What is acute heart failure ?
ACUTE HEART FAILURE
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| Heart-Failure |
History & physical
A- History
¤ >1 million hospitalizations for heart failure per year in US alone.
A- History
¤ >1 million hospitalizations for heart failure per year in US alone.
What is acute heart failure?
Acute heart failure is a sudden, life-threatening condition in which the heart is unable to do its job. The heart is still beating, but it cannot deliver enough oxygen to meet the body's needs. This condition requires emergency medical care.
Acute heart failure is a sudden, life-threatening condition in which the heart is unable to do its job. The heart is still beating, but it cannot deliver enough oxygen to meet the body's needs. This condition requires emergency medical care.
¤ Acute heart failure (AHF):
° Pulmonary edema (3%).
¤ Dyspnea: exertional, orthopnea, paroxysmal nocturnal, “cardiac asthma”
¤ Non-productive cough
¤ Reduced exercise capacity
¤ Generalized weakness and fatigue
¤ Nocturia, oliguria
¤ Confusion, poor memory, insomnia, anxiety, headache, delirium.
2- Right-sided heart failure
Tests:
¤ Basic Blood Tests:
° Often normal, except for other comorbidities, especially indicators of CHF or myocardial infarction.
° Electrolytes:
° BNP (B-type natriuretic peptide) or ntpro-BNP:
¤ Abnormal ventricular or atrial rhythm.
¤ Acute bronchitis/ asthma
¤ Pneumonia
¤ Sepsis
¤ Cardiogenic Shock
° Other non-cardiogenic pulmonary edema (Intravenous narcotics, increased intracerebral pressure, high altitude, transfusion reactions, DIC).
Management
¤ Treat underlying etiology (i.e. myocardial infarction – primary PCI, thrombolysis.
A- General Measures:
¤ Usually more comfortable sitting upright with legs dangling.
¤ Restore and maintain oxygenation:
cardiogenic shock, symptomatic hypotension, SBP < 90
° Relative Contraindications:
catastrophic loss of cardiac function (loss of myocyte function: ischemia/ infarction, inflammation, edema,trauma, post-cardiac bypass, alcohol binge or other toxic substance use/ exposure; structural: papillary muscle rupture, (VSD).
° Rapid onset of symptoms
° Preceding viral illness
° Angina or anginal equivalent.
° Rapid onset of symptoms
° Preceding viral illness
° Angina or anginal equivalent.
What causes heart failure?
Sudden, or acute, heart failure can be caused by an injury or infection that damages your heart, a heart attack, or a blood clot in your lung.
¤ Acute heart failure syndrome (AHFS):
gradual or rapid change in heart failure signs and symptoms resulting in a need for urgent therapy. Approximately 30–60% of patients will have normal systolic function.
° Preceding viral illness
° Angina or anginal equivalent
° Prior myocardial infarction or systolic dysfunction
° Hypertension or other restrictive cardiomyopathy
° Progressive increase in weight, peripheral edema, bloating, dyspnea
° Relatively gradual onset of symptoms
¤ AHFS clinical presentations
¤ Acute decompensated heart failure, de novo or decompensation of chronic heart failure (40–50% of patients).
° Hypertensive acute heart failure (40–50%).
° Preceding viral illness
° Angina or anginal equivalent
° Prior myocardial infarction or systolic dysfunction
° Hypertension or other restrictive cardiomyopathy
° Progressive increase in weight, peripheral edema, bloating, dyspnea
° Relatively gradual onset of symptoms
¤ AHFS clinical presentations
¤ Acute decompensated heart failure, de novo or decompensation of chronic heart failure (40–50% of patients).
° Hypertensive acute heart failure (40–50%).
° Pulmonary edema (3%).
Acute Heart Failure:
° Cardiogenic shock (1%).
° High-output failure (1%).
° Right heart failure.
° Cardiogenic shock (1%).
° High-output failure (1%).
° Right heart failure.
What is acute vs congestive heart failure?
Congestive heart failure (CHF):
refers to the inadequate functioning of the heart muscle such that fluid builds up in the lungs, abdomen, feet, and arms (hence the term "congestive"). The condition can either be acute (meaning it occurs suddenly, with a sharp rise) or chronic (which means it occurs over the long term).
What are the signs of heart failure?
