Treatment of heart failure

Treatment of heart failure is aimed at increasing the contractility of the myocardium, the elimination of stagnant phenomena (fluid retention), the normalization of the functions of internal organs and homeostasis. Of course, a prerequisite is the treatment of the underlying disease that caused heart failure.

General tactics and principles of treatment of chronic heart failure

The goals for the treatment of chronic heart failure are as follows:

• elimination of symptoms of the disease - shortness of breath, palpitation, increased fatigue, fluid retention in the body;
• protection of target organs (heart, kidneys, brain, blood vessels, musculature) from defeat:
• improving the quality of life;
• decrease in the number of hospitalizations:
• improved prognosis (prolongation of life).

In practice, most often only the first of these principles, which leads to a rapid return of decompensation and re-hospitalization. The concept of "quality of life" should be defined separately. It is the patient's ability to live the same full-fledged life as his healthy peers who are in similar social, economic and climatic conditions. Changes in the quality of life are not always parallel to clinical improvement. So, the appointment of diuretics is accompanied by clinical improvement, but the need to be "attached" to the toilet, side effects of drugs worsen the quality of life.

Physical rehabilitation of patients occupies an important place in the complex treatment of patients with chronic heart failure. A sharp restriction of physical activity is justified only in the period of development of left ventricular failure. Out of the acute situation, the absence of loads leads to structural changes in skeletal muscles, which in themselves have been altered in chronic heart failure, the syndrome of detrusion and, subsequently, the inability to perform physical activity. Moderate physical training (walking, treadmill, bicycle training - for older children), of course, against the background of therapy, can reduce the content of neurohormones. Increase the sensitivity to drug treatment and tolerance of stress, and, consequently, improve the emotional tone and quality of life.

With heart failure II B-III stage shows the appointment of strict bed rest: all movements in bed the child carries out with the help of medical personnel or parents. Such a regimen is necessary as prevention of thromboembolic complications, especially when the myocardium is affected by an inflammatory process.

A more extended regime is a bed, which presupposes independent movements of the child in bed. The child can read, draw, for 45 minutes to complete the training tasks. This is a transitional version of the regimen, it is prescribed for stage II heart failure, with the appearance of positive dynamics.

Light-bed, allowing the child to go to the toilet, play room, visit the dining room, appoint a stage II heart failure. With a tendency to positive dynamics and the practical absence of signs of heart failure at rest, a room regimen is prescribed.

In addition to physical rest, the child needs to create an environment. As much as possible sparing his psyche, provide individual care. The best option - the placement of the child in a separate room with the involvement of parents to care for him.

Of great importance is oxygen therapy: older children can receive humidified oxygen from the oxygen system, young children are placed in an oxygen tent.

Heart failure diet

Nutrition in heart failure, in addition to the age-related characteristics of the food package, presupposes preferential steaming of dishes, exclusion of extractives: spices, roast, strong tea, coffee, smoked products, fatty meats, fish, caviar, etc. Limit or exclude products that contribute to the occurrence of flatulence: beans, peas, cabbage, sometimes black bread, etc. It is recommended to use more widely products containing potassium salts, for example apricots, dried apricots, prunes. With regard to potatoes as a product rich in potassium salts, one should be more careful, since the large starch content in this product, as well as the large carbohydrate content in sweets, bakery products, helps to reduce intestinal motility and leads to constipation, which can significantly to worsen a condition of the patient, compelled or forced to besides be in a condition of hypodynamia. In view of this, it is advisable to appoint fermented milk products (kefir, yogurt), as well as vegetable juices. With a severe condition, you can increase the number of meals to 4-5 times or more. The last meal should be 2-3 hours before bedtime.

The amount of table salt is limited to 2-4 g / day, starting with II A stage of heart failure. At II B and III stage with the expressed edematic syndrome for short time it is possible to appoint achloride a diet. In addition, when the edematous syndrome is expressed, 1-2 days in 7-10 days are carried out. Relaxation days include cottage cheese, milk, compotes from dried fruits, apples, raisins (or dried apricots), fruit juice. The goal of fasting days is to facilitate the work of the heart and other organs against the background of a reduced volume of food and liquids.

At the same time, against the background of the restriction of certain types of products, it is best to adhere to a "cardiotrophic" diet with a high content of high-grade and easily digestible protein.

The water regime requires some restrictions, starting with II A of the stage of heart failure, while taking into account diuresis: the amount of liquids drunk and allocated. At the same time, it must be remembered that the restriction of the liquid to more than 50% of the daily requirement of the organism does not ensure the formation of a "metabolic" amount of urine, there is a delay in the slag in the body, which contributes to a worsening of the condition and well-being of the patient with heart failure.

Medication for heart failure

In recent years, the treatment of heart failure has changed somewhat. Prescribe drugs aimed at various links of the pathogenesis of heart failure syndrome.

