Heart failure

Occurs when the heart is unable to maintain output, necessary for the metabolic need of the body (systolic dysfunction) and inability to receive blood in ventricular

cavities at low pressure during diastole (diastolic dysfunction)

Signs

Left sided Either side Right side

TachypneaTachycardiaCoughWheezingRales

Small volume pulsecardiac enlargementPeripheral cyanosisGallop

HepatomegalyFace oedemaJugular venous engorgment

Symptoms

Difficulty in feedingRapid breathingPersistent cough and wheezingIrritability, restlessnessPedal oedema

Step wise management Congestive Heart Failure

Start digoxin and diuretics. Furesemide with spironolactone better than furosemide with K+ supplement

Add ACE inhibitors, if persistant cough; change to ARB

Add isosorbite nitrate if ACE are not tolerated

Inadequate response especially if tachycardia, start carvedilol

Consider once or twice weekly infusion of dobutamine who continue to deteriote. Add carnitine as supplement

Consider for surgical treatment

Rest, propped up position, humidified oxygen, diet, sodium restriction

From : Ghai Paediatrics

Last 2 step applicable especially to rare condition e.g. DCM

Initial therapy based on the sign and symptoms

Suggestive sign and symptoms of low output state

• Narrow pulse pressure• Altered mental sensorium• Cool extremities• Decrease urine output

Suggestive sign and symptoms of volume overload

• Dyspnoea• Increased JVP• Hepatomegaly• Rales• Peripheral odema• Recent weight gain• Increase BNP

Mild volume overload

IV Loop diuretics

Is patient was on oral diuretics at home

Moderate to severe volume overload

• Fatigue• Oral diuretics• Spo2 <93%• Raised creatinine levels• May require CPCP,BIPAP, Ventilation

Mild to moderate

Consider very low output state

• Narrow pulse pressure• Altered mental sense• Pre – renal azotemia• Cool extremities• Decreased urine output

Management of Acute Decompensated Heart FailureFrom : AHA guideline

Give total oral dose as IV

Give IV diureticsFuresemide

1mg/kg

Adequate response

NoYes

Milrinone

SBP normal

Inadequate response

DobutamineMay require inotrope

support for BP

On beta blocker therapy chronically

No

Yes

YesNo

No

Step wise management as

above

Yes

Add inotrops

IV DIURETICS + IV VASODILATORIf Furesemide was given, double the dose

if not start with 1 mg/kg

If SBP > lower limit according to age

Start nitroglycerine 0.5-8mcg/minOr

Nesiritide0.01mcg/min

Considermoderate to severe

overloadOr

Low cardiac output state

Considermoderate to severe

overloadOr

Low cardiac output state

Doses (Nelson and Ghai)

• Dopamine 5-20 mcg/kg/min• Dobutamine 5-20 mcg/kg/min• Milrinone 0.25-1 mcg/kg/min• Amrinone 3-10 mcg/kg/min• Nitroglycerine 0.25-5 mcg/kg/min• Isosorbide nitrate 0.01 mg/kg/day • Enalapril 0.1-1 mg/kg/day• Furesemide 1-3 mg/kg/day (oral)

1mg/kg/day (iv)• Spinolactone 1-3 mg/kg/day• Digoxin Premature 20 μg/kg

Full term 20-30 μg/kgInfant and children 25-40 μg/kg

Digitalisation (orally ) ½ dose initially followed by ¼ after 8 hours followed by ¼ dose after 16 hrs of 1st dose

Maintainence 5-10 μg/kg/day

Comparison of Guidelines for the Management of Systolic Dysfunction*

Drug class Heart Failure Society of America4

ACE inhibitors All patients with systolic dysfunction

Beta blockers All patients in NYHA class II and III

Insufficient evidence to recommend for patients in NYHA class IV

Considered for patients in NYHA class I

Spironolactone (Aldactone) “Considered for patients receiving standard therapy who have severe heart failure (class IV)”

Diuretics All symptomatic patients, dosed as necessary to control symptoms

Digoxin (Lanoxin) “Considered for patients who have symptoms of heart failure and NYHA class IV…while receiving standard therapy”