Congestive Heart Failure 

Congestive Heart Failure

Question. Give definition, etiology, sign and symptoms, investigation and treatment of congestive cardiac failure.
Or
Write clinical features, investigations and treatment of congestive cardiac failure.
Or
Write a short note on congestive cardiac failure.
Or
Write signs and symptoms of congestive cardiac failure.
Or
Describe in brief, congestive cardiac failure

Answer.

It is defied as a pathophysiologic state when heart is not able to maintain its cardiac output to meet the demands of metabolizing tissues or can do so only at the expense of elevating filing pressures. In congestive cardiac failure, patient has features of both right­ and left­sided heart failure.

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Etiology

Left-sided Failure congestive cardiac failure.

1. Myocardial damage:

1. Myocardial infarction
2. Myocarditis
3. Cardiomyopathy
4. Cardiac depressant drugs.

2. Increased load:

1. Hypertension
2. Mitral and aortic valve disease
3. Cardiac arrhythmias
4. Over transfusion.

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Right-sided Failure congestive cardiac failure.

1. Pulmonary hypertension:

1. Secondary to left heart failure
2. Chronic lung disease
3. Pulmonary embolism
4. Left­to­right shunts.
5. Primary pulmonary hypertension.
6. Right ventricular infarction.
7. Pulmonary and tricuspid valve disease
8. Isolated right ventricular cardiomyopathy.

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Signs And Symptoms/ Clinical Features Congestive Cardiac Failure.

Left-sided Failure Congestive Cardiac Failure.

1. Common respiratory signs are tachypnea (increased rate of breathing) and increased work of breathing (non-specifi signs of respiratory distress).
   Rales or crackles, heard initially in the lung bases, and when severe, throughout the lung filds suggest the development of pulmonary edema (flid in the alveoli). Cyanosis which suggests severe hypoxemia, is a late sign of extremely severe pulmonary edema.
2. Additional signs indicating left ventricular failure include a laterally displaced apex beat (which occurs, if the heart is enlarged) and a gallop rhythm (additional heart sounds) may be heard as a marker of increased blood flw, or increased intracardiac pressure.
   Heart murmurs may indicate the presence of valvular heart disease, either as a cause (e.g. aortic stenosis) or as a result (e.g. mitral regurgitation) of the heart failure.
3. Backward failure of the left ventricle causes congestion of the pulmonary vasculature, and so the symptoms are predominantly respiratory in nature.
4. Patient will have dyspnea (shortness of breath) on exertion and in severe cases, dyspnea at rest.
5. Increasing breathlessness on lying flt, called orthopnea, occurs. It is often measured in the number of pillows required to lie comfortably, and in severe cases, the patient may resort to sleeping while sittng up.
6. Another symptom of heart failure is paroxysmal nocturnal dyspnea a sudden night time attck of severe breathlessness, usually several hours after going to sleep.
7. Easy fatigability and exercise intolerance are also common complaints related to respiratory compromise.
8. Cardiac asthma or wheezing may occur.
9. Compromise of left ventricular forward function may result in symptoms of poor systemic circulation such as dizziness, confusion and cool extremities at rest.

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Right-sided Failure Congestive Cardiac Failure.

1. Physical examination may reveal pittng peripheral edema, ascites, and hepatomegaly.
2. Jugular venous pressure is frequently assessed as a marker of flid status, which can be accentuated by eliciting hepatojugular reflx.
3. Backward failure of the right ventricle leads to congestion of systemiccapillaries. Thisgenerates excessflid accumulation in the body.
   This causes swelling under the skin (termed peripheral edema or anasarca) and usually affects the dependent parts of the body fist (causing foot and ankle swelling in people who are standing up, and sacral edema in people who are predominantly lying down).
4. Nocturia (frequent night time urination) may occur when flid from the legs is returned to the bloodstream while lying down at night.
5. In progressively severe cases, ascites (flid accumulation in the abdominal cavity causing swelling) and hepatomegaly (enlargement of the liver) may develop.
6. Signifiant liver congestion may result in impaired liver function, and jaundice and even coagulopathy (problems of decreased blood clottng) may occur.

