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Congestive Heart FailureCongestive Heart Failure

Current PerspectivesCurrent Perspectives

Arvind SindwaniArvind Sindwani

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Congestive Heart FailureCongestive Heart Failure

DefinitionDefinition

““State of systemic & pulmonary congestion”State of systemic & pulmonary congestion”

Failure of heart pumpFailure of heart pump

Metabolic needs of bodyMetabolic needs of body

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Congestive Heart FailureCongestive Heart Failure

ReasonsReasons

Ventricular DysfunctionVentricular Dysfunction

Preserved ventricular function Preserved ventricular function

with volume overloadwith volume overload

Preserved ventricular function with Preserved ventricular function with

pressure overloadpressure overload

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Congestive Heart FailureCongestive Heart Failure

Compensatory mechanismsCompensatory mechanisms ContractilityContractility

Sympathetic over activitySympathetic over activity

Fluid retention ( RAA system)Fluid retention ( RAA system)

>> Compensated Compensated

>> Decompensated Decompensated

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Congestive Heart FailureCongestive Heart Failure

SymptomsSymptoms Infants – Tachypnea, diaphoresis during feedingInfants – Tachypnea, diaphoresis during feeding

Young children – FTT, easy fatigability, recurrent Young children – FTT, easy fatigability, recurrent

cough, wheezingcough, wheezing

Older children – Exercise intolerance, anorexia, Older children – Exercise intolerance, anorexia,

wheezing, dyspnea, palpitation, chest pain, syncopewheezing, dyspnea, palpitation, chest pain, syncope

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Congestive Heart FailureCongestive Heart Failure

Physical ExaminationPhysical Examination TachycardiaTachycardia

Signs of poor perfusionSigns of poor perfusion

SS33 gallop gallop

Tachypnea, Wheeze, CrepitationsTachypnea, Wheeze, Crepitations

HepatomegalyHepatomegaly

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Congestive Heart FailureCongestive Heart Failure

Initial EvaluationInitial Evaluation Chest Radiography – Cardiomegaly, Chest Radiography – Cardiomegaly,

Pulmonary edema, pleural effusion etc.Pulmonary edema, pleural effusion etc.

Electrocardiography- arrthymia, evidence for Electrocardiography- arrthymia, evidence for

myocarditis, cardiomyopathies, ALCAPAmyocarditis, cardiomyopathies, ALCAPA

Echocardiography - To see anatomy and Echocardiography - To see anatomy and

functionfunction

CBC, RFT, LFTCBC, RFT, LFT

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Congestive Heart FailureCongestive Heart Failure

Further EvaluationFurther Evaluation MRI HeartMRI Heart

Cardiac CatheterizationCardiac Catheterization

Additional Blood tests such as cTnT, CK-Additional Blood tests such as cTnT, CK-

MB,CRP, IL-6, TNF-MB,CRP, IL-6, TNF-αα, ESR etc, ESR etc

BNP and NT-pro BNPBNP and NT-pro BNP

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ManagementManagement of CHFof CHF

PrinciplesPrinciples

1.General measures1.General measures

2.Control of congested state2.Control of congested state

- Drug management- Drug management

3.Treatment of precipitating events3.Treatment of precipitating events

4.Treatment of cause4.Treatment of cause

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ManagementManagement of CHFof CHF

General measuresGeneral measures Propped up positionPropped up position

Sedatives/ MorphineSedatives/ Morphine

Supplement OxygenSupplement Oxygen

Respiratory support Respiratory support

Nutritional managementNutritional management

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Drug TreatmentDrug Treatment

>> Compensated stage Compensated stage

>> Acute / Decompensated stage Acute / Decompensated stage

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Drug TreatmentDrug Treatment

> Compensated stage> Compensated stage

DiureticsDiuretics

Afterload reduction (ACE inhibitors) Afterload reduction (ACE inhibitors)

Ionotropes (Digoxin)Ionotropes (Digoxin)

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Drug TreatmentDrug TreatmentDiureticsDiuretics

‘‘Quick relief ’ Quick relief ’ from congestionfrom congestion

Frusemide – standard prescriptionFrusemide – standard prescription

Side effects – Ototoxicity, dehydration, Side effects – Ototoxicity, dehydration,

electrolyte imbalance, renal electrolyte imbalance, renal

stonesstones

Torsemide – More potent than FurosemideTorsemide – More potent than Furosemide

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Drug TreatmentDrug Treatment

