This document discusses congestive heart failure (CHF). It defines CHF as when the heart cannot produce enough cardiac output to meet the body's needs without compensatory mechanisms. The pathophysiology of CHF involves factors that increase preload and afterload on the heart as well as myocardial dysfunction. Common causes include volume overload, pressure overload, and myocardial issues. Clinical features include symptoms ranging from exertion to at rest based on severity. Treatment involves reducing preload and afterload, increasing contractility, and treating underlying causes. Digitalis is discussed as a positive inotropic agent to increase contractility.

1. Congestive Heart Failure (CHF)
Dr Yograj Khinchi

2. Congestive Heart Failure (CHF/CCF)
Heart failure is the state in which the heart can not
produce the Cardiac Output (CO) required to sustain
the metabolic needs of the body without evoking
certain compensatory mechanisms (cardiac reserve).
Cardiac reserve →Compensated CHF
When these mechanisms becomes ineffective there
is cardiac decompensation (decompensated CHF).

3. Congestive Heart Failure (CHF/CCF)
Pathophysiology:
Cardiac Output (CO) = Heart rate X Stroke volume
Heart is a pump with an output:
• Proportional to its filling volume and
• Inversely proportional to the resistance against
which it pumps
As ventricular end diastolic volume increases a healthy
heart increases CO until a maximum is reached and CO
can no longer be augmented.
(Frank -Starling principle)

4. FRANK-STARLING CURVE

5. Pathophysiological factors causing CHF:
1. Preload (volume work): Volume to be ejected = End diastolic volume (↑)
2. Afterload (pressure work) : Impedance against ejection ( ↑ )
3. Myocardial contractility : Ionotropic state (myocardial dysfunction)
4. Frequency of ejection : Heart rate (dysrrhythmia)
Myocardial Dysfunction
↓ Cardiac output
Systemic over reactions:
↑ E, NE (sympathetic system )
↑AVP-Aldosterone(antidiuretic sys)
↑Renin-Angiotensin(renin-angio sys)
Anti diuresis
Na & fluid retention
↑ Pre load
Peripheral
vasoconstriction
↑ After load
Pathophysiology: Vicious Circle

6. Etiology of CHF according to Pathophysiological factors :
1. Excessive volume load (Preload)
•Large L→R shunt: VSD, PDA
•Large valvular insufficiency: MR, AR
•Endocardial cushion defect (ECD)
•TGA with VSD, TGA with Tricuspid atresia
•Secundum ASD
•Excessive blood or fluid transfusion (fluid overload)
2. Pressure load (Afterload)
•Severe Aortic stenosis, coarctation of aorta, mitral atresia
•Systemic hypertension
•Severe pulmonary hypertension
•Total anomalous venous connections (TAPVC)

7. Etiology of CHF according to Pathophysiological factors :
3. Myocardial dysfunction
• Myocarditis: Rheumatic, Viral
• Cardiomyopathy, Endocardial fibroelastosis, Myocardial
ischemia
• Non-structural causes: Hypoglycemia, Hypocalcemia,
Hypoxia
4. Dysrrythmias: Tachyarrhythmia, Heart blocks
5. High out put failures:
Severe anemia, Thyrotoxicosis, Arteriovenous (AV) Fistula

8. Etiology of CHF according to age of onset:
1. Fetal: Severe anemia, Dysrrythmias
2. Premature neonate:
• Fluid overload, Hypertension, Cor pulmonale (broncho
pulmonary dysplasia)
• PDA, VSD
3. Full term neonate:
• Asphyxial cardiomyopathy, viral myocarditis
• Left sided obstructive lesions:
Coarctation of aorta
• Arteriovenous Malformations
• Large mixing defects: single ventricle, Truncus arteriosus

9. Etiology of CHF according to age of onset…
4. Infant- Toddler:
•L→R shunts: VSD
•Hemangiomas (Arterio-Venous Malformations)
•Metabolic cardiomyopathy, viral myocarditis,
Supraventricular tachycardia (SVT)
•Acute hypertension (Hemolyic uremic synddrome),
Kawasaki disease
5. Child-Adolescent:
•Rheumatic fever, RHD
•Acute hypertension (Post streptococcal glomerulonephritis)
•Viral myocarditis, Cardiomyopathy, Endocarditis
•Cor pulmonale,
•Misc: Hemo-chromatosis, Thyrotoxocosis

