Congestive heart failure

Congestive heart failure

1. Definition

   • A condition in which the heart is unable to pump blood at a rate that meets the requirements of the metabolizing tissues, or can only do so only with filling pressures that are higher than normal
     • Left sided heart failure
       • causes
         • Ischemia
         • Hypertension
         • Dilated and restrictive cardiomyopathy
         • MI
       • Decreased forward perfusion
         • Decreased blood flow to kidney
           • Activation of renin-angiotensin system
             • Fluid retention
       • pulmonary congestion
         • Lead to pulmonary edema
           • Results in
             • Dyspnea
               • Refers to the sensation of difficult or uncomfortable breathing.
             • PND
               • Is a sensation of shortness of breath that awakens the patient, often after 1 or 2 hours of sleep, and is usually relieved in the upright position.
             • Orthopnea
               • Is the sensation of breathlessness in the recumbent position, relieved by sitting or standing.
             • Crackles
             • Congested capillaries burst
               • Hemosiderin laden macrophages
     • Right sided heart failure
       • Due to
         • Left sided heart failure
           • Left to right shunt
             • corpulmonale
       • Clinical features
         • Jagular venous distension
           • Painful hepatosplenomegaly
             • Dependent pitting edema

2. Signs and Symptoms

   • dyspnea
     • Blood "backs up" in the pulmonary veins because the heart can't keep up with the supply. This causes fluid to leak into the lungs.
   • Persistent coughing or wheezing
     • Fluid builds up in the lungs
   • Edema
     • The kidneys dispose less sodium and water (as a compensatory mechanism), also causing fluid retention in the tissues.
   • Tiredness, fatigue
     • The heart can't pump enough blood to meet the needs of body tissues. The body diverts blood away from less vital organs, particularly muscles in the limbs, and sends it to the heart and brain.
   • Lack of appetite, nausea
     • The digestive system receives less blood, causing problems with digestion.
   • Confusion, impaired thinking
     • Changing levels of certain substances in the blood, such as sodium, can cause confusion.
   • Increased heart rate
     • To compensate for the loss in pumping capacity

3. Risk Factors

   • High blood pressure
   • Coronary artery disease
   • Diabetes
   • Certain medications
   • Sleep apnea
   • Congenital heart defects
   • Valvular heart disease Viruses
   • Alcohol and Tobacco
   • Obesity

4. Mechanisms of compensation

   • Decreased CO
     • Increased venous distension
       • Increased sympathetic discharge
         • Increased cardiac force
         • Increased cardiac rate
           • Increased CO
             • Compensatory
         • Increased VR
     • Decreased tissue perfusion
       • Decreased renal blood flow
         • Increased renin
           • Increased angiotensin ll
             • Increased afterload
             • Increased preload
             • Increased remodeling
             • Increased aldosterone
               • Increased fluid retention
                 • Edema
                   • causes
                     • Increased capillary hydrostatic pressure
                     • Reduced plasma oncotic pressure
                     • Lymphatic obstruction
                     • Sodium water retention
                     • Inflammation
                     • Increased capillary permeability

5. Complications

   • Cardiac Cachexia
   • Kidney failure
   • Arrhythmias
   • Angina and Heart Attacks
   • Congestion

6. Prognosis

   • Long-term mortality rates for patients with heart failure (HF) have improved over time.
   • The survival of patients with heart failure worsens with age.
   • Survival with heart failure is most limited in patients with amyloidosis, hemochromatosis, HIV infection.

7. Investigations

   • X-ray
     • Cardiomegaly
       • Cardiac width is larger than half trans-thoracic diameter
   • ECG
     • Left ventricular hypertrophy
       • The amplitude of the QRS complex is increased
       • Deviation of the ST segment in the opposite direction of the QRS complex and a typical T wave inversion pattern is present
   • ECHO
     • Dilation of all four and depressed systolic function

8. Management

   • Non- Pharmacological
     • Counselling and education
     • Lifestyle measures
     • Smoking and diet (Low Na)
     • Exercise and rehabilitation
   • Pharmacological
     • Vasodilators in the form of ACE inhibitors or ARBs and diuretics are the basic meds. An alternative would be direct vasodilators, such as nitrates and hydralazine. B blockers are also useful to manage the failing, tachycardic heart

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