Modern treatment of chronic heart failure. Acute and chronic heart failure: principles of treatment. Treatment for chronic heart failure

Heart failure refers to dangerous diseases, in which the heart muscle is too weak and cannot provide the tissues and organs with the necessary amount of blood. Due to the weakening of the function of the heart, a certain amount of blood is retained inside the organ, which increases the pressure on its walls and the pathology is continuously progressing. Chronic heart failure is most common in female patients. At the same time, with this form of the disease, the symptoms can increase significantly even with treatment. Because of this, therapy must begin with the first symptoms of deficiency.

Among the main signs of the disease are the following:

• shortness of breath, at first appears only during physical exertion, then it can disturb at rest;
• the patient begins to complain of severe fatigue, cannot fully perform the previous volumes of work, it is difficult for him to do physical work and sports;
• due to shortness of breath and poor tissue saturation with blood and oxygen, tachycardia is noted;
• the appearance of edema, which begins to move from bottom to top, first affecting the feet, and then moving to the abdominal region;
• the appearance of a cough, which at first has a dry nature, but sputum gradually begins to stand out, in severe cases with traces of blood;
• in horizontal position the patient constantly needs to maintain a certain form, which provides for an elevated position of the head.

Attention! Symptoms of chronic heart failure do not manifest themselves with great intensity on early stages illness. This greatly complicates the diagnosis, and many patients already come to the doctor with serious disorders.

Treatment for chronic heart failure

As soon as the patient has been diagnosed, he needs to begin treatment immediately, which consists not only of prescribing medicines.

1. From the first day it is necessary to limit salt, consuming no more than 3 g per day. Wherein drinking regimen provides for consumption of 1-1.5 liters clean water per day. In chronic heart failure, you should consume high-calorie, but easily digestible food. Any product should be rich in protein and vitamins.
2. Also be sure to weigh yourself daily. This will allow you to see how much fluid is retained in the body. If in 1-3 days the patient gains from 2 kg in weight, you should immediately contact a cardiologist. In the absence of therapy, the patient's condition may deteriorate sharply, hospitalization will be required.
3. Physical activity should be limited as much as possible. At the same time, for some patients, taking into account the cause of CHF, it can be selected individual plan possible workouts. It usually includes walking, swimming and cycling. At the same time, it is strictly forbidden to lift iron and for a long time perform exercises in a static form.
4. The apartment should maintain optimal humidity and air temperature. Trips to the highlands and even a short stay in places where there is not enough oxygen are necessarily excluded.
5. If you need a long flight or ride, you should do gymnastics every 30 minutes or just warm up by walking around the cabin.

ACE inhibitors in heart failure

Captopril

A traditional drug that is taken for any type of heart failure. Treatment should begin with the lowest permitted dose, which is 6.25 mg. active component. This amount of Captopril should be taken three times a day one hour after meals. Gradually, the dosage of the drug should be increased to 25-50 mg of the main component also three times a day. The amount of Captopril is influenced by the severity chronic insufficiency and drug tolerance.

Enalapril

Also the most commonly prescribed drug for heart problems. Enalapril is taken twice a day. At the first stages of therapy, a dose of 2.5 mg in the morning and evening should not be exceeded. To maintain cardiac function, the amount of enalapril is gradually adjusted to 10 mg in the morning and evening. With reduced kidney function, the drug should be adjusted.

Attention! These medicines are taken long time. The decision to cancel a particular medication or change the dose can only be made by a cardiologist.

Beta-blockers for CHF

Acebutolol

A drug that enhances the function of the heart muscle. Available in the form of capsules of 200 and 400 mg active ingredient that cannot be chewed and divided. Therapy with Acebutolol continues for a long time. The drug is taken once a day, it is advisable to do this in morning time, to provide necessary stimulation heart. Treatment begins with a dose of 200 mg, gradually it is required to bring it up to 1200 mg, which will provide Good work the whole organism. Take the drug before meals. Acebutolol is excreted almost completely through the liver, therefore, with its pathologies, the dose should be adjusted.

bisoprolol

Bisoprolol is a traditional drug used to treat chronic heart failure.

A traditional drug used to treat chronic heart failure in many patients. The drug should be taken once before breakfast. The dosage, taking into account the complexity of the disease, can be from 2.5 to 10 mg. active substance. Even with severe currents chronic heart failure should not exceed maximum dose at 10 mg, dividing it into several doses is also prohibited. Bisoprolol is excreted through the kidneys, which should be taken into account in case of problems with their work.

Attention! Beta-blockers should be taken at the same time as ACE inhibitors. This significantly enhances the effect of the two groups of drugs and allows you to achieve the maximum therapeutic effect.

Aldosterone receptor antagonists

Veroshpiron

Issued medicinal product in the form of capsules. Veroshpiron is taken against the background of puffiness that has arisen due to the presence of chronic heart failure. With such a pathology, the patient is recommended to take 0.1-0.2 g of the active substance, which should be divided into three doses. At this dose, the medication is taken for five days, after which you should switch to maintenance treatment. In this case, the dose of Veroshpiron per day is usually 25 mg. It is strictly forbidden to exceed the amount of the main component of 200 mg.

aldactone

The drug is available in the form of tablets for oral use. In case of swelling due to heart failure, patients are recommended to take 100 mg of the active substance in the first five days of treatment, after which, taking into account the severity of the patient's condition, the specialist selects a maintenance dose. It can be equal to 25 or 200 mg of the active substance per day. The duration of therapy is selected individually.

Attention! Aldosterone receptor antagonists are taken in combination with loop or thiazide diuretics. This allows you to quickly achieve results and remove increased puffiness.

Cardiac glycosides in CHF

Digoxin

A medical product available in the form of tablets and injections. The specific form of Digoxin is selected taking into account the severity of the condition. When using a solution for intramuscular injection, the patient is given 0.75-1.25 mg of the active ingredient for 1-1.5 days. With more passive treatment it is necessary to inject 0.5-0.75 mg of the active substance in 3 injections over several days, usually 3-5. Maintenance therapy is determined for each patient, taking into account the rate of withdrawal serious condition and response to treatment.

When prescribing Digoxin in the form of tablets, you should drink the drug at a dose of 0.025 g up to 4 times a day. According to this scheme, the treatment lasts for 3 days. After that, it is necessary to switch to a maintenance dosage of 1-2 tablets per 24 hours. The duration of therapy is selected individually.

Video - Symptoms of heart failure

Novodigal

The drug is taken after a meal. The recommended dose is 0.02 g of the main component three times a day for two days. If necessary, the dosage can be adjusted to 0.3 mg of Novodigal daily for 4 days. For fast withdrawal an attack of chronic heart failure, the patient should be given medication intravenously at a dosage of 2-4 ampoules for three days, after which the patient is transferred to tablets.

Attention! Medicinal preparations are herbal, which provides good digestibility active substance and a small amount side effects in patients.

The cost of medicines

Attention! The exact cost of the listed drugs should be found out from your doctor or pharmacist.

Folk remedies for CHF

A decoction of oats

A decoction of oats is effective remedy in the treatment of CHF

To prepare a home remedy, take 100 ml of peeled oat grains, rinse them thoroughly and pour 500 ml cold water. The mixture is brought to a boil and removed from the stove. After that, 1/3 of a glass of peeled and chopped elecampane roots must be added to the water, only fresh rhizomes are taken.

After thoroughly stirring the broth, it is again put on the stove and again brought to a boil. Infuse the medicine under a tight lid for three hours. The thick must be removed through cheesecloth and two tablespoons are added to the broth natural honey. Use a decoction of oats should be 100 ml three times a day for 15-20 minutes before the main meal. The therapy lasts for 2 weeks.

hawthorn fruit

Such treatment not only significantly strengthens the heart muscle, but also eliminates pain and heaviness in the chest. To prepare the medicine, you should take 500 g of hawthorn fruits, it is important to ensure that they are ripe. Hawthorn washed and pour 1 liter of cold water.

The fruits are cooked from the moment of boiling for about 20 minutes in an enamel pan. After that, it is recommended to strain the broth through cheesecloth and add 2/3 cup of sugar and the same amount of natural honey to it. The components are brought to homogeneity and taken 30 ml daily 30 minutes before meals. The therapy lasts for 30 days. The decoction must be stored in a cold place.

Attention! Using folk remedies in the treatment of chronic heart failure, you should first clarify the safety of their use with a cardiologist.

As soon as the patient has the first signs of chronic heart failure, it is urgent to contact a cardiologist to confirm the diagnosis. Early diagnosis weakening of cardiac function significantly prolongs the life of the patient. At the same time, in without fail should be followed proper nutrition, give up bad habits and reduce physical activity.

Human health largely depends on the ability of the heart to carry out its work normally. The organ, serving as a kind of pump, receives oxygenated blood from the lungs and delivers it to the aorta and arteries of other organs. If the process is disturbed, this leads to the appearance of many serious illnesses.

What is heart failure

With the development of pathological phenomena in the heart tissues (inflammation, necrosis, etc.), the cells undergo a number of changes that cause their dysfunction - this negatively affects the ability of the myocardium to contract. Those tissues that remain healthy can perform their functions for a long time, pumping blood in the human body as usual. However, at some point, decompensation occurs, in which the heart muscle can no longer produce required amount contractions to provide the body with oxygen.

As a result of cardiac decompensation, tissues begin to suffer from hypoxia (lack of oxygen), which leads to a severe deterioration important systems and human organs. Chronic heart failure can be defined as pathological condition, which occurs due to the loss of the heart's ability to provide normal blood circulation in the body.

Symptoms

Like the degree of expression clinical picture, symptoms chronic disease heart depends on the degree and form of its development. However, physicians identify several common symptoms, which are typical for this disease. As a rule, signs of heart failure are already noticeable on initial stages development of pathology. If you find yourself with the symptoms described below, you should visit the clinic for a diagnosis of the disease. To confirm the diagnosis, the specialist uses coronary angiography, the study of hemodynamics, and other methods.

