Heart failure

Heart failure (CH) is a pathological condition caused by heart failure as a pump that provides adequate blood circulation. The manifestation and consequence of pathological conditions affecting the myocardium or obstructing the work of the heart: ischemic heart disease, heart defects, arterial hypertension, diffuse lung diseases, myocarditis, myocardial dystrophy (including thyrotoxic, athletic, etc.), myocardiopathy (including alcoholic) and etc.

Heart failure is acute - either the actual acute, or acute manifestations of chronic heart failure. See also Cardiac asthma, pulmonary edema. On the pathogenesis and forms of acute heart failure, see also below when describing chronic heart failure.

Heart failure is chronic.

Pathogenesis. The consequence and manifestation of HF is a decrease or increase in blood filling, blood flow, or (and) pressure in certain central and peripheral links of the blood circulation. These changes arise not only as a direct mechanical consequence of impairment of the pumping function of the heart, but also as a result of the inadequacy of adaptive reactions. Such reactions include tachy- and bradycardia, changes in vascular peripheral and pulmonary resistance, "centralization" of blood circulation and other forms of redistribution of blood filling, fluid retention, sodium, hypertrophy and enlargement of individual chambers of the heart, etc. Hemodynamic disturbances in turn lead to pathological changes as In the heart and blood vessels, and in other organs and systems, and are accompanied by disorders that limit the patient's vital activity and, ultimately, threaten his life.

Symptoms, the course is not the same for different forms and stages of heart failure.

Clinical forms:

1. Congestive left ventricular failure is typical for mitral malformation, for severe forms of ischemic heart disease - especially in patients with hypertension. Increased pressure in the pulmonary veins contributes to filling the left ventricle and maintaining a sufficient minute volume of the heart. At the same time, stagnant changes in the lungs disrupt the function of external respiration and are the main factor that aggravates the patient's condition with this form of HF. Manifestations: dyspnea, orthopnea, signs of stagnation in the lungs auscultatory (dry wheezes below the level of the scapula, migrating wet rales) and radiographic, cardiac asthma and pulmonary edema, secondary pulmonary hypertension, tachycardia.

2. Left ventricular failure of ejection is characteristic of aortic defect (see), IHD, arterial hypertension. Manifestations: insufficiency of cerebral circulation (dizziness, darkening in the eyes, fainting), coronary insufficiency, sphygmographic and echocardiographic low-emission grits. In severe cases, Chain-Stokes breathing is possible, alternating pulse (rarely), presystolic gallop rhythm (pathological IV tone), clinical manifestations of congestive left ventricular failure. In the terminal stage, right ventricular failure may occur.

3. Congestive right ventricular insufficiency is characteristic of mitral and tricuspidal defect, constrictive pericarditis. Usually it joins stagnant left ventricular failure. Manifestations: swelling of the cervical veins, high venous pressure, acrocyanosis, enlargement of the liver, subic- ticity, edema - cavitary and peripheral.

4. Right ventricular failure of ejection is characteristic for stenosis of the pulmonary artery, pulmonary hypertension. Diagnostic and mainly radiographic (depleted peripheral pulmonary vascular pattern). Other signs of this form may be found: shortness of breath at a strictly defined threshold level of physical activity, hypertrophy of the right ventricle - palpatory, and then ECG signs like the "pressure load" (high I and decrease of the T wave in the right thoracic leads). In especially severe cases, the gray color of the skin.

5. Dystrophic form. As a rule, the terminal stage of right ventricular failure. Variants: a) cachectic; B) edematous-dystrophic with dystrophic changes of the skin (thinning, gloss, smoothness of the pattern, flabbiness), edema - widespread or limited mobile, hypoalbuminemia, in the most pronounced cases - anasarca; C) uncorrected salt depletion.

In a number of cases, changes in the heart (cardiomegaly, atriomegaly, atrial fibrillation) come to the fore, which allows us to speak of a "central" form of HF. As special forms with specific mechanisms of circulatory disturbances and manifestations, HF is considered in "blue" congenital malformations with insufficient blood flow in a small circle and uninjured or excessive - in a large, pulmonary heart disease, anthyroidism, arteriovenous fistula, cirrhosis, and arrhythmogenic CH. Patients with childhood can develop "passive adaptation" (small body weight and height, poor physical development, sharply reduced physical activity, infantilism). The listed forms of HF occur in various combinations, it is often possible to distinguish only the leading form.

