CHAPTER ONE

INTRODUCTION

1. CASE STUDY BACKGROUND

Congestive cardiac failure (CCF) is a complex syndrome that is usually caused by the inability of
heart to pump sufficient blood to meet metabolic needs of body during exercise. The risk factors
predisposing one to heart failure are obesity, high blood pressure, diabetes, and smoking. Heart
failure is commonly characterized by typical signs of fluid retention with symptoms of
breathlessness, fatigue, paroxysmal nocturnal dyspnoea, and reduced exercise tolerance. Jones
NR, et al, (2017).

Congestive Cardiac Failure is a common disease which affects approximately 1-2% of the
general population in developed countries. Prevalence increases with age especially those aged
above 75 years where the prevalence of CCF could be as high as 10%2. In addition, men are
prone to getting heart failure as compared to women1. Each year, there are about 1-5 new cases
of CCF per 1,000 population and it also increased with age40. Approximately 40% of individuals
with CCF die within a year after diagnosis. Malik A, Brito D, Vaqar S, et al. (2023).

The body tries to compensate in different ways. The heart beats faster to take less time for
refilling after it contracts—but over the long run, less blood circulates, and the extra effort can
cause heart palpitations. The heart also enlarges a bit to make room for the blood. The lungs fill
with fluid, causing shortness of breath. The kidneys, when they don’t receive enough blood,
begin to retain water and sodium, which can lead to kidney failure. With or without treatment,
heart failure is often and typically progressive, meaning it gradually gets worse.

Heart Failure usually develop over time as your heart becomes weaker and less able to pump the
blood that your body needs. Heart Failure usually results in an enlarged heart (left Ventricle).

It is a chronic condition in which the heart doesn't pump blood as well as it should. Heart Failure
can occur if the heart cannot pump (Systolic) or Fill (diastolic) adequately. It specifically refers
to the stage in which fluid builds up within the heart and causes it to pump inefficiently.

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THE HEART.

The heart is a vital organ. It is a muscle that pumps blood to all parts of your body. The blood
pumped by the heart provides our body with the oxygen and nutrients it needs to function. The
heart is about the size of owner clenched fist and weighs between 300 and 450g. It lies in the
middle of your chest behind and slightly to the left of your breastbone. The heart can pump up to
four times that amount per minute. Colucci WS. (2022).

THE FOUR CHAMBERS OF THE HEART.

The heart has a right and left side separated by a wall called the SEPTUM. On each side of the
wall, there is a small collecting chamber called an 'artrium' which leads into a large pumping
chamber called a 'Ventricle' there are four Chambers The left artrium and right artrium (Upper
chambers) and the left Ventricle and right Ventricle (Lower chambers) The right side of your
heart collects blood on it's return from the rest of the body. The blood entering the right side of
the heart is low in oxygen. The heart pumps the blood from the right side of the heart to the lungs
so it can receive more oxygen.

Once it has received oxygen the blood returns directly to the left side of the heart, which then
pumps it out again to all parts of the body through an artery called the AORTA.

Blood pressure refers to the amount of force the pumping blood exerts on arterial walls.

THE HEART BEAT

Each artrium is connected to it's Ventricle by a one way valve. The valve on the right side of the
heart is called the TRISCUSPID VALVE While the valve on the left side is called MITRAL
VALVE.

The Familiar 'Lub-dub' sound of the heartbeat is caused by the rhythmic closing of the heart
Values as blood is pumped in and out of the chambers.

The heart rate is regulated by a special cluster of cells in the right artrium called the SINUS
NODE. The Sinus node prompts the upper chambers to cluster to contract first. Then, an
electrical impulse is sent to a second cluster of cells (The artrioventricular node) which is found
between the upper and lower chambers of the heart. The electrical impulse causes the lower
chambers to contract. At rest, the heart beats approximately 60 to 100 times in a minute.

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BLOOD VESSELS OF THE HEART.

The blood vessels of the heart include:-

CORONARY ARTERIES- Like any other organ or tissue, the heart needs oxygen. The coronary
arteries supply the heart muscle with blood and oxygen.

AORTA- This is the longest artery in the body. Oxygen-rich blood is pumped into the AORTA
from the left Ventricle. It divides into branches delivers blood all around the body.

PULMONARY ARTERIES- Blood low in oxygen is pumped by the right Ventricle into the
pulmonary arteries that link to the lungs.

PULMONARY VEINS- The pulmonary Veins returns oxygen rich in blood from the lungs to the
left artrium of their heart.

VANAE CAVAE- Blood low in oxygen is delivered to the right artrium by two veins.

