Congestive heart failure is an ongoing long-term disease that occurs when the heart muscle is weak and does not pump blood as required in the body. It leads to the accumulation of fluids (congestion) in different areas of the body including lungs, liver and the lower limbs. There are different types of CHF based on the heart’s ability to contract and relax: 

Systolic Heart Failure: This is a situation where the pumping action of the heart becomes compromised due to a failure of the cardiac muscles to contract broadly enough to pump sufficient blood in every cycle. 

Diastolic Heart Failure (or HFpEF): In this type, the heart muscle becomes rigid and is unable to relax at the end of systole, thus causing the heart chambers to fill inadequately. 

CHF is a common disease worldwide, which affects millions of people. While it is more frequent in elderly people, it may develop in anyone with various factors such as high blood pressure, diabetes, high body weight, and previous cardiovascular issues. 

Heart failure is a chronic and slowly progressive disease that can be caused by acute episodes or chronic factors such as mutation, infiltration of the cardiac tissue, or ischemic disorders. Firstly, compensatory adaptations increase preload, stroke volume and cardiac output; the sympathetic nervous system and the renin-angiotensin-aldosterone system (RAAS) are main participants in this process. However, chronic activation leads to changes such as myocardial hypertrophy and fibrosis which are deleterious to the heart. This cycle raises the oxygen demand of myocardial cells and leads to cell death, thus lowering cardiac output and resulting in pulmonary congestion. Decompensated HF is characterized by peripheral vasoconstriction and ineffective natriuretic peptide release 

Ischemic heart disease is the leading cause of congestive heart failure (CHF) globally, occurring due to decreased blood flow to the heart muscles and subsequently low ejection fraction. CHF incidence is increasing globally especially in developing nations due to the adoption of western lifestyles and advancement in health care reducing original causes such as myocarditis. 

Valvular Heart Disease such as rheumatic heart disease which mostly affects children and young adults and degenerative diseases of the valves with aging especially the aortic valve also cause CHF. Hypertension without Coronary Artery Disease damages the myocardium by increasing the afterload and thus the ventricular mass, often with other conditions present. 

Hypertrophic, dilated, restrictive, arrhythmogenic right ventricular, and left ventricular noncompaction cardiomyopathies cause enlarged ventricles with impaired function from primary causes. Inflammatory and infiltrative cardiomyopathies originating from genetic predisposition, infections including viral or Chagas disease toxins, and autoimmune disorders worsen CHF conditions and its outcome. 

Lower Ejection Fraction (EF): A lower EF is linked to worse results and a worse prognosis. 

Severity of Symptoms: Prognosis and NYHA functional class are correlated, with higher classes denoting more severe illness. 

Underlying Cause: Prognosis is influenced by cardiomyopathies, valvular heart disease, and ischemic heart disease. 

Comorbidities: Obesity, diabetes, renal failure, and chronic lung disease make treatment more difficult and harm prognosis. 

Elevated Biomarkers: Higher levels of NT-proBNP are associated with a poorer prognosis and higher heart stress. 

Infants and Newborns 

Delayed growth, which is stunted growth because of insufficient oxygen intake and blue skin and mucous membranes referred to as cyanosis.
Symptoms related to breathing are difficult or abnormal breathing, accelerated breathing, and breathlessness. 

Failure to feed young children appropriate foods might lead to failure to gain weight as expected by their age. 

Children and adolescence 

Lack of exercise tolerance leads to exhaustion and problems with exercise or physical labor. 

Recurring respiratory infections: Susceptibility to becoming infected and consequently being infected by pathogens. 

Chest discomfort: In some cases, children and adolescents, especially older ones, may experience chest pains particularly during exercise. 

Delays in development: In severe instances, developmental milestones may be affected or even not be achieved at all. 

Cyanosis: Look for signs of cyanosis in areas such as the lips, tongue, ear lobes and nails that denote reduced oxygen saturation. 

Clubbing: Joints must be inspected to ascertain if they are enlarged at the extremities, particularly if the hands and feet seem like light bulbs, due to chronic hypoxemia. 

Palpation 

Pulses: Feel peripheral pulses to estimate the adequacy of blood circulation. 

Thrills: Tremors; associated with turbulent blood flow especially in congenital heart diseases; palpate for thrills. 

Auscultation: 

Heart Sounds: Look for I, II, and V auscultatory areas for S1 and S2 heart sounds. 

Additional Sounds: Speaking of note S3 and S4 sounds which point at ventricular dysfunction. 

Murmurs: Classify heart murmurs into those are abnormal in location, timing, intensity and radiation. 

Clicks and Snaps: Someone might hear a clicking or snapping sound: as in the case of mitral valve prolapse. 

Rub: Check for pericardial rubs and recommend on the presence of pericardial inflammation. 

Chest Examination: 

Shape: Palpate for expansiveness and perceive for irregularities in reaching for chest wall to rule out congenital heart problems. 

Retractions: It is essential to observe symptoms such as intercostal retractions that point to respiratory distress. 

• Critical Congenital Heart Disease (CCHD): There are some congenital heart diseases that cause severe signs and symptoms within the first weeks of life and need urgent medical intervention. Examples include instances of severe diaphragmatic herniation, parachute umbilical cord, and severely hypoplastic lungs. 
• Acute Decompensation: CHD patients might have mild or more moderate disease and while they are free of symptoms, they can develop acute episode because of infections, stress and other reasons.
• Gradual Onset: Less severe signs may develop slowly over time and the disease may not be detected during childhood or adolescence, but may be diagnosed during adult physical exams, or while the person is being evaluated for other diseases. 

