Congestive Heart Failure

Dr. J. Saravanan
Chennai

Definition
CCF is a clinical syndrome in which the heart is
unable to pump enough blood to the body to meet
its needs, to dispose of venous return adequately or
a combination of the two

Causes
Congenital Heart disease
VSD
PDA
Endocardial Cushion
defect
Hypoplastic left heart
syndrome
TGA

Acquired Heart Disease

Metabolic abnormalities
Viral Myocarditis
Acute Rheumatic Carditis
Rheumatic Valvular heart
diseases MR, AR
Dilated Cardiomyopathy

Causes Contd..
Miscellaneous
Supraventricular Tachycardia
Complete Heart block
Severe Anemia
Acute Hypertension
Bronchopulmonary dysplasia
Acute cor pulmonale

Time of Onset of CCF in Congenital

lesions
Age

Lesion

Birth to 72 hrs

Pulmonary, mitral and aortic atresias or critical stenosis

4 days to 1 week

Hypoplastic left and right heart syndromes, transposition and

malposition of great arteries with poor mixing

1 to 4 weeks

Transposition and malposition complexes, endocardial

fibroelastosis, coarctation of aorta

1 2 months

Transposition and malposition complexes, endocardial cushion

defects, VSD, PDA, TAPVC, ALCAPA

2 to 6 months

Transposition and malposition complexes, VSD, PDA, TAPVC,

Aortic stenosis, Coarctation of Aorta

Clinical Features - Symptoms

Infants
Poor feeding
Tachypnea with feeding
Poor weight gain
Cold sweat on the
forehead

Older children
Shortness of breath which
increases with activity
Easy fatigability
Puffy eyelids
Swollen feet

Signs I
Compensatory responses to impaired cardiac function
Tachycardia
Gallop rhythm
Weak thready pulse
Increased sympathetic discharges growth failure,
perspiration, Cold wet skin
Cardiomegaly X-ray will be useful

Signs II
Pulmonary venous Congestion (Left Sided Failure)
Tachypnea
Dyspnea on Exertion
Orthopnea
Wheezing and pulmonary crackles

Signs III
Systemic Venous Congestion ( Right Heart Failure)
Hepatomegaly
(absence of Hepatomegaly does not rule out CCF)

Puffy Eye lids

Distended neck veins
Ankle edema

Investigations
Xray
Cardiomegaly will be present
Absence of cadiomegaly rule out CCF

ECG May not be useful

Echocardiography
Used to confirm, to find the cause and monitor treatment
of CCF
Enlarged chamber
Impaired left ventricular function - Ejection fraction

CCF - Principle of treatment

Control of excessive salt and water retention
-Diuretics
Improve cardiac contractility - Digoxin
Drugs acting on compensatory neuro hormonal
changes that lead to progressive worsening of
cardiac status - Beta blockers, ACE Inhibitors,
Angiotensin II receptor blockers
Improving oxygen delivery
Enhancing nutrition.

Diet
Salt restricted diet
Water restriction - In the presence of poor renal perfusion
Calories
Infants needs 100 120 K Cal / kg/ day and sodium 2 3
mEq/kg/day
Standard formula which provides 20 kcal / oz is fortified with
dextrose polymer or medium chain triglyceride to achieve 24 30
kcal/oz

Iron supplementation

Digoxin

Weak ionotrope
Slows ventricular rate especially in AF
Decreases sympathetic drive
Pharmacological properties
Sodium pump inhibition Na / ATPase which promotes calcium
influx with increased intra cellular calcium and increased
contractility
Autonomic & Renin Angiotensin system
Parasympathetic activation
Sympathetic inhibition
Inhibition of renin release

Digoxin Contd..
Indication - Most solid indication Chronic CHF with AF. In CHF with
sinus rhythm it obtains symptomatic rather than mortality benefit.
Dose: TDD

Preterm 10 20mcg/kg P.O

Term 20 30 mcg/kg P.O
1 5 years 30 -40 mcg/kg P.O
5 10 20 30 mcg/kg P.O
Adults 10 15 mcg/kg P.O
IV is 80% of P.O dose

Ideal blood level-1-2ng/ml

Reduce in renal dysfunction

Digoxin Contd..
Contra indication
HOCM (unless AF with
severe myocardial
failure)
WPW syndrome with
AF
Significant AV nodal
block
Diastolic dysfunction

Relative Contraindication
low output states Valvular
stenosis
High output states Chronic
corpulmonale and thyrotoxicosis
Hypokalemia
Chronic lung disease
Myxedema
Acute hypoxemia
Renal failure
Co - therapy with drugs altering
digoxine levels or causing
AV inhibition
Severe myocarditis

Diuretics Contd..
Control Pulmonary and Peripheral signs and symptoms of
congestion. Thiazides is used for mild HF and loop diuretic for
severe HF .
As severity of HF increased sequentially nephron block Addition of
the loop diuretic and aldosterone antogonist used. (sequential
nephron block)
DOSE
Furosemide: 1mg/ Kg/dose
Chlorthiazide:5 - 20mg/kg/dose every 12 -24hr oral , IV
Hydrochlorthiazide: 1 1.5mg/kg/dose every 12 24 hrs oral
Spirinolactone: oral 1-2 mg/kg/day

ACE Inhibitors
These group of drugs have symptoms relief and also
improves survival.
ACEI should be used or at least considered for all pts with
CHF and its dose is titrated upwards to the recommended
doses unless hypotension or when symptoms of hypotension
manifests.
When used first especially patients on high dose diuretics,
first dose hypotension should be watched for. If not
tolerating ACEI due to cough Angiotensin receptor blockers
can be used.
DOSE: Captopril 0.1 to 0.5mg /kg/dose PO every 8-12 hrly
upto 4mg/kg/day
Enalapril 0.1mg /kg/dose PO every 12-24 hrly upto
0.5mg/kg/day.