STAGES OF HEART FAILURE

Heart Failure can progress, so researchers have identified four stages of the disease- A,BC,D.
This classification measures a patient's overall heart function and severity of symptoms. In
collaboration with the American college of cardiology, The AHA has identified four stages of
heart Failure. They are described in the table below...

STAGE A People who are at Risk for heart Failure but do not yet have symptoms
At Risk for heart Failure. or structural or functional heart disease.
Risk Factors for people in this stage include, hypertension, coronary
Vascular disease, diabetes, Obesity, exposure to cardiotoxic agents,
genetic Varients for cardiomyopathy and Family History of
Cardiomyopathy.
STAGE B. People without current or previous symptoms of heart Failure but with
Pre- heart Failure. either structural heart disease increased filling pressures in the heart of
other risk failure.
STAGE C. People with current or previous symptoms of heart Failure.
Symptomatic heart
Failure
STAGE D. People with heart Failure symptoms that Interfere with daily life
Advanced Heart Failure functions or lead to repeated hospitalizations.
Source: American Heart Association

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TYPES OF HEART FAILURE AND DESCRIPTION.

Right-sided heart failure: This type affects the lower right heart chamber, called the right
ventricle. Fluid may back up into the belly, legs and feet, causing swelling.

Left-sided heart failure: This type affects the lower left heart chamber, called the left ventricle.
Fluid may back up in the lungs, causing shortness of breath.

Heart failure with reduced ejection fraction (HFrEF), also called systolic heart failure This is
a type of left-sided heart failure. The left ventricle can't squeeze as strong as it should. The heart
isn't strong enough to pump enough blood to the body.

Heart failure with preserved ejection fraction (HFpEF), also called diastolic heart failureThis
is a type of left-sided heart failure. The left ventricle can't relax or fill fully. The heart has a
problem filling with blood.

1.1 PERSONAL DATA

Mrs. Saleh, 60-year-old Female.

STATUS: Married

HOME ADDRESS- AT Borno Village Bali LGA

OCCUPATION-House wife/ Business

ETHNIC GROUP-Fulani

RELIGION- Islam

DATE OF ADMISSION- 9th Nov, 2023

1.2 Family Data - A married woman with eight children all alive.

1.3 Health History

Mrs. Saleh was diagnosed with congestive cardiac failure (CCF) with fluid overload. The patient
also suffered from hypertension.

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1.3.1 Present Medical Health History

When admitted, patient was complained of shortness of breath for 2 weeks and was worsening
on the day of admission. Besides, he also experienced orthopnea, fatigue, and leg swelling up to
his Knee.

On examination, Mrs. Saleh was found to be alert and conscious but she was having pedal
oedema up to his knee. Her body temperature was normal. However, her blood pressure was
found to be elevated upon admission with a record of 159/100 mmHg with an irregular pulse rate
at 85beats/min. His echocardiogram showed that he had left ventricle hypertrophy while chest X-
ray was conducted and revealed that the patient had cardiomegaly.

Lab investigations such as full blood count, liver function test, urea and electrolyte test and
cardiac enzyme were done upon admission. Her creatinine concentration was found to be
143µmol/L. Besides, there was also blood found in the urine and the echocardiography showed
that the patient has sinus tachycardia. In addition, Mr. SB’s random blood glucose was found to
be normal during his hospitalization.

1.3.2 Past Medical Heath History

Mrs. Saleh had been previously admitted on Borno Clinic for the same present medical
condition last year.

Mrs. Saleh had known case of heart failure since 3 years ago and she had also diagnosed with
hypertension for 5 years. Before admitted to the hospital, patient was taking frusemide 40mg,
aspirin 150mg, metoprolol 50mg, amlodipine 10mg, and simvastatin 40mg for his hypertension
and heart failure. Patient is not allergic to any medication and he does not take any traditional
medicines at home. His family history revealed that his father had died of ischemic heart disease
4 years ago while his brother has hypertension. Mrs. SALEH also drinks Occasionally.

1.3.3 Past Surgical Health History- NIL

1.3.4 Gynaecological Health History- NIL

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 CHAPTER TWO

LITERATURE REVIEW
2.1 Aims and Objective of the Study

 To Understand the Pathophysiology of Congestive Cardiac Failure

 To Examine the Risk Factors and Etiology of CCF

 To Evaluate Diagnostic Approaches and Clinical Assessment

 To Explore Treatment Modalities and Patient Management

 To Analyze the Impact on Quality of Life and Healthcare Utilization

2.1.1 Causes

Heart failure can be caused by a weakened, damaged or stiff heart.

