Treatment of chronic heart failure. Chronic heart failure: you need to know the enemy by sight. Causes of chronic heart failure

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 physical exertion. 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. With the disease, weak heart tones are well heard, the heart rhythm is malfunctioning, noises and wheezing are heard in the lungs.

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, 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 work, poor nutrition, lack of vitamins, constant nervous tension.
• Taking certain medicines.

Acute heart failure: symptoms and treatment

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

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 violation of the work of the heart, as a result of which cardiac output worsens, pressure in the pulmonary circulation increases, weak blood microcirculation in tissues and stagnation are observed.

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 a critical condition of the patient, which can lead to cardiac arrest. If you suspect a syndrome, you should immediately call an ambulance with a cardioresuscitation 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 be fatal, 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, an emergency operation can be performed 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, fatigue, which is explained by a gradual decrease in blood flow in the skin and musculature of the skeleton. Even with small physical exertion on the body (long walks, 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 is a clear manifestation of the presence of heart failure, dystrophic changes are 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 contact 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 intermittently with 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 a minimal set of movements can cause an attack, any kind of load 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. The normal functioning of both systole and diastole is disturbed.

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 of the 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 include required amount protein, vitamins and minerals. The patient is also required to monitor his weight and perform dynamic loads on different muscle groups. 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 as part of 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 of valve defects - used for severe stenosis or insufficient number of valves.
3. Heart transplantation is a cardinal, but in some cases necessary 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 the skin, they are connected to the 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, 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. It is necessary to consult a doctor in time and succumb to medical treatment or surgical intervention.

In the absence of treatment, the prognosis for the patient is disappointing. Heart disease usually leads to complications and deterioration of this organ. With 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, a sufficient amount of sleep and time for walking in the fresh air.
• 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.

Chronic heart failure is a formidable pathology of the heart associated with the occurrence of problems with the nutrition of the organ due to its insufficient blood supply during exercise or at rest. This syndrome has a complex typical symptoms, so its diagnosis is usually not difficult. However, the main mechanism this violation is the inability of the body to pump blood due to damage to the heart muscle. As a result of insufficient blood circulation, not only the heart suffers, but also other organs and systems of the body that receive less oxygen and nutrients.

The reasons

CHF syndrome develops against the background of other pathologies of the cardiovascular system. In particular, it can develop due to:

• heart valve damage;
• myocardial damage;
• diseases of the pericardium;
• violations of the working rhythm of the heart.

Pathologies associated with myocardial injury include (with or without), persistent, endocrine diseases, including disruption thyroid gland and diseases of the adrenal glands, infiltrative diseases (,), as well as.

Diseases associated with cardiac arrhythmias include:

• heart block.

Also the reason for the development this syndrome, are congenital and acquired heart valve defects. As for the diseases of the pericardium that cause this syndrome, they include:

• dry and effusion pericarditis;
• constructive .

There are also predisposing factors that can lead to the development of this syndrome, these are:

• smoking;
• alcohol abuse;
• body aging;
• diseases bronchopulmonary system ( , ).

Classification

In medical practice, there is a certain CHF classification. In particular, the syndrome is classified according to functional classes (FC), and there can be 4 types (I, II, III and IV).

In chronic heart failure I FC, a person feels good during physical exertion, and the symptoms of the disease do not appear with it - only slight shortness of breath is noted. At the same time, the recovery period in a person with such a pathology is increased compared to healthy people.

With such a pathology as the syndrome of CHF II FC, the symptoms of the disease are absent at rest, but during exercise the person experiences shortness of breath, his heart rate increases and increased fatigue is noted.

With functional class III CHF, the symptoms of the pathology appear even with a slight load, despite the fact that they are absent at rest. People with this type of pathology require a noticeable restriction of physical activity.

Well, the last type is CHF IV FC. With this type of disease, a person cannot perform any physical work without showing symptoms. That is, the symptoms characteristic of the disease manifest themselves both during physical exertion and at rest.

There is also a classification of the disease by stages - they are distinguished by 4:

• 1 initial;
• 3 end.

Almost no in the first stage symptomatic manifestations, therefore insignificant functional disorders detected exclusively on ultrasound of the heart. At stage 2A, there are pronounced symptoms of impaired blood flow in the systemic and pulmonary circulation. Stage 2B is characterized by pronounced changes in the two circles of blood circulation, as well as the appearance of disorders in the work of the heart and blood vessels. At the 3rd final stage, irreversible changes in the structure of target organs (kidneys, heart, lungs, etc.) are noted.

Next classification this disease- This is a classification according to the area of ​​\u200b\u200bblood stagnation. There are the following types of such a disease as CHF syndrome:

• right ventricular;
• left ventricular;
• biventricular.

With right ventricular CHF, circulatory disturbance occurs mainly in the vessels of the lungs, that is, in the pulmonary circulation. With left ventricular - in the vessels of a large circle (all organs except the lungs), and with biventricular - stagnation of blood is observed in two circles of blood circulation.

And the last classification of this pathology is based on the phases of cardiac dysfunction. Depending on what violations occur in the process of the heart, there is systolic chronic heart failure, diastolic and mixed.

Symptoms

If we talk about the symptoms of chronic heart failure, then they depend on the severity of the pathology and the organs involved in the process. There are several main signs of this pathology, which include:

• violation of the depth and frequency of breathing (development of shortness of breath);
• increased fatigue under the influence of physical activity (and even at rest);
• increased heart rate;
• edema, developing first on the lower extremities, and then the edema spreads up the body, and reaches the hips, lower back, anterior abdominal wall;
• the appearance of a dry cough (with the development of the process, the cough becomes wet, with the release of mucous sputum).

one more severe symptom, which manifests CHF syndrome, is forced position the patient has orthopnea. In this case, a person can only lie in a position with a raised head, otherwise he has an increase in cough and shortness of breath.

Depending on what stage of the disease a person has, his complaints also differ. At the initial stage, patients usually complain of increased fatigue and sleep disturbance. With physical activity, they have an acceleration of the heartbeat and the appearance of shortness of breath. Sometimes there are swelling of the feet and legs after active physical activity (after a long labor day, after playing sports, etc.).

In the second stage, clinical manifestations intensify. Tachycardia and shortness of breath are observed with any type of physical activity, there is a manifestation of edema on the feet and legs, a decrease in the amount of urine excreted. On ultrasound, you can see an increase in the chambers of the heart, with visual inspection- unexpressed cyanosis of the lips, the tip of the nose and the tips of the fingers. A cough with sputum also appears - during auscultation, finely bubbling wet rales are determined in patients. Edema in the second stage is more pronounced, and affects not only the feet and legs, but also the hips of patients.

