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8/11/2019 Management of Cardiac Failure
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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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