DiureticsDiuretics

K sparing diuretics – K sparing diuretics – Spironolactone, EplerenoneSpironolactone, Eplerenone

Spironolactone has shown to improve survival in adultsSpironolactone has shown to improve survival in adults

Thiazide diuretics Thiazide diuretics – Hydrochlorthiazide,Metolazone– Hydrochlorthiazide,Metolazone

Thiazide are mainly used in mild hypertension, edemaThiazide are mainly used in mild hypertension, edema

Caution – Weight & SE monitoringCaution – Weight & SE monitoring

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Drug TreatmentDrug TreatmentACE inhibitorsACE inhibitors

Proven improvementProven improvement in morbidity & mortality in morbidity & mortality in CHF in large scale trialsin CHF in large scale trials

Beneficial effects on ventricular remodeling & hypertrophyBeneficial effects on ventricular remodeling & hypertrophy

First line drugsFirst line drugs

Captopril – 0.5 - 6 mg/kg/dayCaptopril – 0.5 - 6 mg/kg/day

Enalapril – 0.1 - 0.2 mg/kg/day Enalapril – 0.1 - 0.2 mg/kg/day

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Drug TreatmentDrug TreatmentACE inhibitorsACE inhibitors

Side effects - HyperkalemiaSide effects - Hyperkalemia

- Hypotension- Hypotension

- Neutropenia- Neutropenia

- Cough, altered taste- Cough, altered taste

CautionCaution - drug interactions, hyperkalemiadrug interactions, hyperkalemia

- C/I in azotemia & obstructive lesions- C/I in azotemia & obstructive lesions

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Drug TreatmentDrug TreatmentDigoxinDigoxin Dosage Preterm Infants Children

>>Oral Loading 0.02 mg/kg 0.04 mg/kg 0.03 mg/kg ( ½ dose initially, ¼ + ¼ in next 24 hours )

>>MaintenanceMaintenance 0.005 mg/kg 0.01 mg/kg 0.01 mg/kg

>>IntravenousIntravenous - 75% of oral doses

Side Effects - Nausea, vomiting, headache - Arrhythmia

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Drug TreatmentDrug TreatmentDigoxinDigoxin Traditional drug, most widely prescribedTraditional drug, most widely prescribed Mechanism – Inhibition of Na - K ATPaseMechanism – Inhibition of Na - K ATPase Effects – Improve contractilityEffects – Improve contractility

– – Sympatholytic Sympatholytic

– – Vagotonic Vagotonic

– – Delay in AV conductionDelay in AV conduction Role in L Role in L R shunt lesions – controversial R shunt lesions – controversial

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Drug TreatmentDrug TreatmentDigoxinDigoxin

Caution Caution - Hyperkalemia- Hyperkalemia

- Pre – existing rhythm disturbances- Pre – existing rhythm disturbances

- Renal dysfunction- Renal dysfunction

- Drug interactions - Drug interactions

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Drug TreatmentDrug TreatmentNewer DrugsNewer Drugs Selective B – blockersSelective B – blockers - - CarvedilolCarvedilol

Extensively studied in DCMExtensively studied in DCM

Important add-on drug to standard regimenImportant add-on drug to standard regimen

Dose – 0.02 – 0.4 mg/kg/day, titrate up graduallyDose – 0.02 – 0.4 mg/kg/day, titrate up gradually

S/E – hypotension, bradycardia, S/E – hypotension, bradycardia, CF CF

Caution – monitor HR, BP & worsening of CHFCaution – monitor HR, BP & worsening of CHF

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Drug TreatmentDrug Treatment

Newer DrugsNewer DrugsAngiotensin II receptor antagonists - Angiotensin II receptor antagonists - Irbesartan Irbesartan

Losartan Losartan

Recent metanalysis did not show any benefit Recent metanalysis did not show any benefit

over ACE i sover ACE i s

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Drug TreatmentDrug Treatment

>> Acute / Decompensated stageAcute / Decompensated stage

*Acute resuscitation & stabilizationAcute resuscitation & stabilization

*Ionotropic supportIonotropic support

*VasodilatorsVasodilators

*Advanced support & other optionsAdvanced support & other options

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Drug TreatmentDrug Treatment