Peripheral edema

In chronic heart disease, swelling is the main symptom. This sign manifests itself because a violation of the heart causes water retention in the body, resulting in hydrothorax - the accumulation of fluid in pleural cavity. Usually, cardiovascular failure expressed first by swelling of the legs, then the abdomen, face and thighs. In addition, during the development of pathology, swelling of the legs has a characteristic symmetrical shape and is accompanied by cyanosis (blue) of the fingers.

Cardiac dyspnea

Another characteristic symptom chronic heart failure is orthopnea. Shortness of breath develops due to a decrease in the rate of blood supply to the pulmonary vessels and the outflow of blood from the lungs to the legs in a horizontal position of the body. If the symptom occurs while the person is in lying position and in calm state- this may indicate the formation simultaneously with the cardiac lung failure. With the progression of these pathologies, persistent shortness of breath is accompanied by peripheral cyanosis of the skin.

Causes of vascular insufficiency

The pathogenesis of chronic heart failure may be associated with various factors, but, as a rule, the occurrence of the disease is the outcome of progressive heart disease. Sometimes the appearance of pathology is caused by febrile conditions, metabolic failures, alcoholism, diseases thyroid gland, anemia. The most common causes of heart failure are:

• failure of the heart rhythm with developing arrhythmia;
• overload of the heart muscle, which is often caused pulmonary hypertension, hypertension, stenosis of the aorta or pulmonary trunk;
• damage to the heart muscle, which is caused by a heart attack, myocarditis, angina pectoris, and some systemic diseases(lupus, rheumatism, etc.);
• pathologies associated with filling the heart with blood (fibroelastosis, pericarditis, etc.).

In young men, chronic heart failure often occurs as a result of acute infarction myocardium. For women, a key risk factor for the development of pathology is arterial hypertension(hypertension), which manifests itself against the background diabetes. The syndrome of chronic heart failure in a child is the result of an abnormal development of the organ.

CHF classification

Treatment of chronic heart failure should be carried out on the basis of diagnostic data. Doctors strongly do not recommend self-medication upon detection characteristic features illness. To determine which method of therapy will be most effective, it is necessary to establish the form, stage and degree of pathology. To this end, the physician complex diagnostics and only then appoints the patient suitable medications and care.

Functional classes of heart failure

Depending on the severity of the patient's condition, the pathology is classified into four classes:

1. First grade. Characterized by no restrictions physical activity.
2. Second class. Indicates the presence of slight restrictions on physical activity.
3. Third class. It is characterized by a pronounced decrease in human performance.
4. Fourth grade. testifies to strong decline performance both at rest and during physical activity.

Classification of CHF by stages

Chronic pathology heart can have several stages of progression:

1. First. The main symptoms of the disease appear during physical exertion.
2. Second. Signs of pathology are manifested not only during physical exertion, but also in a calm state.
3. Third. Geodynamics is disturbed, structural and pathological changes in organs and tissues develop.

Treatment of chronic insufficiency

The treatment of the disease is carried out using surgical intervention or conservative method. In the case of the latter, patients are prescribed medical treatment for heart failure and a suitable diet is selected. As a rule, the diet for each patient is compiled on the basis of individual indicators, taking into account the severity of his condition and the clinical picture of the pathology.

ACE inhibitors

Medicines of this group stimulate the hemodynamic unloading of the myocardium, as a result of an increase in the volume of urine formed, vasodilation, and a decrease in left and right ventricular pressure. Appointed ACE inhibitors in the diagnosis of clinical signs of the disease and a decrease in the ejection fraction of the left ventricle. The list of drugs in this group includes:

• Captopril;
• Spirapril;
• Zofenopril;
• Ramipril;
• Perindopril;
• Cilazapril;
• Fosinopril.

CHF is a disease that is characterized by poor blood supply to human organs in any condition.

It's about how

This leads to the fact that organs and tissues cease to receive the oxygen necessary for full-fledged life activity in the proper volume.

The consequences of this are sad: poor blood supply is one of the main causes of many diseases.

Against this background, shortness of breath, weakness and swelling immediately appear due to fluid retention in the body.

If we talk about the development of chronic heart failure, it should be noted that this disease develops gradually.

CHF develops for certain reasons.

Let's see what causes heart failure:

• Myocardial infarction, transferred recently.
• All kinds of viral and bacterial diseases.
• Constant high blood pressure.
• Pathological changes in the structure of heart tissues due to inflammatory diseases.
• Exchange disorders in the muscle of the heart.
• Irregular heart rhythm.
• Pathological condition of the heart muscle, provoking an increase in connective scar tissue in the myocardium.
• All kinds of heart failure.
• Inflammation of the heart valves.
• Inflammation serous membrane heart, provoking squeezing of the heart and blood vessels by the accumulated fluid.
• Diseases of the lungs and bronchi.
• The constant effect of alcohol on the body.
• Old age.

Chronic heart failure: symptoms and diagnosis

Chronic heart failure is manifested by symptoms that depend on the extent of damage to the heart muscle.

The main symptoms of the disease can be called:

• Shortness of breath, which is strongly manifested in lying down. The patient has to sleep, almost half-sitting, putting several pillows under his head.
• Coughing with sputum, in which blood particles can be detected. In the supine position, the cough becomes simply unbearable.
• severe weakness even without exercise. The body weakens, as oxygen to the brain is supplied in insufficient quantities.
• Severe edema, especially in evening time. The liquid is not excreted from the body and settles in the tissues of the legs, so it is necessary to regulate the water balance.
• Pain in the abdomen due to swelling of the abdominal cavity.
• Renal and liver failure.
• Blue skin, especially fingers and lips. This is due to the fact that deoxygenated blood poorly circulates and does not saturate tissues with oxygen.
• Tachycardia and arrhythmia.

The diagnosis of chronic heart failure is established by the doctor based on the patient's complaints. When the disease is well auscultated weak heart tones, heartbeat malfunctions, noises and wheezing in the lungs are heard.

During the examination, an ultrasound of the heart is performed, which shows the pathology, as a result of which heart failure began to develop. Also during ultrasound, you can look at the contractile function of the myocardium.

Also appointed laboratory tests, with their poor results, an electrocardiogram may be prescribed to determine coronary disease, signs of postinfarction cardiosclerosis, and heart rhythm. With serious ECG deviations can conduct a daily ECG, blood pressure measurement, treadmill test, bicycle ergometry. This allows you to identify the stage of angina pectoris and CHF.

X-ray is prescribed to determine myocardial hypertrophy. Also in the picture you can see the pathology of the lungs, which appeared as a result of venous stasis or edema.

In the presence of coronary artery disease, the patient can undergo coronary angiography to determine the level of patency of the venous arteries and prescribe surgical treatment. If there is a suspicion of stagnation of blood in the liver and kidneys, an ultrasound of these organs is done.

The disease requires careful diagnosis, which should be prescribed by a doctor.

Factors that can lead to aggravation of CHF:

• The development of a major heart disease that is not treatable.
• The development of additional diseases of the cardiovascular system.
• Development of diseases of other organs.
• Physical labor, poor nutrition, vitamin deficiency, constant nervous tension.
• Taking certain medicines.

Acute heart failure: symptoms and treatment

Acute heart failure is a syndrome in which Clinical signs diseases manifest themselves quickly and very brightly, as a result of deterioration systolic function hearts.

All these failures in the work of the heart lead to hemodynamic disturbances and irreversible changes in the circulation of the lungs.

Acute heart failure is a disorder of the heart that worsens cardiac output, the pressure in the pulmonary circulation increases, there is a weak microcirculation of blood in the tissues and stagnation.

This is a pathological condition that appears due to the development of CHF for its decompensation, although there are cases of the development of pathology without heart disease.

DOS calls for immediate medical care, since it is frequent condition which poses a threat to human life.

Acute heart failure is critical condition patient, which can lead to cardiac arrest. If you suspect a syndrome, you should immediately call ambulance with the cardiac resuscitation team.

Symptoms of right ventricular failure include:

• Shortness of breath at rest. It appears as a result of bronchospasm.
• Pain behind the chest.
• Blue or yellow discoloration of the skin, especially the lips.
• Cold perspiration on forehead.
• Prominence and palpation of the veins in the neck.
• Enlargement of the liver and pain in the area.
• Cardiopalmus.
• Swelling in the legs.
• Bloating.

Symptoms of left ventricular failure include the following:

• Shortness of breath with a suffocating effect.
• Rapid heartbeat and arrhythmia.
• Weakness to the point of fainting.
• Paleness of the skin.
• Cough with the formation of foam and blood impurities.
• Wheezing in the lungs.

Acute heart failure can lead to lethal outcome so medical help is needed. You should not postpone and wait until the attack passes, you must urgently call an ambulance with cardiologists. Upon arrival, doctors will help restore the heartbeat and blood flow through the damaged vessels. For this, thrombolytic agents are injected into the vein.

Upon arrival at the hospital, it may be carried out urgent operation to restore the heart muscle, if there was a rupture.

Doctors also relieve an asthma attack, which caused congestive insufficiency, remove thromboembolism and carry out oxygen therapy. The most commonly used for the treatment of AHF narcotic analgesics. And glycosides and cardiotonic drugs help to normalize the contractile function of the myocardium.

You need to know that for any signs of AHF, you should immediately call an ambulance. It must be remembered that if there is the slightest suspicion of the development of AHF, you must immediately call an ambulance.

Forms and stages of heart failure and their signs

The stages of heart failure according to the classification of cardiologists Strazhesko and Vasilenko are divided according to the development of heart failure.

