heart failure acute
TRANSCRIPT
DEFINITION, CLASSIFICATION MONITORING, AND TREATMENT
OF ACUTE HEART FAILURE
Department of Cardiology and Vascular MedicineDivision of Cardiovascular, Department of Internal
MedicinePadjadjaran University School of Medicine
Hasan Sadikin HospitalBandung
ACUTE HEART FAILURE IS A CHALENGING DISORDER
1. Highly prevalent especially among the elderly
2. High rate of hospital readmission, early recurrent
events, and mortality
3. Progressive disorder
4. Heterogeneity in etiology and LV function
5. Characteristic, management, and outcomes have
been poorly defined
MECHANISM OF HEART
FAILURE
Vena cava
Arteri pulmonali
s
Vena pulmonal
is
Aorta
Atrium kananKatup
trikuspid
Katup mitral
Atrium kiri
Ventrikelkanan
Ventrikelkiri
Paru
SIRKULASI JANTUNG PARU
PERFORMANCE OF THE VENTRICLE
1. PRELOAD
2. CONTRACTILITY
3. AFTERLOAD
Mekanisme Frank-Starling
Volume akhir diastolik ventrikel (preload)
Isi
seku
ncup
Meningkatnya preload akan diikuti oleh meningkatnya kontraktilitas sehingga isi sekuncup akan meningkat pula
Pressure
overload
Volume
overload
Myocardial
contractility
Compensatory
mechanism
Normal pumping function
Heart failure
MECHANISM OF HEART FAILURE
adequate
failed
DEFINITION and
CLASSIFICATION of
HEART FAILURE
DEFINITION OF HEART FAILURE
The heart fails to pump blood
commensurate with the requirement of the
metabolizing tissue
orThe heart can pump blood commensurate
with the requirement of the metabolizing
tissue only from an elevated filling
pressure
HEART FAILURE
DIASTOLIC
SYSTOLIC
RA
RV
LA
LV
HEART FAILURE
BACKWARD
FORWARD
RA
RV
LA
LV
HEART FAILURE
LEFT
RIGHT
RA
RV
LA
LV
HEART FAILURE
ACUTE
CHRONIC
RA
RV
LA
LV
DEFINITION OF CHRONIC AND ACUTE HEART FAILURE
Definition of Chronic Heart Failure
• A syndrome in which patients have symptoms of HF (dyspnea and fatigue) with evidence of cardiac dysfunction and a clinical response to treatment directed to HF alone (The ESC guidelines) 1
• A clinical syndrome as a result of cardiac dysfunction that impairs the ability of the ventricle to fill and eject blood, producing symptomatic manifestation of HF (The ACC/AHA guidelines) 2
1. Remme WJ, Swedberg K. Eur Heart J 2001;22:1521-60
2. Hunt SA et al. Circulation 2001;104:2996-3007
Definition of Acute Heart Failure
Acute heart failure is characterized by a
rapid or gradual onset of sign and
symptoms of heart failure, resulting in
unplanned hospitalization or office or
emergency room visits. Nieminen MS, Harjola V-P. Am J Cardiol 2005;96(suppl):5G-10G
CLINICAL SEVERITY CLASSIFICATION(For Chronic Heart Failure: Hospitalized or
Outpatients)
PERFUSION : warm or coldCONGESTION: dry or wet
Class Classification
I Warm and dry
II Warm and wet
III Cold and dry
IV Cold and wet
Nohria A TS et al. J Am Coll Cardiol 2003;41:1797-1804
INADEQUATE PERFUSION (COLD)
• pulse pressure
• Cool extremities
• Altered mentation
• ACE-I intolerance
• Worsening renal
functionNohria A TS et al. J Am Coll Cardiol 2003;41:1797-1804
PULMONARY CONGESTION (WET)
• Orthopnea
• Rales
• JVP
• Abdominojugular reflux
• Hepatomegali
• Ascites
• EdemaNohria A et al. J Am Coll Cardiol 2003;41:1797-1804
Six-month mortality by determined hemodynamic profiles
Patient profile N (%) Six-month mortality
(%)
Dry-war 123 (27) 11
Wet-warm 222 (49) 22
Wet-cold 91 (20) 40
