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Management of

Cardiac Failure

Dr Christie De Silva

MD.FRCP(Lond) FCCP

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Cardiac Failure

Definition

Types

Clinical manifestations

Causes

Pathophysiology

Diagnosis

Treatment

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Definition

Failure of the heart to maintain adequateperfusion to tissues in spite of adequatevenous return

Acute or Chronic heart failure

Left heart failure

Right heart failure

Congestive cardiac failure

Systolic dysfunction EF

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Clinical manifestations

LVF

Symptoms

Dyspnoea on effort .NYHA Class I-!V

Fatigue

Shock-if acute

Signs

Tachycardia

Pulsus alternans Triple rhythm S3

Cardiomegaly

Basal crepitations

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Clinical manifestations

RHF

Dyspnoea

JVP elevated

Liver enlargement

Oedema

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Causes of Cardiac failure

Ischaemic heart disease

Hypertension

Rheumatic heart disease Cardiomyopathies-dilated,hypertrophic

restrictive

Thyrotoxicosis

Severe anaemia

A-V fistula

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Pathophysiology of heart

failure

Pump failure

Vasoconstriction-sympathetic overactivity

Remodelling of myocardium

Renin-Angiotensin-aldosterone

ADH

BNP.Brain Natriuretic Peptide .ANP

Venous congestion-preload

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Diagnosis of Cardiac

Failure

Clinicallate 50% sensitive

-history,examination,ECG,CXR 2D-Echocardiography-EF < 40%,

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Treatment of Congestive

Cardiac failure

A. Non- pharmacological Bed rest/exercise

Diet

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Treatment of Cardiac

failure

B. Pharmacological

ACE Inhibitors-remodelling, vasodilatory,

Diuretics-frusemide,hydrochlorothiazide

metolazone---preload Beta-blockers-sympatheticactivity,

remodelling

Digoxin-inotrope

ARBs-Angiotensin receptor blockers

Spironolactone- block aldosterone

Vasodilators-hydrallazine + nitrates--afterload

Anticoagulation-warfarin EF

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ACE inhibtors

Captopril 6.25mg tds start----50mg tds

Enalapril 2.5mg daily--------10mg bd

Lisinopril 2.5mg -----20mg bd daily

Ramipril 1.25mg -------10mg daily

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Diuretics

Frusemide 40mg oral -80mg

IV -------upto 200mg daily

Bumetanide-1mg ----upto 5mg daily

Hydrochlorothiazide HCT 50-100mg daily

Metolazone 5mg upto 20mg

Give K supplements

KCl or Addi-K

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Beta blockers

Metoprolol 6.5 mg bd upto 50mg bd

Carvedilol 3.125 mg bd upto 25-50mg bd

Bisoprolol 1.25mg daily upto 5-10mg

Start with low doses .several weeks

NYHA Class II III IV

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Digoxin

Oral-1-1.5mg in divided doses over

24hrs

IV- 0.75-1.0mg over at least 2 hrs Maintain on 0.125mg to 0.25mg daily

K supplements

Digoxin levels

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R s

Losartan 25mg--------100mg daily

Candersartan 8mg--------16 mg daily

Valsartan 80mg ------160mg daily

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Spironolactone

25-50mg/day

Class IV dyspnoea-NYHA\

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Vasodilators

Combination of hydrallazine + nitrates

Hydrallazine 25mg tds to 100mg tds

ISDN 40mg tds

ISMN 40-120mg /day

Amlodepine 5mg daily

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Other therapies for CCF

Ventricular assist devices

Intra-aortic baloon pump

Cardiac transplantation

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Acute Left Ventricular

Failure pulmonary oedema

Prop up

Oxygen 100%

Morphine 2.5mg to 5mg IV repeat

Frusemide 40-80mg IV repeat10-20mg/min IV infusion

GTN IV infusion -10mcg/min upto 200mcg/min

Captopril 6.25mg tds and increase

Dobutamine 5-15mcg/kg/min Dopamine 5-15 mcg/kg/min

Mechanical ventilation

Intra aortic balloon pump

haemodialysis

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