Stage 2A final is characterized by an even greater severity of the above symptoms - cyanosis increases significantly, it becomes increasingly difficult for the patient to breathe, a person can fall asleep only in a sitting position. In addition, edema increases with the development of and, and others also suffer. internal organs leading to symptoms such as:

• loss of appetite;
• diarrhea;
• a sharp decrease in body weight (cardiac cachexia);
• nausea and vomiting;
• increase in heart rate;
• weak filling of the pulse and others.

without timely and adequate treatment against the background of an increase in symptoms, it is noted high percent patient mortality.

Diagnostics

Chronic heart failure among all CVS pathologies is the most common cause of hospitalization, disability and mortality of patients. Therefore, a huge role in reducing these indicators is played by timely diagnosis of the disease, which is based on instrumental examinations, allowing to obtain objective data for making or confirming a diagnosis.

The main diagnostic criteria are the definition major changes in the heart and myocardial dysfunction.

Also, the diagnosis of CHF is carried out by conducting clinical studies (gas and electrolyte composition of the blood, indicators of proteins, creatinine, carbohydrates, urea, etc.). Electrocardiography makes it possible to detect ischemia and hypertrophy of the myocardium, as well as any arrhythmic changes.

X-ray examination is used in the diagnosis of this pathology in order to identify congestion in the lungs, and ventriculography allows you to evaluate contractility ventricles. Echocardiography makes it possible to establish the cause of the development of this syndrome in humans, as well as MRI.

Features of treatment

If we talk about the treatment of chronic heart failure, then its main goal is to slow down the progression of the pathology and alleviate the symptoms of the disease.

The main method is the drug treatment of chronic heart failure, which is prescribed for a long period with the regulation of the required dosage depending on the patient's health status.

Drugs that treat this syndrome include:

• diuretics, which allow to reduce the edema characteristic of this pathology and unload the organs in which stagnation is noted;
• ACE inhibitors, which reduce the level of pressure in the vessels of the bloodstream and protect those organs that are most affected by violations of the heart (kidneys, liver, heart, brain);
• beta-blockers that reduce heart rate and overall vascular resistance, which allows blood to flow freely through the circulatory system;
• anticoagulants that thin the blood, and antiplatelet agents - drugs that prevent the formation of blood clots;
• cardiac glycosides that increase myocardial contractility and reduce heart rate;
• nitrates, which have a relaxing effect on the veins and reduce blood flow to the heart;
• calcium channel antagonists, which also act on blood vessels and relax them, which helps to reduce the strength of heart contractions and reduce blood pressure in the vessels.

Very often doctors combine various drugs to obtain the optimal effect of therapy. The combination depends on the stage of the disease and the nature of its course, and is selected individually for each specific patient.

The importance in the treatment of such a pathology as CHF syndrome is the normalization of the physical activity regimen and adherence to a certain diet. In particular, the norms of physical activity for a patient with different functional categories of CHF will be different, but the diet is the same for everyone and involves the exclusion of products such as:

• alcohol;
• strong tea;
• strong coffee.

Food is recommended to be consumed in small portions 5-6 times a day (no later than 19 hours). In addition, food should be high-calorie, but easy to digest and contain a minimum amount of salt. At any stage of the pathology, it is allowed to take 1 liter of pure water, while reducing the amount of incoming salt. Restricting salt, rather than changing the amount of fluid, reduces swelling, which is the main symptom of CHF.

In some cases, when the symptoms of the disease are pronounced or drug treatment does not have the desired effect, surgical intervention is indicated, which consists in the surgical correction of the initial pathology that caused CHF. These operations include coronary artery bypass grafting, surgical correction valves, heart transplantation and others.

Complications

This syndrome is extremely severe pathology which leads to multiple complications. Among the most common should be noted:

• cardiac arrest;
• development and;
• development ;
• complete depletion of the body.

Prevention

There are primary and secondary prevention pathological condition like chronic heart failure. The primary one helps prevent the development of cardiac pathologies, which subsequently lead to CHF, and the secondary one makes it possible to prevent the progression of already existing chronic insufficiency.

Primary preventive measures are:

• to give up smoking;
• refusal to take alcohol;
• normalized physical. activity;
• proper nutrition, etc.

Secondary prevention consists in the treatment of existing CVS pathologies and in strict observance all doctor's recommendations regarding the treatment of chronic heart failure.

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; certain successes in the treatment of acute and chronic forms of coronary artery disease, AD, which contributed to the chronicity of these diseases, increasing 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 the cardiovascular system, the response of an 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 the work of the myocardium 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 severe. 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;
• severe adverse reactions in the elderly are more likely to occur with the use of 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 a simple way to take them 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 out for possible side effects.

Myocardial damage in the elderly is observed 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 hydrophilicity of tissues, a decrease in the colloid osmotic pressure of 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. Keep in mind the frequent development adverse reactions with medical 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 regard.

With the development kidney 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.

The reduction in the volume of intracellular fluid due to the intake of diuretics can lead to hyperglycemia, increased blood viscosity, and impaired microcirculation. 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 with sinus rhythm 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 an ACE inhibitor to the elderly, it is required to exclude previous renal pathology (diffuse glomerulonephritis, pyelonephritis) in the stage of CRF, 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.

The symptoms of which will be described below, is a pathology, the manifestations of which are associated with impaired blood supply. The condition is noted at rest and during exercise and is accompanied by fluid retention in the body. Treatment is mostly medical and complex. Timely access to a doctor contributes to a more rapid restoration of blood supply and the elimination of pathology. Next, let's take a closer look at what CHF is. Classification of the disease, signs and therapeutic measures will also be described in the article.

General information

CHF, the classification of which is quite extensive, is based on a decrease in the ability of the organ that pumps blood to empty or fill. This condition is primarily due to muscle damage. Equally important is the imbalance of systems that affect cardiovascular activity.

Clinical picture

How does chronic heart failure manifest itself? Symptoms of pathology are as follows:

• Shortness of breath - shallow and rapid breathing.
• Increased fatigue - a decrease in the tolerance of normal physical exertion.
• As a rule, they appear on the legs and feet, over time they rise higher, spreading to the thighs, the anterior wall of the peritoneum, the lower back, and so on.
• Cardiopalmus
• Cough. At the initial stages, it is dry, then scanty sputum begins to stand out. Subsequently, blood inclusions may be detected in it.
• The patient has a need to lie with his head elevated (on pillows, for example). In a flat horizontal position, shortness of breath and cough begin to increase.