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Investigation Congestive Cardiac Failure.

1. Electrocardiogram (ECG): This will reveal arrhythmias, ventricular hypertrophy and myocardial ischemia.
2. Chest X-ray: This will show enlargement of heart, peripheral lung congestion, presence of Kerley’s lines, pulmonary edema, hydrothorax, pulmonary hypertension, double atrial shadow in mitral valve disease and calcifiation of valves.
3. Echocardiogram: In this ultrasound is used to image the heart muscle, valve structures, and blood flw pattrns.
   The echocardiogram is very helpful in diagnosing heart muscle weakness.
   In addition, the test can suggest possible causes for the heart muscle weakness (for example, prior heart attck, and severe valve abnormalities).
   Virtually all patients in whom the diagnosis of congestive heart failure is suspected should ideally undergo echocardiography early in their assessment.
4. Nuclear medicine studies assess the overall pumping capability of the heart and examine the possibility of inadequate blood flw to the heart muscle.
5. BNP or B-type natriuretic peptide level: This level can vary with age and gender but is typically elevated from heart failure and can aid in the diagnosis, and can be useful in following the response to treatment of congestive heart failure.
6. Blood urea and electrolytes: It is done for hypokalemia,hyponatremia and renal failure,

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Treatment Congestive Cardiac Failure.

1. Rest: Complete bed rest is the key stone of management.
   When the patient is dyspneic, bed rest is given with the head end of bed raised to 45°.
   The legs should be kept below the pelvis to prevent the flid present in legs to return to vascular system and precipitate pulmonary edema.
2. Diet: Basic aim is to restrict sodium in the diet. Quantity of salt intake per day should not exceed 0.5 gm.
   Salt substitutes may be used to make diet more palatable.
3. Diuretics: In cardiac failure, there is always sodium and water retention. Hence, diuretics are given to increase sodium extraction.
   Furosemide 40–80 mg orally produces effct in 4–6 hours and on IV administration of furosemide 40–100 mg produces its effct in 20 minutes.
   Spironolactone which is potassium sparing diuretic is given 25 mg orally 4 times a day which removes the symptoms such as hypokalemia due to action of furosemide.
   Triamterene or amiloride hydrochloride is given along with spironolactone.
4. Digitalis: It increases the force of myocardial contraction and decreases work of heart. The commonly used drug is digoxin which is administered orally 0.25 mg BD.
   For rapid digitalization digoxin 0.5–0.75 mg is given slow IV over a period of 5–10 minutes under electrocardiographic control.
5. Sympathomimetic amines: Dopamine at low doses of 3–5 μg/kg / min increases contractility of heart.
6. Vasodilators: Sodium nitroprusside in the dose of 5–10 μg/min have balance dilator effct. Besides this hydralazine,nitrates and ACE inhibitors are used.
7. Inodilator levosimendan: This is a calcium channel sensitizer.
   It has positive inotropic and vasodilator effct.
   It is given IV with loading dose of 6–12µg/kg/min over 10 min followed by infusion 0.05 to 2 µg/kg/min infusion.
8. Oxygen: It is given via Woulfe’s bottle at rate of 5–8 L/min.
9. Miscellaneous drugs: Tranquilizers such as diazepam 2 to 5mg TDS are given to reduce anxiety.
10. Cardiac re-synchronization therapy or biventricular pacing: It is used in patients with symptomatic refractory cardiac failure with conduction abnormality or Left Bundle Branch Block.
    This therapy involves pacing the right atrium, right ventricle and left ventricle to improve synchrony of thecardiac chambers.
11. Left ventricular assist device: Devices such as Intra­aortic balloon pump, Impella device, Heart­Mate, Thoracic are considered when medical management fails. They are usually used as a bridge to cardiac transplant.