Stage 1 - initial. The first signs of heart failure appear. The patient is constantly cold, cold extremities periodically occur, swell Bottom part body (feet, legs). In the first period, edema is unstable, occurs in the afternoon and goes away after a long night's rest. There is also the presence constant feeling fatigue, fast fatiguability, which is explained by a gradual decrease in blood flow velocity in the skin and musculature of the skeleton. Even with small physical exertion on the body (long hiking, walking up the stairs, cleaning the room) shortness of breath appears, a sharp attack of dry cough is possible, the heartbeat quickens.

Stage 2 (A) - the appearance of blood stagnation. The study reveals a violation of the blood flow of a small or great circle circulation. Periodic asthma attacks or pulmonary edema begin to manifest themselves. This is due to venous congestion in the lungs.

Symptoms:

1. Constant bouts of dry cough.
2. Suffocation.
3. A sudden feeling of anxiety.
4. Cardiopalmus.

With pulmonary edema, the patient has a cough with sputum, noisy breathing.

Stage 2 (B) - venous congestion are progressing. The disorder is already present in the 2 main circulation circles.

Stage 3 - a clear manifestation of the presence of heart failure, dystrophic changes already irreversible.

Symptoms:

1. The constant presence of shortness of breath.
2. The impossibility of committing even a small physical activity.
3. Cirrhosis of the liver.
4. Edema formation.
5. Lowering blood pressure.

If you do not urgently turn to a specialist and do not start treatment, then the heart muscle depletes quickly enough, the liver, kidneys, and brain “suffer”. Possible death.

The New York Heart Association has developed its functional classification and defined the following stages of heart failure:

1. Functional class 1 - the patient feels difficulties only in those cases when his physical activity is on high level. There are no signs of heart disease, only an ultrasound machine can fix changes.
2. Functional class 2 - shortness of breath and pain occur periodically at a standard level of physical activity.
3. Functional class 3 - the patient's condition can be considered positive only if he observes the pastel regimen and limits physical activity as much as possible.
4. Functional class 4 - even minimum set movements can cause an attack, any kind of stress is excluded.

There is left ventricular and right ventricular heart failure. Also, if you follow the pathological irreversible changes, you can distinguish between systolic and diastolic type of ventricular dysfunction. In the first case, the cavities of the left ventricle noticeably expand, and the blood flow becomes less. In the second case, the affected organ is not able to completely relax and process the standard volume of blood, which provokes congestion in the lungs.

It is very important that the specialist correctly diagnose the type of ventricular dysfunction by examining the signs of heart failure. The course of treatment also looks different, since physiological pathology of the above forms of pathologies is radically different.

The treatment regimen is drawn up only after the full clinical picture of the disease is revealed. The occurrence and development of pathologies directly depend on the age of the patient, the stage of development of the disease. The patient must also provide their medical history. In this case, it will be easier for the cardiologist to trace the history of the development of the disease and its approximate temporary presence.

Phases of development of pathologies:

1. Systolic heart failure. Violated time intervals of contraction of the ventricles.
2. diastolic heart failure. Violated time intervals of relaxation of the ventricles.
3. Mixed form of violation. violated normal functioning both systole and diastole.

Complications of CHF and methods of treatment

Complications of CHF can occur if treatment of the disease is not started on time.

CHF is often the result of many diseases internal organs and most heart diseases.

In chronic heart failure, the heart does not pump blood in the required volume, resulting in a lack of nutrients in the organs.

The first and obvious signs of CHF are the presence of edema and shortness of breath. Edema is the result of stagnation of blood in the veins. Shortness of breath is a sign of stagnation of blood in the vessels of the lungs.

In the treatment of CHF, the patient must comply with the prescribed diet. This food system is to limit salt and water. Products should be selected nutritious and easily digestible. They must contain the required amount of protein, vitamins and minerals. The patient is also required to monitor his weight and perform dynamic loads on the different groups muscles. The amount and types of load in each individual case is determined by the attending physician.

Medicines that are prescribed for CHF are the main, additional and auxiliary groups. The drugs of the main group prevent the development of the disease, as they protect the heart, internal organs and optimize arterial pressure. This includes ACE inhibitors, angiotensin receptor antagonists (Concor, Anaprilin), beta-blockers, diuretics (Amiloride, Furosemide) and cardiac glucosides.

Also, the doctor can prescribe drugs based on benazepril: this is a modern and effective development of scientists. Another drug can be prescribed in the composition complex therapy- Orthomol Cardio.

It is often advisable to use electrophysiological methods of therapy.

These methods include:

1. An artificial implant that creates an electrical impulse for the muscles of the heart.
2. Three-chamber implantation of the pulse of the right atrium and ventricles of the heart. This ensures simultaneous contraction of the ventricles of the heart on both sides.
3. Implantation of a cardioverter-defibrillator, a device that not only transmits an electrical impulse to the heart, but also minimizes the risks of arrhythmia.

When drug treatment is ineffective and an attack of heart failure does not go away, surgical intervention is used.

Types of surgical intervention for CHF:

1. Coronary artery bypass grafting is performed when the vessels are visibly affected by atherosclerosis.
2. Surgical correction valve defects - used for severe stenosis or insufficient number of valves.
3. Heart transplantation is cardinal, but in some cases required method. During such an operation, the following difficulties often occur: rejection, lack of donor organs, damage to the blood channels of the transplanted heart.
4. Protection of the heart with an elastic mesh frame. Thanks to this method, the heart does not increase in size, and the patient feels better.

It can also be used to install artificial equipment and devices in the human body to improve blood circulation. Such devices surgical method injected into the patient's body. Through skin covering they connect to batteries located on his belt. However, during such an operation it is quite possible infectious complications, thromboembolism and thrombosis. The cost of such devices is very high, which also prevents their use.

If the disease is not treated in time, then the patient may face acute myocardial insufficiency, pulmonary edema, frequent and prolonged pneumonia or even sudden cardiac death, heart attack, stroke, thromboembolism. These are the most common complications of CHF.

Timely treatment - the best prevention listed diseases. You need to see a doctor in time and succumb drug treatment or surgery.

In the absence of treatment, the prognosis for the patient is disappointing. Heart disease usually leads to complications and wear and tear this body. At timely treatment the prognosis is comforting - the disease begins to progress more slowly, or even completely recedes.

With CHF, one should strictly adhere to a certain lifestyle, namely:

• The mode of work and rest, enough sleep and outdoor activities.
• Proper nutrition is the key to overall health. Nutrition should be fractional - 5-6 small meals. The amount of salt should be minimized, limit the amount of fat in the diet, exclude alcohol and nicotine products, eat more seasonal fruits and vegetables, dairy products.
• Observe the regime of physical activity - according to the doctor's prescription, you should engage in physiotherapy exercises.
• Follow all the recommendations of the attending physician - this will help to avoid complications and slow down the progression of the pathology.

So that an attack of heart failure no longer bothers you, you should not only go to a doctor's session in a timely manner, but also take medication.

Catad_tema Heart failure - articles

Features of the treatment of chronic heart failure in elderly and senile patients

Gurevich M.A.
Moscow Regional Research Clinical Institute. M.F. Vladimirsky, Department of Therapy

In economically developed countries, CHF is 2.1% of the entire population, while more than 90% of women and about 75% of men with CHF are patients older than 70 years (B. Agvall et al., 1998). In Russia, the elderly are persons aged 60 to 75 years, aged 75 to 90 years - persons in old age and over 90 years old - centenarians. In the United States and European countries, the elderly are people aged 75–90 years (“young elderly”), over the age of 90 years - “old elderly”, centenarians.

The increase in the frequency of CHF with age is due to a number of significant factors: an undoubted increase in modern world IHD, AH - the main "suppliers" of CHF, especially with their frequent combination; some progress in the treatment of acute and chronic forms coronary artery disease, blood pressure, which contributed to the chronicity of these diseases, an increase in life expectancy similar patients with the development of circulatory decompensation. In addition, an increase in the frequency of CHF with age is due to the formation of an "senile heart" with the accumulation of amyloid and lipofuscin in cardiomyocytes, sclerosis and myocardial atrophy, an increase in atherosclerosis processes not only in the main arteries, but also arteriosclerosis, hyalinosis of small and smallest arteries, arterioles.

In order to more clearly understand the features of therapy in elderly and senile patients, it is necessary to consider issues related to changes in the functions of cardio-vascular system, the reaction of the aging organism to drug exposure.

Changes in the functions and structure of the heart and blood vessels with age in a general form are as follows:

1. A decrease in sympathetic reactivity contributes to a change in the response of the heart to stress.
2. As vascular elasticity decreases, vascular resistance increases, which increases myocardial work and increases its oxygen consumption (CO at rest decreases with age - by the age of 70 it is 25% less than at 20 years; heart rate decreases, VR decreases; peak heart rate decreases load, MO).
3. The duration of LV contraction increases.
4. Changes in collagen tissue lead to an increase in the passive stiffness of the heart, i.e., a decrease in compliance (thickening of the walls of the left ventricle). Focal fibrosis, valve tissue changes are often observed; their calcification contributes to hemodynamic shifts.

With aging, the number of nuclei in the valves decreases, lipids accumulate in the fibrous stroma, collagen degeneration, and calcification occur. aortic valve more changed than the mitral valve, valvular calcification is found in at least 1/3 of persons over 70 years of age. Sclerotic aortic stenosis and mitral insufficiency are more common.

The number of pacemaker cells is reduced, fibrosis and microcalcification of the elements of the conduction system are enhanced. Thickening and fibrosis increase vascular stiffness, which is expressed in the growth of OPSS. The reactivity of baroreceptors decreases, the number of β-adrenergic receptors decreases, and their function worsens.

Under the influence of the aging process, the functional reserve of the heart is significantly reduced. Among persons over 65 years of age (J. Lavarenne e t a l., 1983), 30% of complications from drug therapy. Medicines that act on the heart - vascular system are the cause of 31.3% of complications. The bioavailability of many drugs increases due to inhibition of their metabolism. The rate of elimination of drugs by the kidneys is reduced due to dysfunction of the latter.

