This is A case Study of Congestive Heart Failure, Feel free to use it and sorry for any English mistakes.

1. C O N G E S T I V E H E A RT
FA I L U R E :
C A S E P R E S E N TAT I O N C C U , H E A RT WA R D 1 .
Presented by : Walaa Fahad Al-Juaid , Manal Awn Al-
Osaimi

2. O U T L I N E S :
•T H E C A S E .
•W H AT I S T H E C H F
•D E F I N I T I O N
•C A U S E S
•I N C I D E N C E A N D
P R E VA L E N C E
•D I A G N O S I S
•C O M P L I C AT I O N
•T R E AT M E N T
•I N T E R V E N T I O N

3. T H E C A S E :
• S. a 45 years old female come to the hospital
complaining of shortness of breath , left side
weakness , bilateral foot swelling and did not take
any hypertensive medication .

4. H I S T O RY O F P R E S E N T I L L N E S S
▸Patient is bed ridden with chronic kidney disease,
Ischemic heart disease and hypertension .
▸Family history : Unknown
▸Allergy : No Kind of Allergy .
▸Medication history : Coversyl .

5. R E V I E W O F S Y S T E M S :
‣ Eyes: normal
‣ Mental status: conscious .
‣ Respiratory system: Normal sounds
‣ Cardiovascular system: S1+S2+S4
‣ Chest wall & breast: No any diseases
‣ Abdomen: soft and lax .
‣ Extremities : Bilateral Edema

6. V I TA L S I G N O N A D M I S S I O N
▸ Normal Ranges :
▸ Patient Vital sign :
Temperature PR RR O saturation BP
36-37 60-100 16-20 > 96% 120/80
Temperature PR RR O saturation BP
37 100 20 96% 174/121

7. C B C A N D L A B R E S U LT S :
Normal Ranges
WBC
10^9/uL
RBC
10^12/uL
Hb g/dL
4-10 x10^9/L 4,5 -5,5 X10^12/L 12-16
WBC
10^9/uL
RBC
10^12/uL
Hb g/dL
4 4.5 10
Patient’s Ranges

8. Albumin K Na sCr
3.5-5.2 3.5-5.3 135-153 0.7-1.2
Normal Ranges
Albumin K Na sCr
2.5 3.3 136 1.6
Patient’s Ranges

9. F I N A L D I A G N O S I S :
C O N G E S T I V E H E A RT
FA I L U R E

10. W H AT I S C O N G E S T I V E H E A RT FA I L U R E ?
• Congestive heart failure (CHF) is a chronic
progressive condition that affects the pumping
power of the heart muscles.
• While often referred to simply as “heart failure,”
CHF specifically refers to the stage in which fluid
builds up around the heart and causes it to pump
inefficiently.

11. W H AT A R E T H E M O S T C O M M O N
T Y P E S O F C H F ?
Left-sided CHF is the
most common type of CHF.
It occurs when the left
ventricle doesn’t properly
pump blood out to the
body. As the condition
progresses, fluid can build
up in your lungs, which
makes breathing difficult.
Right-sided CHF occurs
when the right ventricle
has difficulty pumping
blood to the lungs. Blood
backs up in the blood
vessels, which causes fluid
retention in the lower
extremities, abdomen, and
other vital organs.

12. W H AT A R E T H E M O S T C O M M O N
T Y P E S O F C H F ?
O U R PAT I E N T

13. W H AT A R E T H E C A U S E S O F C H F ?
• Hypertension
• Coronary artery disease
• Valve conditions : Valves that don’t open and close
correctly may force ventricles to work harder to
pump blood and this can be a result of a heart
infection or defect.
• Diabetes, thyroid disease and obesity
O U R PAT I E N T

14. I N C I D E N C E A N D P R E VA L E N C E
• In several Middle Eastern countries, like Oman,
Saudi Arabia, and Yemen, around 52% of HF cases
are secondary to IHD ,valvular heart disease also
remains a prevalent cause of HF in the Middle East,
where it accounts for 22.5% of HF cases in Egypt ,
10.5% of cases in Saudi Arabia , 8.4% in Oman, and
7% in Yemen.

