Sandbox/22

Drug Class	Drug	Initial daily dose, target dose (mg)
Thiazide diuretics	Chlorthalidone	12.5, 12.5-25
	Hydrochlorothiazide	12.5-25, 25-100
	Bendroflumethiazide	5, 10
	Indapamide	1.25, 1.25-2.5
ACE inhibitors	Enalapril	5, 20
	Lisinopril	10, 40
	Captopril	50, 150-200
ARBs	Candesartan	4, 12-32
	Losartan	50, 100
	Valsartan	40-80, 160-320
	Eprosartan	400, 600-800
	Irbesartan	75, 300
Beta blockers	Atenolol	25-50, 100
	Metoprolol succinate	50, 100-200
Calcium channel blockers	Amlodipine	2.5, 10
	Diltiazem extended release	120-180, 360
	Nitrendipine	10, 20

Hypertension

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Underlying Anatomic Abnormalities Causing Heart Failure

Heart failure may result from an abnormality of any one of the anatomical structures of the heart:

• Disorders of the great vessels (e.g. pulmonary hypertension)
• Endocardium
• Myocardium
• Pericardium
• Valvular heart disease or

Systolic versus Diastolic Heart Failure

Patients may be broadly classified as having heart failure with depressed contractility or depressed relaxation

Systolic Dysfunction

The left ventricular ejection fraction is reduced in systolic dysfunction and there is depressed contractility of the heart.

Disastolic Dysfunciton

The left ventricular ejection fraction is preserved in diastolic dysfunction and there is an abnormality in myocardial relaxation or excessive myocardial stiffness. Systolic and diastolic dysfunction commonly occur in conjunction with each other.

Left, Right and Biventricular Failure

Another common method of classifying heart failure is based upon the ventricle involved (left sided versus right sided).

Left Heart Failure

• There is impaired left ventricular function with reduced flow into the aorta.

Right Heart Failure

• There is impaired right ventricular function with reduced flow into the pulmonary artery and lungs.

Biventricular Failure

• The most common cause of right heart failure is left heart failure, and mixed presentations are common, especially when the cardiac septum is involved.

High Output Versus Low Output Failure

Low Output Failure

• The cardiac output is reduced, and the systemic vascular resistance (SVR) is high. In low output failure, there is an inadequate supply of blood flow to meet normal metabolic demands.

High Output Failure

• The cardiac output is increased, and the systemic vascular resistance (SVR) is low. Rather than an inadequate supply of blood flow to meet normal metabolic demands as occurs in low output failure, in high output failure there is an excess requirement for oxygen and nutrients and the demand outstrips what the heart can provide. Causes of high output heart failure include severe anemia, Gram negative septicaemia, beriberi (vitamin B₁/thiamine deficiency), thyrotoxicosis, Paget's disease, arteriovenous fistulae, or arteriovenous malformations.

Causes of Acute or Decompensated Heart Failure

Chronic stable heart failure may easily decompensate. This most commonly results from an intercurrent illness (such as pneumonia), myocardial infarction (a heart attack), arrhythmias, uncontrolled hypertension, or a patient's failure to maintain a fluid restriction, diet, or medication. Other well recognized precipitating factors include anemia and hyperthyroidism which place additional strain on the heart muscle. Excessive fluid or salt intake, and medication that causes fluid retention such as NSAIDs and thiazolidinediones, may also precipitate decompensation.

Differential Diagnosis of the Underlying Causes of Chronic Heart Failure

Common Causes of Left Sided Heart Failure

• Aortic regurgitation
• Aortic stenosis
• Hypertension
• Mitral regurgitation
• Myocardial ischemia

A 19 year study of 13,000 healthy adults in the United States (the National Health and Nutrition Examination Survey (NHANES I) found the following causes ranked by Population Attributable Risk score:

1. Ischaemic heart disease 62%
2. Cigarette smoking 16%
3. Hypertension (high blood pressure)10%
4. Obesity 8%
5. Diabetes 3%
6. Valvular heart disease 2% (much higher in older populations)

Cardiomyopathies and Inflammatory Diseases

Restrictive Cardiomyopathies

• Alcohol-Induced cardiomyopathy
• Amyloidosis
• Anthracycline induced cardiomyopathy
• Anthracyclines
• Arrhythmogenic right ventricular dysplasia
• Becker's muscular dystrophy
• Cardiac transplant
• Cocaine related cardiomyopathy
• Diabetic cardiomyopathy
• Endocardial fibrosis
• Eosinophilic heart disease
• Hemochromatosis
• Primary (idiopathic)
• Kearns-Sayre syndrome
• Radiation therapy
• Sarcoidosis
• Storage diseases
• Tumor infiltration

Dilated Cardiomyopathies

• Duchenne muscular dystrophy
• Chagas' disease
• Limb-girdle muscular dystrophy
• Mitochondrial myopathy
• Peripartum cardiomyopathy
• Trastuzumab Herceptin-lnduced Cardiomyopathy