Forms of pathology

Despite the implementation of therapeutic measures, the patient's condition may worsen. In this case, a more thorough diagnosis of the heart and circulatory system is necessary. Deep research will reveal hidden provoking factors. The following stages of CHF are distinguished:

• First (initial). At this stage of CHF, there are no circulatory disorders. Echocardiography reveals latent dysfunction in the left ventricle.
• The second A (clinically expressed). The condition is characterized by impaired hemodynamics (blood flow) of one of the circles.
• Second B (heavy). This stage is characterized by a violation of hemodynamics in both circles. Damage to the structure of the organ and blood channels is also noted.
• Second (final). The condition is accompanied by hemodynamic disturbances of a pronounced nature. Severe, often irreversible changes in the structure of target organs are also characteristic of this form of CHF.

Classification of pathology can also be carried out in accordance with the functional type. There are four in total.

Function types

As in the previous division, changes can be both in the direction of improvement and deterioration even against the background of ongoing therapeutic measures in case of detected CHF. The classification according to functional types is as follows:

• The first type is characterized by the absence of restriction of physical activity. The patient can endure the usual physical activity of the body without showing signs of pathology. Slow recovery or shortness of breath may occur with overexertion.
• The second type is characterized by limited activity to an insignificant degree. Pathology does not manifest itself in any way at rest. The usual, habitual physical activity of the body is tolerated by patients with shortness of breath, increased fatigue or increased rhythm. At this stage, cardiac diagnostics is highly recommended.
• In the third type, there is a more noticeable limitation of activity. Unpleasant sensations in the patient at rest are absent. Less intense than usual physical activity is accompanied by the manifestation of signs of pathology.
• In the fourth type, any activity of the patient is accompanied by the appearance of unpleasant sensations. Signs of pathology are noted in the patient at rest, intensifying with little physical exertion.

Areas of blood stasis

Depending on the predominant localization of the disorder, the patient may have:

• In this case, stagnation is noted in a small circle - the pulmonary blood channels.
• In this case, stagnation is localized in a large circle - in the blood channels of all organs, excluding the lungs.
• Biventricular (biventricular) insufficiency. Stagnation of blood in this case is observed in two circles at once.

Phases

Treatment of cardiovascular diseases is selected in accordance with the clinical picture. Manifestations of pathologies depend on the localization of disorders and provoking factors. Of no small importance in the selection of therapy is the history of the disease. CHF may be associated with impaired diastole and/or systole. In accordance with this, several phases of pathology are distinguished. In particular, there is:

• Systolic heart failure. It is associated with a disorder of systole - the time of contraction of the ventricles.
• diastolic insufficiency. This phase is caused by a violation of diastole - the time of relaxation of the ventricles.
• mixed form. In this case, there are violations of diastole and systole.

The reasons

When choosing a therapeutic method to eliminate CHF, degrees, phases and forms are of great importance. However, it is also important to identify the causes of the development of pathology. Chronic heart failure may result from:

• Myocardial infarction. In this condition, the death of part of the heart muscle occurs, which is associated with the cessation of blood flow to it.
• IHD in the absence of a heart attack.
• Arterial hypertension - persistent increase in pressure.
• Taking medications. In particular, pathology can develop as a result of the use of anticancer drugs and medications to restore the rhythm.
• Cardiomyopathy - lesions of the heart muscle in the absence of pathologies of the organ's own arteries and lesions of its valves, as well as arterial hypertension.
• Diabetes.
• Thyroid lesions.
• Adrenal dysfunction.
• Obesity.
• Cachexia.
• Lack of a number of trace elements and vitamins.
• Amyloidosis.
• Sarcoidosis.
• HIV infections.
• Terminal kidney failure.
• Atrial fibrillation.
• Heart block.
• Exudative and dry pericarditis.
• Congenital and acquired heart defects.

Identification of pathology

The diagnosis of "CHF" is made on the basis of an analysis of complaints and anamnesis. In a conversation with a doctor, the patient should be told when the signs of pathology appeared and what the patient associates them with. It also turns out what ailments the person and his relatives had. The specialist needs to know about all medications taken by the patient. On physical examination, skin color and swelling are assessed. When listening to the heart, it is determined whether murmurs are present. The presence of stagnation in the lungs is also detected. As obligatory researches the analysis of urine and blood is appointed. Studies can detect comorbidities that may affect the course of CHF. Treatment in this case will be comprehensive, aimed at eliminating background ailments. A biochemical blood test is also prescribed. The results determine the concentration of cholesterol and its fraction, urea, creatinine, sugar, potassium. Testing for thyroid hormones. The specialist may prescribe an immunological study. During it, the level of antibodies to heart tissue and microorganisms is determined.

Research using equipment

An ECG allows you to assess the rhythm of heartbeats, determine rhythm disturbances, the size of the organ, and also identify cicatricial changes in the ventricles. A phonocardiogram is used for noise analysis. With its help, the presence of systolic or diastolic murmur is determined in the projection of the valves. Plain radiography of the sternum is used to assess the structure of the lungs and heart. This study also allows you to determine the size and volume of the departments of the organ that pumps blood, to determine the presence of congestion. Echocardiography is used to study all parts of the heart. During the procedure, the thickness of the walls of departments and valves is determined. Also, with the help of echocardiography, it is possible to determine how pronounced the increase in pressure in the pulmonary vessels is. Analysis of the movement of blood is carried out during the Doppler echocardiography. The doctor may prescribe other studies in addition to those described.

First of all, the patient is prescribed a special diet. In the diet, the amount of table salt is limited to three grams and liquids up to 1-1.2 liters per day. Products should be easy to digest, be high in calories, contain vitamins and protein in the required amount. The patient should be weighed regularly. Weight gain of more than 2 kg within 1-3 days usually indicates fluid retention and decompensated CHF. Treatment may include psychological help. It aims to speed up the recovery of the patient. Psychological assistance can also be provided to relatives of the patient. For patients, it is undesirable to refuse loads completely. The level of activity for each patient is determined individually. Preference should be given to dynamic loads.

Basic drug therapy

Drugs for heart failure are divided into groups: basic, additional and auxiliary. The first one includes:

• ACE inhibitors. They help slow down the progression of pathology, protect the heart, kidneys, blood vessels, and control blood pressure.
• Angiotensin receptor antagonists. These drugs are recommended for intolerance to ACE inhibitors or together with them in combination.
• Beta-blockers (drugs "Concor", "Anaprilin" and others). These funds provide control over pressure and frequency of contractions, have an antiarrhythmic effect. Beta-blockers are prescribed together with ACE inhibitors.
• Diuretics (preparations "Amiloride", "Furosemide" and others). These funds help to eliminate excess fluid and salt from the body.
• cardiac glycosides. These drugs are prescribed mainly in small doses for atrial fibrillation.