 If the heart is damaged or weakened, the heart chambers may stretch and get bigger. The
heart can't pump out the needed amount of blood.

 If the main pumping chambers of the heart, called the ventricles, are stiff, they can't fill
with enough blood between beats.

 The heart muscle can be damaged by certain infections, heavy alcohol use, illegal drug
use and some chemotherapy medicines. Your genes also can play a role.

 Coronary artery disease and heart attack. Coronary artery disease is the most common
cause of heart failure. The disease results from the buildup of fatty deposits in the
arteries. The deposits narrow the arteries. This reduces blood flow and can lead to heart
attack.

 High blood pressure. Also called hypertension, this condition forces the heart to work
harder than it should to pump blood through the body. Over time, the extra work can
make the heart muscle too stiff or too weak to properly pump blood.

 Heart valve disease. The valves of the heart keep blood flowing the right way. If a valve
isn't working properly, the heart must work harder to pump blood. This can weaken the
heart over time. Treating some types of heart valve problems may reverse heart failure.

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  Inflammation of the heart muscle, also called myocarditis. Myocarditis is most
commonly caused by a virus, including the COVID-19 virus, and can lead to left-sided
heart failure.

 A heart problem that you're born with, also called a congenital heart defect. If the heart
and its chambers or valves haven't formed correctly, the other parts of the heart have to
work harder to pump blood. This may lead to heart failure.

 Iregular heart rhythms, called arrhythmias. Irregular heart rhythms may cause the heart to
beat too fast, creating extra work for the heart. A slow heartbeat also may lead to heart
failure. Treating an irregular heart rhythm may reverse heart failure in some people.

Causes of sudden heart failure also include:

 Allergic reactions.

 Any illness that affects the whole body.

 Blood clots in the lungs.

 Severe infections.

 Use of certain medicines.

 Viruses that attack the heart muscle.

Heart failure usually begins with the lower left heart chamber, called the left ventricle. This is the
heart's main pumping chamber. But heart failure also can affect the right side. The lower right
heart chamber is called the right ventricle. Sometimes heart failure affects both sides of the heart.

2.1.2 Clinical Manifestations

Symptoms include shortness of breath, fatigue, swollen legs and rapid heartbeat.

People may experience:

 Pain areas: in the chest

 Cough: can be dry or with phlegm

 Whole body: dizziness, fatigue, inability to exercise, or loss of appetite

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  Respiratory: fast breathing, shortness of breath at night, shortness of breath on exercise,
or shortness of breath on lying down

 Gastrointestinal: water retention or bloating

 Also common: frequent urination at night, palpitations, swollen feet, swollen legs, or
weight gain

2.1.3 Diagnosis/Laboratory Test

 Diagnostic hypotheses:
 There’s no one test to diagnose heart failure. Your doctor will consider your medical
history, family history, a physical exam and the results of various tests. These tests can
include:
 Electrocardiogram (EKG): A painless test that gives information about your heart’s
electrical activity, including how fast it beats and whether you’ve had previous heart
attacks.
 Chest X-ray: A picture of the heart, lungs and other chest structures that reveals whether
the heart is enlarged or there are signs of lung damage.
 BNP blood test: B-type natriuretic peptide (BNP) is a hormone that is a marker of
severity and prognosis of heart failure
 Echocardiogram: An ultrasound image of the heart. It’s different from another test, a
Doppler ultrasound, which gives a picture of blood flow to the heart and lungs.

 Holter monitor: A measurement of your heart’s electrical activity, taken by a portable

device that you wear for a day or two.

 Exercise stress test: You walk on a treadmill or ride a stationary bicycle to see how your
heart performs when it has to work hard. If you’re unable to take an exercise test, stress
can be induced by administering a drug that causes a similar reaction.

 Heart failure due to restrictive cardiomyopathy (probably cardiac amyloidosis associated

with multiple myeloma);

 Decompensated heart failure;

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Laboratory tests performed on 9th Nov, 2023, had shown the following results: hemoglobin 13.1
g/dL, hematocrit 40%, mean corpuscular volume (MCV) 87 fL, leukocytes 9,230/mm3 (banded
neutrophils 1%, segmented neutrophils 35%, eosinophils 20%, basophils 1%, lymphocytes 33%,
and monocytes 10%), platelets 222,000 /mm3, cholesterol 207 mg/dL, HDL-cholesterol 54
mg/dL, LDL-cholesterol 138 mg/dL, triglycerides 77 mg/dL, creatine phosphokinase (CPK) 77
U/L, blood glucose 88 mg/dL, urea 80 mg/dL, creatinine 1.2 mg/dL (glomerular filtration rate ≥
60 mL/min/1.73 m2), sodium 131 mEq/L, potassium 6.3 mEq/L, aspartate aminotransferase
(AST) 22 U/L, alanine aminotransferase (ALT) 34 U/L, uric acid 6.3 mg/dL, TSH 1.24 µUI/mL,
free T4 1.36 ng/dL, prostate-specific antigen (PSA) 1.24 ng/mL. On urinalysis, urine specific
gravity was 1.007, pH 5.5, the sediment was normal, and there were no abnormal elements.