15. • The prevalence of risk factors for HF is increasing.
For example, 26% of the Saudi population is
affected by hypertension and approximately 24% is
affected by diabetes mellitus.
• Patients with diabetes are at a higher risk for
developing HF

16. D I A G N O S I S
• Physical exam may involve listening to your heart
with a stethoscope to detect abnormal heart
rhythms
• Electrocardiogram (ECG) records heart’s rhythm.
• An echocardiogram uses sound waves to record the
heart’s structure and motion. The test can
determine poor blood flow, muscle damage, or a
heart muscle that doesn’t contract normally.

17. • MRI takes pictures of heart. With both still and
moving pictures, this allows doctor to see if there’s
damage .
• Stress tests show how well the heart performs
under different levels of stress.
• Blood tests
• Cardiac catheterization can show blockages of the
coronary arteries.

18. T R E AT M E N T
• Heart failure is a serious illness that can affect life. However, generally,
treatment depends on the NYHA classification or (Stages) and
underlying medical condition.
• The major types of heart failure treatment includes:
• Lifestyle changes
• Heart Medications
• Surgery for correctable problems
• Implantable devices
• Heart transplant .

19. O U R PAT I E N T

20. C O M P L I C AT I O N S :
• Atrial fibrillation
• Ventricular fibrillation or tachycardia .
• Kidney failure
• Anemia
• Cardiac cachexia
• Heart valve condition
• Stroke
O U R PAT I E N T

21. B A C K T O T H E C A S E :

22. F I R S T D AY :
• Patient came to the ER complaining of complaining of
shortness of breath , left side weakness , bilateral foot
swelling .
Drug name Dose frequency Route of
administration
Nifedipine 20 mg - oral
Furosemide 40 mg - IV

23. A S S E S S M E N T
• The patient is a hypertension patient’s and she did not
adhere to hypertension management plan
• She also has A CKF stage 3 B ( GFR = 30-40) , LVEF =
20% , So she transferred to the CCU to manage her
CHF.
• They give her Frusemide as a diuretic for edema , and
Nifedipine to reduce her BP .

24. S E C O N D D AY
• In the CCU she treated on plan ( NYHA Class III/IV )
according her symptoms and LVEF reading .
Drug name Dose frequency Route of
administration
Nifedipine 60 mg OD Oral
Furosemide 40 mg TID IV
Aspirin 81 mg OD Oral
Metolazone 2.5 mg OD Oral
Atrovastatin 40 mg OD Oral
Telmisartan 40 mg OD Oral
Carvedilol 6.25 mg BID Oral
Enoxaparin 3000 IU OD S.C
Nitroglycerin 5 mcg/min OD IV

25. ▸ Patient Vital sign :
▸ CBC :
▸ LAB
Temperature PR RR O saturation BP
36.5 70 20 95% 136/70
I M P R O V E D
WBC
10^9/uL
RBC
10^12/uL
Hb g/dL
4 4.5 10
Albumin K Na Mg
1.7 3.4 136 1.4
N O R M A L
( 1 . 6 - 2 . 6 ) M G
/ D L

26. A S S E S S M E N T
• They use NYHA III plan management as they mention on patient
profile
• The patient take Nifedipine, Telmisartan, Carvedilol to control her
hypertension and she is improving on it .
• Furosemide and Metolazone to reduce bilateral edema
• Aspirin and Enoxaparin to prevent Ischemia , Stroke or any
coagulation events
• Nitroglycerin to get benefit to CHF and Renal failure
• Also they add Isosorbide 10 mg Tablet TID as recommendation in the
guideline .