10. • Infants become dyspneic while feeding with
profuse sweating
• Becomes exhausted with less volume/feed
• Irritable infant, poor weight gain, weak cry
• Tachypnea with respiratory distress, persistent
cough/wheeze
• Puffiness of face, pedal edema
• Deep coloring / cyanosis
• Fatigue
• Effort intolerance
• Anorexia, pain abdomen(GIT cogestion)
• Orthopnea / nocturnal dyspnea
Clinical features:

11. NYHA Classification
• Class I
– Symptoms with greater than ordinary activity
• Class II
– Symptoms with ordinary physical activity
• Class III
– Symptoms with minimal physical activity
• Class IV
– Symptoms at rest

12. Left sided failure:
•Tachycardia
•Tachypnea
•Wheeze / cough
•Acute pulmonary edema in severe CHF
Right sided failure:
•Hepatomegaly
•Neck vein distension / Increased JVP
•Edema
Failure of either side:
•Cardiomegaly
•Gallop rhythm
•Cyanosis
•Small volume pulse
» Other clinical features of basic lesion responsible for CHF

13. JVP
• JVP – Measurement
HEIGHT

14. Investigations
X-ray chest:
•Cardiomegaly
•Lungs- Fluffy pulmonary markings / Acute pulmonary edema
ECG:
•Specific chamber enlargement / ischemic / inflammatory disease
•Rhythm disorders
Echocardiography : To assess ventricular function
Investigations for primary cause responsible for CHF

15. Cardio-Thoracic
Ratio
<50%
the cardio-thoracic ratio which
is the widest diameter of the
heart compared to the widest
internal diameter of the rib
cage, normal <50%

16. Cardiomegaly on chest X-ray
Causes
• CHF (causes of CHF)
• Pericardial effusion:
 Transudate: Hypoproteinemia
 Exudate : Infectious, inflammatory, autoimmune, malignancy

17. Management of CHF
1.General management:
•Rest , Mild sedation, Propped up position
•Humidified oxygen
•Salt restriction, fluid restriction
2.Pre load reducing agents: Diuretics (and Venodilators )
•Furosemide
•Chlorthiazide
•Spironolactone
3.Positive ionotropic agents:
•Glycosides: Digitalis
•Catecholamine like non glycoside agents
•Dopamine/ Dobutamine
•Non catecholamine non glycoside agents
•Amrinone , Milrinone

18. 4. After load reducing agents and ACE inhibitors:
» Vasodilators which decrease Peripheral Vescular Resistance (PVR)
» Arterial dilators, Venodilators (also ↓ preload) & arterio-venodilators
•Hydralazine(A)
•Nitropruside (A+V)
•Prazocine (A+V)
► ACE (Angiotensin Converting Enzyme) inhibitors: Captopril (A+V)
5. Other drugs:
•Beta-blockers (used in cardiomyopathy): metoprolol, carvedilol
6. Treatment of precipitating and aggravating factors:
•i.e. infection, anemia
7. Treatment of pathological cause of CHF
Management of CHF…

19. Digitalis: Digoxin
Digitalization:
►Rapid Digitalization: IV / Oral (IV dose is 75% of oral dose)
•Total Digitalizing Dose(TDD): Oral dose
•Newborn = 0.02-0.03mg/kg
•Infant/child = 0.04mg/kg (max 0.5mg); Adolescent = 0.5- 1mg(TDD)
♦ TDD is divided as follows (given in 16 hours):
•Half dose stat
•One fourth dose after 8 hours
•One fourth dose after next 8 hours
♦ Maintenance dose: 1/4th dose of TDD (i.e. 0.01mg/kg/day in infant)
♦ Maintenance dose started after 12 hours of last dose of TDD (3rd dose)
►Slow Digitalization: Oral
Dose is maintenance daily dose only without loading dosage &
will achieve digitalization in 7-10 days
» Monitoring during digitalis: ECG, S. Electrolytes
» Digitalis toxicity, Hypokalemia / Hypercalcemia