Cardiac glycosides

One of the main groups of drugs - cardiac glycosides - cardiotonic agents of plant origin (digitalis, May lily of the valley, sea onions, spring mountain flowers, etc.), which have the following mechanisms of action:

• positive inotropic effect (increase myocardial contractility);
• negative chronotropic action (slowing of the heart rate);
• negative dromotropic action (conduction slowdown);
• positive butmotropic action (increase in the activity of heterotopic foci of automatism).

Cardiac glycosides also increase glomerular filtration and increase intestinal motility.

Cardiac glycosides act on the cardiac muscle through a specific effect on the receptor apparatus, since only 1% of the injected drug is concentrated in the myocardium. In the 90's there were works recommending limited use of digoxin with its replacement by non-glycoside inotropic stimulants. This practice has not been widely used due to the inability to conduct long-term courses of treatment with such drugs, so the only drugs that increase myocardial contractility, remaining in clinical practice, are cardiac glycosides. Predictors of good action of digoxin - ejection fraction less than 25%, cardiothoracic index more than 55%, non-ischemic cause of chronic heart failure.

Cardiac glycosides can be associated with blood albumins, then they are absorbed predominantly in the intestine, act more slowly (digoxin, digitoxin, isolanide) and are shown mainly in chronic heart failure, it turns out that digitoxin is partially converted into digoxin. In addition, digitoxin is more toxic, therefore in clinical practice, digoxin is used. Calculation of digoxin is carried out by several methods. We indicate the method we use in our clinical practice: the dose of digoxin saturation is 0.05-0.075 mg / kg body weight up to 16 kg and 0.03 mg / kg body weight more than 16 kg. The dose of saturation is given within 1-3 days, 3 doses per day. The daily maintenance dose is 1 / 6-1 / 5 of the saturation dose, it is given in 2 doses. In the list of appointments, you should specify the heart rate at which digoxin should not be given. Thus, the patient receiving digoxin is under constant medical supervision. This need for control arises due to the fact that the pharmacological properties of digoxin easily change under the influence of various factors and individual overdose of the drug is possible. According to B.E. Here, "cardiac glycosides are a knife in the hands of the therapist," and the appointment of cardiac glycosides is a clinical experiment, during which "one must persistently and painstakingly choose the right dose of the cardiac glycoside that is most suitable in each case." In chronic heart failure, cardiac glycosides are prescribed already at stage II A.

Cardiac glycosides, not associated with blood proteins, act quickly, they are administered intravenously. These drugs [strophanthin-K, lily of the valley glycoside (korglikon)] are indicated mainly in acute or symptomatic heart failure (severe infections, severe course of somatic pathology). It should be taken into account that feature of strophanthin-K that it acts directly on the AV-connection, inhibiting the impulse, and if the dose is incorrectly calculated, it can cause cardiac arrest. Lily of the herb glycoside (korglikon) does not have this effect, so the prescription of this drug is currently a preference.

In the mid-1970s, ACE inhibitors appeared in clinical practice. The main physiological significance of the use of these drugs is as follows: by blocking ACE activity, the injected drug of the presented group leads to disruption of the formation of angiotensin II, a potent vasoconstrictor. Stimulator of cell proliferation, in addition, promoting the activation of other neurohormonal systems, such as aldosterone and catecholamines. Therefore, ACE inhibitors have vasodilating, diuretic, antitachiocardic effects and can reduce cell proliferation in target organs. Even more, their vasodilating and diuretic effects increase in connection with the blockade of destruction of bradykinin, which stimulates the synthesis of vasodilating and renal prostanoids. An increase in bradykinin content blocks the processes of irreversible changes occurring in CHF in the myocardium, kidneys, smooth muscles of blood vessels. The specific effectiveness of ACE inhibitors determines their ability to gradually block circulating neurohormones, which allows not only to influence the clinical state of patients, but also to protect the target organs from irreversible changes occurring in the progression of chronic heart failure. The appointment of ACE inhibitors has been shown already in the initial stages of chronic heart failure. At present, the effectiveness (positive effect on symptoms, quality of life, prognosis of patients with chronic heart failure) and the safety of the four ACE inhibitors used in Russia (captopril, enalapril, ramipril, trandolapril) have been fully proven. In pediatric practice, captopril is most widely used. Assign nonhyptotensive doses of the drug, amounting to 0.05 mg / kg per day in 3 doses. The duration of use of the drug depends on the indications of hemodynamics. Side effects - cough, azotemia, giperkaliemia, arterial hypotension - are relatively rare.

Diuretics

In terms of evidence-based medicine, diuretics are the most unexplored drugs for the treatment of patients with chronic heart failure. In many respects this is due to the fact that according to the deontological code it is impossible to conduct placebo-controlled studies, since the patients entering into the control group with chronic heart failure will obviously be deprived of the possibility of receiving diuretics. When deciding whether to prescribe diuretics, it is important for a doctor to overcome a stereotype that dictates the appointment of diuretics to any patient with chronic heart failure. It must be firmly understood that diuretics are indicated only in patients with chronic heart failure. Having clinical signs and symptoms of excessive fluid retention in the body.

Diuretics contribute to the volume unloading of the heart. However, caution in prescribing the drugs of this group is dictated by the following provisions:

• diuretics activate neurohormones that promote the progression of chronic heart failure, in particular by activating the renin-angiotensin-aldosterone system:
• diuretics cause electrolyte disturbances.