27. • Atrovastatin for control her lipid profile her total
Cholesterol was 208 which was slightly abnormal and
her LDL was 129.4 ( normal = 00-100 ) .
• They did not use digoxin because the patient
symptoms improve and did not use spironolactone
due to CKD .
• ECG confirm the diagnosis of CHF .

28. T H I R D D AY :
• Patient improve on the medication , so they keep the
same plan they just add Mg sulphate 4 g IV and
Human Albumin 20% 50 ml BID IV .
• Vital sign :
Temperature PR RR O saturation BP
36.5 68 20 97% 140/90

29. ▸ CBC :
▸ LAB
WBC
10^9/uL
RBC
10^12/uL
Hb g/dL
4 4.5 10
Albumin K Na Mg
1.7 3.5 138 1.4
N O R M A L
( 1 . 6 - 2 . 6 ) M G
/ D L

30. A S S E S S M E N T
• The patient continue the same plan , her blood
pressure effected by diuretics and antihypertensive
agent
• They discontinue furosemide to avoid hypokalemia
but keeping use Metolazone to control fluid retention .
• Using Mg sulphate to control Mg levels .
• Using Human Albumin to Control Albumin levels .

31. F O U RT H D AY
• They keep the same plan, patient is stable so they
transfer her to female medical word for only
observation .
• Vital sign :
Temperature PR RR O saturation BP
36.5 68 20 97% 138/82

32. ▸ CBC :
▸ LAB
WBC
10^9/uL
RBC
10^12/uL
Hb g/dL
4 4.5 10
Albumin K Na Mg
2.9 3.5 138 1.6
N O R M A L
( 1 . 6 - 2 . 6 ) M G
/ D L
I M P R O V E D I M P R O V E D

33. A S S E S S M E N T
• The patient’s blood pressure is stable on the
medication , they continuo the same plan .
• Mg level is improve so they discontinue Mg
sulphate .
• Still using Human Albumin to Control Albumin levels .

34. F I F T H D AY
• Patient discharge after her Albumin reach 3.5 which is
improved to the normal levels and her blood pressure
reaching the target and stable on the antihypertensive
medication .
• Vital sign :
Temperature PR RR O saturation BP
36.5 68 20 97% 123/74
TA R G E T >
1 2 5 / 7 5 .

35. A S S E S S M E N T :
• Keep using antihypertensive ( BB , Diuretic ,ARB ,
Nitrate ) medication to control blood pressure and
Atrovastatin to control lipid Aspirin + Clopidogrel
75Mg tablet to prevent ischemia because the patient
has history ischemic heart disease .
• Educate the patient about the important of her
medication to help her to adherence .
• Home visit doctors to continue observation to the
patient .

36. I N T E R V E N T I O N :

37. G O A L S O F T R E AT M E N T :
• (1) to decrease the preload and afterload and to
reduce LVH
• (2) to treat myocardial ischemia.
• (3) to inhibit neurohumoral hyperactivity, especially the
sympathetic nervous system and the renin-
angiotensin-aldosterone system .

38. T R E AT M E N T A C C O R D I N G N Y H A
C L A S S I F I C AT I O N :
Patient Bedridden
high Blood Pressure
Shortness of breath
PAT I E N T M E D I C AT I O N :
1 - T E L M I S A RTA N
2 - C A R V I D I L O L
3 - F U R O S I M I D E
4 - M E T O L A Z O N E
5 - I S O S O R B I D E D E N I T R AT E

39. A C C O R D I N G T O T H E G U I D E L I N E
T H E Y H AV E B E E N U S E D :
• They give her the medication according guideline + nifedipine
because the patient has Hypertension
• And also they give her Aspirin and Colpidogrel to prevent recurrence
IHD .
• Nitroglycerin for CKF and CHF
• Atrovastatin to Control lipids .
T H I S I S W I L L L E A D U S T O
A C C F / A H A G U I D E L I N E F O R
T H E M A N A G E M E N T O F H E A RT FA I L U R E