Signs & Symptoms:
¤ Dyspnea: exertional, orthopnea, paroxysmal nocturnal, “cardiac asthma”
¤ Non-productive cough
¤ Reduced exercise capacity
¤ Generalized weakness and fatigue
¤ Nocturia, oliguria
¤ Confusion, poor memory, insomnia, anxiety, headache, delirium.
¤ Nausea, abdominal discomfort, anorexia.
¤ Consistent with underlying or inciting pathophysiology.
¤ General: distressed, dyspneic, pallor, diaphoresis, cardiac cachexia, jaundice (acute hepatic congestion).
¤ Vital signs: tachycardia (frequent), hypotension or transient hypertension, narrow pulse pressure, tachypnea, low grade fever.
¤ Respiratory: rales, pleural effusion, Cheyne-Stokes respiration pattern.
¤ CV: jugular venous distension,hepato/abdomino-jugular reflux, pulsus alternans (severe), cardiomegaly, LV heave, RV lift, soft S1, loud P2, S3, S4, systolic murmur (functional MR/TR).
¤ Abdominal: hepatomegaly, ascites
¤ Extrem: peripheral, sacral and scrotal edema.
¤ Consistent with underlying or inciting pathophysiology.
¤ General: distressed, dyspneic, pallor, diaphoresis, cardiac cachexia, jaundice (acute hepatic congestion).
¤ Vital signs: tachycardia (frequent), hypotension or transient hypertension, narrow pulse pressure, tachypnea, low grade fever.
¤ Respiratory: rales, pleural effusion, Cheyne-Stokes respiration pattern.
¤ CV: jugular venous distension,hepato/abdomino-jugular reflux, pulsus alternans (severe), cardiomegaly, LV heave, RV lift, soft S1, loud P2, S3, S4, systolic murmur (functional MR/TR).
¤ Abdominal: hepatomegaly, ascites
¤ Extrem: peripheral, sacral and scrotal edema.
What are the types of heart failure?
1- Left-sided heart failure
Left-sided heart failure is the most common type of heart failure.
2- Right-sided heart failure
The right heart ventricle is responsible for pumping blood to your lungs to collect oxygen.
3- Diastolic heart failure.
4- Systolic heart failure.
3- Diastolic heart failure.
4- Systolic heart failure.
Tests:
What blood test are done for heart failure?
¤ Basic Blood Tests:
° Often normal, except for other comorbidities, especially indicators of CHF or myocardial infarction.
° Electrolytes:
Hyponatremia (dilutional or secondary hyperaldosteronism), hypokalemia (diuretic use), hyperkalemia (K-sparing diuretic, K replacement, renal failure),hypophosphatemia,hypomagnesemia (diuretics use, alcohol).
° BUN/ creatinine:
° BUN/ creatinine:
Prerenal azotemia.
° Cardiac enzymes:
° Cardiac enzymes:
elevated troponin or CK-MB (myocardial injury).
What is BNP in heart failure?
What is BNP in heart failure?
° BNP (B-type natriuretic peptide) or ntpro-BNP:
suggestive of elevated cardiac filling pressures or ventricular wall stress; in patents with dyspnea, high levels supportive of heart failureetiology; may be elevated in right-sided heart failure (i.e., corpulmonale, pulmonary embolus).
° D-dimers:
° D-dimers:
occasionally used to assist in dDx of pulmonary embolus.
° Liver function tests:
° Liver function tests:
AST, ALT, LDH, direct and indirect bilirubin elevated in congestive hepatopathy.
° TSH:
° TSH:
hypo- or hyperthyroidism
¤ Basic Urine Tests:
° Proteinuria, high specific gravity, acellular casts.
¤ Specific Diagnostic Tests:
° Chest X-ray:
¤ Basic Urine Tests:
° Proteinuria, high specific gravity, acellular casts.
¤ Specific Diagnostic Tests:
° Chest X-ray:
cardiomegaly (size and shape can assist with dx); pulmonary vascular redistribution, interstitial pulmonary edema (Kerley B lines, perivascular, subpleural effusion), alveolar edema (“butterfly pattern”).
° Electrocardiogram:
° Electrocardiogram:
ischemia/ infarction; evidence of LVH, prior MI, arrhythmias.
