congestive heart failure (D. Pharm)

1. CVS Diseases
Congestive Heart Failure (CHF)

2. Congestive Heart Failure
• CHF - chronic progressive condition
• the heart cannot pump enough blood
• to meet the metabolic needs of the body
• because of pathological changes in the myocardium.

3. Functional Classification of Heart Failure
• As per New York Heart Association (NYHA)
• Class I: Patient has no limitation of physical activity. Ordinary physical
activity does not cause symptoms such as; palpitation, dyspnoea or
fatigue.
• Class II: Patient has slight limitation of physical activity. Comfortable
at rest but ordinary physical activity produces symptoms.

4. Functional Classification of Heart Failure
• As per New York Heart Association (NYHA)
• Class III: Patient has a marked limitation of physical activity.
Comfortable at rest but less than ordinary activity causes
symptoms.
• Class IV: Patient is unable to carry out any physical activity without
discomfort. Heart failure symptoms are present at rest and any
physical activity will cause an increase in discomfort.

5. Etiopathogenesis of CHF
• Common Causes of Heart Failure:
• Cardiac pathologies e.g., coronary artery disease (CAD),
cardiomyopathies, congenital heart disease, tachyarrhythmia, valvular
heart disease.
• Hypertension.
• Infections, e.g., Rheumatic fever, sexually transmitted diseases,
pneumonia.
• Endocrine disorders e.g., Diabetes, dyslipidemia, hypo/hyperthyroidism,
adrenal disorder, pheochromocytoma.

6. Etiopathogenesis of CHF
• Common Causes of Heart Failure:
• Nutritional disorders, e.g., Deficiency of thiamine, selenium, iron, calcium,
phosphates and L-carnitine, cachexia.
• Toxins, e.g., Alcohol, trace elements, illicit drug use such as cocaine,
cannabis.
• Drugs, e.g., Beta-blockers, calcium antagonists, antiarrhythmics,
cardiotoxic chemotherapy agents.
• Severe anaemia.
• Obesity.

7. Etiopathogenesis of CHF
• Development Stages of Heart Failure
• Stage A: At high risk for heart failure but without structural or
functional heart disease or signs or symptoms of heart failure.
Hypertension, atherosclerotic disease, Diabetes, obesity, metabolic
syndrome, use of cardio toxins, family history of cardiomyopathies
may lead to Stage A.

8. Etiopathogenesis of CHF
• Development Stages of Heart Failure
• Stage B: Structural or functional heart disease but without signs or
symptoms of heart failure. Previous myocardial infarction (MI), left
ventricular (LV) remodeling including left ventricular hypertrophy
(LVH) and low ejection fraction (EF), asymptomatic valvular disease
may lead to Stage B.

9. Etiopathogenesis of CHF
• Development Stages of Heart Failure
• Stage C: Structural heart disease with prior or current
symptoms of heart failure. It may include known structural
heart disease, shortness of breath, fatigue and decreased
exercise tolerance.

10. Etiopathogenesis of CHF
• Development Stages of Heart Failure
• Stage D: Refractory or end-stage heart failure. It shows
marked symptoms at rest despite maximal medical therapy
and requires specialized treatment interventions.

11. Clinical Manifestations of CHF
• S3/S4 gallop on auscultation
• Elevated jugular venous pressure
(JVP)
• Tachycardia, various arrhythmias
• Dyspnoea at rest or on exertion
• Fatigue
• Cachexia
• Nocturia
• Pulsusalternans
• Fluid retention
• Slow weight gain

12. Diagnosis and Investigation of CHF
• routine laboratory studies,
• cardiac biomarkers,
• ECG,
• chest X-ray,
• echocardiogram.
• If CHF is confirmed, investigate for underlying causes (consider
coronary angiogram, chest imaging, and advanced cardiac imaging).

13. Management of CHF
• Lifestyle modifications.
• Treatment of associated conditions e.g., hypertension, dyslipidemia, and
diabetes.
• Drugs that reduce the workload of the heart, improve cardiac
performance.
• Avoid drugs that may worsen CHF e.g., most antiarrhythmic agents,
NSAIDs, etc.

14. Non-Pharmacological Management of CHF
• Diet and fluid restriction:
• Salt restriction:
• ≤ 1.5 gm/day in stages A and B,
• ≤ 3 gm/day in stages C and D.
• Fluid restriction:
• 1.5-2 L/day in stage D patients who have edema and/or
hyponatremia.

