Chf

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Chf

  1. 1. Congestive Heart Failure Current Perspectives Arvind Sindwani 1
  2. 2. Congestive Heart FailureDefinition“State of systemic & pulmonary congestion” Failure of heart pump Metabolic needs of body 2
  3. 3. Congestive Heart FailureReasons  Ventricular Dysfunction  Preserved ventricular function with volume overload  Preserved ventricular function with pressure overload 3
  4. 4. Congestive Heart FailureCompensatory mechanisms  ↑ Contractility  Sympathetic over activity  Fluid retention ( RAA system) > Compensated > Decompensated 4
  5. 5. Congestive Heart FailureSymptoms  Infants – Tachypnea, diaphoresis during feeding  Young children – FTT, easy fatigability, recurrent cough, wheezing  Older children – Exercise intolerance, anorexia, wheezing, dyspnea, palpitation, chest pain, syncope 5
  6. 6. Congestive Heart FailurePhysical Examination  Tachycardia  Signs of poor perfusion  S3 gallop  Tachypnea, Wheeze, Crepitations  Hepatomegaly 6
  7. 7. Congestive Heart FailureInitial Evaluation  Chest Radiography – Cardiomegaly, Pulmonary edema, pleural effusion etc.  Electrocardiography- arrthymia, evidence for myocarditis, cardiomyopathies, ALCAPA  Echocardiography - To see anatomy and function  CBC, RFT, LFT 7
  8. 8. Congestive Heart FailureFurther Evaluation  MRI Heart  Cardiac Catheterization  Additional Blood tests such as cTnT, CK- MB,CRP, IL-6, TNF-α, ESR etc  BNP and NT-pro BNP 8
  9. 9. Management of CHFPrinciples 1.General measures 2.Control of congested state - Drug management 3.Treatment of precipitating events 4.Treatment of cause 9
  10. 10. Management of CHFGeneral measures  Propped up position  Sedatives/ Morphine  Supplement Oxygen  Respiratory support  Nutritional management 10
  11. 11. Drug Treatment> Compensated stage> Acute / Decompensated stage 11
  12. 12. Drug Treatment> Compensated stage Diuretics Afterload reduction (ACE inhibitors) Ionotropes (Digoxin) 12
  13. 13. Drug TreatmentDiuretics ‘Quick relief ’ from congestion Frusemide – standard prescription Side effects – Ototoxicity, dehydration, electrolyte imbalance, renal stones Torsemide – More potent than Furosemide 13
  14. 14. Drug TreatmentDiuretics K sparing diuretics – Spironolactone, EplerenoneSpironolactone has shown to improve survival in adults Thiazide diuretics – Hydrochlorthiazide,MetolazoneThiazide are mainly used in mild hypertension, edemaCaution – Weight & SE monitoring 14
  15. 15. Drug TreatmentACE inhibitors Proven improvement in morbidity & mortality in CHF in large scale trials Beneficial effects on ventricular remodeling & hypertrophy First line drugs Captopril – 0.5 - 6 mg/kg/day Enalapril – 0.1 - 0.2 mg/kg/day 15
  16. 16. Drug TreatmentACE inhibitors Side effects - Hyperkalemia - Hypotension - Neutropenia - Cough, altered tasteCaution - drug interactions, hyperkalemia - C/I in azotemia & obstructive lesions 16
  17. 17. Drug TreatmentDigoxin Dosage Preterm Infants Children>Oral Loading 0.02 mg/kg 0.04 mg/kg 0.03 mg/kg ( ½ dose initially, ¼ + ¼ in next 24 hours )>Maintenance 0.005 mg/kg 0.01 mg/kg 0.01 mg/kg>Intravenous - 75% of oral doses Side Effects - Nausea, vomiting, headache - Arrhythmia 17
  18. 18. Drug TreatmentDigoxin Traditional drug, most widely prescribed Mechanism – Inhibition of Na - K ATPase Effects – Improve contractility – Sympatholytic – Vagotonic – Delay in AV conduction Role in L → R shunt lesions – controversial 18