Adverse reactions when taking medications in the elderly occur much more often and are more heavy character. An overdose of diuretics can lead to dangerous complications(as well as sedatives, and glycosides).

The elderly should be prescribed as few drugs as possible, minimum dose and with a simple mode of their reception (sometimes written explanations are required!). It should also be taken into account that the long bed rest and immobility often have an adverse therapeutic and psychological effect.

When prescribing drug therapy in the elderly and senile age, the following should be considered:

• clinically meaningful change the ability to absorb drugs does not occur;
• the total volume of water in the body of the elderly is reduced, with the introduction of a water-soluble drug, its concentration increases, with the use of a fat-soluble drug, it decreases;
• increased bioavailability is due to a decrease in metabolism during the first passage;
• kidney function worsens with age, drug elimination decreases (especially drugs with a low therapeutic index, digoxin, etc.);
• the severity and duration of drug action depend not only on pharmacokinetic changes, but also on how it is modified;
• heavy adverse reactions in the elderly, they are more likely to occur when using the following five groups of drugs: cardiac glycosides, diuretics, antihypertensive drugs, antiarrhythmics, anticoagulants;
• may experience dehydration mental disorders, hyponatremia, hypokalemia, cerebral and thrombotic complications, orthostatic hypotension;
• should be given as soon as possible less medication at the minimum dosage a short time, With in a simple way their reception and regimen;
• it is necessary to identify and, if possible, eliminate the causes of heart failure, improve the pumping function of the heart, correct water and salt retention;
• it is important to use diuretics, vasodilators and ACE inhibitors;
• rather quickly advancing overdose of diuretics, cardiac glycosides, sedatives should be avoided;
• increased blood pressure requires adequate treatment;
• need to limit salt intake<5 г/ сут).

Features of the action of drugs in the elderly, as well as the main causes of these features are presented in Table 1.

Table 1
The main reasons for the characteristics of drug exposure in the elderly

Three “golden” rules for prescribing drugs to elderly patients were formulated by J.B. Schwartz (1998);

1. start treatment with small doses of the drug (1/2 of the usual dose);
2. slowly increase the dosage;
3. watch for possible side effects.

Myocardial damage in the elderly is noted in all forms of coronary heart disease, which occur against the background of already existing organic and functional changes in the heart and blood vessels of an age-related nature. The causes of exacerbations of CHF in the elderly can be transient painful and painless myocardial ischemia, atypical myocardial infarction, cardiac arrhythmias (paroxysmal and tachyarrhythmic forms of atrial fibrillation, ventricular e arrhythmias of high gradations according to Lown, sinus node weakness syndrome, etc.).

Numerous negative extracardiac effects are also important - pulmonary embolism, acute infections, renal failure, respiratory failure, uncorrected hypertension, etc.

It is also necessary to take into account the patient's non-compliance with the regimen and treatment regimen, alcohol abuse, physical and emotional overload, uncontrolled use of drugs (antiarrhythmics, β-blockers, calcium antagonists, corticosteroids, non-steroidal anti-inflammatory drugs, diuretics, vasodilators, antihypertensive drugs, etc.).

The complexity of diagnosing and treating CHF in the elderly is due to the presence of multiple organ failure, more frequent complications, including cardiac arrhythmias, polymorbidity, including the combination with type 2 diabetes mellitus, dyscirculatory encephalopathy, broncho-obstructive diseases.

In CHF, the elderly often do not have overt symptoms of heart failure. Its manifestations can be a feeling of lack of air, shortness of breath with and without physical exertion, coughing, tachycardia, and heart rhythm disturbances. Frequent disorders of cerebral circulation - increased ("unreasonable") fatigue, decreased physical and mental performance, dizziness, tinnitus, sleep disturbance, agitation alternating with prolonged depression.

Peripheral edema in the elderly is not necessarily a consequence of CHF. They can be associated with increased tissue hydrophilicity, a decrease in the colloid osmotic pressure of the blood, a slowdown in blood flow, a decrease in the filtration capacity of the kidneys, varicose veins, adynamia, chronic diseases of the kidneys, liver, etc.

Of particular note is the so-called chronic left ventricular failure with symptoms of incipient pulmonary edema. These conditions of recurrent cardiac asthma can stop on their own, and sometimes require urgent care.

The presented features of HF in the elderly cause undoubted diagnostic difficulties, require individual treatment and motor rehabilitation. Treatment features include:

• early appointment of diuretics - from the initial stages of heart failure, first for a short time, then courses and combined;
• early use of peripheral vasodilators, mainly nitrates, ACE inhibitors, calcium antagonists;
• the appointment of cardiac glycosides for certain indications and in doses appropriate for old age;
• if possible, sufficiently active motor rehabilitation.

Treatment of CHF in the elderly requires a number of additional conditions, taking into account considerable diagnostic difficulties and side effects of drug therapy.

It should be borne in mind that there are drugs that are not recommended for prescription in CHF in the elderly. These include: non-steroidal anti-inflammatory drugs, corticosteroids, class I antiarrhythmic drugs (quinidine, disopyramide, ethacizine, ethmozine, etc.).

Features of pharmacokinetics in the elderly are:

• increased absorption of sublingual forms due to hyposalivation and xerostomia;
• slowing down the absorption of cutaneous ointments, drugs from patches due to a decrease in the resorptive properties of the skin;
• prolongation of the half-life for enteral forms due to a decrease in the activity of liver enzymes;
• greater severity of hemodynamic reactions with the introduction of the drug.

Changes in the pharmacokinetics and pharmacodynamics of drugs in the elderly should take into account the individualization of the dose of the drug and its possible change. Often there is a need to treat the underlying and concomitant disease, taking into account frequent polymorbidity. Correction of doses of drugs is required (more often in the direction of reduction!) Taking into account the age-related decline in the functions of various organs and systems. It is necessary to keep in mind the frequent development of adverse reactions in drug treatment. Finally, it is in elderly patients with CHF that one should take into account a decrease in adherence to treatment, often due to a decrease in memory and/or intelligence.

Table 2 shows the main drugs used to treat CHF in the elderly.

table 2
The main drugs used to treat CHF in the elderly

When using diuretic drugs, it is necessary to take into account a number of features of the senile organism: manifestations of cellular dehydration; redistribution of electrolytes between the cell and the environment with a tendency to hypokalemia; originality of age-related neuroendocrine regulation; age-related features of the exchange of water and electrolytes.

All of the above, apparently, involves the use of diuretics at a lower dose, possibly in short courses, with mandatory monitoring and correction of the electrolyte profile and acid-base state of the body, compliance with the water-salt regimen, respectively, the stage of CHF. With CHF I-II FC, daily fluid intake is not more than 1500 ml, sodium chloride - 5.0-3.0 g; with CHF II-IIIFC: liquids - 1000-1200 ml, table salt - 3.0-2.0-1.5 g; with CHF IV FC: liquids - 900700 ml, table salt - 1.5-1.0 g.

The sequence of diuretic use in geriatric patients with CHF is determined in each case individually, but usually they start with the use of dichlorothiazide (hypothiazide), then triamterene with spironolactone (veroshpiron, aldactone) and, finally, loop diuretics (furosemide, lasix, uregit). In cases of severe CHF (III-IV FC), various combinations of diuretics are prescribed with the indispensable use of furosemide. Unfortunately, it is in the elderly with CHF that the side effects of diuretics develop quite quickly - increased weakness, thirst, drowsiness, orthostatic hypotension and oliguria, which indicates dilutional hyponatremia. In such cases, the use of potassium salts is indicated. To prevent hypokalemia, potassium-sparing drugs (spironolactone, triamterene, amiloride) are prescribed, which also protect the myocardium from metabolic disorders.

Excessive diuretic therapy in geriatric patients may contribute to hypokalemia and a decrease in CO, a decrease in renal blood flow and filtration with the onset of azotemia. Thiazide diuretics are especially unfavorable in this respect.

With the development of renal failure against the background of the use of potassium-sparing agents, hyperkalemia occurs, manifested by rigidity and paresthesia in the limbs with muscle weakness, dyspeptic disorders (abdominal pain, metallic taste in the mouth, nausea, vomiting, etc.). At the same time, a slowdown in intraventricular conduction, an increase in the amplitude of the T wave can be recorded on the ECG. The means of correcting hyperkalemia is repeated intravenous administration of solutions of sodium bicarbonate, calcium gluconate.

Reducing the volume of intracellular fluid due to the intake of diuretics can lead to hyperglycemia, increased blood viscosity, and microcirculation disorders. This increases the risk of thromboembolic complications. Diuretics (especially thiazide ones) contribute to the retention of uric acid, hyperuricemia, and lead to severe arthralgia. In table. 3 shows possible side effects and contraindications to the use of diuretics in geriatric practice.

Table 3
Side effects and contraindications to the use of diuretics in geriatric practice

With prolonged use of diuretics in senile patients with CHF, refractoriness to them often develops. The causes of this phenomenon are hypokalemia, dilutional hyponatremia, metabolic alkalosis, and age-related hypoalbuminemia. This is facilitated by an increase in the activity of ADH and the mineralocorticoid function of the adrenal glands in old age.

Possible reactions of diuretics with other drugs in elderly patients are presented in Table. four.

Table 4
Possible interaction reactions of diuretics with other drugs

The use of diuretics in geriatric practice requires knowledge of possible side effects and frequent contraindications in their administration, as well as the interaction of diuretics with other drugs. Doses of diuretic drugs and their combinations should be determined in each case purely individually. However, the general trend in geriatric pharmacology towards lower diuretic doses continues.

The use of cardiac glycosides in the elderly without clinically delineated signs of heart failure is inappropriate. This is due to the high possibility of side effects, the lack of clear data on the effectiveness of drugs and information that cardiac glycosides in the elderly can even increase mortality.

