RISK FACTORS: Inappropriate sodium and/or fluid excess, Intercurrent arrhythmia, eg. AF, Administration of drug with negative inotropic effects, Excessive physical, emotional, or environmental stress, Thyrotoxicosis, pregnancy
GENERAL MEASURES :
β’ Immediate treatment of the heart failure
β’ Search for underlying correctable conditions
β’ Eliminate contributing factors when possible
β’ Supplemental oxygen
β’ Antiembolism stockings
β’ Fluid and sodium restriction. Education about this is imperative for long term control. Daily weights guide
overall therapy.
β’ Identify and control underlying correctable conditions (e.g., acute MI, valvular disease, hyperthyroidism, but
most commonly inadvertent salt and/or fluid overload)
SURGICAL MEASURES :
β’ Heart valve surgery - possibly, if defective heart valve is responsible; mitral valve repair especially helpful if
mitral regurgitation is aggravating CHF
β’ Cardiac transplantation - to be considered in patients (age < 55) without other disqualifying medical problems,
who are developing CHF unresponsive to other therapeutic maneuvers, and who are felt to have a life
expectancy of less than a year
β’ Biventricular pacing
ACTIVITY :
β’ During severe stage, bed rest with elevation of head of bed and anti-embolism stockings to help control leg
edema
β’ Gradual increase in activity with walking will help increase strength
DIET :
β’ Sodium restriction (initially 4 gm sodium qd)
β’ Weight reduction diet if appropriate
β’ Low fat diet to retard coronary artery disease
β’ Appropriate fluid restriction
DRUG(S) OF CHOICE :
. Diuretics, usually in combination with digitalis are used to initiate therapy. ACE inhibitors have become a
mainstay of therapy. For acute pulmonary edema, IV morphine remains cornerstone of therapy.
. Digoxin :
. Improves contractility, slows ventricular rate in atrial fibrillation
. May be harmful in acute MI, hypertrophic cardiomyopathy, or aortic stenosis
. Loading dose should be sufficient to have early beneficial effect, especially in atrial fibrillation with a rapid
rate, e.g., 0.5-1.0 mg IV/PO, then another 1.0-1.5 mg in divided doses q4-6h
. Diuretics :
. Furosemide (Lasix): IV or PO, depending on severity of pulmonary congestion. May require continuous
drip.
. Metolazone (Zaroxolyn): excellent addition when furosemide does not seem to be sufficient
. Spironolactone: when used carefully, to avoid hyperkalemia. An important addition to difficult chronic cases.
. ACE Inhibitors :
. Used to decrease afterload - shown to increase survival
. Improve general symptomatology and overall exercise capacity
. Beta-blockers :
. Carvedilol (Coreg) 3.125 mg po bid for 2 weeks, then 6.25 mg bid for 2 weeks, increased to maximum 25
mg bid for class I to III CHF
. Bisoprolol (Zebeta) 5-20 mg/day: in CIBIS-II study significantly decreases all-cause mortality and sudden
death (treatment effects were independent of the severity or cause of heart failure)
. Vasodilators :
. IV nitroglycerin may be of short-term benefit to decrease preload, afterload, and systemic resistance.
. Oral medications, e.g., hydralazine, prazosin, and Isosorbide dinitrate demonstrate tachyphylaxis
ALTERNATIVE DRUGS :
. Sympathomimetic amines. Can be used in severe CHF unresponsive to above measures
. Dopamine and dobutamine have been successful for short periods in treatment
. Dobutamine can be used on an intermittent outpatient basis with intermittent infusion. However, in spite of possibly improving quality of life, reduces long-term survival.
PATIENT MONITORING :
β’ Variable depending on clinical circumstances. Initially every 2-3 weeks after patient stabilized.
β’ Closely follow - history and physical fi ndings, chest x-ray, electrolytes, BUN, and creatinine
PREVENTION/AVOIDANCE : Treatment of underlying disorders when possible
POSSIBLE COMPLICATIONS :
β’ Electrolyte disturbance
β’ Atrial and ventricular arrhythmias
β’ Mesenteric insufficiency
β’ Protein enteropathy
β’ Digitalis intoxication
EXPECTED COURSE/PROGNOSIS :
β’ Result of initial treatment is usually good, whatever the cause
β’ Long-term prognosis variable. Mortality rates range from 10% with mild symptoms to 50% with advanced,
progressive symptoms.