Dr Christie De Silva

MD.FRCP(Lond) FCCP
Definition
Types
Clinical manifestations
Causes
Pathophysiology
Diagnosis
Treatment

Failure of the heart to maintain adequate
perfusion to tissues in spite of adequate
venous return
Acute or Chronic heart failure
Left heart failure
Right heart failure
Congestive cardiac failure
Systolic dysfunction EF <40%
Diastolic dysfunction



Symptoms

Dyspnoea on effort .NYHA Class I-!V
Fatigue
Shock-if acute

Signs

Tachycardia
Pulsus alternans
Triple rhythm S3
Cardiomegaly
Basal crepitations


Dyspnoea

JVP elevated
Liver enlargement
Oedema


Ischaemic heart disease
Hypertension
Rheumatic heart disease
Cardiomyopathies-dilated,hypertrophic
restrictive
Thyrotoxicosis
Severe anaemia
A-V fistula
Pump failure
Vasoconstriction-sympathetic overactivity
Remodelling of myocardium
Renin-Angiotensin-aldosterone
ADH
BNP.Brain Natriuretic Peptide .ANP
Venous congestion-preload
Clinical late 50% sensitive
-history,examination,ECG,CXR
2D-Echocardiography-EF < 40%,<35%
Plasma BNP levels
A. Non- pharmacological
Bed rest/exercise
Diet <2gm salt
Avoid alcohol
Avoid certain drugs-
verapamil,diltiazem,beta blockers(some)
Thiazolidenediones.(eg.pioglitazone) ,sildenafil
NSAIDs
Treat precipating factors-infection,arrhythmias,
Treat underlying heart disease

B. Pharmacological

ACE Inhibitors-remodelling, vasodilatory,
Diuretics-frusemide,hydrochlorothiazide
metolazone---preload
Beta-blockers-sympathetic activity,
remodelling
Digoxin-inotrope
ARBs-Angiotensin receptor blockers
Spironolactone- block aldosterone
Vasodilators-hydrallazine + nitrates--afterload
Anticoagulation-warfarin EF<15-20%


Captopril 6.25mg tds start----50mg tds
Enalapril 2.5mg daily--------10mg bd
Lisinopril 2.5mg -----20mg bd daily
Ramipril 1.25mg -------10mg daily
Frusemide 40mg oral -80mg
IV -------upto 200mg daily
Bumetanide-1mg ----upto 5mg daily
Hydrochlorothiazide HCT 50-100mg daily
Metolazone 5mg upto 20mg
Give K supplements
KCl or Addi-K

Metoprolol 6.5 mg bd upto 50mg bd
Carvedilol 3.125 mg bd upto 25-50mg bd
Bisoprolol 1.25mg daily upto 5-10mg

Start with low doses .several weeks
NYHA Class II III IV
Oral-1-1.5mg in divided doses over
24hrs
IV- 0.75-1.0mg over at least 2 hrs
Maintain on 0.125mg to 0.25mg daily

K supplements
Digoxin levels
Losartan 25mg--------100mg daily
Candersartan 8mg--------16 mg daily
Valsartan 80mg ------160mg daily

25-50mg/day

Class IV dyspnoea-NYHA\






Combination of hydrallazine + nitrates
Hydrallazine 25mg tds to 100mg tds
ISDN 40mg tds
ISMN 40-120mg /day
Amlodepine 5mg daily
Ventricular assist devices
Intra-aortic baloon pump
Cardiac transplantation
Prop up
Oxygen 100%
Morphine 2.5mg to 5mg IV repeat
Frusemide 40-80mg IV repeat
10-20mg/min IV infusion
GTN IV infusion -10mcg/min upto 200mcg/min
Captopril 6.25mg tds and increase
Dobutamine 5-15mcg/kg/min
Dopamine 5-15 mcg/kg/min
Mechanical ventilation
Intra aortic balloon pump
haemodialysis