The pharmacokinetics of cardiac glycosides in the elderly has its own characteristics:

• increased intestinal absorption due to decreased peristalsis and a tendency to constipation;
• an increase in the content of the active free fraction in the blood plasma due to age-related albuminemia and a decrease in the amount of water in the body;
• slowing down the excretion of glycosides by the kidneys and slowing down their biotransformation in the liver (this applies mainly to digoxin).

These features at the same dose of the drug provide the concentration of cardiac glycosides in the blood plasma in the elderly 1.5-2 times higher than in middle-aged people. This leads to the conclusion that in geriatric practice, doses of cardiac glycosides reduced by 1.5-2 times should be used.

The pharmacodynamics of cardiac glycosides in old age also has certain features:

• increased sensitivity and decreased myocardial tolerance to cardiac glycosides;
• more pronounced arrhythmogenic effect and greater refractoriness to drugs.

Age-related features of pharmacokinetics and pharmacodynamics determine not only the severity of the cardiotonic effect, but also the rapidity of the onset of glycoside intoxication. At the same time, the risk of side effects during glycosidotherapy is high.

Cardiac glycosides (digoxin) in geriatric practice are prescribed for CHF only under strict indications. This is a tachyarrhythmic form of atrial fibrillation, atrial flutter or paroxysms of supraventricular tachycardia. The expediency of prescribing digoxin to patients with CHF in sinus rhythm is doubtful due to the lack of a significant improvement in hemodynamics in such a situation.

The technique of glycoside therapy in geriatric practice includes a period of initial digitalization (saturation period) and a period of maintenance therapy. In normal, non-urgent cases, saturation with cardiac glycosides is carried out slowly (within 6-7 days). A fixed daily dose of the drug is administered daily in 2 divided doses. This rate of administration helps to prevent the arrhythmogenic effect of drugs.

The optimal therapeutic effect in geriatric patients is accompanied by the following phenomena:

• positive dynamics of the general condition and well-being of the patient (decrease in shortness of breath, disappearance of asthma attacks, increase in diuresis, decrease in congestion in the lungs, decrease in the size of the liver, edema);
• decrease in heart rate to 60-80 in 1 minute;
• positive response to individual physical activity.

During therapy, elderly people often (up to 40%) develop symptoms of glycoside intoxication: dysfunction of the heart, gastrointestinal tract and nervous system.

It should be noted quite frequent neurological symptoms in the elderly and the elderly: increased fatigue, insomnia, dizziness, confusion, "digital dilirium", syncope, and yellow or green surroundings.

Peculiar risk factors for glycoside intoxication in old age are increased adrenergic effects on the heart, hypoxia, myocardial dystrophy, dilatation of cavities, as well as the frequent interaction of cardiac glycosides with other drugs (Table 5)

Table 5
Interaction of cardiac glycosides with other drugs

It should be pointed out that various metabolic agents (ATP, cocarboxylase, riboxin, neoton, preductal, etc.) are widely used in glycoside therapy in geriatric practice, as well as the correction of possible neuropsychiatric disorders.

The features of the pharmacotherapy of coronary artery disease in the elderly include the following:

• for the relief and prevention of angina attacks, the priority form is a spray;
• course therapy: retarded forms of one-two doses (isosorbide dinitrate, I-5-M);
• with a decrease in memory, physical activity, it is advisable to use cutaneous patches with nitroglycerin;
• restriction in the use of buccal forms due to the frequent pathology of the oral cavity;
• it is necessary to consider adherence of the patient to a certain nitrate.

Nitrate tolerance is a real problem in the elderly with CAD. The retarded form of isosorbide dinitrate is most effective in the elderly - the dose is quite high - from 120 to 180 mg / day, painful rather than painless myocardial ischemia undergoes the greatest dynamics.

Nitroglycerin in geriatric patients often causes headache, nausea, lowering blood pressure with reflex tachycardia. Contraindications to the appointment of nitrates are severe arterial hypotension, glaucoma, cerebral hemorrhage, increased intracranial pressure. Long-acting nitroglycerin preparations (sustak, nitrong, nitromac, nitrosorbide, isomak, isoket, isodinite, etc.) rarely cause headaches, but give other side effects; isosorbide dinitrate derivatives have not only antianginal, but also hemodynamic properties, and therefore are successfully used in the treatment of CHF in the elderly.

After a few weeks, some patients become addicted to nitrates. The effectiveness of drugs is markedly reduced and, which is practically important, does not increase with an increase in single and daily doses. Hemodynamic and antianginal action of nitrates does not occur. In such cases, it is necessary to gradually reduce the dose of nitrates up to complete abolition. After 1-2 weeks. sensitivity to nitrates may be restored. It is possible to use mononitrates - olicard, monocinque, etc., which give less tolerance and a greater hemodynamic effect.

Direct vasodilators (nitroglycerin and its derivatives, isosorbide dinitrate, mononitrates, etc.) are widely used in the treatment of acute heart failure (pulmonary edema, cardiogenic shock, etc.), as well as in pain forms and other painless variants of chronic coronary artery disease in the elderly, combined with CHF. The use of these drugs allows to achieve an antianginal effect by reducing myocardial ischemia.

In recent years, materials have appeared on the cardioprotective effect of mononitrates (olicard, monocinque, etc.) in CHF. When they were prescribed with other cardiotropic drugs (ACE inhibitors, cardiac glycosides, etc.), a significant improvement in the main hemodynamic parameters was found in the treatment of CHF in the elderly.

Negative phenomena in the use of parenteral nitrates in the elderly occur in 40% of cases and more often (sharp headache, nausea, etc.). Headache is associated with venous stasis, a sharp arteriolodilatation of cerebral vessels. With a severe headache, it is possible to use caffeine-sodium benzoate orally as a solution (1 ampoule of caffeine solution per 5-7 ml of 40% glucose solution).

Molsidomin also quite often (about 20% of cases) causes headache, dizziness and nausea.

When using hydralazine hydrochloride (apressin), the elderly are more likely than middle-aged people to experience headache, nausea and vomiting, palpitations, flushing of the skin, a feeling of heat and burning in the eyes.

The use of sodium nitroprusside and prazosin in the elderly, especially without detailed clinical and hemodynamic control, may be accompanied by side effects in the form of headache, nausea and vomiting, abdominal pain, hyperthermia, irritability, and an increase in the number of angina attacks.

ACE inhibitors are widely used in the treatment of CHF in elderly patients. They have replaced cardiac glycosides and peripheral vasodilators in geriatric practice. Possible side effects of ACE inhibitors include skin rash, dry cough, loss of taste, glomerulopathy (proteinuria), and excessive arterial hypotension. When prescribing ACE inhibitors to the elderly, it is required to exclude previous renal pathology (diffuse glomerulonephritis, pyelonephritis) in the stage of chronic renal failure, careful titration of the drug dose to prevent uncontrolled arterial hypotension. It is in the elderly with CHF that it is advisable to use ACE inhibitors with a distinct long-term, prolonged action that do not cause hypotension of the first dose. These include perindopril - 2-4 mg / day, quinapril - 2.55 mg / day.

The appointment of an ACE inhibitor is advisable for all classes of CHF, with left ventricular dysfunction, not yet accompanied by symptoms of CHF. This is relevant for patients with myocardial infarction with latent heart failure; they can be used with preserved LV systolic function, preventing the development of overt HF and prolonging the time to decompensation. A positive effect of ACE inhibitors on heart rhythm disorders, atherogenesis, kidney function, etc. has been revealed.

When prescribing ACE inhibitors to the elderly with CHF, a number of principles should be taken into account: this is, first of all, verified HF, the absence of contraindications to the use of ACE inhibitors; special care must be taken with CHF I V FC according to NYHA, an increase in creatinine levels over 200 mmol / l, symptoms of generalized atherosclerosis. Treatment should begin with minimal doses: captopril - 6.25 mg 3 times a day, enalapril - 2.5 mg 2 times, quinapril - 2.5 mg 2 times, perindopril - 2 mg 1 time. Doses are doubled every 3-7 days. If necessary, the titration speed can be increased or decreased.

The appointment of an ACE inhibitor requires taking into account a number of points: the effectiveness of the drug, the ease of selecting an adequate dose; lack of effect of the first dose in terms of landslide hypotension; side effects and tolerability; availability; adherence to the drug; price.

β-blockers can be used in the treatment of CHF in the elderly. First of all, the antitachycardiac effect of the drug, its effect on the suppression of neurohumoral factors of heart failure is taken into account. Side effects of β-blockers are associated primarily with their ability to cause sinus bradycardia, slowing of sinoauricular, atrioventricular and, to a lesser extent, intraventricular conduction, a certain decrease in the pumping function of the heart, arterial hypotension, bronchospasm.

The initial single dose of propranolol should not exceed 10 mg, then 20 mg, and the daily dose should not exceed 80 mg. The drugs of choice are cardioselective β-blockers - metoprolol, bisoprolol, carvedilol, nebivolol, etc. A single dose of metoprolol should not exceed 12.5-25 mg, daily - 75-100 mg. Contraindications to the appointment of β-blockers are severe bradycardia and hypotension, sick sinus syndrome, atrioventricular blockade, bronchial asthma and asthmatic bronchitis in the acute stage, severe diabetes mellitus.

The use of calcium antagonists in the elderly is especially indicated when CHF is combined with hypertension, including isolated systolic hypertension.

Undoubted advantages are slow-acting, prolonged calcium antagonists - amlodipine, felodipine, altiazem, diltiazem, etc.

Side effects when using calcium antagonists in the elderly are manifested by headache, edema of the lower extremities associated with the state of peripheral vessels, slowing of sinoatrial and atrioventricular conduction, sinus tachycardia.