Additional funds

• Satins are prescribed if the cause of CHF is IHD.
• Anticoagulants of indirect action. The drugs of this group are prescribed with a high probability of thromboembolism and with atrial fibrillation.

Auxiliary medicines

These funds are prescribed in special cases, with severe complications. These include:

• Nitrates. These drugs improve blood flow and dilate blood vessels. Medicines of this group are prescribed for angina pectoris.
• calcium antagonists. These medicines are indicated for persistent angina pectoris, arterial hypertension (persistent), increased pressure in the pulmonary blood channels, and pronounced valve insufficiency.
• Antiarrhythmic drugs.
• Disaggregants. These drugs have the ability to impair clotting by preventing platelets from sticking together. Medicines of this group are indicated for secondary
• Inotropic non-glycoside stimulants. These funds are used for a pronounced decrease in blood pressure and heart strength.

Surgical methods

In the absence of the effectiveness of drug exposure, surgical, mechanical intervention is used. In particular, the patient may be prescribed:

• performed with severe atherosclerotic vascular damage.
• Surgical correction of valve defects. Intervention is carried out in case of severe stenosis (narrowing) or valve insufficiency.
• Organ transplant. A heart transplant is quite a radical measure. Its implementation is associated with a number of difficulties:

  Probable rejection;
  - insufficient number of donor organs;
  - damage to the blood channels of the transplanted organ, which is poorly amenable to therapy.

• The use of artificial devices that provide auxiliary blood circulation. They are injected directly into the patient's body. Through the skin surface, they are connected to batteries located on the patient's belt. However, the use of devices is also accompanied by problems. In particular, infectious complications, thromboembolism and thrombosis are likely. Prevents a more extensive use of devices and their high cost.
• The use of an elastic mesh frame. They envelop the heart with dilated cardiomyopathy. This measure allows you to slow down the increase in the size of the body, increase the effectiveness of drug exposure, improve the patient's condition.

Chronic heart failure(CHF) - a cardially caused violation of the (pumping) function with the corresponding symptoms, which consists in the inability of the circulatory system to deliver the amount of blood necessary for their normal functioning to organs and tissues.
Thus, this is a disproportion between the state of blood circulation and the metabolism of substances, which increases with an increase in the activity of vital processes; pathophysiological condition in which dysfunction of the heart does not allow it to maintain the level of blood circulation necessary for metabolism in tissues.
From the modern clinical point of view, CHF is a disease with a complex of characteristic symptoms (shortness of breath, fatigue and decreased physical activity, edema, etc.), which are associated with inadequate perfusion of organs and tissues at rest or during exercise and often with fluid retention in the body.

The root cause is a deterioration in the ability of the heart to fill or empty, due to damage to the myocardium, as well as an imbalance in the vasoconstrictor and vasodilating neurohumoral systems. It would seem a trifle: before the syndrome, now the disease.
It would be hard to imagine if there were no data that CHF is clearly associated with the gender of specific genes, and this already “pulls” for nosology.

Chronic heart failure is characterized by recurrent episodes of exacerbation (decompensation), manifested by a sudden or, more often, a gradual increase in symptoms and signs of CHF.

Epidemiology. The prevalence of clinically pronounced CHF in the population is at least 1.8-2.0%.
Among people over 65 years of age, the incidence of CHF increases to 6-10%, and decompensation becomes the most common cause of hospitalization of elderly patients.
The number of patients with asymptomatic LV dysfunction is at least 4 times higher than the number of patients with clinically severe CHF.
In 15 years, the number of hospitalizations diagnosed with CHF has tripled, and in 40 years it has increased 6 times.
Five-year survival of patients with CHF is still below 50%. The risk of sudden death is 5 times higher than in the general population.
In the United States, there are more than 2.5 million patients with CHF, about 200 thousand patients die annually, the 5-year survival rate after the onset of signs of CHF is 50%.

The reasons. CHF can develop against the background of almost any disease of the cardiovascular system, however, the main three are the following supra-nosological forms: coronary artery disease, arterial hypertension and heart defects.

ischemic heart disease. From the existing classification, acute myocardial infarction (AMI) and ischemic cardiomyopathy (ICMP is a nosological unit introduced into clinical practice by ICD-10) most often lead to the development of CHF.

The mechanisms of occurrence and progression of CHF due to AMI are due to a change in the geometry and local contractility of the myocardium, called the term "left ventricular (LV) remodeling", with ICMP there is a decrease in total myocardial contractility, called the term "hibernation ("hibernation") of the myocardium".

Arterial hypertension. Regardless of the etiology of hypertension, there is a structural restructuring of the myocardium, which has a specific name - "hypertensive heart". The mechanism of CHF in this case is due to the development of LV diastolic dysfunction.

Heart defects. Until now, Russia has been characterized by the development of CHF due to acquired and uncorrected rheumatic malformations.

A few words must be said about dilated cardiomyopathy (DCM) as a cause of CHF.
DCM is a rare disease of unspecified etiology that develops at a relatively young age and quickly leads to cardiac decompensation.

Establishing the cause of CHF is necessary for the choice of treatment tactics for each individual patient.
The fundamental "novelty" of modern ideas about the pathogenesis of CHF is associated with the fact that not all patients have symptoms of decompensation as a result of a decrease in the pumping (propulsive) ability of the heart.
Important factors in the development and progression of CHF are a decrease in cardiac output (in most patients), sodium retention and excess fluid in the body.

From the point of view of modern theory, the main role in the activation of compensatory mechanisms (tachycardia, Frank-Starling mechanism, constriction of peripheral vessels) is played by hyperactivation of local or tissue neurohormones. Basically, these are the sympathetic-adrenal system (SAS) and its effectors - norepinephrine and adrenaline and the renin-angiotensin-aldosterone system (RAAS) and its effectors - angiotensin II (A-11) and aldosterone, as well as the system of natriuretic factors.