° Echocardiogram:
° Echocardiogram:
Cardiac function, structure, wall motion and valvular abnormalities.
¤ Other Tests as Appropriate:
° Radionuclide Ventriculogram (RVG; MUGA):
¤ Other Tests as Appropriate:
° Radionuclide Ventriculogram (RVG; MUGA):
Cardiac function,wall motion abnormalities.
° Exercise or pharmacologic stress testing:
° Exercise or pharmacologic stress testing:
assess myocardial ischemia risk.
° Cardiac catheterization:
° Cardiac catheterization:
define coronary anatomy, possible.
Interventions:
Differential diagnosis:
Interventions:
Differential diagnosis:
¤ Abnormal ventricular or atrial rhythm.
¤ Acute bronchitis/ asthma
¤ Pneumonia
¤ Sepsis
¤ Cardiogenic Shock
° Other non-cardiogenic pulmonary edema (Intravenous narcotics, increased intracerebral pressure, high altitude, transfusion reactions, DIC).
Management
What is the first line of treatment for heart failure?
Loop diuretics should be used as first-line agents, with thiazides added for refractory fluid overload. Diuretic treatment should be combined with a low-salt diet, a β-blocker, and an ACE inhibitor.
What to do first?
¤ Check and monitor vital signs, oxygenation and ECG.
¤ Evaluate for underlying etiology (see differential diagnosis), especially sepsis, myocardial ischemia/ infarction, cardiac mechanicalabnormalities (valvular, VSD, etc..).
¤ Evaluate for underlying etiology (see differential diagnosis), especially sepsis, myocardial ischemia/ infarction, cardiac mechanicalabnormalities (valvular, VSD, etc..).
¤ Treat underlying etiology (i.e. myocardial infarction – primary PCI, thrombolysis.
A- General Measures:
¤ Usually more comfortable sitting upright with legs dangling.
¤ Restore and maintain oxygenation:
supplemental oxygen, non-invasive positive pressure ventilation (BiPAP), mechanical ventilation, morphine.
¤ Reduce volume overload (preload):
¤ Reduce volume overload (preload):
diuretics, nitrates, morphine,nesiritide, ultrafiltration
¤ Reduce afterload:
¤ Reduce afterload:
nitroprusside, nitroglycerin, nesiritide
¤ Improve cardiac function:
¤ Improve cardiac function:
positive inotropes (dobutamine, milrinone), intra-aortic balloon counterpulsation, left ventricular assist device.
¤ Maintain blood pressure, renal perfusion:
¤ Maintain blood pressure, renal perfusion:
dopamine (low dose).
¤ Consider Swann-Ganz pulmonary artery catheter to measure cardiac output, PCWP and vascular resistances and guide therapy, especially if:
° Cardiogenic shock/ near shock unresponsive to fluid challenge
° Unresponsive pulmonary edema, especially with hypotension or shock
° Assist in diagnosis between cardiogenic and non-cardiogenic etiology
B- Specific therapy:
Indications for Treatment:
¤ Poor oxygenation
¤ Poor peripheral perfusion
¤ Poor central perfusion
¤ Volume overload
¤ Hypotension
Treatment Options:
1- Morphine:
¤ Consider Swann-Ganz pulmonary artery catheter to measure cardiac output, PCWP and vascular resistances and guide therapy, especially if:
° Cardiogenic shock/ near shock unresponsive to fluid challenge
° Unresponsive pulmonary edema, especially with hypotension or shock
° Assist in diagnosis between cardiogenic and non-cardiogenic etiology
B- Specific therapy:
Indications for Treatment:
¤ Poor oxygenation
¤ Poor peripheral perfusion
¤ Poor central perfusion
¤ Volume overload
¤ Hypotension
Treatment Options:
1- Morphine:
intravenous, subcutaneous (in mild cases)
° Indication:
Reduce preload, decrease anxiety and hyperadrenergic state
° Side Effects and Complications:
Decreased ventilatory drive with possible CO2 retention, hypotension, paralytic ileus, toxic megacolon, seizures, somnolence, constipation, urinary retention,dizziness, dry mouth, headache, nausea/ vomiting, rash.
° Absolute Contraindications:
Narcotic-induced pulmonary edema, respiratory depression, paralytic ileus.