New tests (15th Nov, 2023- morning) showed the following results: hemoglobin 11.9 g/dL,
hematocrit 36%, leukocytes 7,780/mm3 (neutrophils 83%, eosinophils 2%, lymphocytes 9%, and
monocytes 6%), platelets 188,000 /mm3, urea 301 mg/dL, creatinine 4.14 mg/dL, sodium 125
mEq/L, potassium 4.4 mEq/L, CRP 97.06 mg/L. On venous blood gas analysis, pH was 7.33,
bicarbonate 19.9 mmol/L, and base excess (-) 5.4 mmol/L. Additional tests performed on the
same day (November 11, 2013 – 5:44 pm) showed hemoglobin of 6.3 g/dL, sodium of 123
mEq/L, potassium of 5.4 mEq/L, venous lactate of 93 mg/dL, PT (INR) of 3.2 and aPTT (rel) of
1.98.

2.1.4 Pathophysiology

Congestive cardiac failure (CCF), also known as heart failure, is a complex syndrome
characterized by the heart's inability to pump blood effectively to meet the body's metabolic
demands. The pathophysiology of CCF involves a series of interrelated mechanisms that
contribute to impaired cardiac function.

1. Impaired Myocardial Contractility:

o Description: The heart's ability to contract and pump blood is compromised.

o Mechanism: Factors such as ischemic heart disease, myocardial infarction, or

cardiomyopathies lead to damage to the heart muscle, reducing its contractility.

2. Volume Overload and Fluid Retention:

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o Description: Inability of the heart to effectively pump blood leads to volume overload and
fluid accumulation in the circulatory system.

o Mechanism: The diminished cardiac output triggers compensatory mechanisms, including

activation of the renin-angiotensin-aldosterone system (RAAS) and increased secretion of
antidiuretic hormone (ADH), resulting in fluid retention and increased preload.

3. Increased Afterload:

o Description: The resistance against which the heart must pump blood is elevated.

o Mechanism: Conditions such as hypertension or stenosis of the aortic valve increase the
afterload, requiring the heart to work harder to eject blood into the systemic circulation.

4. Inflammatory and Immune Responses:

o Description: Inflammation plays a role in the progression of heart failure.

o Mechanism: Inflammatory mediators are released in response to cardiac injury, contributing

to ongoing damage and exacerbating the progression of heart failure.

5. Cellular and Molecular Changes:

o Description: Altered cellular and molecular processes contribute to cardiac dysfunction.

o Mechanism: Molecular changes, such as alterations in calcium handling, energy

metabolism, and apoptosis, impact the function of cardiac myocytes and contribute to the
development of heart failure.

2.1.5 Prevention/Control Measures

Prevention and control measures for heart failure involve a combination of lifestyle
modifications and medical interventions. Here are some key strategies.

1. Lifestyle Modifications:

- Eat a heart-healthy diet: Consume a balanced diet that is low in saturated and trans fats,
cholesterol, and sodium. Include plenty of fruits, vegetables, whole grains, lean proteins, and
healthy fats.

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 - Manage weight: Maintaining a healthy weight reduces the strain on the heart and lowers the
risk of heart failure.

- Avoid smoking: Smoking damages the blood vessels and increases the risk of heart disease.

- Limit alcohol consumption: Excessive alcohol intake can weaken the heart muscle and
contribute to heart failure.

- Exercise regularly: Engage in moderate-intensity aerobic exercises, as approved by your

healthcare provider. Regular physical activity strengthens the heart and improves overall
cardiovascular health.

- Manage stress: Adopt stress management techniques like yoga, meditation, deep breathing
exercises, or engaging in hobbies to reduce stress levels.

- Get enough sleep: Aim for 7-8 hours of quality sleep each night.

2. Medications

- ACE inhibitors, ARBs, beta-blockers, or diuretics may be prescribed to manage heart failure
symptoms and improve heart function.

- Anticoagulant medications might be recommended if a blood clot or atrial fibrillation is

present.