>> Acute / Decompensated stageAcute / Decompensated stage

GoalsGoals

*Restoration of adequate BPRestoration of adequate BP

*Effective perfusionEffective perfusion

*Correction of hypoxia & acidosisCorrection of hypoxia & acidosis

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Drug TreatmentDrug TreatmentCHFCHF

Decompensated / ShockDecompensated / Shock

NormotensiveNormotensiveHypotensiveHypotensive

EpinephrineEpinephrine

DopamineDopamine

Nor epinephrineNor epinephrine

DopamineDopamine

DobutamineDobutamine

Amrinone/ MilrinoneAmrinone/ Milrinone

IonotropesIonotropes

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MyocardialMyocardial DysfunctionDysfunction

• MilrinoneMilrinone (5 Phosphodiasterase inhibitors)(5 Phosphodiasterase inhibitors)

DoseDose• 0.25 - 0.8 mcg/kg/minute IV infusion0.25 - 0.8 mcg/kg/minute IV infusion

Side effectsSide effects

• Hypotension, Arrhythmia (less)Hypotension, Arrhythmia (less)

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Drug TreatmentDrug Treatment

VasodilatorsVasodilators Nitroglycerine – VenodilatorNitroglycerine – Venodilator

Dose – 0.5 – 1 mcg/kg/minDose – 0.5 – 1 mcg/kg/min Effective in pulmonary edemaEffective in pulmonary edema Caution – BP monitoringCaution – BP monitoring

Sodium Nitroprusside – Arterial dilatorSodium Nitroprusside – Arterial dilator Dose – 0.5 to 10 mcg/kg/minDose – 0.5 to 10 mcg/kg/min Acute LVF/ hypertensionAcute LVF/ hypertension Caution – BP monitoring, cyanide toxicityCaution – BP monitoring, cyanide toxicity

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Drug TreatmentDrug Treatment

VasodilatorsVasodilators Nesiritide – Human type B natriuretic peptideNesiritide – Human type B natriuretic peptide

Dose – 2 mcg/Kg stat f/b 0.01 mcg/kg/minDose – 2 mcg/Kg stat f/b 0.01 mcg/kg/min Systemic vasodilator with modest natriuretic Systemic vasodilator with modest natriuretic

propertiesproperties Limited data in pediatric patientsLimited data in pediatric patients

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Drug TreatmentDrug Treatment

InotropesInotropes Levosimendan – Calcium channel sensitizerLevosimendan – Calcium channel sensitizer

Does not increase myocardial ODoes not increase myocardial O2 Consumption2 Consumption

Not arrythmogenic at therapeutic levelsNot arrythmogenic at therapeutic levels

Istaroxime – Nonglycoside Na K ATPase inhibitorIstaroxime – Nonglycoside Na K ATPase inhibitor Uncouples inotropy and arrythmogenicityUncouples inotropy and arrythmogenicity Lesser tachycardia than dobutamineLesser tachycardia than dobutamine

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Drug TreatmentDrug TreatmentVasopressin Receptor AntagonistsVasopressin Receptor Antagonists2 types of vasopressin receptors V1a and V22 types of vasopressin receptors V1a and V2

Dual (V1a&V2)receptor antagonist:Dual (V1a&V2)receptor antagonist:

ConivaptanConivaptan,, SelectiveV1areceptor antagonist: SelectiveV1areceptor antagonist:

RelcovaptanRelcovaptan Selective V2 receptor antagonist :Selective V2 receptor antagonist :

Tolvaptan, Tolvaptan, Mozavaptan , ,Satavaptan

Although provide short term benefit in hyponatremia Although provide short term benefit in hyponatremia and edema long term results are awaitedand edema long term results are awaited

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Role of PGE 1Role of PGE 1

Life saving drug in critically ill neonatesLife saving drug in critically ill neonates

Duct dependent CHDs Duct dependent CHDs

– – CoA, HLHS, PS, TGACoA, HLHS, PS, TGA

Dose – 0.05 - 0.4 mcg/kg/min infusionDose – 0.05 - 0.4 mcg/kg/min infusion

S/E – Apnea, hypotension, irritability, seizuresS/E – Apnea, hypotension, irritability, seizures

