Heart failure is defined as the inability of the heart muscle to ensure normal haemodynamic function.
The left heart failure (often secondary to coronary artery disease, valvular heart disease and / or hypertension) is the most common form.
We distinguish:
– Chronic heart failure with insidious onset,
– Acute heart failure involving the immediate life-threatening, manifested in two forms: acute pulmonary edema (PAO) and cardiogenic shock.
Clinical signs:
– Heart failure secondary to left ventricular failure left:
• fatigue and / or progressive dyspnoea, occurs on exertion and then at rest (accentuated by the decubitus position, preventing the patient from lying down)
• PAO: acute dyspnoea, laryngeal crackles, cough, frothy sputum, anxiety, pallor, more or less cyanosis, rapid and weak pulse, crackles in both lung fields, muffled heart sounds sometimes gallop.
– Heart failure secondary right to right ventricular failure:
• leg edema, jugular veins, hepatomegaly, hepato-jugular reflux;
• ascites in advanced stages.
Rarely isolated, it is often a complication of left ventricular failure.
– Global heart failure secondary to the failure of two ventricles:
• combination of left and right signs. Signs of right heart failure are often in the foreground.
Treatment of acute heart failure (OAP and cardiogenic shock):
– Case 1: TA preserved
• Place the patient in a semi-reclined position with legs.
• Oxygen mask, broadband.
• Lower the pulmonary pressure by combining furosemide + morphine + nitro derivative Rapid Action:
furosemide IV (onset of action in 5 minutes and maximum 30 minutes): 40 to 80 mg repeated every 2 hours according to clinical response, monitoring BP, pulse and urine output
+ Morphine depending on the severity, 3-5 mg slow IV or 5 to 10 mg SC
+ Sublingual glyceryl trinitrate: 0.25 to 0.5 mg. Monitor blood renew after 30 minutes if required when systolic BP <100 mm Hg.
• In severe cases, if none of these drugs are available, rapid bleeding (300 to 500 ml in 5 to 10 minutes) from the basilica vein (elbow fold) and monitor the blood.
– 2nd case: blood pressure collapsed, see cardiogenic shock.
Treatment of chronic heart failure:
The objective is to improve the prognosis and quality of life.
– Dietary modification: reduce salt intake to limit fluid retention, normal fluid intake (except in cases of hydrops: 750 ml / 24 hours).
– Treatment of fluid retention
• In the first line: furosemide PO
During congestive episodes: 40 to 120 mg / day in one take. When the flare is controlled, dose reduction to 20 mg / day in one take.
• The dosage can be increased (up to 240 mg / day). If these doses are still insufficient, the combination of hydrochlorothiazide PO (25 to 50 mg / day for a few days) may be considered.
• In case of inefficiency and in the absence of severe renal impairment, furosemide spironolactone PO: 25 mg / day in one take.
• Drainage of pleural effusions by needle aspiration.
Note: diuretic administration exposed to the risks of dehydration, hypotension, hypo- or hyperkalemia, hyponatremia and renal failure.
Clinical monitoring (hydration, blood) and if possible biological (blood electrolytes, creatinine) should be regular, especially at high doses or in elderly patients.
– Background Processing
• Angiotensin converting enzyme (ACE) inhibitors are the first-line treatment. Start with low doses, especially in patients with low blood, kidney failure, hyponatremia or diuretic.
enalapril PO 1: 5 mg / day once daily for one week, then double the dose each week until the effective dose, usually around 10 to 40 mg / day in 2 divided doses. The increase in dosage is done under pressure control (systolic must remain above 90 mm Hg) and biological (risk of hyperkalemia and renal failure 2).
In patients treated with diuretics, if possible reduce the dose of the diuretic during the introduction of the IEC.
If the patient is treated with high-dose diuretic, halving the initial dose of enalapril (risk of symptomatic hypotension).
Do not combine ACE inhibitors and spironolactone (risk of severe hyperkalemia).
• Digitalis are indicated only when proven atrial fibrillation (ECG).
In the absence of cons-indications (bradycardia, unidentified rhythm disturbances):
digoxin PO: 0.5 to 1 mg in 3 divided or 4 taken on day 1 and 0.25 mg / day in one take.
The therapeutic dose is near the toxic dose. Do not exceed the recommended dosage and reduce by two or four (1 day of 2) in the elderly, malnourished or renal impairment.
1* Enalapril may be replaced by captopril: start with 6.25 mg 3 times / day for the first week, the effective dose is usually around 50 mg 2 times / day. The terms of increased dosage, precautions and patient monitoring are the same as for enalapril.
2* A moderate hyperkalemia is common, it is not alarming as it remains <5.5 mEq / L.
• In heart failure left and overall, nitrates can be used in case of signs of intolerance to ACE inhibitors (chronic cough, kidney failure, severe hypotension).
isosorbide dinitrate PO: start with 10 to 15 mg / day in 2 divided to 3 doses and increase to the effective dose, usually 15-60 mg / day. Larger doses (up to 240 mg / day) may be required.
• Whatever the treatment prescribed, monitoring should be regular: clinical improvement and treatment tolerance:
– Clinical monitoring is based on weight control, BP, pulse rate (arrhythmias) and the evolution of signs (dyspnea, edema, etc.).
– Laboratory monitoring is adapted according to the treatment.
Etiological treatment:
Hypertension Anemia:
Cardiovascular beriberi or “wet” by deficiency of vitamin B1
IM or IV thiamine
Child: 25 to 50 mg / day for a few days
Adult: 50 to 100 mg / day for a few days
Then change to oral treatment with thiamine PO
Children and adults: 3 to 5 mg / day once daily for 4 to 6 weeks
Rheumatic fever:
– Antibiotic
benzathine benzylpenicillin IM
Children under 30 kg: 600 000 IU as a single injection
Children over 30 kg and adult: 1.2 MIU as a single injection
– Anti-inflammatory therapy
Starting with acetylsalicylic acid PO: 50 to 100 mg / kg / day.
If the fever or cardiac signs persist, replace with a corticosteroid:
prednisolone PO
Children: 1-2 mg / kg / day
Adult: 60 to 120 mg / day
Continue this treatment for 2-3 weeks after normalization of the erythrocyte sedimentation rate and decrease the dose gradually (over two weeks).
To avoid a relapse, resume the acetylsalicylic acid in parallel with the lower doses of prednisolone. Aspirin was continued two to three weeks after complete cessation of corticosteroids.
– Secondary prophylaxis
Prophylactic treatment lasts for several years (until the age of 18 years or 25 years in case of cardiac involvement; for life if chronic valvular disease).
benzathine benzylpenicillin IM
Children under 30 kg: 600 000 IU injection every 4 weeks
Children over 30 kg and adult: 1.2 MIU as an injection every 4 weeks