  19. 19. Drug TreatmentDigoxinCaution - Hyperkalemia - Pre – existing rhythm disturbances - Renal dysfunction - Drug interactions 19
  20. 20. Drug TreatmentNewer DrugsSelective B – blockers - Carvedilol  Extensively studied in DCM  Important add-on drug to standard regimen  Dose – 0.02 – 0.4 mg/kg/day, titrate up gradually  S/E – hypotension, bradycardia, ↓ CF 20
  21. 21. Drug TreatmentNewer DrugsAngiotensin II receptor antagonists - Irbesartan Losartan  Recent metanalysis did not show any benefit over ACE i s 21
  22. 22. Drug Treatment> Acute / Decompensated stage * Acute resuscitation & stabilization * Ionotropic support * Vasodilators * Advanced support & other options 22
  23. 23. Drug Treatment> Acute / Decompensated stageGoals * Restoration of adequate BP * Effective perfusion * Correction of hypoxia & acidosis 23
  24. 24. Drug TreatmentIonotropes CHF Decompensated / Shock Hypotensive Normotensive Epinephrine Dopamine Dopamine Dobutamine Nor epinephrine Amrinone/ Milrinone 24
  25. 25. Myocardial Dysfunction• Milrinone (5 Phosphodiasterase inhibitors) Dose • 0.25 - 0.8 mcg/kg/minute IV infusion Side effects • Hypotension, Arrhythmia (less) 25
  26. 26. Drug TreatmentVasodilators Nitroglycerine – Venodilator  Dose – 0.5 – 1 mcg/kg/min  Effective in pulmonary edema  Caution – BP monitoring Sodium Nitroprusside – Arterial dilator  Dose – 0.5 to 10 mcg/kg/min  Acute LVF/ hypertension  Caution – BP monitoring, cyanide toxicity 26
  27. 27. Drug TreatmentVasodilators Nesiritide – Human type B natriuretic peptide  Dose – 2 mcg/Kg stat f/b 0.01 mcg/kg/min  Systemic vasodilator with modest natriuretic properties  Limited data in pediatric patients 27
  28. 28. Drug TreatmentInotropes Levosimendan – Calcium channel sensitizer  Does not increase myocardial O2 Consumption  Not arrythmogenic at therapeutic levels Istaroxime – Nonglycoside Na K ATPase inhibitor  Uncouples inotropy and arrythmogenicity  Lesser tachycardia than dobutamine 28
  29. 29. Drug TreatmentVasopressin Receptor Antagonists2 types of vasopressin receptors V1a and V2  Dual (V1a&V2)receptor antagonist: Conivaptan,  SelectiveV1areceptor antagonist: Relcovaptan  Selective V2 receptor antagonist : Tolvaptan, Mozavaptan ,Satavaptan Although provide short term benefit in hyponatremia and edema long term results are awaited 29
  30. 30. Role of PGE 1 Life saving drug in critically ill neonates Duct dependent CHDs – CoA, HLHS, PS, TGA Dose – 0.05 - 0.4 mcg/kg/min infusion S/E – Apnea, hypotension, irritability, seizures 30
  31. 31. Severe PAH• Sildenafil  Dose - 0.3mg/kg – 3mg /kg / 6-8 hrly  Caution - Infection, Deranged LFT - Gross CHF Monitor - CBC, RFT, LFT 31
  32. 32. Severe PAH• Nitric Oxide Dose- 5 – 80 ppm  Problems - Cost - Special Equipment 32
  33. 33. Anaemia & CHF• No structural heart defect • Hb <6 gm%• Acyanotic heart defect • Hb <10 gm%• Cyanotic heart disease • Hb <12 gm% 33
  34. 34. ArrhythmiasCause of CHF – Tachyarrhythmia (common) – Bradyarrhythmia ( rare )Precipitating/ Contributory factor Diagnose and treat accordingly 34
  35. 35. Arrhythmias Tachycardia• 8 months old/M• Persistent CHF• ECG – Narrow QRS Tachycardia• Echo – Dilated LV,LV Dysfunction – No Structural Heart Defect 35
  36. 36. Arrhythmias SVT• Treated With – Adenosine IV bolus Inj Adenosine – Continued Tx with • Digoxin • Flecainide – Follow up at 6 months • Normal LV size and function 36
