Heart failure is a term used to cover three distinctive clinical presentations. The human heart has four chambers that constrict and relax to pump blood throughout the body. There are two atria and two ventricles. In a normal heart, there are open connections between the right atrium and right ventricle through the tricuspid valve and also between the left atrium and left ventricle through the mitral valve. There are no open connections between the two atria and the two ventricles. Therefore, the left and right halves of the heart actually function as two hearts. The failure of the left half causes a distinct set of symptoms and signs which is called left heart failure. The failure of the right half causes a distinct set of features collectively called right heart failure. The combination of the two is known as congestive heart failure. Therefore, it is important to understand that congestive heart failure is a type of heart failure and not a totally different condition.
Causes for heart failure can be many. There are three main pathologies that lead to heart failure; pump failure, increased pre-load, and increased after-load. Pump failure can occur due to myocardial infarction, cardiomyopathy, poor heart rate (negative chronotropic drugs), poor contractility (negative inotropic drugs) and poor filling (restrictive pericarditis). Preload may go up due to fluid overload, aortic and pulmonary regurgitation. Afterload may go up due to excessively high systemic blood pressure, aortic and pulmonary stenosis. Left heart failure causes poor output and increased pulmonary venous pressures. Therefore, the patient presents with dizziness, lethargy, poor exercise tolerance, syncope, fainting attacks, amaurosis fugax (due to poor output), dyspnea, orthopnea, paroxysmal nocturnal dyspnea and pink frothy sputum (due to increased pulmonary venous pressures). Right heart failure causes poor pulmonary circulation and increased systemic venous pressures. Therefore, the patient presents with dependent edema, enlarged liver, elevated jugular venous pressure (due to increased systemic venous pressure), reduced exercise tolerance and dyspnea (due to poor pulmonary circulation).
ECG, 2D echo, Troponin T, serum electrolytes and serum creatinine are essential investigations done in all types of heart failure. Congestive heart failure presents with a combination of symptoms of both left and right heart failure. Acute heart failure is a medical emergency. The patient should be admitted at once. Patient should be put on a bed, propped up, given oxygen via a mask, attached to a cardiac monitor, cannulated, catheterized, and blood should be taken for ancillary investigations. ECG should be immediate. Intra venous Furosemide injections should be started to reduce pulmonary edema. Furosemide injection can be repeated while keeping an eye on electrolyte levels and blood pressure. Morphine is helpful, but should be given in very small doses because it drops blood pressure. If blood pressure crashes, inotropic support should be given while giving Furosemide to clear the lungs. Management of causative factors should go hand-in-hand. Once the patient is stable, oral furosemide should be started. ACE inhibitors, selective beta blockers (with caution), calcium channel blockers (only nifedipine class drugs can be prescribed with a beta blocker), potassium sparing diuretics, nitrates, hydralazine and prazosin should be given as needed.
Heart Failure vs Congestive Heart Failure
• Congestive cardiac failure is a combination of left and right heart failure.
• The management principles are the same for both conditions.
• Difference between congestive cardiac failure and other types is that congestive heart failure has features of both other types while isolated left or right heart failure present with characteristic symptoms and signs.