Given these provisions, diuretics can not be attributed to pathogenetically valid means of treating chronic heart failure, but they remain an essential component of treatment. Currently, the principal points in the appointment of diuretics are identified: the use of diuretics together with ACE inhibitors, the appointment of the weakest effective diuretic in this patient. The appointment of diuretics should be done daily in minimum doses, which allow to achieve the necessary positive diuresis.

The practice of prescribing "shock" doses of diuretics 1 time in several days is vicious. And it is hard for patients to suffer.

The tactics of diuretic treatment involve two phases.

• Active phase - elimination of excess fluid, manifested in the form of edema. In this phase, it is necessary to create a forced diuresis with excess of excreted urine over the consumed liquid.
• After reaching the optimal dehydration of the patient go to the supporting stage of treatment. During this period, the amount of liquid drunk should not exceed the amount of urine released.

In the mechanism of action of diuretics, the main role is attached to the processes occurring in the nephron. Diuretics are usually prescribed starting with stage II B-III of heart failure. As a rule, they combine the appointment of powerful diuretics, causing maximum sodium nares, and potassium-sparing diuretics (spironolactone). Actually, spironolactone (veroshpiron) - not a very strong diuretic, it exerts an enhanced effect along with loop and thiazide diuretics. The greater pathogenetic significance of spironolactone has as an antagonist of aldactone, i.e. As a neurohormonal modulator, blocking the renin-angiotensin-aldosterone system. Spironolactone is prescribed in the first half of the day, usually in 2 doses. The main adverse reactions may be hyperkalemia requiring control, and the androgenic properties of the drug that cause gynecomastia in 7-8% of cases.

To powerful diuretics include furosemide (lasix) and ethacrynic acid. Treatment begins with the appointment of furosemide at a dose of 1-3 mg / kg body weight per day in 3-4 sessions. Perhaps as oral. And intramuscular injection of the drug. Etakrinovuyu acid (Uregit) is used in the same cases as furosemide, especially in children with the development of refractoriness, long received furosemide.

Hydrochlorothiazide (hypothiazide) is considered to be moderate-acting diuretics, it is prescribed in stage II A of heart failure in isolation or in combination with spironolactone, the maximum dose of hydrochlorothiazide is 1-2 mg / kg body weight.

To replenish potassium, excreted from the body with the appointment of most diuretics, prescribe, in addition to products containing a sufficiently high amount of potassium salts, such drugs as potassium and magnesium asparaginate (panangin, asparcam), potassium acetate (10%) orally. It should be borne in mind that the appointment of potassium chloride orally is unacceptable, since this drug has ulcerogenic effect on the mucosa of the gastrointestinal tract.

You can start treatment with diuretics from smaller doses with a gradual increase in them, which allows you to choose a dose individually, and also does not cause rapid fluid convergence and electrolyte disturbances. In addition, increasing the viscosity of blood contributes to thrombosis. When the condition is stabilized, you can switch to intermittent treatment with diuretics.

It should be noted that everything said above about the appointment of diuretics is advisory in nature, each individual case is treated individually.

Other drugs

The use of beta-blockers for the treatment of chronic heart failure is based on the fact that they increase hemodynamic function of the heart with an increase in the density of beta-adrenoreceptors of the heart, which is usually sharply reduced in patients with chronic congestive heart failure. It should be noted that the use of beta-blockers in children is limited by the lack of convincing data from multicenter studies, as well as the risk of reducing myocardial contractility and cardiac output in conditions of existing cardiac dysfunction.

The use of vasodilators of other groups, in particular nitrates, is not currently widely used in pediatric practice.

For the treatment of heart failure according to indications, you can use glucocorticoids, cardiotropic drugs, vitamin complexes and membrane stabilizing drugs.

In the syndrome of chronic heart failure, drugs that improve the metabolic state of the myocardium are of great interest. Against this background, interest in magnesium products is experiencing a second birth. Magnesium - a universal regulator of energy, plastic, electrolyte metabolism, a natural calcium antagonist. It promotes the fixation of potassium in the cell and ensures the polarization of the cell membranes, thereby controlling the normal functioning of the myocardium cell at all levels, including regulating the contractile ability of the myocardium. Natural food sources, as a rule, are not rich in magnesium, therefore, for use in therapeutic practice, it is suggested to use a magnesium-magnerot preparation. With his appointment, as shown by experimental data, the contractility of the left ventricle improves.

A distinctive feature of the preparation of magnerot is that the presence of orotic acid in the structure of the molecule promotes the best, in comparison with other drugs, penetration of magnesium ions into the cell and fixation on the ATP membrane. In addition, the drug does not cause or exacerbate intracellular acidosis, which often occurs with heart failure. Drugs are prescribed for 4-6 weeks. Since the drug does not have significant contraindications, and it is prescribed even during pregnancy and lactation, it is all the more possible to administer it to children with heart failure. Doses are an average of 1 tablet 2-3 times a day.