Download MBBS Cardiac Failure Treatment Lecture PPT

CARDIAC FAILURE
Inability of heart to maintain an output,
necessary for metabolic needs of body
(systolic failure) &

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inability to receive blood into ventricular
cavities at low pressure during diastole
(diastolic failure)

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INVESTIGATIONS

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X ray chest
--to assess cardiac size& pulmonary congestion
--exclude pulmonary etiology
--detect congenital heart disease
ECG

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-may show nonspecific T & ST segment changes
-tal P wave
-specific patterns of congenital&aquired heart dis
Echocardiography
--most useful,widely available,low cost test

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--provides immediate data on
cardiac morphology& structure,
chamber volumes/diameters,
wal thickness,
ventricular systolic/diastolic function,

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pulmonary pressure

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OTHERS
Hemogram
Serum electrolytes
Blood gas analysis

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Renal function test
Blood culture

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AIM OF TREATMENT
Correction of inadequate cardiac output

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1.Correction
2.Reduce
of underlying
cardiac work
cause

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3.Augment
4.Improve
myocardial
cardiac
contractility

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performance

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CORRECTING THE UNDERLYING CAUSE
Important when CCF is caused or precipitated by:
? Anemia

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? Nephrosis
? Overloading of circulation
? Severe chest infection
? Hypertension
? Fever

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? Arrhythmias
? Pulmonary embolism
? Infective endocarditis
? Thyrotoxicosis
? Drug toxicity etc.

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Surgical y treatable causes:
? Valvular lesions
? Obstructive lesions
? Shunts
Conditions that might be missed :

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? sustained tachyarrhythmias,
? coarctation of aorta.& obstructive aortitis,
? anomalous origin of LCA from pulm artery,
? hypocalcemia

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Uncommon causes of CCF in children:

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- upper respiratory obstruction
-hypoglycemia
-hypocalcemia
-neonatal asphyxia

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REDUCTION OF CARDIAC WORK
Restrict patient activities
Sedatives
Rx of conditions causing stress to heart
Vasodilators

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Mechanical ventilation

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Mx of NEONATE WITH HEART FAILURE
? Nursed in an incubator & handled minimal y
? Baby is kept propped up at an incline of about 30.
(Pooling of edema fluid in the dependant areas fluid

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col ection in lungs reduce work of breathing)
? Temp ? 36-37 C (overal circulatory and metabolic needs
are minimal reduce work of heart)
? Humidified oxygen to maintain a conc.of 40-50%
(improves impaired oxygenation due to pulm congestion)

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SEDATIVES
If infant or child is restless or dyspneic
Opiates (morphine)
Benzodiazepine(midazolam)

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To reduce anxiety & lower catacholamine secretion
Reduce ?physical activity ,
-- respiratory rate ,
--heart rate

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RX OF CONDITIONS CAUSING STRESS TO HEART
Fever
Infection
Anemia
Obesity

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Thyrotoxicosis
Repeated pulmonary emboli

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RX OF CONDITIONS CAUSING STRESS TO HEART
INFECTIONS

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In infants & smal children,presence of
superadded pulmonary infection is difficult to
recognise. Therefore , antibiotics administered
emperical y
In older children, antibiotics are used only if

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evidence of infection is present

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RX OF CONDITIONS CAUSING STRESS TO HEART
Anemia
stress on heart bcoz of decreased oxygen carrying

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capacity of heart
Anemia leads to tachycardia &hyperkinetic
circulatory state
Correction of anemia decrease cardiac work
Packed cel volumes of 10-20 mL/kg are required

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to correct severe anemia
(single dose furosemide iv is given prior to
transfusion)

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VASODILATORS
Counteract inappropriately excessive
compensatory mechanisms in heart failure&
improve cardiac output

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VASODILATORS

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VASODILATORS
Nitrates are used as preferential venodilators
In acute care setting, sodium nitroprusside is

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used since it is a mixed arterio & venodilator
Phospho diesterase inhibitors (milrinone) &
Calcium sensitisers(levosimendan)
---popular especial y in post op period
---have powerful vasodilatory and inotropic

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effects

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VASODILATORS
SPECIFIC INDICATIONS
q Acute mitral or aortic regurgitation

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q Ventricular dysfunction due to myocarditis
q Anomalous coronary artery from pulmonary
artery
q Early postoperative setting

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ACE INHIBITORS
Eg: Captopril, Enalapril
Effective for treating heart failutre in infants and
children
Prevent cardiac remodel ing

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They suppress RAAS
Reduce vasoconstriction& salt and water retention
reduce work of heart
By suppressing catacholamines,they prevent
arrhythmias and other adverse effects on myocardium

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S/E--- Cough
(persistent coughuse angiotensin receptor blocker-
Losartan)

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BETA BLOCKERS

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Improve symptoms especial y in patients with
dilated cardiomyopathy,who continue to have
tachycardia
Metoprolol ,Carvedilol
Carvedilol ?preferred----since it has properties

