ahf in ed 2008
TRANSCRIPT
Acute Heart Failure
Rapid onset of s/sx secondary to abnormal cardiac function (systolic/diastolic dysfx;
arrythmias; preload & afterload mismatch)
Causes of Acute heart failure
• Acute de novo heart failure:– Myocardial Infarction
– Uncontrolled Hypertension
– Myocarditis
• Acute decompensation of chronic heart failure
Distinct clinical condition
• Acute decompensated HF• Hypertensive AHF• Pulmonary edema• Cardiogenic shock• High output failure
Congestion at Rest
LowPerfusion
at Rest
No
No Yes
Yes
Warm & Dry Warm & Wet
Cold & WetCold & Dry
Signs/symptoms of congestion Orthopnea/PND JVD Ascites Edema Rales (rare in HF)
Possible evidence of low perfusion Narrow pulse pressure Sleepy/obtunded Low serum sodium
Cool extremities Hypotension with ACE inhibitor Renal dysfunction (one cause)
Stevenson LW. Eur J Heart Fail. 1999;1:251
Hemodynamic Profile Assessment
Yes
Stevenson LW. Eur J Heart Fail. 1999;1:251
No
Warm & DryPCWP normal
CI normal (compensated)
Cold & WetPCWP elevatedCI decreased
Cold & DryPCWP low/normal
CI decreased
VasodilatorsNitroprussideNitroglycerin
Inotropic DrugsDobutamine
MilrinoneCalcium Sensitizers
Normal SVR
High SVR
Congestion at Rest
LowPerfusion
at Rest
No
Yes
Warm & WetPCWP elevated
CI normal
Natriuretic PeptideNesiritide or
Patient Selection and Treatment
Treatment of Acute Heart Failure ‘treat the cause’
• AMI:– Reperfusion therapy, if possible i.e. thrombolytic
therapy or primary PTCA• Other complications
– surgery for ruptured VSD, severe mitral regurgitation– Arrhythmias – pacing for bradycardia; cardioversion
for AF, VT– Cardiac tamponade - drainage