Stages of development and severity of congestive heart failure. Of the many signs of HF listed in describing one or another stage, it is necessary to identify a few, each of which is sufficient to determine a specific stage. Stage I: subjective symptoms of heart failure with moderate or more significant stress. Stage IIА: 1) expressed subjective symptoms of heart failure with insignificant loads; 2) orthopnea; 3) attacks of suffocation; 4) radiographic, in some cases - electrocardiographic signs of secondary pulmonary hypertension; 5) re-occurrence of edema; 6) repeated enlargement of the liver; 7) cardiomegaly without other signs of this stage; 8) atrial fibrillation without other signs of this stage. Stage IIB: 1) repeated attacks of cardiac asthma; 2) permanent peripheral edema; 3) significant cavity edema - permanent or recurring; 4) persistent enlargement of the liver, which during treatment can be reduced, but remains enlarged; 5) atriomegaly; 6) cardiomegaly combined with at least one of the signs of the previous stage; 7) atrial fibrillation in combination with at least one of the signs of the previous stage. Stage III, terminal: 1) severe subjective disorders with minimal stress or at rest; 2) episodes of cardiac asthma repeated throughout the week; 3) dystrophic changes in organs and tissues.

If there is at least one "sufficient" sign of a more severe stage, then this stage should be established. Priority is given to clinical criteria. Negative results of instrumental research often prove to be non-indicative. Such most obvious terminal manifestations of heart failure as a decrease in the minute volume, insufficient blood supply to organs and tissues, and insufficient supply of oxygen to them may be absent not only at rest, but also with the available load. Similar to arterial pressure, the corresponding indices can not go beyond the broad limits of the norm variants and in severe CH - up to the last days and hours of the patient's life ("compensation at the pathological level").

The most significant "direct" manifestations of heart failure that determine the patient's quality of life are assessed according to the scale adopted in the international practice of the modified classification of the New York Heart Association. Functional classes (PK) are determined by the appearance of painful dyspnea, palpitation, excessive fatigue or anginal pain - at least one of these subjective manifestations of HF. These manifestations are absent in "FC O". For classes I-IV, they arise at loads of one or another intensity; FC! - at loads higher than ordinary (when walking fast on a level ground or when climbing on a gentle slope); FC II - with ordinary, accompanying daily activities, moderate stresses (appear when the patient goes on an equal footing with other people of his age on an even place); FC III - with minor, less ordinary loads, which cause you to stop when walking on a level place at a normal pace, with a slow rise to one floor; FC IV - with minimal loads (several steps around the room, putting on a dressing gown, shirts) or at rest.

To assess the tolerance to physical activity, samples are taken with a dosed physical load (veloergometer, treadmill). In acute and subacute forms of IHD, aortic and subaortic stenosis, high arterial hypertension, severe HF, they are contraindicated.

In the expanded diagnosis, the form and extent (stage) of HF, as well as its main manifestations: atrial fibrillation, cardiac asthma (rare, partial episodes), pulmonary edema, secondary pulmonary hypertension, hepatomegaly, ascites hydropericardium, anasarca, cachexia, cardiomegaly, atriomegaly .

Objective symptoms should be objectively evaluated and verified that they are caused by HF, rather than another cause, such as, for example, lung disease or neurotic reaction. In doubtful cases, it is necessary to exclude pulmonary, renal failure, cirrhosis, myxedema.

Treatment. Mode and diet: in! Stage - compliance with the regime of work and rest, moderate exercise (but not sports!). In more severe stages, physical exertion should be limited, periodically or permanently assigned a bed, half-bed regime. Diet - full, easily digestible, rich in proteins, vitamins, potassium. The diet of the 10th does not meet these requirements. She should prefer a diet number 5, preferably - enriched with fruits, cottage cheese with sour cream. With a tendency to fluid retention and arterial hypertension, moderate restriction of table salt is shown. With massive edema, a short-term, strict, salt-free diet can be prescribed. Long-term (more than 1-week) application of diet No. 10, especially in combination with saluretic therapy, can lead to dangerous salt depletion. Effective unloading days, during which a monotonous, easily digestible, sodium chloride-poor food (rice, apple-rice, etc. days) is used. Sanatorium treatment is shown in stages I and IIA, and, in exceptional cases, in stage IIB.

