Congestive Heart Failure

Mulualem W.MD
DMU,DEPARTMENT OF INTERNAL
MEDICINE
FOR HO STUDENTS
Congestive heart failure
 Heart failure : inability of the heart to pump
an adequate amount of blood to the body
relative to the body’s demand.
 Congestive heart failure : state in which

abnormal circulatory congestion existsas a

result of heart failure.
-Backward vs forward HF
-Left vs right HF
-Highoutput vs lowoutput HF
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 Causes

 Impaired myocardial contractility

 Increased ventricular stiffness or impaired
myocardial relaxation
 Others:
 valve disease
 Intra cardiac shunting
 Disorders of heart rate or rhythm
 Increased peripheral blood flow or metabolic
requirements
Precipitating factors for heart failure
 The most important precipitating factors may be represented
with the mnemonic, HEART FAILES
H- Hypertension (systemic)
E- Endocarditis (infections)
A- Anemia
R- Rheumatic fever and myocarditis
T- Thyrotoxicosis and pregnancy
F- Fever (infections)
A- Arrhythmia
I- infarction (myocardial)
L- Lung infection
E- Embolism (pulmonary)
S- Stress (emotional, physical, environment, dietary, fluid excess)
Manifestations of heart failure …

 Dyspnea
 Orthopnea
 Paroxysmal Nocturnal Dyspnea
 Fatigue and weakness
 Cheyne-Stokes respiration
 Physical Findings
 ↑ JVP or positive hepato jugular reflux
 S3 gallop
 pulmonary rales
 Edema
Diagnosis of heart failure
 Hx
 P/E
 Ix
 Framingham criteria(Hx &P/E)
 Major criteria Minor criteria
 PND Exterimity edema
 Neck vein distention Night cough
 Rales Dyspnea on exertion
 Cardiomegally Hepatomegally
 Acute plumonary edema Pleural effusion
Con`t
 S3gallope VC reduced
by1/3
 Increased venous pressure Tachycardia
 Positive hepato jugullar reflex

 Dx by atleast 1Mj and 2Minor criterias

NYHA classification
Class1 : Without limitation of physical activity.
ordinary PA doesnot cause fatigue,palpitation,dyspnea
or anginal pain
Class2 : Slight limitation of PA
Comfortable at rest
Ordinary activities case fatigue,palpitation,dyspnea or
angina.
Class3 : Marked limitation of PA
Comfortable at rest
Less than ordinary activities cause Sx
Class 4:Inability to carry out ordinary activities W/O
discomfort.
Sx present at rest.
Stages of heart failure

Stage A:At risk of developing HF but with out

disease or Sx of HF
e.g pt with HTN,DM
Stage B:Structural heart disease without Sx of HF
e.g pt with previus MI or Asx LV
dysfunction
StageC:Structural heart disease ,Sxtic
e.g pt with previous MI with dyspnea & fatigue
Stage D:Pt with refractory HF requiring special intervention
e.g pt with refractory Hf requiring cardiac
transplantation
Treatment
 Prevent HF
 Prevent disease progression wtth drugs
 Sxic managment
 Therapy depending on NYHA classification

Asxit(class 1) -Rx slow disease progression(By

blockig neuro hormonal systems that
lead tocardiac remodelling)
Sxtic(class 2-4)-Alleviate fluid retention
-Lessen disability
-Decrease risk of further disability
Principles of managment
 General measures
 Identification and treatment of prcipitating

factors
 Control of congestive state
 Improve myocardial performance
 Prevention of deterioration of myocardial

function
 Treatment of underlying cause
General measures
 Rest and positioning
 Screen for and treat comorbidities
 Aviod drugs that worsen HF:NSAIDS
 Dietary salt restriction(<3g/day)
 Fluid restriction(<21days)
 Caloric supplementation:pt with advanced HF

&weight loss
Activity and life style modification
 Control of congestive state.
Diuretics
relive congestion and prevent edema
Cntrl fluid retension in advanced HF
Loop diuretics
Addition of thiazide diuretics to loop diuretics
Enhancing myocardial activity
 Digoxine: ionotropic effect
 Neurohormonal modulation
 Pt with Sxtic lv systolic dysfunction esp if they

have atrial fibrillation

 Pt who have Sx&Stm of HF while recieving

standard treatment(ACEI+Bblocker)
vasodilators
 In pt with sever acute HF with systemic
vasoconstiction despite ACE therapy
 decreased peripheral resistance and after
load
improve cardiac perfomance

hydralizine
Isosorbide
dinitrate
D. Prevention of deterioration of myocardial
function and disease progression
 By inhibiting the neurohormonal measures
which cause cardiac remodelling and
progression of HF
 DRUGS THAT INTERFERE WITH EXCESS

ACTIVATION OF RAAS AND ADRENGIC NS

◦ ACEIs
Afterload reduction and neurohormonal modulation
DRUGS captopril, Enalaprin
Anti coagulant and antiplatlet
therapy
 Pts with HF have an increased risk of
thromboembolic events
 Decreased LV function promote stasis of

blood in dilated cardiac chambers with

increased risk of thrombus formation
◦ Warfarin
.
◦ Aspirin
 HF pts with MI
Mngt of acute HF
 Goals
◦ Stabilization of hemodynamic derangements that
proceed the signs
◦ Identification and Rx of factors that precipitated
decompensation
◦ Prevention of d’se progression and relapse
 Vasodilators
◦ IV vasodilators
 Nitroglycerin
 Nitrorusside............ Dilatation of arterial resistance
and venous capacitance..........
 Lowering of LV filling pressure and improve forward COP
S/E... Hypotension and hypoxia
.
 Ionotopic agents
◦ Stimulate contrality and produce vasodilation.........
Increasing COP
◦ Eg dobutamine and Milirinone
 Vasoconstrictors
Dopamine...... B- agonist, increase contractility and
selective renal vasodilator
Mechanical and surgical
interventions
 If physiologic intrevention fail to estabilize
the pt with refractory HF
General measures
 Rest
 Positioning
 Diatry salt restriction( >3g/dl)
 Fluid restriction (<2g/day)
 Avoid extrem tempratures, cessation of

smoking, limitation of alcohol intake

 PPV along with other drugs
Specific measures
1. Enhance myocardial contractility
2. Removal of excessive retained fluid and
NA+
3. Identification and Rx of precipitating factors
4. Correction of underlying cause/s
Underlying causes
1. Decrease contraction.............. VHD, CHD,
CMP
2. Increased preload.............. Systemic HTN
3. Abnormalities in preload............ Excessive/
decreased
4. decreased compliance states..........
Constictive precarditis, RCMP
References
 Harrison`s principles of internal medicine
.

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