Calcium antagonists are contraindicated in severe arterial hypotension, in patients with sinoauricular and atrioventricular blockade, severe CHF III-IV FC. However, it should be borne in mind that calcium antagonists do not actually affect the reduction of CHF.

AII receptor antagonist drugs are sometimes an alternative for long-term CHF therapy in the elderly. In the absence of contraindications, patients with CHF II-III FC and LV systolic dysfunction should receive an ACE inhibitor with proven efficacy and one of the β-blockers used in the treatment of CHF (bisoprolol, carvedilol, metoprolol ZOK and nebivolol) almost for life.

In the presence of stagnation, a loop or thiazide diuretic is added. In the treatment of elderly patients with CHF I II-IV FC, a combination of four drugs is used: ACE inhibitors, β-blockers, diuretic, spironolactone. In the presence of atrial fibrillation in combination with CHF - indirect anticoagulants.

Life-threatening arrhythmias in the elderly with CHF require special treatment. These include paroxysmal tachycardia, complete AV block, sinus node dysfunction with asystole for more than 3-5 s, frequent paroxysms of atrial fibrillation, low-grade ventricular extrasystoles, etc.

It should be emphasized that these arrhythmias can be an independent pathogenetic factor in the development and exacerbation of CHF in the elderly. With the ineffectiveness of medical treatment of life-threatening arrhythmias, surgical treatment is possible - destruction (ablation) of the His bundle, temporary and permanent electrical stimulation of the heart, implantation of a cardioverter - defibrillator.

Pharmacological correction of energy metabolism opens up new perspectives in the treatment of HF in the elderly. Promising and pathogenetically substantiated is the use of the cytoprotective drug trimetazidine in chronic coronary artery disease in the elderly with CHF. The anti-ischemic, antianginal and metabolic effects of trimetazidine have been confirmed in randomized controlled trials. The drug can be used both as monotherapy and in combination with other known cardiotropic drugs; at the same time, an additive effect is observed, which is especially important in the treatment of coronary artery disease and heart failure in the elderly.

Heart failure (treatment and drugs for this, prevention) is an important and large section of both cardiology and pharmaceuticals. Scientists from all over the world are struggling with this disease, but even now the number of people with such a disease is in the tens of millions. However, science is moving forward, and drugs are being improved every year, making it possible to give a good prognosis for the treatment of cardiovascular diseases.

Basic principles of treatment

In accordance with WHO recommendations, heart failure should be considered a syndrome in which, as a result of cardiovascular disease, the pumping function of the heart is reduced, which leads to an imbalance between the body's blood demand and the actual capacity of the heart. Without affecting the very complex pathogenesis of heart failure, it is possible to identify the main pathologies that this syndrome manifests in the human body: a disease of the cardiovascular system, a decrease in cardiac output, sodium retention and excess fluid in the body.

Generally recognized are the following tasks that the treatment of heart failure must solve: stopping the disease by protecting the heart and other organs that are affected by pathology; reducing the number of relapses, increasing the prognosis of recovery, preventing the staged development of insufficiency, eliminating the symptoms of the disease, increasing working capacity and other life opportunities.

Non-drug treatment

Heart failure should be treated without the use of drugs. Rational nutrition, optimal daily routine, dosing loads and therapeutic exercises, psychological training, sanatorium rest, traditional methods of treatment and some other methods - this is the basis of therapy.

In the diet, it is necessary to provide for limiting the intake of salt and liquid. Daily intake of sodium chloride (salt) should be no more than 3 g in the initial stages of the disease, no more than 1.8 g in more severe forms. Drinking liquid is limited to 1.5 liters (in any form), and for stages 2 and 3 - 750 ml.

Physical prevention should become a mandatory component of treatment. Calm walking or cycling are recommended 5 times a week for 30 minutes with constant heart rate control. An important condition is fresh air.

In terms of the complete exclusion of physical activity, care should be taken. Such an action is possible only in severe forms of the disease. In general, the complete absence of loads leads to structural changes in muscle tissues, which can adversely affect the future. Moderate dosed physical exercises reduce the level of neurohormones, increase the effectiveness of drug therapy, and increase the overall tone of the body.

Principles of drug therapy

When heart failure develops, drug treatment becomes the main focus of cardiology.

The appointment of such treatment should be based on an accurate diagnosis and after checking the individual sensitivity of the diseased organism.

In general, therapy uses a medicine for heart failure of two types: basic and additional drugs in the form of tablets.

Essential medicines

They can be divided into 6 main types:

1. Angiotensin-converting enzyme inhibitors (ACE inhibitors).
2. Beta blockers.
3. Aldosterone antagonists.
4. cardiac glycosides.

Additional drugs for heart failure are prescribed based on the individual characteristics of the patient to improve the effectiveness of treatment.

ACE inhibitors.

ACE inhibitor drugs are prescribed to all patients with heart failure at any stage. Long-term experience of use has been obtained on drugs such as enalapril and captopril. Newer recommended agents are fosinopril, lisinopril, perindopril. These drugs can be prescribed even in the presence of concomitant hypertension. Treatment begins with a minimum dosage with a frequency of 1 time per day, with a gradual increase to optimal doses.

The effectiveness of ACE inhibitors is based on the fact that they are a dual-action drug. First, they have an immediate effect by blocking active neurohormones. Secondly, the drug is able to act with a delay for the gradual blockade of tissue neurohormones.

Of similar importance in the fight against heart failure are beta-blockers (BABs). This drug is able to significantly slow down deficiency at any stage, affecting the negative properties of catecholamines and other processes. The greatest effect is achieved by the combined use of ACE inhibitors and BAB. At the same time, BAB is a fairly strong drug, and you should start with the lowest dosage once a week.

Aldosterone antagonists.

An important place in the complex treatment of heart failure is occupied by drugs to overcome hyperhydration and hypomagnesemia, which are potassium-sparing agents. These include aldosterone antagonists. Tablets such as spironolactone at doses up to 50 mg/day are well combined with ACE inhibitors and BAB, and when used individually, the dose is increased to 100-200 mg/day. For the severe stage of the disease, eplerenone is recommended, which can be prescribed with the simultaneous manifestation of diabetes mellitus. The heart responds favorably to the complex treatment of ACE inhibitors, β-blockers and antagonists.

Angiotensin receptor blockers.

The practice of complex treatment under the auspices of WHO shows the effectiveness of the use of receptor blockers, which prevent the disease from developing into a more severe stage. The most commonly used is candesartan. Successful blocking of deficiency, even in the presence of diabetes mellitus and nephropathy, is achieved by prescribing losartan and valsartan tablets. In addition to the main function, they are used to prevent cardiac decompensation.

Diuretics are an effective means of combating sodium retention and excess water in the body. They are prescribed for any stage of heart failure, the treatment of which requires the removal of edema. Diuretics are divided into several groups according to the targeting of the impact. Carbonic anhydrase inhibitors act in the area of ​​the proximal tubules. A bright representative is a drug like acetazolamide. The cortical zone is under the influence of thiazide diuretics.

These include the following agents: hypothiazide, indrapamide, chlorthalidone. Loop diuretics serve their zone: furosemide, bumetanide, torasemide. Competitive (spironolactone) and non-competitive (triamterone) diuretics are classified as potassium-sparing agents that act in the area of ​​the distal tubules. The greatest and universal use was received by drugs of the thiazide and loop groups.

Diuretics are prescribed together with ACE inhibitors, and their main function is dehydration of the body. They provide two phases of action: active during fluid stagnation and maintaining a euvolumic state after compensation. The introduction of drugs should ensure, during the active phase, an excess of urine output over the liquid drunk by 1-2 liters per day.

Treatment begins with minimal doses of drugs, with a gradual increase in the number and transition to a combination of different diuretics. So, the appointment of torasemide begins with a dose of 5-10 mg with a gradual increase to 100-200 mg.

cardiac glycosides.

The main fight against the symptoms of heart failure is carried out with the help of cardiac glycosides, acting on the inotropic, chronotropic and neuromodulatory mechanism. Most often, digoxin is prescribed, which has optimal characteristics and is combined with other drugs. Strofantin and corglicon are also used.

Additional funds

Peripheral vasodilators (dihydropyridines, hydralazines), statins, indirect anticoagulants, antiarrhythmic drugs (amiodarone), antiplatelet agents, and some others are used as additional drugs for the treatment of heart failure. Their task is to help get rid of side effects, taking into account the individual characteristics of the patient. Such assistance is especially needed in the presence of coronary disease, hypertension, diabetes and other concomitant diseases. So, in the presence of atrial fibrillation, the appointment of an antirhythmic drug, digoxin, is effective.

Heart failure is a dangerous syndrome that indicates functional disorders of the heart. Such a disease should not be ignored and requires timely optimal therapy. The appointment of complex drug treatment should be based on accurate diagnosis using modern research methods.

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Main causes of heart failure

The main causes of heart failure are:

• ischemic heart disease, especially after myocardial infarction;
• also the cause of heart failure can be long-term and untreated hypertension;
• heart defects (congenital and acquired);
• another cause of heart failure is cardiomyopathy (heart pathology congenital or acquired, caused by inflammatory heart disease, alcohol abuse, etc.).

Treatment of chronic heart failure with medicines

For the treatment of chronic heart failure, there are highly effective drugs that can help the patient. But the selection of drugs for heart failure can only be done by a cardiologist on the basis of an examination and data from an objective and instrumental examination of the patient. Depending on the course and severity of chronic heart failure, there is a constant correction of treatment: the selection of drugs and their doses. This may be quite enough to ensure a normal quality of life and improve the prognosis. But for some patients with chronic heart failure, drug therapy alone may not be enough. Today, there are modern methods of treating this pathology: external intensive counterpulsation, shock wave therapy, surgical interventions.

For the first time, severe shortness of breath or suffocation is a serious symptom of the onset or exacerbation of a number of cardiovascular diseases.

cardiac asthma- an attack of suffocation caused by weakness of the left ventricle.