Drug therapy is not the same for different forms, manifestations and the origin of HF. It should be performed against the background of physical activity limitations. In chronic HF, adequate medication should be permanent - unreasonable withdrawal often leads to decompensation.

Cardiac glycosides are indicated mainly in congestive heart failure, with atrial fibrillation. They are contraindicated in obstructive hypertrophic cardiomyopathy, with severe hypo- and hyperkalemia, hypercalcemia, atrioventricular blockade, WPW syndrome, weakness of the sinus node, ventricular extrasystoles - frequent, paired, polytopic, and in the rhythm of allorrhythmia, as well as in paroxysms of ventricular tachycardia. With reduced elimination of cardiac glycosides (renal failure, elderly age), the maintenance dose is reduced by 2-3 times and, if possible, corrected taking into account the content of serum glycoside or creatinine.

Cardiac glycosides are prescribed in doses close to the maximum tolerated, with stable HF - permanently. At the beginning (2 - 3 days) a saturating dose is given, then the daily dose is reduced by 1.5 - 2 times. Subsequently, the maintenance dose is refined depending on the patient's individual response so that the pulse rate is kept at 52-68 per 1 minute at rest and does not exceed 90-100 per min after minimal stress. With the expansion of the motor regime, the maintenance dose is increased. When there are symptoms of glycosidic intoxication, overdose (bradycardia or its threat - a rapid decrease in the pulse rate to 60 in 1 min or less, nausea, vomiting, the appearance of pulmonary extrasystoles - polytopic, paired or with a frequency of more than 5-6 per 1 min, atrioventricular blockade and Etc.), treatment with cardiac glycosides should be stopped immediately, without limiting the dose. With the disappearance of signs of an overdose, but no earlier than 2-3 days (after digitoxin - after 2 4 weeks), treatment is resumed with a 25-50% reduction in the daily dose. In more severe cases of glycosidic intoxication appoint unitiol (5% solution 5 - 0 ml IV, then you 5 ml 34 times a day). According to the indications, antiarrhythmic therapy is performed (see Arrhythmias, Blockade of the heart). The patient and his relatives should be acquainted with the individual scheme of treatment with cardiac glycosides and with signs of their overdose.

Digoxin is prescribed 2 times a day in gyu tablets 0.00025 g or parenterally by 0.5-1.5 ml of 0.025% solution (saturation period), then 0.25-0.75 mg (maintenance dose) per day. Instead of digoxin, less potent celanid or isolanide may be given in tablets of 0.00025 g or in drops of 10 to 5 drops of 0.05% solution and anthoside for 15 to 20 drops 2 to 3 times a day. One tablet of digoxin corresponds to 1.5-2 tablets of Celanide or 16-0 drops of Celanide and Lantozide. The use of the most active cardiac glycoside digitoxin (0.1 mg tablets) requires special care (the toxic effect with the risk of cardiac arrest may persist after withdrawal of the drug to 2 - ~ weeks). Selection of a dosage of cardiac glycosides, as a rule, should be done in a hospital. Parenteral administration of short-acting drugs (strophanthin, korglikon) is carried out in the first days of treatment of the most severe patients with a subsequent transition to oral medication. 0.05% solution of strophantin in 0.25 - 1 ml or 0.06% solution of Korglikona for 0.5-1 ml is injected mainly into the vein with isotonic sodium chloride solution or with 5-10% glucose solution 2 times a day. With tachycardia, it is advisable to begin treatment with intravenous administration of digoxin.