- Medications to manage underlying conditions like high blood pressure, diabetes, and high
cholesterol are important to reduce the risk of heart failure or its progression.

3. Medical Interventions

- Cardiac resynchronization therapy (CRT): This involves the implantation of a device that
helps synchronize the heart's electrical signals, improving its pumping efficiency.

- Implantable cardioverter-defibrillator (ICD): It is a small device implanted under the skin that
delivers electric shocks or pacing to restore normal heart rhythms and prevent sudden cardiac
arrest.

- Ventricular assist devices (VAD): These are mechanical pumps, implanted in the chest, that
help the heart pump blood in cases of severe heart failure.

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 - Heart transplantation: In advanced heart failure cases, a heart transplant may be considered.

4. Regular Medical Check-ups:

- Regularly visit your healthcare provider to monitor your heart function, manage medications,
and address any concerns.

- Follow up on recommended tests, including echocardiograms, blood tests, and

electrocardiograms.

Remember, the management and prevention of heart failure should be tailored to an individual's
specific needs and may require ongoing collaboration with healthcare professionals.

2.3 NURSING MANAGEMENT

2.3.1 INTERPERSONAL/NURSE-PATIENT RELATIONSHIP

The interpersonal relationship between the nurse and a patient is focused on providing effective
healthcare. The nurse-patient relationship is built on trust, empathy, respect, and effective
communication, which are key elements in providing quality care and supporting the patient's
overall well-being.

1. Trust: Trust is the foundation of any healthy relationship, and it is especially important in the
nurse-patient relationship. Patients need to feel confident that their nurse has their best interests
at heart and will provide them with safe and appropriate care. Nurses can establish trust by being
reliable, honest, and maintaining confidentiality.

2. Empathy: Empathy involves understanding and sharing the feelings of others. Showing
empathy helps nurses connect with patients on an emotional level, making them feel heard and
understood. By demonstrating empathy, nurses can provide comfort and support to patients
during challenging times, enhancing the therapeutic relationship.

3. Respect: Respect is fundamental to any relationship, and the nurse-patient relationship is no

exception. Respecting the patient's dignity, autonomy, and individuality is crucial. Nurses should
actively listen to patients, value their input, and involve them in decisions about their care.
Treating patients with respect helps promote their sense of self-worth and fosters a positive
relationship.

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4. Communication: Effective communication is essential in the nurse-patient relationship.
Nurses should strive to communicate clearly, using language that patients can understand. They
should actively listen to patients, encourage questions, and address any concerns or uncertainties.
Open and honest communication helps build trust and minimizes misunderstandings.

5. Advocacy: Nurses often serve as patient advocates, ensuring that their needs and preferences
are recognized and respected. Advocacy involves standing up for the patient's rights, promoting
informed decision-making, and facilitating effective communication with other healthcare
providers. By advocating for their patients, nurses can help empower them and enhance the
nurse-patient relationship.

2.3.4 PHYSICAL EXAMINATION

When conducting a physical examination of a patient with heart failure, it is important to assess
various aspects related to cardiac function and overall health. Here are some key components of
the physical examination:

1. Vital signs: Measure the patient's blood pressure, heart rate, respiratory rate, and temperature.
Elevated blood pressure or an irregular heart rate may indicate worsening heart failure.

2. Inspection: Observe the patient for signs of respiratory distress, such as increased respiratory
effort, use of accessory muscles, or cyanosis (bluish discoloration of the lips and extremities).
Look for signs of fluid retention, including swelling or edema in the lower extremities, abdomen,
or neck veins.

3. Auscultation: Use a stethoscope to listen to the heart sounds. Pay attention to abnormal
sounds such as S3 (ventricular gallop), S4 (atrial gallop), or any additional heart murmurs. These
can indicate ventricular dysfunction, fluid overload, or valvular abnormalities.

4. Palpation: Feel the patient's pulse for its rate, rhythm, and quality. Assess for any
irregularities or rapid, thready pulses commonly seen in heart failure patients. Palpate the
precordial area for any thrills or heaves, which may signify an enlarged heart.

5. Percussion: Perform percussion to assess for dullness or fluid accumulation in the chest,
which can suggest pleural effusion or pulmonary congestion.

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6. Respiratory examination: Auscultate the lungs for crackles or fine rales, which can indicate
pulmonary edema. Evaluate the respiratory effort and assess for signs of respiratory distress or
increased work of breathing.

7. Abdominal examination: Palpate the abdomen for any hepatomegaly (enlarged liver) or
ascites (fluid accumulation). These findings may suggest right-sided heart failure.