° Relative Contraindications:
Neurogenic pulmonary edema,seizure disorder, increased intracerebral pressure,
2- Intravenous loop diuretics (furosemide, torsemide, bumetanide,ethacrynic acid):
° Indication:
Reduce preload, decrease anxiety and hyperadrenergic state
° Side Effects and Complications:
Decreased ventilatory drive with possible CO2 retention, hypotension, paralytic ileus, toxic megacolon, seizures, somnolence, constipation, urinary retention,dizziness, dry mouth, headache, nausea/ vomiting, rash.
° Absolute Contraindications:
Narcotic-induced pulmonary edema, respiratory depression, paralytic ileus.
° Relative Contraindications:
Neurogenic pulmonary edema,seizure disorder, increased intracerebral pressure,
2- Intravenous loop diuretics (furosemide, torsemide, bumetanide,ethacrynic acid):
bolus and/ or infusion. May be combined with thiazide diuretics (oral or IV) for potentiation of effect
° Indication:
- Volume overload, reduce preload.
° Side Effects and Complications:
renal failure, thrombocytopenia, orthostatic hypotension, dizziness, dry mouth, headache,nausea/ vomiting, dyspepsia, impotence, rash, hypokalemia, arrhythmias, muscle cramps, ototoxicity.
° Absolute Contraindications:
° Indication:
- Volume overload, reduce preload.
° Side Effects and Complications:
renal failure, thrombocytopenia, orthostatic hypotension, dizziness, dry mouth, headache,nausea/ vomiting, dyspepsia, impotence, rash, hypokalemia, arrhythmias, muscle cramps, ototoxicity.
° Absolute Contraindications:
hepatic coma
° Relative Contraindications:
° Relative Contraindications:
anuria, severe electrolyte depletion
3- Nitroglycerin:
3- Nitroglycerin:
sublingual, intravenous, topical (decreased absorption in shock states); requires careful blood pressure monitoring
° Indication:
° Indication:
Reduce preload, treat ischemia, mild afterload reduction
° Side Effects and Complications:
° Side Effects and Complications:
hemolytic anemia, methemoglobinemia, headache, dizziness, hypotension, syncope, angina, reflex tachycardia, nausea/ vomiting, edema rash.
° Absolute Contraindications:
° Absolute Contraindications:
Increased intracerebral pressure, cerebral hemorrhage, symptomatic hypotension, angle-closure glaucoma
° Relative Contraindications:
° Relative Contraindications:
stroke, hypotension, severe anemia
4- Nitroprusside:
4- Nitroprusside:
IV; careful blood pressure monitoring advised (often
invasive), follow thiocyanate levels
° Indication:
invasive), follow thiocyanate levels
° Indication:
Reduces preload and afterload
° Side Effects and Complications:
° Side Effects and Complications:
cyanide/thiocyanate toxicity,methemoglobinemia, headache, dizziness, hypotension, syncope, angina, reflex tachycardia, nausea/vomiting, edema rash
¤ Absolute Contraindications:
¤ Absolute Contraindications:
increased intracerebral pressure,cerebral hemorrhage, symptomatic hypotension
° Relative Contraindications:
° Relative Contraindications:
stroke, hypotension, severe anemia
5- Nesiritide:
5- Nesiritide:
IV, recombinant human B-type natriuretic peptide; requires careful blood pressure monitoring.
° Indication:
° Indication:
Reduce preload, afterload reduction; improve symptoms of dyspnea
° Side Effects and Complications:
° Side Effects and Complications:
headache, dizziness, hypotension, syncope, nausea/vomiting, occasional worsening of renal function.
° Absolute Contraindications:
° Absolute Contraindications:
cardiogenic shock, symptomatic hypotension, SBP < 90
° Relative Contraindications:
stroke, hypotension, severe anemia, significant valvular stenosis, restrictive or obstructive cardiomyopathy, constrictive pericarditis, pericardial tamponade, or other conditions in which cardiac output is dependent upon venous return, or for patients suspected to have low cardiac filling pressures
6- Dobutamine:
6- Dobutamine:
intravenous; requires blood pressure and ECG monitoring.
° Indication:
° Indication:
Increases myocardial contractility, mildly reduces preload, mild afterload reduction
° Side Effects and Complications:
° Side Effects and Complications:
arrhythmias, hypotension, asthma exacerbation, nausea/ vomiting, headache, angina,thrombocytopenia, local injection site reaction.