With an exacerbation of chronic heart failure, an extremely dangerous situation is possible due to the fact that the heart is not able to push blood. As a result, blood stagnation occurs in the pulmonary arteries, and fluid leaves the vessels, accumulating in the tissues and body cavities. The patient develops suffocation at rest, palpitations, coughing, hemoptysis, rises or falls in blood pressure, pulse speeds up to 100 - 130 beats / min, respiratory rate - 30-40 per minute (normal 18-20). This is how cardiac asthma begins, and with gurgling in the chest, even pulmonary edema. This extremely difficult and dangerous situation leads to the development of acute oxygen starvation of the body. In this case, it is necessary to urgently call an ambulance, since only doctors of emergency medical care and cardio resuscitation will be able to provide timely and qualified assistance.

ACE inhibitors: dilate peripheral vessels, facilitating the work of the heart, improve pregnosis - Kapoten, Monopril, Fozikard, Prestarium, Enalapril, Ramipril.

Beta blockers: Betalok-Zok, Egilok, Corvitol, Concor, Nebilet - slow down the heart rate, and it starts to work more economically. Long-term use improves its function.

Increase the amount of urine excreted, helping to get rid of excess fluid and sodium - Hypothiazid, Indapamide, Arifon, Furosemide, Diuver.

cardiac glycosides: slow down the heart rate, increase its contractility - Digoxin, etc.

First aid for heart failure

When providing first aid for heart failure, the following steps should be taken:

1. Urgently call an ambulance.

2. Body position - sitting with legs down (20% of the blood does not flow from the legs, which contributes to the unloading of the left ventricle).

3. Mandatory control of blood pressure. With high blood pressure 170-200 / 100-110 mm Hg. Art. it is urgent to take antihypertensive drugs: nifedipine 0.01-0.02 mg (chew) or clonidine 0.075 mg.

4. Take 1-2 tablets of furosemide (40-80 mg).

5. With satisfactory blood pressure (120-130 / 80 and above), it is necessary to take nitroglycerin (1 tablet under the tongue) or nitrospray. If it is ineffective, repeat the intake of nitroglycerin after 5-7 minutes.

However, it must be taken into account that there are other diseases that can begin with shortness of breath or suffocation: bronchial asthma, pneumonia, pulmonary embolism (thrombus in the pulmonary vessels), pneumothorax (air in the pleural cavity with chest injuries), effusion pleurisy (large the amount of fluid in the pleural cavity - up to 1 - 1.5 l). Only a doctor can clarify the diagnosis and provide adequate emergency care!

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Symptoms of chronic heart failure

Among the main signs of the disease are the following:

• shortness of breath, at first appears only during physical exertion, then it can disturb at rest;
• the patient begins to complain of severe fatigue, cannot fully perform the previous volumes of work, it is difficult for him to do physical work and sports;
• due to shortness of breath and poor tissue saturation with blood and oxygen, tachycardia is noted;
• the appearance of edema, which begins to move from bottom to top, first affecting the feet, and then moving to the abdominal region;
• the appearance of a cough, which at first has a dry nature, but gradually sputum begins to stand out, in severe cases with traces of blood;
• in a horizontal position, the patient constantly needs to maintain a certain shape, which provides for an elevated position of the head.

Attention! Symptoms of chronic heart failure do not manifest themselves with great intensity in the initial stages of the disease. This greatly complicates the diagnosis, and many patients already come to the doctor with serious disorders.

Treatment for chronic heart failure

As soon as the patient has been diagnosed, he must immediately begin treatment, which consists not only of prescribing drugs.

1. From the first day it is necessary to limit salt, consuming no more than 3 g per day. At the same time, the drinking regime provides for the consumption of 1-1.5 liters of clean water per day. In chronic heart failure, you should consume high-calorie, but easily digestible food. Any product should be rich in protein and vitamins.
2. Also be sure to weigh yourself daily. This will allow you to see how much fluid is retained in the body. If in 1-3 days the patient gains from 2 kg in weight, you should immediately contact a cardiologist. In the absence of therapy, the patient's condition may deteriorate sharply, hospitalization will be required.
3. Physical activity should be limited as much as possible. At the same time, for some patients, taking into account the cause of CHF, an individual plan of possible training can be selected. It usually includes walking, swimming and cycling. At the same time, it is strictly forbidden to lift the iron and perform exercises in a static form for a long time.
4. The apartment should maintain optimal humidity and air temperature. Trips to the highlands and even a short stay in places where there is not enough oxygen are necessarily excluded.
5. If you need a long flight or ride, you should do gymnastics every 30 minutes or just warm up by walking around the cabin.

ACE inhibitors in heart failure

Captopril

A traditional drug that is taken for any type of heart failure. Treatment should begin with the minimum permitted dose, which is 6.25 mg of the active ingredient. This amount of Captopril should be taken three times a day one hour after meals. Gradually, the dosage of the drug should be increased to 25-50 mg of the main component also three times a day. The amount of Captopril is influenced by the severity of chronic insufficiency and the tolerability of the drug.

Enalapril

Also the most commonly prescribed drug for heart problems. Enalapril is taken twice a day. At the first stages of therapy, a dose of 2.5 mg in the morning and evening should not be exceeded. To maintain cardiac function, the amount of enalapril is gradually adjusted to 10 mg in the morning and evening. With reduced kidney function, the drug should be adjusted.

Attention! These medicines are taken for a long time. The decision to cancel a particular medication or change the dose can only be made by a cardiologist.

Beta-blockers for CHF

Acebutolol

A drug that enhances the function of the heart muscle. Available in the form of capsules of 200 and 400 mg of the active substance, which can not be chewed and divided. Therapy with Acebutolol continues for a long time. The drug is taken once a day, it is advisable to do this in the morning to provide the necessary stimulation to the heart. Treatment begins with a dose of 200 mg, gradually it is required to bring it up to 1200 mg, which will ensure the good functioning of the whole organism. Take the drug before meals. Acebutolol is excreted almost completely through the liver, therefore, with its pathologies, the dose should be adjusted.

bisoprolol

A traditional drug used to treat chronic heart failure in many patients. The drug should be taken once before breakfast. The dosage, taking into account the complexity of the disease, can be from 2.5 to 10 mg of the active substance. Even in severe cases of chronic heart failure, the maximum dose of 10 mg should not be exceeded; it is also forbidden to divide it into several doses. Bisoprolol is excreted through the kidneys, which should be taken into account in case of problems with their work.

Attention! Beta-blockers should be taken at the same time as ACE inhibitors. This significantly enhances the effect of the two groups of drugs and allows you to achieve the maximum therapeutic effect.

Aldosterone receptor antagonists

Veroshpiron

The drug is available in the form of capsules. Veroshpiron is taken against the background of puffiness that has arisen due to the presence of chronic heart failure. With such a pathology, the patient is recommended to take 0.1-0.2 g of the active substance, which should be divided into three doses. At this dose, the medication is taken for five days, after which you should switch to maintenance treatment. In this case, the dose of Veroshpiron per day is usually 25 mg. It is strictly forbidden to exceed the amount of the main component of 200 mg.

aldactone

The drug is available in the form of tablets for oral use. In case of swelling due to heart failure, patients are recommended to take 100 mg of the active substance in the first five days of treatment, after which, taking into account the severity of the patient's condition, the specialist selects a maintenance dose. It can be equal to 25 or 200 mg of the active substance per day. The duration of therapy is selected individually.

Attention! Aldosterone receptor antagonists are taken in combination with loop or thiazide diuretics. This allows you to quickly achieve results and remove increased puffiness.

Cardiac glycosides in CHF

Digoxin

A medical product available in the form of tablets and injections. The specific form of Digoxin is selected taking into account the severity of the condition. When using a solution for intramuscular injection, the patient is given 0.75-1.25 mg of the active ingredient for 1-1.5 days. With more passive treatment, it is necessary to administer 0.5-0.75 mg of the active substance in 3 injections over several days, usually 3-5. Maintenance therapy is determined for each patient, taking into account the speed of removal of a serious condition and the response to the treatment provided.

When prescribing Digoxin in the form of tablets, you should drink the drug at a dose of 0.025 g up to 4 times a day. According to this scheme, the treatment lasts for 3 days. After that, it is necessary to switch to a maintenance dosage of 1-2 tablets per 24 hours. The duration of therapy is selected individually.

Video - Symptoms of heart failure

Novodigal

The drug is taken after a meal. The recommended dose is 0.02 g of the main component three times a day for two days. If necessary, the dosage can be adjusted to 0.3 mg of Novodigal daily for 4 days. To quickly relieve an attack of chronic heart failure, the patient should be given medication intravenously at a dosage of 2-4 ampoules for three days, after which the patient is transferred to tablets.

Attention! Medicinal preparations are herbal, which ensures good absorption of the active substance and a small number of side effects in patients.

The cost of medicines

Attention! The exact cost of the listed drugs should be found out from your doctor or pharmacist.

Folk remedies for CHF

A decoction of oats

To prepare a home remedy, you should take 100 ml of peeled oat grains, rinse them thoroughly and pour 500 ml of cold water. The mixture is brought to a boil and removed from the stove. After that, 1/3 of a glass of peeled and chopped elecampane roots must be added to the water, only fresh rhizomes are taken.

After thoroughly stirring the broth, it is again put on the stove and again brought to a boil. Infuse the medicine under a tight lid for three hours. The thick must be removed through cheesecloth and two tablespoons of natural honey are added to the broth. Use a decoction of oats should be 100 ml three times a day for 15-20 minutes before the main meal. The therapy lasts for 2 weeks.

hawthorn fruit

Such treatment not only significantly strengthens the heart muscle, but also eliminates pain and heaviness in the chest. To prepare the medicine, you should take 500 g of hawthorn fruits, it is important to ensure that they are ripe. Hawthorn washed and pour 1 liter of cold water.

