Congestive Heart Failure

Notes
  • It affects about 23 million people globally.
  • The heart is unable to pump blood adequately to maintain the flow to meet the requirement of the body.
  • Causes of CHF include: infections, idiosyncratic cardiomyopathy, myocardial infarction, hypertension, atrial fibrillation, valvular heart disease, anaemia, pulmonary thromboembolism and excess consumption of alcohol.
  • Precipitating factors of CHF include: pregnancy and poor compliance to drug treatment
Symptoms
  • Dyspnea (mainly due to Left ventricular failure) that is worsened by the exercise but also present when the patient is lying down. The patient may be awoken by this dyspnea at night.
  • Raised jugular vein pressure (JVP)
  • Tachycardia
  • Gallop rhythm (three or four sounds)
  • Tender hepatomegaly
  • Basal crepitations / crackles / rales
  • Swelling of the ankles and legs (mainly due to right ventricular failure)
  • Excessive feeling of tiredness
Diagnosis
  • History and physical examination
  • Haemogram;
  • Urea and electrolytes
  • Electrocardiography (ECG)
  • Chest radiography
  • Echocardiography
Differential
  • Acute Respiratory Distress Syndrome
  • COPD/pulmonary fibrosis
  • Deep venous thrombosis
  • Emphysema
  • Myocardial Infarction
  • Pneumonia
  • Pulmonary embolism
  • Venous stasis
Prevention
  • Lifestyle modifications that include
  •   Dietary changes
  • Cessation of smoking
  • Physical exercise 
  • Control of hypertension
Management
  • Lifestyle modifications that include: dietary changes, cessation of smoking and physical exercise.
  • Oxygen in case where the patient is cyanosed.
  • Restrict salt-intake
  • Bed rest in cardiac position
  • Weight monitor
  • Pharmacological Management

Treatment of underlaying disease such as hypertension

Frusemide ; 40-160mg OD orally (or higher doses)

Digoxin : When symptoms are mild, slow digitalization is safer and just as effective as the rapid method. If symptoms are moderately severe, the rapid oral method may be used, but the patient should be examined before each dose with particular attention to the cardiac rhythm. An ECG should be recorded if there is any doubt about the nature of the pre-therapy rhythm or changes during digitalization. Intravenous digitalization is rarely required in chronic heart failure; it should be used only in hospitalized patients with careful monitoring.Adults: Rapid digitalization orally: 0.75mg to 1.5mg as single dose followed by maintenance dose. Slow digitalization orally: 0.25-0.75mg daily for about one week, followed by maintenance dose. Maintenance dose: 0.25-0.5mg daily. Children under 10 years: Digitalization; 10-20mcg/kg 6 hourly. Maintenance; 10-20mcg/kg in a single or divided dose. Emergency digitalization; 0.5-1.0mg given by total parental dose slowly.

Potassium supplements: fruits mainly bananas and oranges.

Heparin  (as a prophylactic anticoagulant in case of prolonged bed rest)   2,500 IU BD SC.

 

Where the above treatment is not effective add the following:

 

ACE Inhibitors;

 Either;

Tab Captopril 6.25-12.50mg TID

Or;

Tabs Enalapril 2.5-10mg OD or BD

 

Other drugs not in the EDL (Kenya) include;

 

Carvedilol: 12.5mg OD, increased after 2 days to 25mg OD. If need be, the dose may be increased to 50mg OD at an interval of at least 2 weeks.

  1. Prevention
  • Lifestyle modifications that include

 Dietary changes, Cessation of smoking, Physical exercise 

  • Control of hypertension
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