The problem is that the “launched” mechanism of neurohormone hyperactivation is an irreversible physiological process.
Over time, short-term compensatory activation of tissue neurohormonal systems turns into its opposite - chronic hyperactivation.
The latter is accompanied by the development and progression of systolic and diastolic LV dysfunction (remodeling). If the heart is damaged, the stroke volume of the ventricle will decrease, and the end-diastolic volume and pressure in this chamber will increase.
This increases the end-diastolic stretch of the muscle fibers, which leads to greater systolic shortening (Starling's law).
The Sterling mechanism helps maintain CO, but the resulting chronic rise in diastolic pressure will be transmitted to the atria, pulmonary veins, or systemic veins. Increasing capillary pressure is accompanied by fluid extravasation with the development of edema. Reduced CO, especially with a decrease in blood pressure, activates the SAS, simulating myocardial contractions, heart rate, venous tone, and a decrease in kidney perfusion leads to a decrease in glomerular filtration rate, reabsorption of water and sodium chloride, and activation of the RAAS.
Tissue hypoxia in CHF is not only the resulting link in pathogenesis, but also a factor that has a direct provoking effect on the rest of its leading components - a decrease in the pumping capacity of the heart, preload, afterload and heart rhythm. Hypoxia is a complex multi-component, multi-stage process. The direct primary effects of hypoxia are directed at targets localized at various levels: organismal, systemic, cellular, and subcellular. At the subcellular level, hypoxia initiates the development of apoptosis [Boitsov S.A. 1995].

The result of the described processes is an increase in peripheral vascular resistance and BCC with a corresponding increase in afterload and preload.

CHF classification.

The functional classification of the New York Heart Association is the most convenient and meets the requirements of practice, assuming the allocation of four functional classes according to the ability of patients to endure physical activity.
This classification is recommended for use by WHO.

The principle underlying it is an assessment of the patient's physical (functional) capabilities, which can be identified by a doctor with a targeted, thorough and accurate history taking, without the use of complex diagnostic techniques.

Four functional classes are allocated (FC) CHF.
I FC. The patient does not experience restrictions in physical activity. Ordinary exercise does not cause weakness (lightheadedness), palpitations, shortness of breath, or anginal pain.
II FC. Moderate limitation of physical activity. The patient feels comfortable at rest, but the performance of ordinary physical activity causes weakness (lightheadedness), palpitations, shortness of breath, or anginal pain.
III FC. Severe limitation of physical activity. The patient feels comfortable only at rest, but less than usual physical activity leads to the development of weakness (lightheadedness), palpitations, shortness of breath or anginal pain.
IV FC. Inability to perform any load without discomfort. Symptoms of heart failure or angina syndrome may occur at rest. When performing a minimum load, discomfort increases.

The easiest way to determine the FC in patients is by the distance of a 6-minute walk.
This method has been widely used in the last 4-5 years in the USA, including in clinical trials.
The condition of patients who are able to overcome from 426 to 550 m in 6 minutes corresponds to mild CHF; from 150 to 425 m - medium, and those who are not able to overcome even 150 m - severe decompensation.

Thus, the functional classification of CHF reflects the ability of patients to perform physical activity and outlines the degree of changes in the functional reserves of the body.
This is especially significant in assessing the dynamics of the patients' condition.

Clinical manifestations. Most patients develop primary left heart failure. The most common complaint is inspiratory dyspnea, initially associated with exercise and progressing to orthopnea, paroxysmal postural, to dyspnea at rest. Characterized by complaints of unproductive cough, nocturia. Patients with CHF note weakness, fatigue, which are the result of reduced blood supply to the skeletal muscles and the central nervous system.

With right ventricular failure, there are complaints of pain in the right hypochondrium due to stagnation in the liver, loss of appetite, nausea due to intestinal edema or reduced gastrointestinal perfusion, and peripheral edema.

On examination, it can be noted that some patients, even with severe CHF, look good at rest, while others have shortness of breath when talking or with minimal activity; patients with a long and severe course look cachexic, cyanotic.
In some patients, tachycardia, arterial hypotension, a drop in pulse pressure, cold extremities, and sweating (signs of SAS activation) are found.
Examination of the heart reveals a cardiac impulse, an extended or elevating apical impulse (ventricular dilatation or hypertrophy), a weakening of the I tone, a protodiastolic gallop rhythm.

With left ventricular failure, hard breathing, dry rales (congestive bronchitis), crepitus in the basal sections of the lungs are heard, dullness in the basal sections (hydrothorax) can be determined. With right ventricular heart failure, swollen jugular veins, liver enlargement are detected; slight pressure on it can increase the swelling of the jugular veins - a positive hepatojugular reflex.
Ascites and anasarca appear in some patients.

Diagnosis of CHF.
stopping the diagnosis of CHF is possible in the presence of 2 key criteria:
1) characteristic symptoms of heart failure (mainly shortness of breath, fatigue and limitation of physical activity, swelling of the ankles);
2) objective evidence that these symptoms are related to damage to the heart and not to any other organs (eg, lung disease, anemia, kidney failure).

It should be emphasized that CHF symptoms may be present at rest and/or during exercise.
At the same time, objective signs of cardiac dysfunction must be detected at rest.
This is due to the fact that the appearance of such a sign (for example, low LV EF) during exercise (for example, in a patient with coronary artery disease) may not be a sign of HF, but of coronary insufficiency.
By analogy with LV EF, this also applies to other objective signs of myocardial damage.

In doubtful cases, the diagnosis of HF can be confirmed by a positive response to therapy, in particular, to the use of diuretics.

A standard diagnostic set of laboratory tests in a patient with HF should include determination of hemoglobin, red blood cell, white blood cell, and platelet counts, plasma electrolytes, creatinine, glucose, liver enzymes, and urinalysis.
Also, as necessary, it is possible to determine the level of C-reactive protein (exclusion of inflammatory etiology of heart disease), thyroid-stimulating hormone (exclusion of hyper- or hypothyroidism), urea and plasma uric acid. With a sharp deterioration in the patient's condition, it is advisable to assess the content of cardiospecific enzymes in order to exclude acute MI.

Anemia refers to a factor that aggravates the course of CHF. Elevated hematocrit may indicate a pulmonary origin of dyspnea, as well as be a consequence of cyanotic heart defects or pulmonary arteriovenous fistula.

An increase in the level of creatinine in a patient with CHF can be:
associated with primary pathology of the kidneys;
a consequence of a concomitant disease or condition (hypertension, diabetes, advanced age);
a consequence of heart failure (renal hypoperfusion, congestive kidney);
associated with excessive intake of diuretics and / or iALF.

With stagnation of blood in the liver, an increase in the activity of liver enzymes can be observed.
Urinalysis is appropriate to detect proteinuria and glucosuria, which will allow us to conclude that there may be an independent primary renal pathology or DM - conditions that provoke the development or aggravate the course of HF.