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SevereSevere PAHPAH

• Sildenafil Sildenafil Dose - 0.3mg/kg – 3mg /kg / 6-8 hrly Caution

- Infection, Deranged LFT

- Gross CHFMonitor

- CBC, RFT, LFT

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SevereSevere PAHPAH

• Nitric OxideNitric Oxide

Dose- 5 – 80 ppm

Problems

- Cost

- Special Equipment

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AnaemiaAnaemia & CHF& CHF

• No structural heart defectNo structural heart defect

• Hb <6 gm%Hb <6 gm%

• Acyanotic heart defectAcyanotic heart defect

• Hb <10 gm%Hb <10 gm%

• Cyanotic heart diseaseCyanotic heart disease

• Hb <12 gm%Hb <12 gm%

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ArrhythmiasArrhythmias

Cause of CHFCause of CHF

– Tachyarrhythmia (common)Tachyarrhythmia (common)

– Bradyarrhythmia ( rare )Bradyarrhythmia ( rare )

Precipitating/ Contributory factorPrecipitating/ Contributory factor

Diagnose and treat accordinglyDiagnose and treat accordingly

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ArrhythmiasArrhythmiasTachycardiaTachycardia

• 8 months old/M8 months old/M

• Persistent CHFPersistent CHF

• ECGECG– Narrow QRS TachycardiaNarrow QRS Tachycardia

• EchoEcho– Dilated LV,LV DysfunctionDilated LV,LV Dysfunction– No Structural Heart DefectNo Structural Heart Defect

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ArrhythmiasArrhythmiasSVTSVT

• Treated WithTreated With– Adenosine IV bolusAdenosine IV bolus

– Continued Tx withContinued Tx with• DigoxinDigoxin

• FlecainideFlecainide

– Follow up at 6 monthsFollow up at 6 months• Normal LV size and function Normal LV size and function

Inj Adenosine

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ArrhythmiasArrhythmias - Bradycardia- Bradycardia

• 1 year / F, Failure to thrive1 year / F, Failure to thrive• On exam – LVE, CHFOn exam – LVE, CHF• ECGECG

– Complete Heart BlockComplete Heart Block

• EchoEcho– Corrected TGA, no septal defectCorrected TGA, no septal defect

• Underwent PPIUnderwent PPI

– No LVE / CHF at 1 y FUNo LVE / CHF at 1 y FU

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CardiacCardiac LesionsLesions

L R shunts

Obstructive Lesions

Admixture Lesions

Ventricular Dysfunction

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L L R Shunts R Shunts

• Patent Ductus ArteriosusPatent Ductus Arteriosus• Premature Babies – Premature Babies –

– Indomethacin / IbuprofenIndomethacin / Ibuprofen– Surgical ligation Surgical ligation

» Ventilator dependenceVentilator dependence» If CHF / PAH persistingIf CHF / PAH persisting Even in NICU settingEven in NICU setting

• Term Babies – Term Babies –

If CHF – Closure at presentation If CHF – Closure at presentation

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L L R Shunts R Shunts

• VSD– Single large VSD Single large VSD

» Elective surgery at 3-6 m Elective surgery at 3-6 m

» Early if indicatedEarly if indicated

– Multiple VSDs Multiple VSDs

» PA band as initial palliationPA band as initial palliation

» Closure of VSDs after 1 yearClosure of VSDs after 1 year

• ASDASD– Elective closure 2-3 yrsElective closure 2-3 yrs

– Early if CHFEarly if CHF

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L L R Shunts R Shunts

• AVSDAVSD• Elective surgery Elective surgery

– 8-12 weeks8-12 weeks

– Early surgery Early surgery

» Significant MRSignificant MR

» Persistent CHF / FTTPersistent CHF / FTT

• Aorto-Pulmonary WindowAorto-Pulmonary Window• Surgery at 4-8 weeksSurgery at 4-8 weeks

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ObstructiveObstructive LesionsLesions• Left sided lesionsLeft sided lesions

• Critical AS Critical AS – – Balloon Aortic ValvoplastyBalloon Aortic Valvoplasty

• Critical CoACritical CoA – – Surgery / Balloon DilationSurgery / Balloon Dilation