Beta Blockers
It is now recognized as an integral part of therapy for HF and have
to shown to reduce mortality by up to 30 %.
Carvedilol, metoprotol & Bisoprolol have been extensively evaluated
in Heart Failure
BISOPROLOL 0.2 0.4 mg/kg/day oral
METAPROLOL 1-2mg / kg/day PO 2 divided doses.
CARVEDILOL 0.08 mg/kg/dose 12th hrly if tolerated increase by
0.08 mg/kg/dose every 1 2 wks to max 0.5 0.75 mg/kg/dose12th
hrly.

Dopamine
Dose
< 2.5mcg/kg/min - Increase blood flow to cerebral coronary renal
and splanchnic vascular bed through DA1 postsynaptic receptor.
2.5-5 mcg/kg/mt - Inotropic effect through b receptor
5-10 mcg/kg/mt - Both a and b effects occur.
>10 mcg/kg/mt- Arterial tone progressively increases.

Indications
Cardiogenic shock with Hypotension

Complication
Tachyarrhytmias
Extremity gangrene
Increases Pulmonary vascular resistance particularly in hypoxemic
pulmonary hypertension and may suppress central respiratory drive

Dobutamine
Primarily 1 agonist
Indications:
Cardiogenic shock with normal or high blood pressure
If inadequate response - Dopamine may be added.

Dose: 2.5 20 mcg/kg/mt.

Complication:
Tachyarrhythmias

Epinephrine
Indications

Inadequate Cardiac output

Hypotension
Symptomatic bradycardia
Pulseless cardiac arrest
Septic shock.

RARELY USED AS FIRST LINE AGENT

Useful in patients with left ventricular dysfunction that
remains refractory to dopamine or dobutamine
Once stabilized it is withdrawn as early as possible.
It increases Systolic BP, HR and reduces Diastolic BP
Dose 0.05-0.1mcg/kg/min upto max 0.3 mcg/kg/min.

Isoproterenol
Pure agonist
Increase HR, contractility, Systolic BP and decrease
Diastolic BP & Systemic Vascular Resistance.
0.01-0.05mcg/kg/mt temporary measure with some form of
symptomatic bradycardia.
0.05 0.1 mcg/kg/min for positive ionotropic response.
Useful in children with poorly contractile myocardium with
slow heart rate yet peripheral vascular resistance in high
eg-After cardiac surgery with prior blockade.

Norepinephrine
Generally used in patients with low systemic vascular
resistance as in septic shock, Spinal shock, anaphylaxis,
drug overdose (Tricyclic antidepressant, neuroleptic drugs
having blocking action).
Not used in cardiogenic shock.
Systolic BP, Diastolic BP, Systemic vascular resistance
increases, HR may decrease due to stimulation of
baroreceptor.
Cardiac Output -increases, decreases or no effect.
Dose:
0.05 0.1 mcg/kg/min.

Phosphodiesterase Inhibition
Milrinone (Iondilators)
Dose: Slow IV infusion- 50 -75mcg/kg followed
by 0.375 0.750 mcg/kg/min up to 48 hrs maximum
dose is 1.13mg/kg
Complication:
Ventricular arrhythmia.
Contraindicated in tight aortic stenosis, HOCM.
Reduce dose in renal failure.

Afterload Reduction
Sodium Nitroprusside, Nitroglycerine, iondilators
Indication:
Increased ventricular filling pressure
Increased systemic vascular resistance

Normal blood pressure or hypertension

Systolic BP
Neonate >50 mmHg
1 mo to 12 mo >60mmHg
1 to 12 yrs > 70 + (Age x 2 )

Sodium Nitropruside
It is a rapidly acting balanced vasodilator of
systemic arterioles and veins by its direct action on
vascular smooth muscle, it also reduced pulmonary
vascular resistance.
Dose: 0.5 10 mcg/kg/min but infusion at maximal
rate should never last > 10minutes
Complication:
Cyanide toxicity.
Hypotension
In renal failure - Thiocyanide accumulates

Nitroglycerine
IV infusion 1- 10 mcg/kg/min
Use polyethylene lined syringe and tubing (NOT
PVC)

Preparation Of Vasoactive Drugs

Epinephrine /Norepinephrine: 0.6 x body wt
(kg)=mg to be added to sufficient diluent to create a
total volume of 100ml.
Dopamine, Dobutamine, Sodium nitroprusside:
6 x body wt (kg) equals mg to be added to sufficient
diluent to create total volume of 100ml.
1ml / hr delivers 1.0 mcg/kg/min

Intra Aortic Balloon Counter Pulsation

Provides circulatory assistance by decreasing LV
after load, during systole and augmenting aortic
perfusion pressure during diastole
Done by repetitive catheter mounted pneumatic
inflation and deflation of a catheter balloon placed
within thoracic aorta by percutaneous femoral
arterial technique

Heart Failure Treatment Contd..

Cardiac resynchronization therapy.
Implantable cardiovertor defibrillator
Mechanical assist device
LV assist device
Total artificial heart

Extra Corporal Membranous Oxygenation

Thank you