Management – general measures
The cause of heart failure must be established and remediablecauses sought and treated. These may include thereplacement or repair of valves, stripping of the pericardiumin constriction, or the closure of significant intracardiacshunts.
The overall aim of therapy in chronic (non-surgical) heart failure is to relieve symptoms, to enhance high quality oflife and functional capacity, and lastly to enhance longevity.The general measures really should contain stopping smoking,lowering alcohol intake, fluid restriction, and possiblyregular physical exercise coaching.
Bed rest is valuable only in acute myocardial infarction,active myocarditis, infective endocarditis and intractablecongestion unresponsive to conventional doses of diuretics. The disadvantages of bed rest (skeletaland myocardial deconditioning, muscular atrophy andweakness, bedsores, deep vein thrombosis, autonomicmaladjustment) outweigh the positive aspects. Patients who areasymptomatic at rest should be encouraged to mobilize assoon as possible, as physical exercise rehabilitation may possibly improvefunctional capacity even in severe chronic heart failure.
Drug therapy to increase prognosis is now possible, and(3-blockers, ACE inhibitors, spironolactone and nitratehydralazinecombinations are the most effective, althoughthe prolongation of survival only averages 6 months. About 20-50% of patients in heart failure die suddenly. No antiarrhythmicagent has been shown to be useful in reducingthis incidence, although the use of amiodarone appearspromising. Patients with life-threatening arrhythmia mayneed AICD.
Drugs utilized in chronic heart failure
Diuretics
This class of drug is nonetheless the first-line treatment for symptomaticcongestive cardiac failure due to the fact it is the mosteffective at relieving the symptoms of congestion, therebyproducing the greatest impact on high quality of life. They areall natriuretic and aquauretic some of them conserve K+and Mg2+, whereas other people induce losses. Injudicious use ofdiuretics could lead to severe electrolyte imbalance (resultingin arrhythmias and sudden death) and hypovolaemia(resulting in tissue hypoperfusion and renal failure).
Thiazide diuretics
These are employed principally to treat hypertension, but mayoccasionally have a role in controlling mild oedema and,when added to loop diuretics, could induce a diuresis whenresistance to loop diuretics has arisen. Hypokalaemia andhyperuricaemia are two of the much more generally encounteredproblems with these drugs. To combat the former,combination with potassium-sparing agents is advised.Metolazone is a curious thiazide-like diuretic with a verypowerful ability to induce diuresis when combined withloop agents in patients with renal impairment or resistanceto loop diuretics. Nevertheless, it is also remarkably potentin inducing electrolyte disturbances, and the most difficultone to correct is severe hyponatraemia. It really should thereforebe employed sparingly, and stopped just before hyponatraemiaoccurs. Bendroflumethiazide (bendrofluazide) Hydrochlorothiazide Metolazone 2.five-5.0mg per day 25-100 mg per day 5-10 mg per day
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