Definition: Heart failure is a clinical syndrome characterized by inadequate systemic perfusion to meet the body's metabolic demands as a result of abnormalities of cardiac structure or function. • This may be further subdivided into:  Systolic heart failure: Reduced cardiac contractility  Diastolic heart failure: Impaired cardiac relaxation and abnormal ventricular filling Etiology: Most common cause of CHF - Left ventricular systolic dysfunction (about 60 - 70%) 1. Decreased contractile function a) Valvular heart disease b) Coronary Heart Disease : Myocardial ischemia c) Myocardial Disease : Cardiomyopathy , Myocarditis 2.Increased after load a)Acute systemic hypertension 3.Abnormalities in preload a)Excessive preload b)Reduced preload Reduced compliance states:  Constrictive pericarditis  Restrictive cardiomyopathy Precipitating factors: o Represented with the mnemonic HEARTFAILES H- Hypertension (systemic) E- Endocarditis (infections) A- Anemia R- Rheumatic fever and myocarditis T- Thyrotoxicosis and pregnancy F- Fever (infections) A- Arrhythmia I- infarction (myocardial) L- Lung infection E- Embolism (pulmonary) achycardia and Tachypnea • Jugular venous distention (JVD) • Pulsus alternans (alternating weak and strong pulse) • Lung auscultation -Wheezing or rales may be heard • Cardiac auscultation - Aortic or mitral valvular abnormality • Skin may be diaphoretic or cold, gray, and cyanotic • Lower extremity edema  Physical findings: hest x-ray :  Cardiomegaly  Pulmonary edema, and  Pleural effusion  Echocardiography : may help identify  Valvular abnormalities  Ventricular dysfunction  Cardiac temponade  Pericardial constriction, and  Pulmonary embolus  Electrocardiogram (ECG) (nonspecific tool)  Concomitant cardiac ischemia,  Prior myocardial infarction (MI),  Cardiac dysrhythmias,  Chronic hypertension, and other causes of left ventricular hypertrophy.  Other laboratory tests (biomarkers)  Hemoglobin, Urinalysis, BUN, Creatinine  Diagnostic approaches Principles of CHF management 1. Identify and treat the precipitating factors 2. Control the congestive state 3. Improve myocardial performance 4. Prevention of deterioration of myocardial function 5. Treat the underlying cause  Management of Heart Failure  References • Kasper L., Braunwald E., Harrison’s principles of Internal medicine, 16th Edition, Heart failure, pages 1367-1377. • Getachew Tizazu, Tadesse Anteneh, internal medicine Lecture notes For Health Officers, Heart failure, pages 2010-2017 • Karen Whalen, Richard S. Finkel, Thomas A. Panavelil Wolters Kluwer, Lippincott Illustrated Reviews: Pharmacology, Sixth Edition, • Kemp CD, Conte JV. The pathophysiology of heart failure. Cardiovasc Pathol. 2012 Sep-Oct;21(5):365-71. • King M, Kingery J, Casey B. Diagnosis and evaluation of heart failure. Am Fam Physician. 2012 Jun 15;85(12):1161-8. 5/06/2022

1. 1
Congestive Heart Failure (CHF)
By: Mihret Bezabih (BSc.)
June, 2022.
Arba Minch, Ethiopia.
Arba Minch College of Health Sciences
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2. Outlines
• Introduction
• Etiologic agents of CHF
• Pathophysiology of CHF
• Clinical manifestation of CHF
• Diagnostic approach of CHF
• Management of congestive heart failure
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3. Learning objectives
At the end of this lesson the students will be able to :
– Define congestive heart failure.
– List the etiologic agents of congestive heart failure.
– Describe the pathophysiology of CHF
– Identify the clinical manifestations of CHF
– Understand the diagnostic approach of CHF
– Manage patients with congestive heart failure.
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4. 4
Introduction
 Definition: Heart failure is a clinical syndrome characterized
by inadequate systemic perfusion to meet the body's
metabolic demands as a result of abnormalities of cardiac
structure or function.
• This may be further subdivided into:
 Systolic heart failure: Reduced cardiac contractility
 Diastolic heart failure: Impaired cardiac relaxation and
abnormal ventricular filling.
