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LECTURE No. 5. Chronic heart failure in children. Clinic, diagnosis, treatment



Heart failure is a condition in which the heart, despite a sufficient flow of blood, does not provide the body with a need for blood supply. Causes of chronic circulatory failure: direct effect on the myocardium (toxic, infectious, traumatic), cardiovascular disease.

Classification. Classification of chronic heart failure (according to Strazhesko-Vasilenko).

I stage. Compensated.

ON stage. Decompensated-reversible.

NB stage. Decompensated-irreversible.

III stage. Terminal.

International Classification of Chronic Heart Failure.

I functional class.

II functional class.

III functional class.

IV functional class.

Pathogenesis. The pathogenesis of chronic heart failure is manifested by a decrease or increase in blood supply, blood flow and / or pressure in the central or peripheral parts of the blood circulation. These changes arise as a mechanical consequence of a violation of the pumping function of the heart and as a result of the inadequacy of adaptive reactions. These reactions include tachy- and bradycardia, changes in vascular peripheral and pulmonary resistance, redistribution of blood supply, hypertrophy and expansion of individual chambers of the heart, fluid retention, sodium. Hemodynamic disorders lead to pathological changes in the heart, blood vessels and other organs and systems.

Clinical manifestations.

Clinical forms.

1. Congestive left ventricular failure is more common with mitral defect. An increase in pressure in the pulmonary veins leads to the filling of the left ventricle and the preservation of the cardiac output. Congestive changes in the lungs violate the function of external respiration and are a factor aggravating the patient's condition with congestive left ventricular failure. Clinical manifestations: dyspnea, orthopnea, with auscultation, there are signs of stagnation in the lungs (dry rales below the scapula level, migrating moist rales) and radiological changes, cardiac asthma and pulmonary edema, secondary pulmonary hypertension, tachycardia.

2. Left ventricular failure is characteristic of aortic defect, ischemic heart disease, arterial hypertension. Clinical manifestations: cerebrovascular insufficiency, manifested by dizziness, darkening in the eyes, fainting, coronary insufficiency and echocardiographic signs of low ejection. In severe cases, Cheyne-Stokes respiration appears, presystolic gallop rhythm (pathological IV tone), congestive left ventricular failure.

3. Congestive right ventricular failure manifests itself in mitral, tricuspid malformation or constrictive pericarditis. More often associated with congestive left ventricular failure. Clinical manifestations: cervical vein swelling, increased venous pressure, acrocyanosis, enlarged liver, peripheral and cavity edema.

4. Right ventricular failure is observed with stenosis of the pulmonary artery and pulmonary hypertension.

Clinical manifestations of chronic heart failure.

I stage of chronic heart failure (I f. K.).

Complaints of weakness. An objective examination - pallor of the skin. Signs of heart failure only with heavy physical exertion: shortness of breath, tachycardia. Hemodynamics is not broken.

LA stage of chronic heart failure (II f. K.) Complaints: sleep disturbance, increased fatigue. Signs of heart failure at rest:

1) left ventricular heart failure, shortness of breath (no cough), tachycardia;

2) right ventricular heart failure an increase in the liver and its pain, pastiness in the evening on the lower extremities (no edema).

IB stage of chronic heart failure (II f. K.) Complaints: irritability, tearfulness. All signs of heart failure at rest: ictericity, cyanosis of the skin, expressed by LVSN and PZHSN, decreased diuresis, expansion of the borders of the heart, muffled tones, arrhythmia.

III stage of chronic heart failure (IV f. K.) Cachexic circulation, emaciation, skin color "light tan".
Edematous blood circulation (thirst, edema, abdominal edema (pulmonary edema)). The progression of chronic heart failure is manifested by oliguria, hepatosplenomegaly.

Treatment.

The principles of treatment.

1. Cardiac glycosides.

2. Diuretics.

3. ACE inhibitors

4. in-blockers.

Tactics for the treatment of chronic heart failure.

I stage - (I f. K.) basic therapy of the underlying disease.

ON stage (II f. K.) - diuretics.

NB stage (III f.k.) - diuretics, cardiac glycosides.

Stage III (IV f.k.) - diuretics, cardiac glycosides, peripheral vasodilators.

In stage I, it is necessary to observe the regime of work and rest, moderate exercise. In severe stages, physical activity should be limited, bed, half-bed mode is prescribed. High-grade easily digestible food, rich in proteins, vitamins, potassium. With a tendency to fluid retention and arterial hypertension, a moderate restriction of sodium chloride is indicated. With massive edema, a short-term strict salt-free diet is prescribed. Cardiac glycosides are not prescribed for obstructive hypertrophic cardiomyopathy, for severe hypokalemia, for hyperkalemia, for hypercalcemia, for atrioventricular heart block, sinus node weakness syndrome, ventricular extrasystoles, and for paroxysms of ventricular tachycardia. Cardiac glycosides are prescribed in doses close to the maximum tolerated. First, a saturating dose is used, then the daily dose is reduced by 1.5-2 times. In case of glycoside intoxication, unitiol is prescribed (5% solution of 5-20 ml iv, then IM 5 ml 3-4 times a day). According to indications, antiarrhythmic therapy is performed. The patient and his relatives should be acquainted with the individual treatment regimen for cardiac glycosides and with the clinical signs of their overdose. Digoxin is prescribed 2 times a day in tablets of 0,00025 g or parenterally in 0.5-1.5 ml of a 0.025% solution (saturation period), then 0.25-0.75 mg (maintenance dose) per day . The use of cardiac digoxin glycoside requires special care. Selection of the dosage of cardiac glycosides should be carried out in a hospital. Diuretics are used for edema, liver enlargement, congestive changes in the lungs. Use the minimum effective dose for treatment with cardiac glycosides. The treatment regimen is individual, which is corrected during treatment. Complications of diuretic therapy are hypokalemia, hyponatremia, hypocalcemia (loop diuretics), hypochloremic alkalosis, dehydration and hypovolemia. Hypotaazide is used in tablets of 0.025 g, loop diuretic furosemide or lasix in tablets of 0.04 g or parenterally. Peripheral vasodilators are prescribed in severe cases with inefficiency of cardiac glycosides and diuretics. With stenosis (mitral, aortic), as well as with systolic (blood pressure decreased from 100 mm Hg. Art. And below), they should not be used. Mostly venous dilators, nitro drugs reduce the filling pressure of the ventricles with congestive insufficiency, the arteriolar hydralazine dilator 0.025 g is prescribed 2-3 tablets 3-4 times a day, as well as calcium antagonist nifedipine, corinfar. Venulo-arteriolar vasodilators: captopril in a daily dose of 0.075-0.15 g. The use of venulo-arteriol dilators is used together with severe heart failure refractory to cardiac glycosides and diuretics with significant dilatation of the left ventricle. Potassium preparations can be prescribed together with cardiac glycosides, diuretics and steroid hormones. Potassium preparations are prescribed for ventricular extrasystoles, hypokalemia, for tachycardia refractory to cardiac glycosides, for flatulence in seriously ill patients. It is necessary to ensure the need for potassium due to the diet (prunes, dried apricots, apricots, peach, apricot, plum juice with pulp). Potassium chloride is usually poorly tolerated by patients; appoint inside only in a 10% solution of 1 tbsp. l Potassium (aldosterone antagonist spironolactone (veroshpiron)) in tablets has a moderate diuretic effect, manifested on the 2nd-5th day of treatment.

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LECTURE No. 5. Chronic heart failure in children. Clinic, diagnosis, treatment

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