HEART FAILURE

Clinical syndrome caused by inadequate cardiac output for the  body’s needs, despite adequate venous return.

For management purposes, it can be classified into:

  • Congestive/acute heart failure
  • Chronic heart failure
  • Acute pulmonary oedema

Causes

  • Hypertension
  • Valvular heart disease, e.g. rheumatic heart disease
  • Myocardial infarction
  • Myocarditis
  • Prolonged rapid irregular heartbeat (arrhythmias)
  • Congenital heart disease
  • Severe anaemia, thyroid disease

Clinical features

Infants and young children

  • Respiratory distress with rapid respiration, cyanosis, wheezing, subcostal, intercostal, and sternal recession
  • Rapid pulse, gallop rhythm, excessive sweating
  • Tender hepatomegaly
  • Difficulty with feeding
  • Cardiomegaly

Older children and adults

  • Palpitations, shortness of breath, exercise intolerance
  • Fatigue, orthopnea, exertional dyspnoea, wheezing
  • Rapid pulse, gallop rhythm
  • Raised jugular venous pressure (JVP)
  • Dependent oedema, enlarged tender liver
  • Basal crepitations

Differential diagnosis

  • Severe anaemia, severe acute malnutrition
  • Nephrotic syndrome, cirrhosis
  • Severe pneumonia
  • Any severe sickness in infants

Investigations

  • Chest X-ray
  • Blood: Haemogram (for ESR, anaemia)
  • Urea and electrolytes
  • Echocardiogram, ECG

Management of congestive heart failure

  • Bed rest with head of bed elevated
  • Prop up patient in sitting position
  • Reduce salt intake and limit fluid intake (1-1.5 L/ day)
  • Furosemide 20-40 mg oral or IV daily for every 12 hours increasing as required to 80-160 mg according to response
    Child: 1 mg/kg oral or IV daily or every 12 hours according to response (max: 8 mg/kg daily)
  • ACE inhibitors: start with low dose enalapril (or lisinopril) 2.5 mg once daily, increase gradually over 2 weeks to 10-20 mg (max 40 mg) if tolerated
  • Child: 0.1-1 mg/kg daily in 1-2 doses
    Or
  • Captopril 6.25-12.5 mg 8 -12 hourly, increase over 2-4 weeks to max 150 mg daily in divided doses
  • Child: 0.1-0.3 mg/kg daily every 8-12 hours

If available and when patient stable add:

  • Carvedidol 3.125 mg every 12 hours, increase gradually every 2 weeks to max 25 mg 12 hourly Child: 0.05 mg/kg every 12 hours, increase gradually to max 0.35 mg/kg every 12 hours

Additional medicines (second/third line)

  • Spironolactone 25-50 mg once a day
    Child: Initially 1.5-3 mg/kg daily in divided doses
  • Digoxin 125-250 micrograms/daily
    Child maintenance dose: 15 micrograms/kg daily

Caution

  • Use ACE inhibitors and beta blockers with caution if systolic BP is less than 90 mmHg: monitor renal function
  • Use digoxin with caution in elderly and renal disease

Prevention

  • Management of risk factors
  • Early diagnosis and treatment of the cause (e.g. hypertension)
  • Treatment adherence

Chronic heart failure

Patients with chronic heart failure need continuous treatment to control symptoms and prevent disease progression and complications.

Management

  • Periodic monitoring of body weight, blood pressure, heart rate, respiratory rate and oxygen saturation
  • Salt and fluid restriction
  • Limit alcohol intake
  • Regular exercise within limits of symptoms
  • Continued treatment with the medicines listed above, with doses progressively increased to achieve control