chronic heart failure

Question 1

etiology

Answer 1

• Ischaemic heart disease
• Cardiomyopathy
• Hypertension
• Valvular heart disease
• Congenital heart disease (ASD, VSD)
• Alcohol and drugs (inotropic effect,Ca blocker,hypotensive drugs,vasodilators, chemotherapy)
• Right heart failure (pulmonary hypertension, pulmonary embolism, cor pulmonale (COPD))
• Arrhythmias (atrial fibrillation)
• Pericardial disease (constrictive pericarditis, pericardial effusion)
• Infections (Chagas‘ disease)
• kidney pathology:acute glomerular nephritis,renal failure
• vitaminosis,bad nutrition,stress,associated disease:pneumonia,anemia

Question 2

pathogenesis

Answer 2

heart fails, Small cardiac output, ↓ contractility of cardiac muscle, compensatory mech to maintain cardiac output and peripheral perfusion such as
- Ventricular dilatation
- Myocyte hypertrophy
- Increased collagen synthesis
- Altered myosin gene expression - Increased ANP (Atrial natriuretic peptide) secretion (vasodilator)
- Salt and water retention (renin–angiotensin–aldosterone system)
- Sympathetic stimulation
- Peripheral vasoconstriction

However, as heart failure progresses, these mechanisms become pathophysiological causes cardiac decompensation. Factors involved are venous return, outflow resistance, contractility of the myocardium, and salt and water retention. late course causes accumulation of edema

Question 3

types and classification

Answer 3

Types of heart failure
- Systolic heart failure – failed contractility with ejection fraction less than 50%;
- Diastolic heart failure – impairment of myocardial relaxation with filling defect;
- Mixed type;

Left side failure, right side failure, complete variant
Acute and chronic types

classiification
stages
I - Latent stage, intra cardiac dysfunction
II A - Moderate disorders (odema) in one side of circulation, adaptive remodeling of the heart
IIB - Severe disorders in systemic circulation, maladaptive
remodeling of the heart, dystrophy of inner organs
III - Final decompensation of systemic circulation, polyorganic disorders

functional classes
I - No restriction of physical activity. .Excessive efforts may lead to dyspnea and slow recuperation
II - Slight restriction of physical activity : at rest no signs , common physical activity lead to dyspnea, tachycardia, fatiguability
III - Moderate restriction of physical activity : at rest no signs , physical efforts below common lead to symptoms appearance
IV - Inability to perform any physical activity. Signs of heart failure at rest

Question 4

TREATMENT - cardiac glycosides, diuretics, vasodilators, angiotensin-converting enzyme inhibitors

Answer 4

1. Cardiac glycosides
   - Digoxin 0.125–0.25 mg daily (reduce dose in elderly or renal impairment), is indicated in patients in atrial fibrillation with heart failure
   - Digitoxin, Strophantin
2. Diuretics
   a. Furosemide 20–40 mg daily/max. 250–500 mg daily
   b. Bumetanide 0.5–1.0 mg daily/max. 5–10 mg daily
   c. Bendroflumethiazide 2.5 mg daily/max. 10 mg daily
   d. Metolazone 2.5 mg daily/max. 10 mg daily
   - Loop diuretics (e.g. furosemide and bumetanide) and thiazide diuretics (e.g. bendroflumethiazide, hydrochlorothiazide) -relief of dyspnoea and improve exercise tolerance, relieve fluid retention, reduce edema and jugular venous distention
   a. Thiazides
   - Hypothiazides ( 25-100mg/d )
   - Cyclomethiazines ( 0.5-1.5mg/d )
   b. Spironolactone
   - Veroshspirone ( 0.25mg 1 tablet with combination to other drugs )
   - Triamterine ( 50mg ), Amiloride ( 5 mg )
3. Vasodilators and nitrates
   a. Isosorbide dinitrate 20–40 mg × 3 daily
   b. Hydralazine 37.5–75 mg × 3 daily
4. Angiotensin-converting enzyme inhibitors ACEI
   a. Captopril 6.25 mg × 3 daily/25–50 mg × 3 daily
   b. Enalapril 2.5 mg daily/10 mg × 2 daily
   c. Ramipril 1.25–2.5 mg daily/2.5–5 mg × 2 daily
   d. Candesartan 4 mg daily/32 mg daily
   e. Valsartan 80 mg daily/320 mg daily
   f. Losartan 50 mg daily/100 mg daily