Diuretics are indicated not only for edema, liver enlargement, obvious stagnant changes in the lungs, but also for latent fluid retention, one of the signs of which is the reduction of dyspnea in response to a trial diauretin. Assign in minimal effective doses, as a rule, against the background of treatment with cardiac glycosides. A massive diuretic therapy is started in bed rest. The treatment regimen is individually developed and corrected during treatment. The most effective is usually intermittent treatment, when the drug is prescribed 2-3 times a week and less often or short (2 - 4 days) courses. Increased doses and frequency of use of a given drug should be preferred alternation (shift) or joint use of diuretics with different mechanisms of action and effects on the acid-base state. With the advent of refractoriness to diuretics, temporary (for 5-7 days) cancellation may be useful, an attempt to enhance the treatment with spironolactone. In most cases, diuretics are more effective if taken on an empty stomach, the patient remains in bed for 4-6 hours and if an unloading diet is prescribed on the day of their admission. On the effectiveness of therapy in addition to increasing diurnal daily diuresis, convergence of edema and weight loss is indicated by a reduction in dyspnea and, in part, a reduction in liver size. Attempts to achieve significant reduction in liver size with the help of massive diuretic therapy are usually unsuccessful and fraught with the danger of irreversible disturbance of the water-salt balance. At the expressed cavity edemas (hydrosorax, hydropericardium, but only forcedly - with massive ascites) evacuation of fluid can be mechanical (puncture). The main complications of diuretic therapy are hypokalemia, hyponatremia, hypocalcemia (loop diuretics), hypochromaemic alkalosis, dehydration and hypovolemia - sometimes with the formation and progression of phlebothrombosis. More rarely (mainly with prolonged massive treatment with certain drugs, in particular, thiazide derivatives, ethacrynic acid), hyperglycemia, hyperuricemia And other adverse manifestations. It should be especially caution against life-threatening diuretics when dehydrated (dry mucous cheeks).

Dichlorothiazide (hypothiazide) is used in tablets of 0.04 g, or preferably in triampur (tablets containing 12.5 mg of dichlorothiazide and 25 mg of potassium-sparing diuretic, triamterene). These drugs are prescribed in a dose of 1 tablet 1 to 2 times a week to 1 tablet 2 times a day for the first 2 to 5 days, then 1 tablet 1 to 3 times a week or daily. Powerful loop diuretic furosemide (Lasix) in tablets of 0.04 g or parenterally (2 ml of 1% solution of lasix) causes forced diuresis, lasting up to 4 - 6 hours. Massive (more than 5 - 8 tablets per week) treatment leads to a decrease in diuretic Effect and hypokalemia. With prolonged maintenance therapy, it is advisable to confine furosemide to 112 tablets (0.02 g) up to 2 to 3 times a week, alone or in combination with triampur. Rapid action and furosemide inherent in the initial extrarenal effect of redistribution of blood with unloading of the small circle make it especially valuable intravenous administration of it at a dose of 0,04-0,08 g in urgent cases (cardiac asthma, pulmonary edema). Clopamid (Brinaldix) in tablets of 0.02 grams by the diuretic effect is inferior to furosemide, but it is better tolerated (unpersified diuresis - up to a day). It is prescribed for 10 - 20 mg from 1 - 2 times a day to 1 time in 10 - 15 days. The hypotensive effect is more pronounced than in other diuretics, treatment with clopamid is not accompanied by orthostatic reactions. Ectrinoic acid (uregit) in tablets of 0.05 g is used alone or with potassium-sparing diuretics in doses from 1 tablet 1-2 times a week to 2 to 3 tablets in the morning after eating short courses for 2 to 4 days with interruptions 2 to 3 days . Diakarb (fonurit) in tablets of 0.25 g is given every other day or in short (2 to 3 days) courses; Is shown only for pulmonary heart failure, hypercapnia.

Peripheral vasodilators are prescribed in more severe cases with insufficient efficacy of cardiac glycosides and diuretics alone or together with preparations of these groups. With a sharp stenosis (mitral, aortic), as well as with systolic blood pressure of 100 mm Hg and below, they should not be used. Mostly venous dilators - nitro drugs (nitrosorbide for 0.02 g, etc.) in large doses reduce the ventricular filling pressure ("preload") and are effective in congestive failure. The arteriolar dilator of apressin (hydralazine), 0.025 grams in the tablet, is prescribed 2 to 3 tablets 3 times a day, and the calcium antagonist phenygidine (nifedipine, corinfar) in tablets of 0.01 g is prescribed to reduce afterloading in hypertensive HF; They can be useful for moderate HF in patients with aortic or mitral insufficiency. Powerful vasodilators of universal, venuloarterial action: prazosin is prescribed from 2 to 10 mg / day (the first dose of 0.5-1 mg, short courses), captopril at a daily dose of 0.075-0.15 g. The combined use of venous and arteriolodilators is indicated when Severe, refractory to cardiac glycosides and diuretics of CH with a significant dilatation of the left ventricle, as well as with hypertensive heart failure. Effective treatment with combined vasodilators is accompanied by a decrease in the volume of the left ventricle and restoration of sensitivity to glycosides and diuretics.