  37. 37. Arrhythmias - Bradycardia • 1 year / F, Failure to thrive • On exam – LVE, CHF • ECG – Complete Heart Block • Echo – Corrected TGA, no septal defect • Underwent PPI – No LVE / CHF at 1 y FU 37
  38. 38. Cardiac Lesions L →R shunts Obstructive Lesions Admixture Lesions Ventricular Dysfunction 38
  39. 39. L → R Shunts• Patent Ductus Arteriosus • Premature Babies – – Indomethacin / Ibuprofen – Surgical ligation » Ventilator dependence » If CHF / PAH persisting Even in NICU setting • Term Babies – If CHF – Closure at presentation 39
  40. 40. L → R Shunts • VSD – Single large VSD » Elective surgery at 3-6 m » Early if indicated – Multiple VSDs » PA band as initial palliation » Closure of VSDs after 1 year • ASD – Elective closure 2-3 yrs – Early if CHF 40
  41. 41. L → R Shunts• AVSD • Elective surgery – 8-12 weeks – Early surgery » Significant MR » Persistent CHF / FTT• Aorto-Pulmonary Window • Surgery at 4-8 weeks 41
  42. 42. Obstructive Lesions• Left sided lesions • Critical AS – Balloon Aortic Valvoplasty • Critical CoA – Surgery / Balloon Dilation• Right sided lesions • Critical PS – Balloon Pulmonary Valvoplasty 42
  43. 43. Admixture Lesions • TGA • Arterial switch – Intact Septum – 2 to 4 wks – With VSD – 4 to 8 wks • TAPVC • Surgery at presentation • Truncus Arteriosus • Elective Surgery at 4 – 8 weeks 43
  44. 44. Myocardial Dysfunction• ALCAPA – Surgery at time of presentation – Excellent results 44
  45. 45. Myocardial Dysfunction• 45 days / M• Clinical evaluation • Convulsion, CHF• Blood Inv • Hypocalcaemia• Echo – LVEF-30 %,N coronaries• Tx – Cal, Vit D, Decongestives• Follow up – n EF after 8 wks 45
  46. 46. Myocardial dysfunction Myocarditis• Role of IVIG (May be helpful)• Beta Blockers• IV Inotropes - Milrinone 46
  47. 47. Advanced life support Extracorporeal Membrane Oxygenation (ECMO) Ventricular Assist Devices (VADs) Intraaortic Balloon Pump (IABP) Biventricular synchronized pacing 47
  48. 48. Management of CHFNutritional Management Failure to thrive - common - multifactorial High caloric diet – up to 150 – 170 kcal / kg / day Low salt diet, Fluid restriction (If hyponatremic) Nasogastric, Transpyloric, Gastrostomy feeds Better nutritional care → Improved survival 48
  49. 49. Cardiac Transplantation• Heart / Heart- Lung transplantation• Patients with * End stage heart disease * Complex CHDs * Eisenmenger’s Syndrome 49
  50. 50. Take Home MessagePresently most patients with CHF can besalvaged, if evaluated timely andmanaged appropriately 50
  51. 51. Facilities Available in Department of Paediatrics8 bedded Tertiary Care NICUHigh end state of art neonatal ventilatorComputerized monitors for measuring invasiveBlood pressure, Heart rate,ECG,SpO2 etc. 51
  52. 52. Facilities Available in Department of PaediatricsOpen care warmers.Syringe pumpsCFL Phototherapy unitInfant Flow driver CPAP machineExperienced nursing staff withneonatal training. 52
  53. 53. Facilities Available in Department of PaediatricsTaking care of extreme preemies,Newborns with birth asphyxia,Meconium aspiration, pneumonia etcwith morbidity and mortality levelscomparable to best centers in India. 53
  54. 54. Facilities Available in Department of PaediatricsHigh end state of artPaediatricVentilatorSuccessfully doing various Paediatriccardiac, surgical and urologic proceduressuch as PDA ,ASD device closure, VSDclosure, TOF repair, Ureteric 54
  55. 55. 55

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