ACUTE HEART

FAILURE

R A C H M A T RA S A D I

S U P E R V I SO R :

D R . M R

I DW A N M

. AP P S

P. J P

DEFINITION

Heart failure can be defined as an abnormality of cardiac structure or function leading to failure of the heart to deliver oxygen at a rate commensurate with the requirements of the metabolizing tissues

Acute heart failure is defined as the rapid onset of symptomsand signs secondary to abnormal cardiac function. It may occur with or without previous cardiac disease. The cardiac dysfunction can be related to systolic or diastolic dysfunction, to abnormalities in cardiac rhythm, or to pre-load and after-load mismatch.

EPIDEMIOLOGYApproximately 1–2% of the adult population in developed

countries has HF, with the prevalence rising to ≥10% among persons 70 years of age or older.

CLASSIFICATIONNew York Heart Association functional classification based on severity of symptoms and physical activityClass I No limitation of physical activity. Ordinary physical activity

does not cause undue breathlessness, fatigue, or palpitations.Class II Slight limitation of physical activity. Comfortable at rest,

but ordinary physical activity results in undue breathlessness, fatigue, or palpitations.

Class III Marked limitation of physical activity. Comfortable at rest, but less than ordinary physical activity results in undue breathlessness, fatigue, or palpitations.

Class IV Unable to carry on any physical activity without discomfort. Symptoms at rest can be present. If any physical activity is undertaken, discomfort is increased.

PATHOPHYSIOLOGY OF AHF

The vicious circle in the acute failing heartMyocardial stunningHibernation

DIAGNOSE

SIGN AND SIMPTOMSymptoms SignsTypical More SpecificBreathlessness Elevated jugular Venous PressureOrthopnoea Hepatojugular refluxParoxysmal nocturnal dyspnoae Third Heart Sound (gallop rhythm)Reduced exercise tolerance Laterally displaced apical impulseFatigue, tiredness, increased time to recover after exercise

Cardiac murmur

Ankle swelling  Less typical Less spesificNocturnal cough Peripheral oedemWheezing Pulmunary crepitationsWeight gain (>2kg/week) Reduced air entry and dullness to

precussion at lung bases (plueral effusion)

Weight loss TachycardiaBloated feeling Irreguler pulseLoss of appetice TachypnoeaConfusion HepatomegalyDepression AscitesPalpitation Tissue wastingSyncope  

MOST COMMON ABNORMALITIES ON THE ELECTROCARDIOGRAM IN HEART FAILURE

LABORATORY TEST IN PATIENT HOSPITALIZED WITH AHF

Blood count AlwaysPlatelet count AlwaysINR If patient anticoagulated or in

severe heart failure

CRP AlwaysD-dimer Always (may be falsely positiveif

CRP elevated or patient has been hospitalized forprolonged period)

Urea and Electrolytes(Naþ, Kþ, Urea, Creatinine)

Always

Blood glucose AlwaysCKMB, cardiac TnI/TnT AlwaysArterial blood gases In severe heart failure, or in

diabetic patients

Transaminases To be consideredUrinanalysis To be consideredPlasma BNP or NTproBNP To be considered

TREATMENTThe goals of treatment in patients with established HF are to

relieve symptoms and signs (e.g. oedema), prevent hospital admission,and improve survival. Although the focus of clinical trials waspreviously mortality, it is now recognized that preventing HFhospitalization is important for patients and healthcare systems.

Angiotensin converting enzyme (ACE)-inhibitorsDiureticsβ-blockerDigoxin and other digitalis glycosidesVasodilators

COMPLICATION

Coronary artery diseaseValvular diseaseAortic dissectionRenal failurePulmonary diseases and bronchoconstriction

PROGNOSISMany variables provide prognostic information, although most

of this can be obtained from readily available data such as age, aetiology, NYHA class, EF, key co-morbidities (renal dysfunction, diabetes, anaemia, hyperuricaemia), and plasma natriuretic peptide concentration.

Patients with AHF have a very poor prognosis.

THANK YO

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