Congestive Heart Failure

Clinical Description

Defined as a clinical syndrome in which patients have typical symptoms and signs resulting from abnormalities of Ventricular function. There is reduced cardiac output and increased venous pressures. Heart failure is a syndrome not a final diagnosis therefore it is very important to establish the cause

Causes

• Congenital heart diseases, Cardiomyopathies, Rheumatic heart disease, Ischemic heart disease, Hypertension

Signs and Symptoms

• Shortness of breath, Cough, fatigue, Orthopnea, Exercise intolerance, Paroxysmal nocturnal dyspnea, Diaphoresis, Failure to thrive, Tachycardia, tachypnoea, Oedema

Investigations

• Chest Xray, ECG, Echocardiography, Urea, electrolytes, and creatinine, Full blood count, HIV, Cardiac enzymes

Treatment

Objective

• To reduce preload, afterload and improve myocardial contractility

Non-pharmacological

• Patient and family education on heart failure
• Restriction of fluids and salt
• Reduce salt intake
• Bed rest
• Daily weights
• Moderate exercises
• Stop smoking and alcohol intake
• Clinicians to screen and treat other comorbidities
• Active Cycle Breathing Technique

Pharmacological

Children

Initial treatment:

• Frusemide 1mg/kg PO/IV one to four times a day
• Spironolactone 1mg/kg PO one to two times a day

Discuss with cardiologist before commencing patient on ACE-inhibitors and digoxin

Referral

• All patients for diagnostic work up

Adults

Symptomatic relief:

• Give Frusemide 40-160 mg in divided doses
• Give atenolol 50-100mg daily or Digoxin (0.125 mg daily) which is recommended in patients with heart failure and rapid atrial fibrillation
• Oxygen supplement if hypoxic

Symptomatic relief and mortality benefit in heart failure with reduced ejection fraction:

• ACE inhibitors: Enalapril, start at low doses 2.5-5mg and escalate to 10 mg twice a day.
• Spironolactone: 25 mg daily dose for patients with persistent symptoms of heart failure (NYHA II-IV)
• Beta-blockers e.g., Atenolol 50mg od and titrate up to 100mg od po or carvedilol, start at low dose 3.125mg bd then increase to 6.25mg bd then 12.5mg bd then increase to 25mg bd. Dose should be increased at intervals of at least two weeks up to highest tolerated dose or nebilong (nebivolol) 5mg OD po

Note: ARB (Angiotensin Receptor Blocker) or Hydralazine + Nitrate can be an alternative if a patient cannot tolerate ACE inhibitors or has acute renal failure.