Additionally, it may be necessary to check peripheral pulses, measure oxygen saturation, and
perform a neurologic examination if there are concerns about organ perfusion and oxygenation.

Remember, the physical examination should be interpreted in conjunction with the patient's
history, symptoms, and other diagnostic tests to make an accurate diagnosis and guide
appropriate treatment for heart failure. It is essential to consult a healthcare professional for a
comprehensive evaluation and management plan.

2.3.5 VITAL SIGNS

Vitals are:

Pulse: 120,

Respiration: 22,

Temperature: 97.8° F,

Blood Pressure: 150/80, and SpO2% of 94%.

2.3.5 HEALTH EDUCATION

Health Education for a patient with heart failure is essential in managing their condition and
improving their overall quality of life. Here are some important points to consider in a patient's
heart failure education:

1. Understand the condition: Explain to the patient what heart failure is and how it affects their
heart's ability to pump blood effectively. Provide them with information about the causes,
symptoms, and potential complications of heart failure.

2. Medication management: Educate the patient about the medications prescribed to them,
including their purpose, dosage, and potential side effects. Encourage them to take their

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medications as prescribed and discuss any concerns or queries they may have with their
healthcare provider.

3. Diet and Fluid management: Emphasize the importance of adhering to a heart-healthy diet
low in sodium and saturated fats. Encourage the patient to limit their intake of processed foods,
high-sodium snacks, and beverages. Teach them to read food labels and choose low-sodium
alternatives. Discuss fluid restriction if necessary and encourage them to track their daily fluid
intake.

4. Physical activity: Educate the patient on the benefits of regular exercise and encourage them
to engage in a suitable exercise program. Depending on the severity of their condition,
recommend activities such as walking, swimming, or cycling. Explain the importance of starting
slowly and gradually increasing activity levels, always under the guidance of their healthcare
provider.

5. Recognizing and managing symptoms: Teach the patient to recognize the signs and
symptoms of worsening heart failure, such as shortness of breath, swelling of the legs or
abdomen, and fatigue. Instruct them on when to seek medical attention and how to manage
symptoms at home, such as by adjusting their medication or following a specific plan provided
by their healthcare team.

6. Lifestyle modifications: Discuss the importance of quitting smoking and limiting alcohol
consumption. Explain how smoking and excessive alcohol can worsen heart failure symptoms
and increase the risk of complications.

7. Regular follow-up visits: Stress the significance of regular follow-up appointments with their
healthcare provider. These visits allow for monitoring their condition, adjusting medications if
needed, and addressing any concerns or questions the patient may have.

8. Emotional support: Acknowledge the emotional impact of living with heart failure and
provide resources for support, such as patient support groups, counseling services, or educational
materials that focus on coping strategies and stress management.

10. Salt and fluid restriction: Explain the role of sodium in fluid retention and how it can
exacerbate heart failure symptoms. Encourage the patient to limit their sodium intake by
avoiding processed foods, canned goods, and fast food. Provide tips on using herbs and spices to

15
enhance the flavor of their meals instead of relying on salt. Discuss the importance of monitoring
fluid intake and adhering to recommended fluid restrictions.

11. Stress management: Emphasize the impact of stress on heart health and encourage the
patient to develop effective stress-management techniques such as deep breathing exercises,
meditation, yoga, or engaging in activities they enjoy. Stress reduction can help prevent heart
failure exacerbations and promote overall well-being.

12. Importance of weight management: Discuss how maintaining a healthy body weight can
help reduce strain on the heart. Educate the patient on setting realistic weight loss goals and the
benefits of incorporating regular exercise and a balanced diet into their routine.

14. Smoking cessation: If the patient is a smoker, stress the importance of quitting smoking.
Explain how smoking damages blood vessels, increases the risk of heart disease, and worsens
heart failure symptoms. Provide resources and support for smoking cessation, such as nicotine
replacement therapy or smoking cessation programs.

16. Understanding the cardiovascular rehabilitation program: If appropriate, inform the

patient about the benefits of participating in a cardiovascular rehabilitation program. Explain that
these programs involve supervised exercise, education, and support to help individuals with heart
failure improve their physical fitness and overall well-being.

17. Importance of social support: Discuss the significance of a strong support system in
managing heart failure. Encourage the patient to involve family members and close friends in
their journey and to seek support from community resources, such as support groups or online
forums.

18. Recognizing and avoiding triggers: Identify common triggers that can worsen heart failure
symptoms, such as extreme temperatures, heavy physical exertion, excessive alcohol
consumption, and certain medications. Educate the patient on how to minimize exposure to these
triggers to prevent heart failure exacerbations.

