Congestive heart failure is considered when heart is unable to pump sufficiently to maintain blood flow to meet the body’s needs. The purpose of medications is to optimize patient’s heart rate, blood pressure and exercise tolerance to the desirable level.
Medications:
- Start with tab. Valzaar 40 (Valsartan 40 mg) 1 tablet once a day. Increase dose by 40 mg once a day every 2 weeks till maximum dose of 160 mg once a day.
- If optimum results are not achieved, add beta blocker (avoid in acute heart failure) – tab. Carvistar 3.125 (Carvedilol 3.125 mg) 1 tablet twice a day. Gradually increase till maximum dose of 25 mg twice a day (for body weight less than 85 kg) and 50 mg twice a day (for body weight more than 85 kg).
- If optimum results are not achieved, then combine Valzaar and Carvistar with tab. Aldactone 25 (Spironolactone 25 mg) 1 tablet once a day (avoid in case of renal impairment). Increase the dose after 2 weeks to 50 mg once a day. Monitor serum potassium and creatinine, one week after starting or increasing the dose, then monthly for 3 months and later quarterly for one year.
- If optimum results are not achieved, then combine Valzaar, Carvistar, Aldactone with tab. CTD 6.25 (Chlorthalidone 6.25 mg) 1 tablet once a day (avoid in case of renal impairment). Increase the dose in small steps every 2 weeks till maximum dose of 25 mg per day. Monitor serum potassium 2 weeks after starting dose and later every six months.
Adjunct treatments:
- Tab. Ivabrad 5 (Ivabradine 5 mg) 1 tablet once a day with meals. Gradually increase till maximum dose of 7.5 mg twice a day.
- For volume overload/pulmonary congestion – tab. Lasix 40 (Furosemide 40 mg) – half tablet once a day. Increase dose by 20 mg till desired diuretic effect is achieved (maximum dose is 600 mg per day). Monitor renal functions and electrolytes carefully.
Combination treatment based on NYHA classification:
- NYHA class 1 – tab. Valzaar (Valsartan) + tab. Carvistar (Carvedilol)
- NYHA class 2 – tab. Valzaar (Valsartan) + tab. Carvistar (Carvedilol)+ tab. Aldactone (Spironolactone) + tab. Lasix (Furosemide) [if volume overload] + Digoxin (if refractory)
- NYHA class 3 – tab. Valzaar (Valsartan) + tab. Carvistar (Carvedilol)+ tab. Aldactone (Spironolactone) + tab. CTD (Chlorthalidone) + tab. Lasix (Furosemide) [if volume overload] + Digoxin (if refractory)
- NYHA class 4 – tab. Valzaar (Valsartan) + tab. Carvistar (Carvedilol)+ tab. Aldactone (Spironolactone) + tab. CTD (Chlorthalidone) + tab. Ivabrad (Ivabradine) + tab. Lasix (Furosemide) [if volume overload] + Digoxin (if refractory)
New York Heart Association (NYHA) classification
- Class 1 – No symptoms or limitations in ordinary physical activity e.g. shortness of breath when walking, climbing stairs etc.
- Class 2 – Mild symptoms (mild shortness of breath and/or angina) and slight limitation during ordinary activity.
- Class 3 – Marked limitation in activity due to symptoms, even during less than ordinary activity, e.g. walking short distances (20 to 100 meters). Comfortable only at rest.
- Class 4 – Severe limitations including symptoms even while at rest. Mostly bed-bound patients.
General advice:
- Restrict salt in the diet
- Graded physical exercise under expert supervision.
Investigations:
- ECG – to rule out myocardial infarction and diagnose arrythmia.
- 2-D echocardiogram – to assess left ventricular function and other abnormalities.
- Chest X ray – to identify pleural effusion and cardiomegaly.
- Troponin I – to rule out myocardial ischemia.
- Complete blood count – to rule out sepsis and anaemia.
- Serum electrolytes and renal function – to adjust the dose of above treatments.
- B type natriuretic peptide level – to assess cardiac function.
Referral:
Consider referral to cardiologist if patient fails to respond or if presents with additional complications.