Hyponatremia and signs of renal dysfunction in HF indicate a poor prognosis.

Echocardiography. This is an imaging technique, which is given a paramount role in the diagnosis of CHF due to its ease of implementation, safety and ubiquity.
Echocardiography allows solving the main diagnostic problem - to clarify the very fact of dysfunction and its nature, as well as to conduct a dynamic assessment of the state of the heart and hemodynamics.

The most important hemodynamic parameter is the LV EF, which reflects the contractility of the LV myocardium.
It is better to determine the normal level of LV EF for each laboratory.
This is due to the population characteristics of the population, equipment, counting methods, etc.
In the literature, "normal" levels range from EF > 50% (MONICA, V-HeFT-I) to > 35% (SOLVD).

As an “average” indicator, we can recommend a “normal” LV EF > 45%, calculated by the 2-dimensional echocardiography no Simpson.
Methods for assessing the severity of CHF. Assessment of the severity of the patient's condition and especially the effectiveness of the treatment is an urgent task for every practitioner.
From this point of view, a single universal criterion for the condition of a patient with CHF is needed.
It is the dynamics of FC during treatment that allows us to objectively decide whether our therapeutic measures are correct and successful.

The conducted studies have also proved the fact that the definition of FC to a certain extent predetermines and possible forecast diseases. The use of a simple and affordable 6-minute corridor walk test makes it possible to quantitatively measure the severity and dynamics of the state of a patient with CHF during treatment and his tolerance to physical activity.
In addition to the dynamics of FC and exercise tolerance, to monitor the condition of patients with CHF, an assessment of the patient's clinical condition (severity of dyspnea, diuresis, changes in body weight, degree of congestion, etc.) is used; dynamics of LV EF (in most cases according to the results of echocardiography); assessment of the quality of life of the patient, measured in points using special questionnaires, the most famous of which is the questionnaire of the University of Minnesota, designed specifically for patients with CHF.

Forecast. The annual mortality rate in patients with CHF of functional class I according to the classification of the New York Heart Association (FC NYHA) is about 10%, with II FC - 20%, with III FC - 40%, with IV FC - more than 60%. Despite the introduction of new methods of therapy, the mortality rate of patients with CHF does not decrease.

Treatment of CHF.
The goals of CHF treatment are to eliminate or minimize the clinical symptoms of CHF - fatigue, palpitations, shortness of breath, edema; protection of target organs - blood vessels, heart, kidneys, brain (similar to hypertension therapy), as well as prevention of the development of malnutrition of striated muscles; improving the quality of life, increasing life expectancy reducing the number of hospitalizations.
There are non-pharmacological and medical methods treatment.

Non-drug methods
Diet. Main principle- restriction of salt intake and, to a lesser extent, fluids.
At any stage of CHF, the patient should take at least 750 ml of fluid per day.
Restrictions on salt intake for patients with CHF 1 FC - less than 3 g per day, for patients with II-III FC - 1.2-1.8 g per day, for IV FC - less than 1 g per day.

Physical rehabilitation. Options - walking or exercise bike for 20-30 minutes a day up to five times a week with the implementation of self-monitoring of well-being, heart rate (load is considered effective when 75-80% of the patient's maximum heart rate is reached).

Medical treatment of CHF.
The entire list of drugs used to treat CHF is divided into three groups: main, additional, auxiliary.

The main group of drugs fully complies with the criteria of "medicine of evidence" and is recommended for use in all countries of the world: ACE inhibitors, diuretics, SG, b-blockers (in addition to ACE inhibitors).

An additional group, the efficacy and safety of which has been proven by large studies, but requires clarification (meta-analysis): aldosterone antagonists, A-H receptor antagonists, CCBs latest generation.

Auxiliary drugs: their use is dictated by certain clinical situations. These include peripheral vasodilators, antiarrhythmics, antiplatelet agents, direct anticoagulants, non-glycoside positive inotropic agents, corticosteroids, and statins.

Despite the large selection of drugs in the treatment of patients, polypharmacy (unjustified prescription of a large number of groups of drugs) is unacceptable.

At the same time, today, at the level of the polyclinic link, the main group of drugs for the treatment of CHF does not always occupy a leading position, sometimes preference is given to drugs of the second and third groups.

Below is a description of the drugs of the main group.

ACE inhibitors. In Russia, the efficacy and safety of the following ACE inhibitors in the treatment of CHF has been fully proven: captopril, enalapril, ramipril, fosinopril, trandolapril.
The appointment of an ACE inhibitor is indicated for all patients with CHF, regardless of the stage, functional class, etiology and nature of the process.
Non-appointment of ACE inhibitors leads to an increase in mortality in patients with CHF. The earliest appointment of ACE inhibitors, already in FC I CHF, can slow down the progression of CHF.
ACE inhibitors can be prescribed to patients with CHF at blood pressure levels above 85 mm Hg. Art.
With an initially low blood pressure (85-100 mm Hg), the effectiveness of ACE inhibitors is preserved, so they should always be prescribed, reducing the starting dose by half (for all ACE inhibitors).

Arterial hypotension may occur immediately after the start of ACE inhibitor therapy due to the rapid effect on circulating neurohormones.
With therapy in titrating doses, this effect either does not occur or decreases at most by the end of the second week of therapy.
And the long-term effect of ACE inhibitors is realized through the blockade of tissue neurohormones.
Minimization of arterial hypotension is achieved by refusing the simultaneous appointment of ACE inhibitors and vasodilators of b-blockers, CCBs, nitrates), after stabilization of the level of blood pressure, if necessary, you can return to the previous therapy; refusal of previous active diuretic therapy, especially the day before, in order to avoid the potentiating effect of drugs.

In patients with initial hypotension, short-term use of small doses is possible. steroid hormones- 10-15 mg / day, however, if the initial systolic blood pressure (BP) is less than 85 mm Hg. Art., ACE inhibitor therapy is not indicated.

The start of therapy with any ACE inhibitor should begin with the minimum (starting) doses, which are discussed below.
Possible adverse reactions, in addition to arterial hypotension, when prescribing an ACE inhibitor (in the amount of not more than 7-9% of the reasons for withdrawal) are: dry cough, an increase in the degree of CRF in the form of azotemia, hyperkalemia.
Dry cough, which occurs in about 3% of cases, is due to the blockade of the destruction of bradykinin in the bronchi.
The possibility of prescribing ACE inhibitors in the presence of chronic bronchitis or bronchial asthma, while the degree of cough does not increase.
Fosinopril has the least risk of this side effect.