2.3.6 Medication

Chronic cardiac failure should be treated immediately once it is diagnosed. The goal of treatment
is to improve patient’s quality of life by alleviating the symptoms, improving exercise tolerance,

16
preventing the progression of myocardial damage as well as reducing hospital admission and
mortality.

Angiotensin-converting enzyme inhibitors (ACEis)

ACE inhibitors are considered as first line therapy in patients with CCF5. They bind to and
inhibit angiotensin converting enzyme which subsequently inhibit the action of angiotensin I. As
a consequence, the production of angiotensin II is prevented. Angiotensin II is a potent
vasoconstrictor which has a direct action on kidney to stimulate the secretion of aldosterone and
antidiuretic hormone (ADH). This will cause sodium and water retention. Hence, ACE inhibitors
improve cardiac function and relieve symptoms of oedema by promoting sodium and water
excretion41. Besides, they also increase the concentration of a potent vasodilator, bradykinin.
This results in a fall in blood pressure as bradykinin is associated with the release of nitric oxide
and prostacyclin. However, high levels of bradykinin also responsible for the main adverse effect
of ACE inhibitors, dry cough42. Other common side effects include hyperkalaemia, profound
hypotension and gastrointestinal disturbances15. ACE inhibitors are contraindicated in patients
with renal impairment even though some studies have shown that they have renal protective
properties43. Example of ACE inhibitors are captopril, enalapril, and ramipril. The starting dose
for ACEis should be low and the dose should be increased gradually to target doses5.

Beta blockers

Beta blockers used to be contraindicated in patients with CCF as it may worsen the condition of
the heart due to its negative inotropic effect. Nowadays, beta blockers should be considered in all
patients with heart failure unless contraindicated5 as they have been shown to reduce the
mortality, hospitalization and the progression of heart failure. Beta blockers should be introduced
following treatment with ACE inhibitor once the patient’s condition is stable7. Only bisoprolol,
carvedilol, and nebivolol are currently licensed to be used in the treatment of heart failure in
UK8. Both nebivolol and bisoprolol are cardioselective where they act on beta1 receptors. On the
other hand, carvedilol is a non-selective beta blocker9, 10. The mode of action of beta blockers
in heart failure is poorly understood but the proposed mechanisms include antiarrhythmic action,
anti-ischaemic action, and attenuation of cathecholamine toxicity as well as reduced cardiac
modelling through blockade of sympathetic influences on the heart9. Besides, carvedilol has an
additional antioxidant property which may be thought to slow down the process of atherogenesis

17
by inhibiting the oxygen-free radicals11, 12. The starting dose should be low as high doses may
worsen the condition of heart failure7. Over time, the dose of beta blocker should be gradually
titrated upward if the patient is well tolerated until target dose is reached5.

Diuretics

Diuretics are often used to relief the congestive symptoms and fluid retention7. Hence, they
should be used in heart failure patients with the symptom of oedema7. Frusemide, a loop diuretic
is the most commonly used agent in heart failure. It is considered as the first choice of drug for
the long-term treatment of CCF with the advantages of improves cardiac function, exercise
tolerance, as well as symptoms of breathlessness and oedema13. The main site of action is at the
thick ascending limb of the loop of Henle. Furosemide acts at the Cl- binding site of
Na+/K+/2Cl- co-transport and as a result, sodium reabsorption is inhibited. This promotes the
excretion of sodium up to 20-25% as well as enhances water clearance13. Consequently, it
reduces the blood volume thus reducing the preload on the heart. As a result, ventricular ejection
is improved and the heart is able to pump more efficiently14. The most common side effect is
hypokalaemia. Hence, it is important that patient’s potassium level and the renal function are
closely monitored.

Aldosterone Antagonists

Patients with moderate to severe heart failure should be considered for the treatment of
aldosterone antagonists such as spironolactone15. It is a potassium sparing diuretic where its
action is mainly on the renin-angiotensin-aldosterone (RAA) system18. Spironolactone prevents
the synthesis of basolateral Na+/K+-ATPase pump protein by acting as a competitive inhibitor at
the aldosterone receptor site in the distal convoluted tubules. As mentioned earlier, aldosterone
promotes sodium and water retention and the use of spironolactone therefore inhibits sodium and
water reabsorption while retains potassium. As a result, spironolactone reduces the workload of
the heart and the heart is therefore able to work more efficiently18. It is often use in conjunction
with other agents such as diuretic in the management of CCF44. Nevertheless, spironolactone
may cause hyperkalaemia, particularly in patients with renal impairment due to the inhibition of
potassium excretion. Hence, the patient’s potassium level and the renal function should be
closely monitored.