The fruits are cooked from the moment of boiling for about 20 minutes in an enamel pan. After that, it is recommended to strain the broth through cheesecloth and add 2/3 cup of sugar and the same amount of natural honey to it. The components are brought to homogeneity and taken 30 ml daily 30 minutes before meals. The therapy lasts for 30 days. The decoction must be stored in a cold place.

Attention! When using folk remedies in the treatment of chronic heart failure, you should first clarify the safety of their use with a cardiologist.

As soon as the patient has the first signs of chronic heart failure, it is urgent to contact a cardiologist to confirm the diagnosis. Early diagnosis of weakened cardiac function significantly prolongs the life of the patient. At the same time, it is imperative to adhere to proper nutrition, give up bad habits and reduce physical activity.

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Diuretic (diuretic) drugs in the treatment of chronic heart failure

Fluid retention in the body and the formation of edematous syndrome is one of the most well-known manifestations of chronic heart failure. Therefore, dehydration therapy is one of the most important components of successful treatment of patients with chronic heart failure. However, it must be remembered that complex neurohormonal mechanisms are involved in the development of edematous syndrome, and thoughtless dehydration causes only side effects and rebound fluid retention. Excess fluid must first be transferred from the extracellular fluid to the vascular bed, delivered to the kidneys, filtered, and only then diuretics in the tubules should block its reabsorption. Only when these conditions are met will positive diuresis develop and dehydration begin.
Therefore, diuretics play the role of only one of the elements of dehydration treatment. Therefore, the use of diuretics should be strictly justified, be sure to be combined with the use of neurohormonal modulators, such as ACE inhibitors and aldosterone antagonists, as well as drugs that retain fluid in the vascular bed and improve renal blood flow and filtration.
The main provisions of dehydration therapy, including the use of diuretics, are as follows:

• Diuretics are used to eliminate edematous syndrome and improve the clinical symptoms of patients with chronic heart failure. Diuretics do not slow the progression of chronic heart failure and do not improve the prognosis of patients. Their impact on the quality of life if administered incorrectly (loading doses every 3-4-5-7 days) can even be negative.
• Treatment with diuretics begins only with clinical signs of stagnation (stage II A, II FC).
• Treatment with diuretics begins with the use of the drug, the weakest effective in this particular patient.
• Preference should be given to thiazide diuretics (hypothiazid) and only if they are not effective enough to proceed to the appointment of powerful "loop" diuretics (furosemide, uregit, bumetanide).
• Treatment should be started with small doses (especially in patients who have not previously received diuretic drugs), subsequently selecting a dose according to the principle of quantum satis.
• Recommended doses:

• Hypothiazide - starting - 25 mg, maximum - 75-100 mg
• Furosemide - starting -20-40 mg, maximum - up to 500 mg
• Uregita - starting - 25-50 mg, maximum - up to 250 mg
• Bumetanide - starting - 0.5-1.0 mg, maximum - up to 10 mg.

The two most powerful modern diuretics are loop torasemide (doses from 5-10 mg to 100-200 mg) and thiazide - metolazone (doses from 2.5 to 10 mg).
Thiazide diuretics (hypothiazide) disrupt sodium reabsorption in the cortical segment of the ascending loop of Henle and in the initial part of the distal tubules. They increase diuresis and natriuresis by 30-50%, are effective at filtration levels up to 30-50 ml/min. Therefore, in case of renal insufficiency, their use is useless.

• "Loop" diuretics (furosemide, uregit, bumetanide) are the most effective diuretics that block sodium reabsorption throughout the ascending part of the loop of Henle and remain active even with chronic renal failure and filtration<5 мл/мин. Иными словами, они эффективны даже при явлениях почечной недостаточности.
• These two classes of diuretics are used for dehydration in chronic heart failure; therapy has two phases - active and maintenance.
• In the active phase, the excess diuresis over the fluid taken should be 1-2 liters per day, with a decrease in weight daily by ~ 1 kg. No rapid dehydration can be justified and only leads to hyperactivation of neurohormones and rebound fluid retention in the body.
• In the maintenance phase, diuresis should be balanced and body weight stable with regular (daily) diuretic administration.
• The algorithm for prescribing diuretics, depending on the severity of chronic heart failure, is as follows:

I FC - do not treat with diuretics
II FC (without stagnation) - do not treat with diuretics
II FC (stagnation) - thiazide diuretics
III FC (decompensation) - loop (thiazide) + aldosterone antagonists, in high doses

• FC (maintenance) - thiazide (loop) + aldactone (small doses)
• Loop FC + thiazide (metolazone should be used if possible) + aldosterone antagonists + carbonic anhydrase inhibitors (diacarb 0.5 g 3 times / day for 2-3 days, every 3 weeks, to acidify the environment and increase sensitivity to active diuretics) .

Adhering to these principles, it is possible to successfully treat most patients with cardiac decompensation and edematous syndrome. However, in some cases, tolerance to dehydration treatment, in particular, to the use of diuretics, may develop.
Refractoriness is early (the so-called "inhibition of the effect") and late.
Early develops in the first hours or days after the start of the active prescription of diuretics, depends on the hyperactivation of neurohormones and the stronger, the more active dehydration (with profuse diuresis). Overcome by adequate (not excessive) diuresis plus mandatory co-administration of an ACE inhibitor and/or aldactone.
Late refractoriness, which develops after weeks of continuous diuretic therapy, is associated with hypertrophy of the apical tubular cells, where diuretics act. Dealing with this kind of refractoriness is more difficult. Requires periodic (every 3-4 weeks) change of active diuretics and in their combination with ACE inhibitors.
With refractory edematous syndrome, there are relatively simple techniques for overcoming resistance to the use of diuretics:

• The use of diuretics only against the background of ACE inhibitors and aldactone. This is the main condition for success.
• The introduction of large (twice as large as the previous ineffective dose) doses of diuretics only intravenously.
• The combination of diuretics with drugs that improve filtration. With AD sys. more than 100 mm Hg. Art. - aminofillin (10 ml of a 2.4% solution intravenously drip and immediately after the dropper - lasix) or cardiac glycosides, with lower blood pressure - dopamine (2-5 mcg / min).
• The use of diuretics with albumin or plasma.
• With hypotension - a combination with steroids.
• Combinations of diuretics according to the principles indicated above.
• The use of mechanical methods for removing fluid (pleural, pericardial puncture, paracentesis) is carried out only for vital indications.
• Isolated ultrafiltration is an effective way to treat drug-resistant edematous syndrome. Contraindications - valve stenosis, low cardiac output and hypotension. Unfortunately, these symptoms are present in most patients with refractory edema.

cardiac glycosides

Cardiac glycosides remain among the main treatments for chronic heart failure, although they are not at the top of this list. The drugs of this group do not improve the prognosis of patients with chronic heart failure and do not slow down the progression of the disease, but they improve clinical symptoms, quality of life, and reduce the need for hospitalization due to exacerbation of decompensation.
Glycosides have three main mechanisms of action - positive inotropic, negative chronotropic and neuromodulatory effects. Digoxin in patients with chronic heart failure should always be used in low doses: up to 0.25 mg / day (for patients weighing more than 85 kg up to 0.375 mg / day), when it acts mainly as a neurohormonal modulator, it has a weak positive inotropic effect and does not stimulate the development of cardiac arrhythmias.
With symptoms of renal failure, the daily dose of digoxin should be reduced in proportion to the decrease in creatinine clearance (in these cases, digitoxin may be used). In elderly patients, daily doses of digoxin should be reduced to 0.0625-0.0125 mg (¼ - ½ tablets).
In atrial fibrillation, digoxin can be used as a first-line agent due to its ability to slow atrioventricular conduction and reduce heart rate, and not because of a positive inotropic effect.
In sinus rhythm, digoxin is only the fourth drug after ACE inhibitors, β-blockers and diuretics. Its use requires caution, especially in patients with coronary pathology and angina pectoris.
Predictors of success in the treatment of glycosides in patients with chronic heart failure is low EF (<25%), большие размеры сердца (кардиоторакальный индекс >55%), non-ischemic etiology of heart failure. Beneficial is the combination of cardiac glycosides with β-blockers, in which the heart rate is better controlled, the risk of life-threatening ventricular arrhythmias is reduced, and the risk of exacerbation of coronary insufficiency is reduced.

Aldosterone antagonists (aldactone)

With exacerbation of decompensation phenomena, aldactone is used in high doses (150-300 mg or 6-12 tablets, administered once in the morning or in two doses - in the morning and at lunch) for a period of 2-3 weeks until compensation is achieved. After this, the dose of aldactone should be reduced. The criteria for the effectiveness of the use of aldactone in the complex treatment of persistent edematous syndrome are:

• an increase in diuresis within 20-25%, although this is not much, it is especially important for persistent, refractory edema;
• an indicator of the effectiveness of treatment is a decrease in thirst, dry mouth and the disappearance of a specific "liver" odor from the mouth;
• stable concentration of potassium and magnesium in plasma (no decrease), despite the achievement of positive diuresis.

In the future, for long-term treatment of chronic heart failure in patients with severe decompensation of III-IV FC, it is recommended to use small (25-50 mg) doses of aldactone in addition to ACE inhibitors and BAB in as a neurohumoral modulator that allows more complete blocking of the RAAS, improve the course and prognosis of patients with chronic heart failure.
Of the main adverse reactions of aldactone (except for possible hyperkalemia and an increase in creatinine levels), the development of gynecomastia (up to 10%), impotence (up to 2%), and menstrual irregularities in women (up to 2%) should be noted. This is due to the non-selectivity of the drug's action on aldosterone receptors. Despite this, aldactone rightfully occupies a place in the list of five main groups of drugs used to treat chronic heart failure.