Congestive cardiac failure (CCF) actually means right-sided heart failure. There is inability of the
right ventricle to propel blood resulting in backflow of blood to systemic veins causing engorged
vein, enlarged liver and dependent oedema (Table 2).

Causes of CCF

• Secondary to left sided heart failure (common cause).
• Mitral stenosis with pulmonary hypertension.
• Chronic cor pulmonale due to any cause.
• Pulmonary hypertension.
• Pulmonary valve disease (stenosis or regurgitation).
• Tricuspid regurgitation.
• Shunt anomaly (ASD, VSD), when there is reversal of shunt (Eisenmenger’s syndrome).
• Cardiomyopathy.
• Right ventricular myocardial infarction.


• Breathlessness on exertion, cough with mucoid sputum.
• Palpitation.
• Pain in right upper abdomen (due to hepatomegaly).
• Swelling in legs.
• Weakness, weight loss.
• Anorexia, nausea, vomiting.
• Oliguria, nocturia.


• Pulse—low volume.
• BP—may be low.
• JVP—engorged and pulsatile.
• Dependent pitting oedema—in legs or sacral oedema if lying.

Precordium examination

• Visible cardiac impulse.
• Apex beat—may be shifted.
• Thrill—absent or present, according to the cause.
• Heart sounds according to the vulvular lesion .
• Murmur, according to the vulvular lesion.


• Liver is enlarged and tender.
Cardinal Signs of Congestive Cardiac Failure
• Engorged and pulsatile neck veins.
• Enlarged and tender liver.
• Dependent pitting oedema.


• X-ray chest—shows cardiomegaly.
• ECG.
• Echocardiogram.
• Others—CBC, ESR, urea, creatinine, electrolytes, lung function test (if COPD).


• Complete rest.
• Restriction of fluid and salt.
• Diuretic—frusemide, bumetanide, aldosterone antagonist (e.g. spironolactone, eplerenone).
• Vasodilator (ACE inhibitor or ARB).
• Beta-blocker (bisoprolol 1.25 mg daily and gradually increase the dose over 12 weeks up to
10 mg daily).
• Digoxin (helpful in CCF with atrial fibrillation).
• Treatment of arrhythmia (e.g. amiodarone).
• Treatment of the underlying cause.
• Heart transplantation—if all above measures fail.

Complications of Digoxin

• Extracardiac—
–– Gastrointestinal—anorexia, nausea, vomiting, diarrhoea.
–– Altered colour vision (xanthopsia).
–– Others—weight loss, confusion, headache, gynaecomastia.
• Cardiac—
–– Bradycardia.
–– Multiple ventricular ectopics.
–– Ventricular bigeminy.
–– Atrial tachycardia with variable block.
–– Ventricular tachycardia.
–– Ventricular fibrillation.

Treatment of Digoxin Toxicity

• Digoxin should be stopped.
• Serum electrolytes, creatinine and digoxin level should be checked.
• Correction of electrolytes, if any.
• If bradycardia—IV atropine, sometimes pacing may be needed.
• Correction of arrhythmia.

Causes of Biventricular Failure