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Mineralocorticoid Receptor Antagonists: These medications, such as spironolactone
(Aldactone) and eplerenone (Inspra), help reduce fluid retention and block the effects of a
hormone called aldosterone. They may be prescribed in addition to ACE inhibitors or ARBs.

Digoxin: Digoxin helps strengthen the heart's contractions and can improve symptoms in some
cases. It is usually prescribed when other medications are not sufficient. Close monitoring of
digoxin levels is required due to its narrow therapeutic range.

2.3.7 Diet and nutrition for a patient with heart failure

diet. If you eat too much salt or drink too much fluid, your body's water content may increase
and make your heart work harder. This can worsen your CHF. The following diet will help
decrease some of your symptoms.

Reduce the Salt in Your Diet

Enjoying what you eat is important. Even if you crave salt you can learn to like foods that are
lower in salt. Your taste buds will change soon, and you will not miss the salt. Removing salt can
bring out flavors that may have been hidden by the salt.

Reduce the salt content in your diet by trying the following suggestions:

Choose plenty of fresh fruits and vegetables. They contain only small amounts of salt.

Choose foods that are low in salt, such as fresh meats, poultry, fish, dry and fresh legumes, eggs,
milk and yogurt. Plain rice, pasta and oatmeal are good low-sodium choices. However, the
sodium content can increase if salt or other high-sodium ingredients are added during their
preparation.

Season with herbs, spices, herbed vinegar and fruit juices. Avoid herb or spice mixtures that
contain salt or sodium. Use lemon juice or fresh ground pepper to accent natural flavors. Try
orange or pineapple juice as a base for meat marinades. See "Salt-Free Herb Blends," below, for
other ideas.

Read food labels before you buy packaged foods. Check the nutrition facts on the label for
sodium content per serving. Find out the number of servings in the package. How does the
sodium in each serving compare to the total sodium you can eat each day? Try to pick packaged
foods with a sodium content less than 350 milligrams for each serving. It is also useful to check

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the list of ingredients. If salt or sodium is listed in the first five ingredients, it is too high in
sodium.

When Checking Labels:

Use the nutrition information included on packaged foods. Be sure to notice the number of
servings per container.

When Cooking or Preparing Food:

Shake the habit. Remove the salt shaker from the kitchen counter and table. A 1/8 teaspoon "salt
shake" adds more than 250 milligrams of sodium to your dish.

Be creative. Instead of adding salt, spark up the flavor with herbs and spices, garlic, onions and
citrus juices. See the recipes for salt-free herb blends, below.

Be a low-salt cook. In most recipes, you can cut back on salt by 50 percent or even eliminate it
altogether. You can bake, broil, grill, roast, poach, steam or microwave foods without salt. Skip
the urge to add salt to cooking water for pasta, rice, cereal and vegetables. It is an easy way to
cut back on sodium.

Be careful with condiments. High-sodium condiments include various flavored salts, lemon
pepper, garlic salt, onion salt, meat tenderizers, flavor enhancers, bouillon cubes, catsup,
mustard, steak sauce and soy sauce.

2.4 Medical management/chemotherapy approach

For congestive cardiac failure, medical management may include:

1. Diuretics: To reduce fluid buildup and alleviate symptoms of congestion.

2. Angiotensin-Converting Enzyme (ACE) Inhibitors or Angiotensin II Receptor

Blockers (ARBs): To dilate blood vessels, reduce blood pressure, and improve cardiac
function.

3. Beta-Blockers: To decrease heart rate, reduce blood pressure, and improve the efficiency
of the heart's pumping.

4. Aldosterone Antagonists: To help manage fluid balance and reduce strain on the heart.

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 5. Inotropes: In certain cases, medications to improve the strength of the heart's
contractions.

6. Statins: To manage cholesterol levels and reduce the risk of further cardiovascular
issues.

7. Lifestyle Modifications: Including a low-sodium diet, regular exercise within the

patient's capacity, and fluid restriction.

2.5 Community Mobilization

Community mobilization for congestive cardiac failure (CCF) involves uniting individuals,
healthcare providers, and support networks to enhance awareness, prevention, and management.
By fostering collaboration, communities can create tailored strategies for early detection,
lifestyle interventions, and patient support. Empowering individuals through education and
advocacy helps destigmatize CCF and encourages timely medical intervention. Building social
networks and leveraging community resources contribute to a holistic approach, promoting
heart-healthy behaviors and improving overall well-being for those affected by CCF.

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