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 Etiology: Most common cause of CHF - Left
ventricular systolic dysfunction (about 60 - 70%)
1. Decreased contractile function
a) Valvular heart disease
b) Coronary Heart Disease : Myocardial ischemia
c) Myocardial Disease : Cardiomyopathy , Myocarditis
2.Increased after load
a)Acute systemic hypertension
3.Abnormalities in preload
a)Excessive preload
b)Reduced preload
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6. 6
4. Reduced compliance states:
 Constrictive pericarditis
 Restrictive cardiomyopathy
Precipitating factors:
o Represented with the mnemonic HEARTFAILES
H- Hypertension (systemic)
E- Endocarditis (infections)
A- Anemia
R- Rheumatic fever and myocarditis
T- Thyrotoxicosis and pregnancy
F- Fever (infections)
A- Arrhythmia
I- infarction (myocardial)
L- Lung infection
E- Embolism (pulmonary)
S- Stress
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 Pathophysiology of CHF
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Clinical Manifestations of CHF
• Progressive dyspnea
• Orthopnea and paroxysmal nocturnal dyspnea (PND)
• Cough productive of pink, frothy sputum (highly
suggestive)
• Peripheral edema and ascites
• Nonspecific complaints
• Easy fatigability
• Light headedness ,
• Malaise
• Anxiety abdominal pain , nausea etc.
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 Classification of stages of CHF
• ‘New York Heart Association Heart Failure Classification’ scheme is
used to assess the severity of a patient's functional limitations
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• Tachycardia and Tachypnea
• Jugular venous distention (JVD)
• Pulsus alternans (alternating weak and strong pulse)
• Lung auscultation -Wheezing or rales may be heard
• Cardiac auscultation - Aortic or mitral valvular abnormality
• Skin may be diaphoretic or cold, gray, and cyanotic
• Lower extremity edema
 Physical findings:
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 Chest x-ray :
 Cardiomegaly
 Pulmonary edema, and
 Pleural effusion
 Echocardiography : may help identify
 Valvular abnormalities
 Ventricular dysfunction
 Cardiac temponade
 Pericardial constriction, and
 Pulmonary embolus
 Electrocardiogram (ECG) (nonspecific tool)
 Concomitant cardiac ischemia,
 Prior myocardial infarction (MI),
 Cardiac dysrhythmias,
 Chronic hypertension, and other causes of left ventricular
hypertrophy.
 Other laboratory tests (biomarkers)
 Hemoglobin, Urinalysis, BUN, Creatinine
 Diagnostic approaches
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12. 12
• Principles of CHF management
1. Identify and treat the precipitating factors
2. Control the congestive state
3. Improve myocardial performance
4. Prevention of deterioration of myocardial function
5. Treat the underlying cause
 Management of Heart Failure
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• Dietary sodium restriction (should be <3g/day)
• Activity and life style modification
– Reduce anxiety
– Avoid excess physical exertion (above the limit of the patient’s
cardiac function )
– Weight loss (obese patients)
– Cessation of smoking
– Avoid other CVD risk factors
1. General managements
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14. 2. Control of the Congestive state
• Diuretics: are useful in relieving congestion
and reduce or prevent edema
– Furosemide: Initial dose of 20-40 mg PO 1-2 X daily or 20
mg IV to 400 mg PO/day or 80 mg IV /day
– Hydrochlorothiazide: Initial dose of 25 mg PO/day
to 100 mg PO/day
– Spironolactone: Initial dose of 25 mg PO/day to 50 mg PO
BID or higher
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15. 3. Enhancement of Myocardial contractility :
• Digoxin:
– Inotropic effect - increase myocardial contractility
– Neuro-hormonal modulation
– Doses of 0.125 mg PO/day to maximum of 0.25 mg
PO/day
• Vasodilators:
– Initial dose: Hydralazine 25 mg PO TID
: Isosorbide dinitrate 10 mg PO TID
Maximum dose: Hydralazine 150 mg PO QID
Isosorbide dinitrate 80 mg PO TID
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16. 4. Prevention of deterioration of Myocardial
function
• Angiotensin Converting Enzyme (ACE) Inhibitors
– Initial dose: Captopril 6.25 mg PO/day
: Enalapril 2.5 mg PO BID
– Maximum dose: Captopril 50-100 mg PO QID
: Enalapril 10-20 mg PO BID
• Angiotensin-II Receptor blocker
– Lasortan 25-50 mg once 0r twice daily
• Beta Adrenorecepter blockers
– Metoprolol with initial dose of 6.5mg BID to
maximum dose of 75mg PO BID 16
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 Contraindications and side effects of common drugs used in CHF management
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 Summary
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19.  References
• Kasper L., Braunwald E., Harrison’s principles of Internal medicine,
16th Edition, Heart failure, pages 1367-1377.
• Getachew Tizazu, Tadesse Anteneh, internal medicine Lecture notes
For Health Officers, Heart failure, pages 2010-2017
• Karen Whalen, Richard S. Finkel, Thomas A. Panavelil Wolters Kluwer,
Lippincott Illustrated Reviews: Pharmacology, Sixth Edition,
• Kemp CD, Conte JV. The pathophysiology of heart failure. Cardiovasc
Pathol. 2012 Sep-Oct;21(5):365-71.
• King M, Kingery J, Casey B. Diagnosis and evaluation of heart
failure. Am Fam Physician. 2012 Jun 15;85(12):1161-8. 19
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