15. Non-Pharmacological Management of CHF
• Advise regular exercise.
• Weight loss in obese patients.
• Cessation of smoking, alcohol consumption, and recreational drug
use.
• Invasive device therapy, heart transplant, mechanical circulatory
support, coronary revascularization, valvular surgery.

16. Pharmacological Management of CHF
• The goals of pharmacotherapy in CHF are
• Restoration of cardiac performance and
• Arrest/reversal of disease progression
• Treatment is based on the stage of heart failure. Additional drugs are
added to the baseline medications as symptoms worsen. From stage
B onward, device therapy can be considered alongside
pharmacotherapy.

17. Pharmacological Management of CHF
• Drugs that improve the CHF condition are:
• Beta blockers.
• ACE inhibitors/Angiotensin receptor blockers (ARB)
• Angiotensin receptor neprilysin inhibitor (ARNI)
• Mineralocorticoid receptor antagonists (MRA)/Aldosterone antagonists
• Hydralazine with nitrate
• Ivabradine
• Diuretics and digoxin improve symptoms and significantly reduce the number of
hospitalizations.

18. Pharmacological Management of CHF
a) Oral Diuretics:
Control of excessive salt and water retention with diuretics.
Loop diuretics are preferred diuretic for the treatment of HF
i) Frusemide: 1 - 2 mg/kg/day or
ii) Hydrochlorothiazide: 1 - 1.5 mg/kg/dose every 12 - 24 hours

19. Pharmacological Management of CHF
b) Beta Blockers:
Beta-blocker is an integral part of congestive heart failure therapy
nowadays.
It is recommended in all stable NYHA Class II-IV patients with HFrEF to
relieve angina, unless contraindicated or not tolerated.
These are preferred first-line treatment to control ventricular rate for
patients in NYHA Class I-III provided they are euvolemic.

20. Pharmacological Management of CHF
c) Angiotensin Converting Enzyme (ACE) Inhibitors/Angiotensin Receptor
Blockers (ARB):
ACE inhibitors are indicated for all patients with congestive heart failure.
i) Captopril: 0.1 to 0.5 mg/kg/dose oral every 8 to 12 hourly upto 4
mg/kg/day or
ii) Enalapril: 0.1 mg/kg/dose oral every 12-24 hourly upto 0.5 mg/kg/day.
ARBs are recommended as an alternative in patients who are intolerant of
ARNI or ACE inhibitors. e.g. Candesartan

21. Pharmacological Management of CHF
d) Angiotensin Receptor-Neprilysin Inhibitor (ARNI):
These are indicated for patients with HFrEF (EF≤ 40%), NYHA Class II-IV.
e.g., Sacubitril/Valsartan.
They act by inhibiting neprilysin which slows down the degradation of
natriuretic peptides, bradykinin and other peptides leading to high
amounts of circulating A-type natriuretic peptide and BNP resulting in
diuresis, natriuresis and relaxation and anti-remodeling of the
myocardium.

22. Pharmacological Management of CHF
d) Angiotensin Receptor-Neprilysin Inhibitor (ARNI):
ARNI treatment should not be combined with ACE inhibitor
or ARB or initiated within 36 hours from the last dose of ACE
inhibitor due to a higher risk of angina edema.

23. Pharmacological Management of CHF
e)Mineralocorticoid Receptor Antagonists (MRA)/Aldosterone
Antagonists:
MRA are recommended for NYHA Class II-IV patients who remain
symptomatic despite treatment with ACE inhibitor (or ARB) and beta-
blocker. e.g., Spironolactone and Eplerenone.
MRAs should only be used in patients with adequate renal function and
normal serum potassium.
Regular monitoring of serum electrolytes & renal enzymes mandatory.

24. Pharmacological Management of CHF
f) Digoxin
Digoxin has positive inotropic effect characterized by an increase in the force of
myocardial contraction. It also reduces the conductivity of the heart through
atrioventricular (AV) node.
Hypokalemia may make digitalis toxicity worse especially with concomitant
diuretic administration.
Oral KCl supplement or potassium sparing diuretics such as spironolactone
should be used.

25. Pharmacological Management of CHF
g) Ivabradine:
β-channel blocker. It slows heart rate.
Note: Avoid simultaneous use of non - dihydropyridine calcium channel
blockers with beta blockers as this can cause complete heart block.