With a decrease glomerular filtration below 60 ml / min, the doses of all ACE inhibitors should be halved, and with a decrease below 30 ml / min, by 3/4. The same applies to the treatment of elderly patients with CHF, in which renal function is usually impaired.

An exception is fosinopril, the dose of which does not need to be adjusted in renal insufficiency and in elderly patients, since it has two routes of excretion from the body - the kidneys and the gastrointestinal tract.
Spirapril also has a balanced dual route of excretion from the body, which also makes it possible to recommend it to patients with renal insufficiency.

Basic principles of dosing ACE inhibitors. There is a concept of starting and maximum (target) doses for each specific drug. Doubling the dose of the drug is made no more than 1 time per week (titration), provided wellness patient, the absence of adverse reactions, as well as the level of blood pressure at least 90 mm Hg. Art.
Antagonists of AN receptors (candesartan) - can be used along with ACE inhibitors as a first-line agent for blockade of the RAAS in patients with clinically severe decompensation.
Do not lose their effectiveness in women (unlike ACE inhibitors).
At the same time, a preventive effect in preventing symptomatic CHF has not been proven, and there is no effectiveness in CHF with preserved LV systolic function, when the effectiveness of ACE inhibitors is preserved.
The ability to prevent the development of CHF in patients with diabetic nephropathy proven for another representative of the class of angiotensin II receptor antagonists (ArATP) - losartan.

Aldosterone antagonists(spironolactone) has been successfully used in complex diuretic therapy for severe CHF as a potassium-sparing diuretic since the mid-1960s.
The indication for such use of the drug is the presence of decompensated CHF, hyperhydration and the need for treatment with active diuretics. It is as a reliable partner of thiazide and loop diuretics that the appointment of spironolactone should be considered.
During the period of achieving compensation (especially in patients with CHF III-IV FC), the use of spironolactone is absolutely necessary and you can not be afraid of combining its high doses with ACE inhibitors or ArATP if active diuretics are used correctly in parallel and positive diuresis is achieved.
However, once compensation has been achieved, high-dose spironactone should be discontinued and consideration should be given to long-term appointment low doses of the drug as an additional neurohormonal modulator.
Only the combination of high doses of spironolactone and high doses of ACE inhibitors is not recommended for long-term treatment of CHF. To achieve a state of compensation during exacerbation of CHF and hyperhydration, such a combination, as mentioned above, is indicated, but requires careful monitoring of potassium and creatinine levels.
With exacerbation of decompensation phenomena, spironolactone is used in high doses (100-300 mg, or 4-12 tablets, administered once in the morning or in two doses in the morning and afternoon) for a period of 1-3 weeks until compensation is achieved.
After this, the dose should be reduced.
Criteria for the effectiveness of the use of spironolactone in complex treatment persistent edematous syndrome are: increased diuresis within 20-25%; reduction of 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 patients with severe decompensation of III-IV FC, it is recommended to use small (25-50 mg) doses of spironolactone in addition to ACE inhibitors and β-blockers as a neurohumoral modulator, which allows more complete blocking of the RAAS, improve the course and prognosis of patients with CHF.
The concentration of spironolactone in the blood plasma reaches a plateau by the third day of treatment, and after discontinuation (or a decrease in the dose of the drug), its concentration and effect disappear (decrease) after three days.
Of the based adverse reactions of spironolactone (except for possible hyperkalemia and an increase in creatinine levels), the development of gynecomastia (up to 10% of patients) should be noted.
In the presence of advanced level serum creatinine (> 130 μmol / l), a history of renal failure, hyperkalemia, even moderate (> 5.2 μmol / l), the combination of aldosterone antagonists with ACE inhibitors requires careful clinical and laboratory monitoring.

Diuretics (diuretics).

The main indication for the appointment of diuretics is the clinical signs and symptoms of excessive fluid retention in the body of a patient with CHF. However, it should be remembered that diuretics have two negative properties - they hyperactivate the neurohormones of the renin-angiotensin-aldosterone system, and also cause electrolyte disturbances.

Principles of diuretic therapy:
- combined with ACE inhibitors, which allows to reduce the dose of diuretics with the same clinical effect;
- appointed the weakest of effective diuretics in order to prevent the development of the patient's dependence on diuretics, as well as to be able to have a reserve for the type and dose of the diuretic during the period of CHF decompensation;
- are prescribed daily in the minimum dose with the achievement of a positive fluid balance in diuresis in the phase of therapy for decompensation of CHF 800-1000 ml, with maintenance therapy - 200 ml under the control of body weight.

Characteristics of the most commonly used diuretics.

Currently, two groups of diuretics are mainly used - thiazide and loop.
From the group of thiazide diuretics, preference is given to hydrochlorothiazide, which is prescribed for moderate CHF (NYHA II-III FC). At a dose of up to 25 mg per day, it causes a minimum of adverse reactions; at a dose of more than 75 mg, diselectrolyte disorders can be recorded.
The maximum effect is 1 hour after administration, the duration of action is 12 hours.

One of the most powerful loop diuretics is furosemide, the initial effect is after 15-30 minutes, maximum effect- after 1-2 hours, duration of action - 6 hours.
The diuretic effect also persists with reduced kidney function. The dose varies from the severity of CHF symptoms - from 20 to 500 mg per day.
Recommended to take in the morning on an empty stomach.

Ethacrynic acid is a drug similar to furosemide, however, due to its action on various enzymatic systems of the loop of Henle, it can be used in the development of refractoriness to furosemide, or combined with it for persistent edema.
Dosage - 50-100 mg per day, maximum dose- 200 mg.
Recommended to take in the morning on an empty stomach.

Dehydration therapy for CHF has two phases - active and maintenance.
AT active phase the excess of excreted urine over the accepted liquid should be 1-2 liters per day, with a decrease in weight daily ~ 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.
Most common mistake in the appointment of diuretics in Russia - an attempt to "shock" diuresis (once every few days).

It is difficult to imagine a more erroneous treatment strategy, both taking into account the quality of life of the patient and the progression of CHF.

Algorithm for prescribing diuretics(depending on the severity of CHF) appears as follows:
IFC - do not treat with diuretics,
II FC (without stagnation) - do not treat with diuretics,
II FC (stagnation) - thiazide diuretics, only if they are ineffective, loop diuretics can be prescribed,
III FC (decompensation) - loop (thiazide) + aldosterone antagonists, in doses of 100-300 mg / day,
III FC (maintenance treatment) - thiazide (loop) + spironolactone (small doses) + acetazolamide (0.25 x 3 times / day for 3-4 days, every 2 weeks),
IV FC - loop + thiazide (sometimes a combination of two loop diuretics furosemide and uregit) + aldosterone antagonists + carbonic anhydrase inhibitors (acetazolamide 0.25 x 3 times / day for 3-4 days, every 2 weeks).