Potassium preparations are prescribed in the treatment of cardiac glycosides, diuretics and steroid hormones. They should be used when there are ventricular extrasystoles, ECG signs of hypokalemia, with tachycardia refractory to cardiac glycosides, with meteorism in critically ill patients. It is most appropriate, although not always sufficient, to meet the need for potassium at the expense of a proper diet (prunes, dried apricots, apricots, apricots, Peach, plum juice with pulp, etc.). Potassium normin, or foamy potassium is prescribed for 1 tablet 2 to 3 times a day during meals; Potassium acetate (2 tablespoons 3 times a day) is usually well tolerated, it is a moderate osmotic diuretic and is especially useful in case of a threat of development of acidosis in seriously ill patients. They are well tolerated, but contain little potassium panangin and asparks (6 tablets per day are prescribed). Potassium chloride is usually poorly tolerated by patients; Prescribe inside only in 10% solution for 1 tablespoon 2 4 times a day after meals with milk, jelly, fruit juice. The intake of potassium drugs should be stopped immediately with pain in the abdomen (threat of ulceration and perforation of the wall of the stomach, small intestine). The introduction of potassium into the intracellular space is facilitated by intramuscular injection of insulin in small (4-6 UU) doses. Potassium-sparing antagonist aldosterone spironolactone (veroshpiron, aldactone) in tablets of 0.025 g prescribed 3 to 4 tablets in less severe and up to 10 - 1 2 tablets per day in more severe, resistant to therapy cases; Has a moderate independent diuretic effect, manifested on the 2 - 5 th day of treatment. Causes mild acidosis. With prolonged treatment, reversible gynecomastia is possible.

In the dystrophic stage, iv is injected with albumin, essenciale is used, anabolic steroids are retabopil (1 ml of the 5'1 solution every 10-20 days) or phenoboline (1 ml of a 2.5% solution every 7 to 1 5 Days) into the muscle. These drugs are contraindicated in prostate adenoma, fibrotic mastopathy, neoplasms. The need for evacuation of fluid from the pleural cavity or pericardial cavity is an indication for emergency hospitalization.

Infusion therapy is rarely required in patients with chronic heart failure, a violation of the water-salt balance and a complex redistribution of the circulating blood volume (BCC). It requires special care even when very small volumes are introduced that are not comparable with diuresis and BCC deficiency. It is necessary to take into account the threat of dangerous hypervolemia, circulatory congestion of the heart, extra- and intravascular hyperhydration, intracellular hyperhydration (risk of glucose introduction) and hypohydration (danger of introducing concentrated hyperosmolar solutions, sodium hporide, diuretics), and imbalance of extra- and intracellular potassium and other Electrolytes. The result of these disorders may be cerebral edema, pulmonary edema and other life-threatening complications, sudden death. Infusion therapy should be performed according to strict indications, differentially, preferably directly after forced diuresis, under the supervision of medical personnel. Intravenous infusion should be carried out under the control of venous pressure, easily carried out and without special equipment by means of a glass tube connected through a tee with a hose of the system for intravenous infusion.

To limit emotional loads, appoint tranquilizers - sibazon (diazepam) to 0,005 g or nazepam (tazepam) to 0.01 g. With insomnia appoint nitrazepam (radedorm) 0,005 - 0,01 g per night.

The incapacity in the first stage is preserved; Heavy physical work is contraindicated; In IIA stage, the work capacity is limited or lost; In IIB - it is lost, in III stage patients need constant extraneous care.

Prevention of heart failure is reduced to the prevention and treatment of the underlying disease, vocational guidance, employment. Systematic adequate treatment of HF, prevention and vigorous treatment of intercurrent diseases prevents (inhibits) the progression of heart failure.