Inflammatory Cardiomyopathies

• Bacterial Myocarditis
• Fungal myocarditis
• Giant Cell Myocarditis
• Protozoal Myocarditis: Trypanosomiasis (Chagas Disease)
• Rickettsial Myocarditis
• Sarcoidosis
• Spirochetal Infections
• Viral Myocarditis

Congestive Heart Failure as a Consequence of Valvular Heart Disease

• Acute aortic regurgitation
• Acute mitral regurgitation
• Aortic stenosis with Left Ventricular Systolic Dysfunction
• Chronic aortic regurgitation
• Chronic mitral regurgitation
• Mitral Stenosis

Congestive Hert Failure Secondary to Congenital Heart Disease

A. Causes of Congestive Heart Failure in Adults with Unoperated Congenital Heart Diseases

• Arrhythmia
• Atrial septal defect with mitral regurgitation] secondary to myxomatous mitral valve
• Congenital mitral regurgitation
• Drug abuse, alcohol abuse
• Eisenmenger's syndrome
• Endocarditis
• Fibrocalcific degeneration of abnormal aortic valve
• Pregnancy
• Systemic ventricular dysfunction and/or tricuspid regurgitation in congenitally corrected transposition of the great arteries
• Other degenerative diseases (coronary artery disease, hypertension)

B. Causes of Congestive Heart Failure in Adults with Operated Congenital Heart Diseases

• Arrhythmia
• Endocarditis
• Myocardial dysfunction
• Persistent left-to-right shunt
• Prosthetic valve dysfunction
• Pulmonary vascular disease
• Status post Fontan operation
• Valvular regurgitation
• Other degenerative diseases (coronary artery disease, hypertension)

Right Ventricular Failure

Factors affected right ventricle and to be eliminated during management of congestive heart failure. A. Right ventricular myocardial dysfunction

1. Right ventricular myocardial infarction
2. Dilated cardiomyopathy
3. Right ventricular dysplasia

B. Primary right ventricular pressure overload

1. Left ventricular failure
2. Mitral valve disease
3. Atrial myxoma
4. Pulmonary veno-occlusive disease
5. Cor pulmonale

   • Chronic obstructive pulmonary disease
   • Primary pulmonary hypertension
   • Pulmonary embolism

6. Pulmonic stenosis

   • Supravalvular pulmonic stenosis
   • Valvular pulmonic stenosis
   • Subvalvular pulmonic stenosis

7. Ventricular septal defect
8. Aortopulmonary communication

C. Primary right ventricular volume overload

1. Pulmonic regurgitation
2. Tricuspid regurgitation
3. Atrial septal defect
4. Partial anomalous pulmonary venous return

D. Impediment to right ventricular inflow

1. Tricuspid stenosis
2. Cardiac tamponade
3. Constrictive pericarditis
4. Restrictive cardiomyopathy

Differential Diagnosis of Causes of Heart Failure Segregated by Left and Right Sided Heart Failure

Left Ventricular Failure

Most Common Causes:

• Aortic regurgitation
• Aortic stenosis
• Hypertension
• Mitral regurgitation
• Myocardial ischemia

Expanded List of Causes:

• Atrial fibrillation
• Alcoholism
• Anemia
• Angina
• Aortic regurgitation
• Aortic Stenosis
• Arteriovenous fistula
• Beriberi
• Cardiac aneurysm
• Cardiomyopathy
• Constrictive pericarditis
• Drugs, toxins
• Hypertension
• Hyperthyroidism
• Hypovolemia
• Hypoxia
• Mediastinal tumors
• Mitral Regurgitation
• Myocardial Infarction
• Paget's Disease
• Pancoast's Tumor
• Pericardial effusion
• Pericardial tamponade
• Perimyocarditis
• Protein deficiency
• Restrictive cardiomyopathy
• Rupture of the papillary muscles
• Sepsis
• Superior Vena Cava thrombosis

Right Ventricular Failure

Most Common Causes:

• Cardiomyopathy
• Cor pulmonale
• Diffuse myocarditis
• Left heart failure

Other Causes:

• After left ventricular failure
• After pulmonary resection
• Allergic alveolitis
• Bronchial asthma
• Chronic bronchitis
• Honeycomb lung
• Hyperglobulia
• Emphysema
• Mitral Stenosis
• Right ventricular myocardial infarction
• Pickwickian Syndrome
• Pleural fibrosis
• Pneumoconiosis
• Pulmonary fibrosis
• Pulmonic regurgitation
• Pulmonic stenosis
• Sarcoidosis
• Severe relapsing pulmonary emboli
• Silicosis
• Tachycardia
• Tricuspid insufficiency

Others

• Ascorbic acid deficiency
• Cardiac amyloidosis
• Carnitine deficiency
• Cervical vein stasis of non-cardiac genesis
• Congenital heart disease
• Cyanosis of non-cardiac genesis
• Diabetes Mellitus
• Dyspnea of non-cardiac genesis
• Edema of non-cardiac genesis
• Hemochromatosis
• Pleural effusion of non-cardiac genesis
• Pulmonary edema of non-cardiac genesis
• Thiamine deficiency
• Thyroid disease