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of beta blockers with peripheral vasodilation
Treatment- started at low dose & increased
depending on tolerability
Dose--0.08 - 0.4 mg/kg/day
Maximum--1 mg/kg/day

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AUGMENTING MYOCARDIAL CONTRACTILITY
INOTROPIC AGENTS
DIGOXIN
Rapid onset of action

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Eliminated quickly
Available as oral & parenteral
Oral digoxin---available as 0.25 mg tablets&
digoxin elixir(1 ml=0.05 mg)
Parenteral---(0.5 mg/2 ml)

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---dose- 70% of oral dose
Beneficial for symptom relief
Can be combined with ACE inhibitors for
synergistic effect

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DIGOXIN- MECHANISM OF ACTION

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DOSAGE

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Children are digitalised within 24 hour period
1/2 of calculated digitalising dose is given

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initial y
Fol owed by ? in 6-8 hours
Final ? after another 6-8 hours
Maintenance dose is usual y 1/4 of digitalising
dose

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DIGITALIS TOXICITY
Rx --
DIGIBIND
? before 3rd daily dose an ECG is done to rule out digitalis
toxicity

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? Toxicity can be control led by omitting next one or two doses
? PR interval is a useful indicator; if it exceeds initial interval
by 50%,digitalis toxicity is present

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Digitalis is used with caution in:
1. Premature neonates

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2. Heart failure due to myocarditis
3. Very cyanotic patients

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New Intravenous inotropic agents
1. Catacholamine inotropes:
Dopamine,Dobutamine, Adrenaline

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2. Phosphodiesterase inhibitors:
Amrinone,Milrinone
3. Levosimendan (calcium sensitiser)
4. Xamoterol ( agonist- cardiac stimulant)
5. Flosequinan

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DOPAMINE
Used if B.P is low
At a dose less than 5 g/kg/minperipheral
vasodilation& increase myocardial contractility
DOBUTAMINE

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Dose--2.5- 15g/kg/min
In pts with dilated cardiomyopathy,it is used as 24 hr
infusion once or twice a week
MILRINONE
Infusion 0.3-0.7g/kg/min fol owing a loading dose of

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50g/kg
LEVOSIMENDAN
6- 12g/kg loading dose over 10 minutes fol owed by
0.05-0.2g/kg/min

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IMPROVING CARDIAC PERFORMANCE
BY REDUCING SIZE OF HEART
q DIURETICS
q DIGOXIN
q DIET

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IMPROVING CARDIAC PERFORMANCE
BY REDUCING VENOUS RETURN(PRELOAD)
DIURETICS
(first line of management in congestive failure)

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MECHANISM OF ACTION
(i) Reduce blood volume,reduce venous return &
ventricular fil ing
Reduce heart size& volume
Wal tension decrease

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Improves myocardial function & cardiac output

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(ii) reduce total body sodium
Reduce B.P & peripheral vascular resistance
Increase cardiac output & reduce work of heart

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DOSAGE OF DIURETICS

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Furosemide
1 -3 mg/kg/day oral y OR
1 mg/kg/dose IV
Spironolactone
1 mg/kg oral y every 12 hr

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DIET
Sodium restriction is recommended ;but
difficult to implement in infants and young
children

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Since heart failure increases calorie
requirements,adequate intake is adviced
(150 kcal/kg/day)(smal and frequent meals
are given)
Severely ill- not able to suck,nasogastric tube

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NEW THERAPIES
Ivabradine
Neprilysin inhibitor & valsartan
Device therapy

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1. Implantable cardioverter defibrillator
2. Cardiac resynchronisation therapy

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STEPWISE RX OF PEDIATRIC CCF

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REFRACTORY CCF
Children with CCF that is refractory to above
mentioned measures need:
Re-evaluation with a special search for
unrecognised precipitating/underlying factor

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Therapy with a -vasodilator nitroprusside
-iv inotropic(dopamine)
-beta blocker(propranolol)
under strict hemodynamic monitoring
Ultrafiltration or dialysis in the presence of renal

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shutdown
Cardiac transplantation

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8 wks old baby with fast breathing and resp
distress.O/E, resp rate -78, HR-172, temp-
103,SPO2-84, BP-94/60,MODERATE

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RETRACION,cardiomegaly wiyh pan systolic
murmer of grade 5 in lower left sternal
border,tender hepatomegaly present

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8 month old baby with ,admitted with resp
distress. O/E, severe pal or

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,tachypnea,tachycardia,cardiomegaly &tender
hepatomegaly.on evaluation, hb was found to
be 3

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4 month old baby admitted with 3 days upper
resp tract infection,O/E,there is

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tachypnea,tachycardia,hypotension,
cardiomegaly
ECG showed ST-T CHANGES and
echocardiogram showed dilated cardiomyopathy
with LV dysfunction

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