° Absolute Contraindications:
° Absolute Contraindications:
IHSS, severe obstructive valvular disease.
° Relative Contraindications:
° Relative Contraindications:
hypertension, recent MI, arrhythmia, volume depletion.
7- Milrinone:
7- Milrinone:
intravenous, many centers no longer use bolus dose to avoid hypotension; requires careful blood pressure and ECG monitoring; may consider if patient on a beta-blocker.
° Indication:
° Indication:
Increases myocardial contractility, mildly reduces preload, afterload reduction.
° Side Effects and Complications:
° Side Effects and Complications:
arrhythmias, hypotension, nausea/ vomiting, headache, angina, myocardial infarction, local injection site reaction.
° Absolute Contraindications:
° Absolute Contraindications:
IHSS, severe obstructive valvular disease, myocardial infarction
° Relative Contraindications:
° Relative Contraindications:
hypertension, arrhythmia, volume depletion.
8- Dopamine:
8- Dopamine:
IV, low dose for “renal effects”; requires careful blood pressure and ECG monitoring.
° Indication:
° Indication:
Increases myocardial contractility, mildly reduces preload, afterload reduction.
° Side Effects and Complications:
° Side Effects and Complications:
arrhythmias, hypotension, nausea/ vomiting, headache, angina, myocardial infarction, local necrosis at injection site reaction.
° Absolute Contraindications:
pheochromocytoma, IHSS, severe obstructive valvular disease.
° Relative Contraindications:
hypertension, arrhythmia, volume depletion, myocardial infarction, severe peripheral vascular disease.
9- Ultra-filtration:
° Absolute Contraindications:
pheochromocytoma, IHSS, severe obstructive valvular disease.
° Relative Contraindications:
hypertension, arrhythmia, volume depletion, myocardial infarction, severe peripheral vascular disease.
9- Ultra-filtration:
may require only peripheral IV lines; may preserve
renal function, avoid hypokalemia and reduce rehospitalization.
° Indication:
renal function, avoid hypokalemia and reduce rehospitalization.
° Indication:
usually used for large volume removal.
° Side Effects and Complications:
Hypotension, filter and access
complications, risks associated with anticoagulation
° Absolute Contraindications:
Uncontrolled symptomatic hypotension.
10- Intra-Aortic Balloon Counterpulsation Pump:
° Side Effects and Complications:
Hypotension, filter and access
complications, risks associated with anticoagulation
° Absolute Contraindications:
Uncontrolled symptomatic hypotension.
10- Intra-Aortic Balloon Counterpulsation Pump:
usually inserted via femoral artery; requires invasive blood pressure and ECG monitoring.
° Indication:
° Indication:
Augments diastolic coronary flow and forward output, afterload reduction.
° Side Effects and Complications:
° Side Effects and Complications:
arrhythmias, headache, nausea/vomiting, peripheral vascular insufficiency, emboli, infarction and gangrene, aortic dissection, rupture, pericardial tamponade.
° Absolute Contraindications:
° Absolute Contraindications:
aortic insufficiency, aortic aneurysm or dissection
° Relative Contraindications:
° Relative Contraindications:
severe peripheral vascular disease.
Follow-up:
A- During Treatment:
¤ Often requires intensive care or telemetry unit monitoring early in course of treatment
¤ Monitor electrolytes, especially potassium, and renal functionRoutine
B- Follow-up after treatment of acute episode:
A- During Treatment:
¤ Often requires intensive care or telemetry unit monitoring early in course of treatment
¤ Monitor electrolytes, especially potassium, and renal functionRoutine
B- Follow-up after treatment of acute episode:
diagnose and treat underlying abnormalities (ischemia, hypertension).
¤ Emphasize lifestyle changes such as reduced sodium intake, compliance with medications.
Complications and Prognosis:
¤ Complications usually related to underlying pathophysiology.
¤ 3–5% in-hospital mortality.
¤ 10–25% 6-month mortality.
¤ Emphasize lifestyle changes such as reduced sodium intake, compliance with medications.
Complications and Prognosis:
¤ Complications usually related to underlying pathophysiology.
¤ 3–5% in-hospital mortality.
¤ 10–25% 6-month mortality.
