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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 cause-
     infection,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. Poor weight gain
2. Difficulty in feeding
3. Breathes too fast
4. 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
                         • Hepatomegaly
                         • Facial edema
•   Tachypnea
                         • Jugular venous engorgement
•   Tachycardia
                         • Edema on feet
•   Cough
                         Failure of either side
•   Wheezes
                         • Cardiac enlargement
•   Rales in the chest
                         • 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   Maintanence
                           dose(mg/kg)          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