• Right sided lesionsRight sided lesions• Critical PSCritical PS

– – Balloon Pulmonary ValvoplastyBalloon Pulmonary Valvoplasty

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AdmixtureAdmixture LesionsLesions• TGATGA

• Arterial switch Arterial switch

– Intact Septum – 2 to 4 wksIntact Septum – 2 to 4 wks

– With VSD – 4 to 8 wksWith VSD – 4 to 8 wks

• TAPVC TAPVC • Surgery at presentationSurgery at presentation

• Truncus ArteriosusTruncus Arteriosus

• Elective Surgery at 4 – 8 weeksElective Surgery at 4 – 8 weeks

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Myocardial DysfunctionMyocardial Dysfunction

• ALCAPAALCAPA

–Surgery at time of presentationSurgery at time of presentation

–Excellent resultsExcellent results

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Myocardial DysfunctionMyocardial Dysfunction• 45 days / M45 days / M• Clinical evaluationClinical evaluation

• Convulsion, CHFConvulsion, CHF

• Blood InvBlood Inv• HypocalcaemiaHypocalcaemia

• EchoEcho– LVEF-30 %,N coronariesLVEF-30 %,N coronaries

• Tx – Cal, Vit D, DecongestivesTx – Cal, Vit D, Decongestives

• Follow up – n EF after 8 wksFollow up – n EF after 8 wks

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MyocardialMyocardial dysfunctiondysfunctionMyocarditisMyocarditis

• Role of IVIG (May be helpful)Role of IVIG (May be helpful)

• Beta BlockersBeta Blockers

• IV Inotropes - MilrinoneIV Inotropes - Milrinone

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Advanced life supportAdvanced life support

Extracorporeal Membrane Oxygenation Extracorporeal Membrane Oxygenation (ECMO)(ECMO)

Ventricular Assist Devices (VADs)Ventricular Assist Devices (VADs)

Intraaortic Balloon Pump (IABP) Intraaortic Balloon Pump (IABP)

Biventricular synchronized pacingBiventricular synchronized pacing

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ManagementManagement of CHFof CHF

Nutritional ManagementNutritional Management Failure to thriveFailure to thrive - common- common - multifactorial - multifactorial

High caloric diet – up to 150 – 170 kcal / kg / dayHigh caloric diet – up to 150 – 170 kcal / kg / day

Low salt diet, Fluid restriction (If hyponatremic) Low salt diet, Fluid restriction (If hyponatremic)

Nasogastric, Transpyloric, Gastrostomy feedsNasogastric, Transpyloric, Gastrostomy feeds

Better nutritional care Better nutritional care Improved survival Improved survival

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Cardiac TransplantationCardiac Transplantation

• Heart / Heart- Lung transplantationHeart / Heart- Lung transplantation

• Patients withPatients with

*End stage heart diseaseEnd stage heart disease

*Complex CHDsComplex CHDs

*Eisenmenger’s SyndromeEisenmenger’s Syndrome

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Take Home Message Take Home Message

Presently most patients with CHF can be Presently most patients with CHF can be

salvaged, if evaluated timely and salvaged, if evaluated timely and

managed appropriatelymanaged appropriately

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Facilities Available in Facilities Available in Department of PaediatricsDepartment of Paediatrics

8 bedded Tertiary Care NICU

High end state of art neonatal ventilator

Computerized monitors for measuring

invasiveBlood pressure, Heart rate,

ECG,SpO2 etc.

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Facilities Available in Facilities Available in Department of PaediatricsDepartment of Paediatrics

Open care warmers.

Syringe pumps

CFL Phototherapy unit

Infant Flow driver CPAP machine

Experienced nursing staff with

neonatal training.

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Facilities Available in Facilities Available in Department of PaediatricsDepartment of Paediatrics

Taking care of extreme preemies,

Newborns with birth asphyxia,

Meconium aspiration, pneumonia etc

with morbidity and mortality levels

comparable to best centers in India.

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Facilities Available in Facilities Available in Department of PaediatricsDepartment of Paediatrics

High end state of art

PaediatricVentilator

Successfully doing various Paediatric

cardiac, surgical and urologic procedures

such as PDA ,ASD device closure, VSD

closure, TOF repair, Ureteric

reimplantation etc.

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