Medical Management: Several CHDs may be treated by ensuring proper heart function, eliminating fluid accumulation, regulating blood pressure, discouraging clot formation or relieving symptoms using drugs and medication. In certain cardiac diseases, preventative antibiotics might be advised before dental or certain medical procedures to reduce the risk of infective endocarditis. 

Catheter-Based Interventions: 

Balloon Angioplasty: Conditions like pulmonary stenosis and aortic stenosis can be treated using a catheter which has the shape of a balloon and is placed on the tip. 

Device Closure: Some patients have anomalous connections such as atrial septal defects (ASD) and ventricular septal defects (VSD) that may be closed without surgical procedure with intravascular devices.

Open-Heart Surgery: Most of the CHD are complex and are treated with open heart surgery. This may require surgery to fix or replace the heart valves, if there are defects in the structure of the heart, or if the vessels need to be redirected. 

Heart Transplant: Heart transplantation is the last option where the heart is severely damaged, and the structure cannot be fixed.

Palliative Procedures: 

Temporary Shunts: In some situations, such as in newborns with severe congenital heart disease, initial palliative procedures like placing shunts may be used to increase blood flow to the lungs or other organs while a more definitive surgery is planned and performed. 

Cardiology, General

Lifestyle and Dietary Management: 

Nutritional Support: It is important to note that some infants born with congenital heart disease may need feeding modifications or even enteral tube feedings. 

Physical Activity: People with heart conditions may require limited recommendations depending on their type of condition or may require restrictions on their physical activity. 

Palliative Procedures: 

Temporary Shunts: Sometimes, especially in neonates with complicated CHD, patients may undergo placement of temporary shunts to aid in circulation until definitive repair is possible. 

Cardiology, General

Cardiology, Interventional

Pediatrics, Cardiology

Furosemide (Lasix): This specific diuretic functions at the kidneys’ loop of Henle by inhibiting the reabsorption of salt and chloride within the renal tubules, thereby enhancing production of urine. Lasix is commonly used to treat cases of fluid overload especially in cases where the patient has been diagnosed with heart failure due to CHD. It also has a beneficial effect in decreasing edema and improving respiratory manifestations. 

Cardiology, General

Digoxin: It increases the intracellular calcium levels since it inhibits sodium potassium pump. This leads to increased positive inotropic effect and the better heart’s pumping ability. Digoxin is effective in the treatment of congestive heart failure resulting from CHD, particularly in the needy categories of patients, the children. It can consequently enhance the occurrence of symptoms and decrease important hospitalizations. 

Cardiology, General

Propranolol: It is a cardio selective beta-blocker, and it opposes both the beta-1 and the beta-2 adrenoreceptors. It decreases the rate and force of the heartbeat and decreases blood pressure. It is employed in the treatment of the arrhythmias most of which are characterized by tachycardia or fast heart rates. It may also be applied to control systemic/inorganic sign related to hypertrophic cardiomyopathy. 

Cardiology, General

Losartan: In the management of hypertension with CHD, losartan is often recommended. It is also given in situations that involve formation of an aortic aneurysm. 

Valsartan: It is another drug belonging to the ARB class that can be used to treat hypertension and heart failure in people with CHD. 

Cardiology, General

Coronary Artery Bypass Grafting (CABG): This surgery is done for patients who have severe blockages in the coronary arteries, to increase blood flow to the heart, to relieve symptoms and to enhance the overall function of the heart. 

Percutaneous Coronary Intervention (PCI): Known as angioplasty, this procedure involves passing a catheter fitted with an inflatable balloon into a blocked coronary artery. The balloon is inflated to open the blocked artery and it is usually thereafter backed up using a stent.

Implantable Cardioverter-Defibrillators (ICDs): These devices are inserted in patients with Implantable Cardioverter Defibrillators or ICDs due to ventricular arrhythmias. ICDs continuously record heart rate and pace and can treat cardiac arrhythmias by issuing electric shocks.

Cardiology, General

Acute Phase: 

Assess the patient clinically and use ECG, chest X-ray and biochemical profile including BNP/NT-proBNP. First, assess if there are any life-threatening conditions that needs immediate attention to stabilize the patient. 

Give diuretics to remove excess fluids in the body, venodilators to decrease after load and inotropic agents in case cardiac output needs to be boosted. Oxygen therapy or non-invasive ventilation may be needed for patients with hypoxia. 

Subacute Phase: 

Optimize the doses of ACE inhibitors or ARBs, beta-blockers, aldosterone antagonists, and diuretics to cope with possible manifestations. Teaching on CHF, which includes signs and symptoms of CHF worsening, importance of taking medication as instructed, no use of salt or foods high in sodium, and making positive behavioural changes. Discharge planning should involve regular follow-up visits, home healthcare services if required, and proper guidelines on signs and symptoms to look out for and when to seek healthcare services. 

Chronic Phase: 

To maintain the heart failure status and prevent further deterioration, all long-term medications prescribed should be continued and modified accordingly in case of inefficiency or occurrence of side effects. It is recommended to perform follow-up visits every 3 to 6 months to perform clinical examination, laboratory tests, and imaging for the assessment of heart function and signs of conversation. Promote and maintain a heart-healthy diet, exercise habits, monitoring the weight, quitting smoking, and the moderate consumption of alcoholic beverages.