increase
of myocardial contractility

Used for : congestive heart failure & atrial fibrillation

:Side EFFECT
usually associated with excessive dosage-
GIT: Anorexia ,nausea, V/D ,abdominal pain
CNS: visual disturbance ,headache ,fatigue, delirium
CVS: arrhythmia heart block
 Supportive measures

:Bed rest
To decrease work load on the heart

O2 therapy
prescription
Name : Age : 70 years
Sex : M Date :
MR#
Dx: congestive heart failure

Px:
captopril 25 mg tablet p.o 1 tab TID 1 week -
- Furosomide 250mg, IV over 1 hr
- Digoxin 1.5 mg tablet OD

Dr’s Name:
:signature
 Instructions
Life style modification : bed rest & exercise ♦
Increase potassium intake ♦
Low Na intake ♦
Low fat diet ♦
Follow up (2 weeks) ♦
Thank you