Savannah Pantoja

Congestive Heart Failure

ESSAY OBJECTIVE: To Find out what Heart Failure is, what causes it,
the associated symptoms and the various treatments modalities.

Congestive Heart Failure

Introduction
Heart ailments are becoming a common occurrence in our country. The various conditions
associated with the heart affect populations of all kinds. Congestive heart failure is quickly
becoming a leading cause of morbidity and mortality in many patients. More funds are being
channeled into research for the various treatment modalities of the condition. This is in the hope
that better control is going to be achieved and eventually the levels of the condition among
various populations will go down. This paper aims to find out what Heart failure is concerned
with, what causes it and the treatment modalities available in the market.

Definition

Heart Failure is a clinical syndrome that occurs in patients who, because of an inherited or
acquired abnormality of cardiac structure and/or function, develop a constellation of clinical
symptoms (dyspnea and fatigue) and signs (edema and rales) that lead to frequent
hospitalizations, a poor quality of life, and a shortened life expectancy. This abnormality is
responsible for the inability of the heart to eject or fill with blood at a rate commensurate with
the requirements of the metabolizing tissues.

Forms of Heart Failure

Systolic vs. diastolic failure which involves the Inability of the ventricle to contract
normally and expel sufficient blood vs. its inability to relax and fill normally.

Low vs. high-output heart failure: Low-output HF occurs secondary to ischemic heart
disease, hypertension, dilated cardiomyopathy, and valvular and pericardial disease,
while high-output HF occurs in patients with reduced systemic vascular resistance, i.e.,
hyperthyroidism, anemia, pregnancy, arteriovenous fistulas, beriberi, and Paget's disease.

Acute vs. chronic heart failure

Right-sided vs. left-sided heart failure

Etiology

Myocardial contraction dysfunction which may be primary or secondary.

Normal myocardial function with hemodynamic problems which can be Acute or

Chronic.

A combination of the above two.

Underlying causes such as Ischemic heart disease, Cardiomyopathies, Congenital heart

disease, Valvular heart disease and Hypertensive heart disease.

Right sided heart failure which Causes Left sided failure.

Precapillary obstruction mainly caused by Congenital (shunts, obstruction) and Idiopathic

pulmonary hypertension.

Primary right ventricular failure.

Cor pulmonale as a result of Hypoxia induced vasoconstriction, Pulmonary embolism or

COPD

Left sided heart failure.

Volume over load as a result of a Regurgitant valve or High output status.

Pressure overload due to Systemic hypertension or Outflow obstruction.

Loss of muscles

Restricted Filling due to pericardial diseases, Restrictive cardiomyopathy and

tachyarrhythmia.

Precipitating causes such as Infection, Arrhythmias, Physical, Dietary, Fluid,

Environmental, and Emotional Excesses.

Myocardial Infarction.

Pulmonary Embolism.

Anemia.

Thyrotoxicosis and Pregnancy.

Aggravation of Hypertension.

Rheumatic, Viral, and Other Forms of Myocarditis.

Infective Endocarditis.

Signs and symptoms of congestive heart failure

General Appearance and Vital Signs may include:

Dyspnea

Orthopnea

Paroxysmal Nocturnal Dyspnea

Fatigue and weakness

Cheyne - Stokes respiration-most often in patients with cerebral atherosclerosis and other
cerebral lesions.

Abdominal symptoms- Anorexia, nausea, abdominal pain and fullness.

Cerebral symptoms- confusion, difficulty in concentration, impairment of memory,

headache, insomnia, and anxiety, nocturia.

Physical findings include:

Tachycardia

High diastolic BP & occasional decrease in systolic BP (decapitated BP)

Jugular venous distension

Displaced and sustained apical impulses

Third heart

Hydrothorax and Ascites

Cardiac edema- pretibial region and ankles, sacral, arms and face though rare

Congestive Hepatomegaly.

Jaundice.

Cardiac Cachexia-serious weight loss.

The pulse pressure may be diminished, reflecting a reduction in stroke volume.

Sinus tachycardia is a nonspecific sign caused by increased adrenergic activity.

Other Manifestations are the extremities may be cold, pale, and diaphoretic. Urine flow is
depressed, impotence and depression are common.

In mild or moderately severe Heart Failure, the patient appears in no distress at rest,
except for feeling uncomfortable when lying flat for more than a few minutes. In more

severe Heart Failure, the patient must sit upright, may have labored breathing, and may
not be able to finish a sentence because of shortness of breath.

Peripheral vasoconstriction leading to cool peripheral extremities and cyanosis of the lips
and nail beds.

Examination of the jugular veins provides an estimation of right atrial pressure. In the
early stages of HF, the venous pressure may be normal at rest but may become
abnormally elevated with sustained (~1 min) pressure on the abdomen (positive
abdominojugular reflux).

Investigations

Recommended initial laboratory tests include

CBC, UECs, LFTS, FBG, TFTs and Iron studies.

ANA
Viral studies in case of myocarditis
Plasma BNP
Thiamine levels

Imaging modalities involved are chest x-ray and echocardiogram

Treatment

The main principles are to Identify and treat precipitating cause, to treat underlying cause and
finally Treatment of Heart Failure per se.
The aims of treatment are to improve survival and the Quality of life and symptom control
and Prevention.
Treatment may be Pharmacologic or non pharmacologic.

Pharmacological Treatment

Diuretics

Aldosterone receptor antagonists

Angiotensin-converting enzyme inhibitors

Angiotensin receptor blockers

Beta blockers

Cardiac glycosides

Vasodilators e.g. Hydralazine which is given to patients with Intolerance to ACEI/ARB

Beta agonists e.g. dopamine

Bipyridines

Natriuretic peptide

Digitalis glycosides Improves symptoms and reduces hospitalizations

ALDOSTERONE

Main side effect, gynaecomastia/breast pain

There is no role of NO ROLE Calcium Channel Blockers, or Alpha Blockers.

A stepwise approach would be to begin with ACE inhibitors or ARBs and then if there is fluid
congestion, a diuretic is added. Once t6he patient is stable introduce Beta Blockers. If the patient
is still symptomatic, Aldosterone is added together with Digitalis.
There is no routine use for Positive inotropes.

Non-Pharmacological therapy

This is indicated both for the underlying cause and Heart failure.
Cardiac Surgery which may involve Transplantation, MV surgery, Ventriculectomy or a
Definitive corrective surgery.
Revascularization is also another approach
Cardiac Pacing, specifically biventricular also known as cardiac resynchronization therapy
(CRT) may also be applied.
In conclusion the major steps in management of patients with chronic heart failure are:

Reduce work load of the heart by limiting activity level of the patient, reducing the
patients weight and control of hypertension
Restrict sodium
Restrict water
Give diuretics

Conclusion

Despite many recent advances in the evaluation and management of HF, the development of
symptomatic HF still carries a poor prognosis.
Community based studies indicate that 3040% of patients die within 1 year of diagnosis and
6070% die within 5 years, mainly from worsening HF or as a sudden event (probably
because of a ventricular arrhythmia).
Although it is difficult to predict prognosis in an individual, patients with symptoms at rest
[New York Heart Association (NYHA) class IV] have a 3070% annual mortality rate,
whereas patients with symptoms with moderate activity (NYHA class II) have an annual
mortality rate of 510%. Thus, functional status is an important predictor of patient outcome
(see Table 227-2).

References

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