In refractory edematous syndrome, there are the following tricks overcoming resistance to the use of diuretics:
- the use of diuretics only against the background of ACE inhibitors and spironolactone;
- the introduction of a larger (twice as high as the previous ineffective dose) dose of a diuretic and only in / in (some authors suggest administering furosemide (lasix) twice a day and even constantly in / in drip);
- a combination of diuretics with drugs that improve filtration (with blood pressure more than 100 mm Hg. Art.
- eufillin 10 ml of a 2.4% solution intravenously drip and immediately after the dropper - lasix or SG, with lower blood pressure - dopamine 2-5 mcg / min);
- the use of diuretics with albumin or plasma (possible together, which is especially important for hypoproteinemia, but also effective in patients with normal plasma protein levels);
- with severe hypotension - a combination with positive inotropic agents (dobutamine, dopamine) and, in last resort, with glucocorticoids (only for the period of critical hypotension);
- a combination of diuretics according to the principles indicated above; mechanical methods of fluid removal (pleural, pericardial puncture, paracentesis) - are used only for vital indications; isolated ultrafiltration (contraindications - valvular stenosis, low cardiac output and hypotension).

cardiac glycosides.
Currently, the most common cardiac glycoside in Russia is digoxin, the only drug from the group of positive inotropic agents that remains in wide use. clinical practice with long-term treatment of CHF.

Non-glycoside agents that increase myocardial contractility adversely affect the prognosis and life expectancy of patients and can be used in the form of short courses in decompensated CHF.
The effect of SG is currently associated not so much with their positive inotropic effect, but with a negative chronotropic effect on the myocardium, as well as with the effect on the level of neurohormones, both circulating and tissue, as well as with the modulation of the baroreflex.

Based on the characteristics described above, digoxin is a first-line drug in patients with CHF in the presence of a permanent tachysystolic form of AF.
In sinus rhythm, the negative chronotropic effect of digoxin is weak, and myocardial oxygen consumption increases significantly due to the positive inotropic effect, which leads to myocardial hypoxia.

Thus, it is possible to provoke various rhythm disturbances, especially in patients with ischemic etiology of CHF.

So, the optimal indications for prescribing SG are as follows: permanent tachysystolic form of MA; severe CHF (III-IV functional class NYHA); ejection fraction less than 25%; cardiothoracic index over 55%; non-ischemic etiology of CHF (DCMP, etc.).

Principles of treatment at the present time: the appointment of small doses of SG (digoxin no more than 0.25 mg per day) and, which is desirable, but problematic in all-Russian practice, under the control of the concentration of digoxin in the blood plasma (no more than 1.2 ng / ml).
When prescribing digoxin, it is necessary to take into account its pharmacodynamics - plasma concentration increases exponentially by the eighth day from the start of therapy, so such patients are ideally shown to perform daily monitoring ECG to monitor rhythm disturbances.
Meta-analysis of Regulatory Studies on Digoxin evidence-based medicine, showed that glycosides improve the quality of life (through a decrease in the symptoms of CHF); the number of hospitalizations associated with exacerbation of CHF is reduced; however, digoxin does not affect the prognosis in patients.

b-blockers.
In 1999, in the USA and European countries, and now in Russia, b-blockers are recommended for use as the main means for the treatment of CHF.

Thus, the postulate about the impossibility of prescribing drugs with a negative inotropic effect to patients with CHF was refuted.
The effectiveness of the following drugs has been proven:
- carvedilol - has, along with b-blocking activity, antiproliferative and antioxidant properties;
- bisoprolol - the most selective b1-receptor selective b-blocker;
- metoprolol (retard form with slow release) - a selective lipophilic b-blocker.

Principles of therapy with b-blockers.
Before the appointment of b-blockers, it is necessary to perform following conditions:
- the patient should be on a regulated and stable dose of an ACE inhibitor that does not cause arterial hypotension;
- it is necessary to strengthen diuretic therapy, since due to a temporary short-term decrease in pumping function, an exacerbation of CHF symptoms is possible;
- if possible, cancel vasodilators, especially nitropreparations, with hypotension, a short course of corticosteroid therapy (up to 30 mg per day orally) is possible;
- the starting dose of any b-blocker in the treatment of CHF is 1/8 of the average therapeutic dose: 3.125 mg for carvedilol; 1.25 - for bisoprolol; 12.5 - for metoprolol; doubling the dosages of b-blockers no more than once every two weeks, provided steady state patient, absence of bradycardia and hypotension;
achievement of target doses: for carvedilol - 25 mg twice a day, for bisoprolol - 10 mg per day once (or 5 mg twice), for slow-release metoprolol - 200 mg per day.

The principles of the combined use of fixed assets for the treatment of CHF,
Monotherapy in the treatment of CHF is rarely used, and in this capacity only ACE inhibitors can be used for initial stages CHF.
Dual therapy with ACE inhibitor + diuretic - optimally suited for patients with CHF II-III FC NYHA with sinus rhythm;
the diuretic + glycoside regimen, extremely popular in the 1950s and 1960s, is not currently used.

Triple therapy (ACE inhibitor + diuretic + glycoside) - was the standard in the treatment of CHF in the 80s. and now remains an effective scheme for treating CHF, however, when giving patients with sinus rhythm, it is recommended to replace the glycoside with a b-blocker.

The gold standard from the early 90s to the present is a combination of four drugs: ACE inhibitor + diuretic + glycoside + b-blocker.

Effect and influence aids on the prognosis of patients with CHF are not known (not proven), which corresponds to the level of evidence C. Actually, these drugs do not need (and it is impossible) to treat CHF itself, and their use is dictated by certain clinical situations that complicate the course of decompensation itself:
peripheral vasodilators (PVD) = (nitrates) used for concomitant angina;
slow calcium channel blockers (CBCC) - long-acting dihydroperidines for persistent angina and persistent hypertension;
antiarrhythmic drugs (except for BAB, which are among the main drugs, mainly class III) for life-threatening ventricular arrhythmias;
aspirin (and other antiplatelet agents) for secondary prevention after myocardial infarction;
non-glycoside inotropic stimulants - with exacerbation of CHF, occurring with low cardiac output and persistent hypotension.