40. A C C F / A H A G U I D E L I N E F O R T H E M A N A G E M E N T
O F H E A R T FA I L U R E ( 2 0 1 3 ) U P D AT E D ( 2 0 1 7 ) :
Stage Definition Of Stage Usual Treatments
Stage
A
People At High Risk Of Developing
Heart Failure (Pre-Heart Failure),
Including People With:
High Bp , D M , C A D .
• Exercise Regularly, Quit Smoking.
• Treat High Blood Pressure.
• Treat High Cholesterol.
• (Ace Inhibitor) Or (Arb) For Previous
Heart Attack Or Diabetes, High Blood
Pressure, Or Other Vascular Or Cardiac
Conditions.
• Beta Blockers May Be Prescribed For
Previous Heart Attack Or High Blood
Pressure.
Stage
B
People Who Have Developed Heart
Failure But Without Signs And
Symptoms Of Heart Failure.
• Treatment Methods Above For Stage A
Apply.
• All Patients Should Take An Angiotensin
Converting Enzyme Inhibitor (Ace
Inhibitor) Or Angiotensin Ii Receptor
Blocker (Arb).
• Beta-Blockers Should Be Added For
Everyone.

41. Stage Definition Of Stage Usual Treatments
Stage
C
Patients With Known Systolic Heart
Failure And Symptoms.
Most Common Symptoms Include:
Shortness Of Breath
Fatigue
Reduced Ability To Exercise
• Treatment Methods Above For Stage A
Apply.
• All Patients Should Take Ace Inhibitor
And Beta-Blocker.
• Diuretics And Digoxin May Be
Prescribed If Symptoms Persist.
• An Aldosterone Inhibitor May Be
Prescribed When Symptoms Remain
Severe With Other Therapies.
• Restrict Dietary Sodium (Salt).
• Monitor Weight.
• Restrict Fluids (As Appropriate).
• Drugs That Worsen The Condition
Stage
D
Patients With Systolic Heart Failure
And Presence Of Advanced Symptoms
After Receiving Optimum Medical
Care.
• Treatment Methods For Stages A, B & C
Apply.
• Patient Should Be Evaluated To
Determine If The Following Treatments
Are Available Options: Heart Transplant,
Ventricular Assist Devices Or Surgery
Options
O U R
PAT I E N T

42. S O . .
• The plan is good and on the guideline BUT patient is CKF
and according to her condition these modification should
be conceder :
• Loop diuretics should be used as first-line agents in
patients with GFR <30 mL/min/1.73 m2 < they do it by
using Frousimide.
• (2) In patients with CKD and ESRD, anemia has been
associated with LV hypertrophy and dilatation, we suggest
that in people with CKD and HF anemia should be treated
according to the guidelines used in the general CKD
population, targeting a serum hemoglobin of 11 to 12 g/dL
< they did not treat the anemia

43. • According to KDIGO Clinical Practice Guideline for
Anemia in Chronic Kidney Disease ( 2012 ) : the
Anemia treated by : Using a trial of IV iron (or in CKD
patients alternatively a 1–3 month trial of oral iron
therapy) if:increase in Hb concentration without
starting ESA treatment is desired* and TSAT is r30%
and ferritin is r500 ng/ml (r500 mg/l) .

44. R E F E R E N C E S :
• Mostafa Q Al-Shamiri, Heart Failure in the Middle East,2013 May; 9(2): 174–
178.
• Journal of the American College of Cardiology, ACCF/AHA Guideline for
the Management of Heart Failure , updated 2017 on website http://
www.onlinejacc.org .
• Michelle M. Kittleson, MD, PhD; Jon A. Kobashigawa, MD ,Management of
Advanced Heart Failure , April 2011;123:1569-1574.
• Liviu Segall, Ionut Nistor, and Adrian Covic , Heart Failure in Patients with
Chronic Kidney Disease, 2014 (2014), Article ID 937398, 21.
• KDIGO Clinical Practice Guideline for Anemia in Chronic Kidney Disease
( 2012 )