Dry-cold 16 (4) 17
Nohria A et al. J Am Coll Cardiol 2003;41:1797-1804
The New York Heart Association functional classification
Class ClassificationI Patients with cardiac disease but without limitation of
physical activity. Ordinary physical activity does not cause undue fatique, palpitation, dyspnea, or anginal pain
II Patients with cardiac disease resulting in slight limitation of physical activity. They are comfortable at rest. Ordinary physical activity results in fatique, palpitation, dyspnea, or anginal pain
III Patients with cardiac disease resulting in marked limitation of physical activity. They are comfortable at rest. Less than ordinary physical activity results in fatique, palpitation, dyspnea, or anginal pain
IV Patients with cardiac disease resulting in inability to carry on any physical activity without discomfort. Symptoms of cardiac insufficiency or anginal syndrome may be present even at rest. If any physical activity is undertaken, discomfort is increased
Goldman L et al. Circulation 1981;64:1227
KILLIP CLASSIFICATION
STAGE I : No clinical signs
STAGE II : Heart failure. Diagnostic criteria: rales S3 gallop and pulmonary veins hypertension. Pulmonary congestion with wet rales in the lower half of the lung fields
STAGE III : Severe heart failure. Frank pulmonary edema with rales over the lung filds
STAGE IV : Cardiogenic shock. Signs: hypotension (SBP 90 mm Hg), and evidence of peripheral vasoconstriction such as oliguria, cyanosis and diaphoresis
FORRESTER CLASSIFICATION
Adapted from Forester et al. Am J Cardiol 1977;39:137
0,5
1
1,5
2
2,5
3
3,5
0 5 10 15 20 25 30 35 40
CI (
L/m
/m2 )
18
2.2
PCWP (MM Hg)
Hypovolemia Pulmonary congestion
Normal
Hypovolemic shock
Cardiogenic shock
DiureticsVasodilators: NTG, Nitropruside
Mortality 22.4% Mortality 55.5%
Hyp
oper
fusi
on
Fluid administration
H-I C-I
H-II C-II
H-III C-III
H-IV C-IV
Pulmonary edema
Mortality 2.2% Mortality 10.1%
Fluid administration
Normal BP: vasodilatorReduced BP: inotropics or vasopressor
The routine use of invasive
hemodynamic monitoring in
patients with ADHF is not
recommended. (Strength of
Evidence A)Adams Jr, KF, Lindenfeld J, Arnold JMO, et al. Executive Summary: HFSA 2006 Comprehensive
Heart Failure Practice Guideline. J Cardiac Failure 2006;12:10–38.
TREATMENT GOALS
Aim of Treatment
FEEL BETTER OR
LIVE LONGER
Clinicians want to treat AHF rapidly by adding new therapies
GOAL OF TREATMEN
T
QoL improvement
Morbidity and mortality reduction
• Improve symptoms, especially congestion and low-output symptoms
• Optimize volume status• Identify etiology • Identify precipitating factors• Optimize chronic oral therapy• Minimize side effects• Identify patients who might benefit from
revascularization• Educate patients concerning medications and self
assessment of HF• Consider and, where possible, initiate a disease
management program
Treatment Goals for Patients Admitted for ADHF
Adams Jr, KF, Lindenfeld J, Arnold JMO, et al. Executive Summary: HFSA 2006 ComprehensiveHeart Failure Practice Guideline. J Cardiac Failure 2006;12:10–38.
Patient distressed or in pain
Analgesia or sedation
Arterial O2 saturation 95%Increase Fi02, considered CPAP
Normal heart rate and rhythm
Pacing, antiarrhythmics
Mean BP 70 mm Hg
Vasodilators, consider diuresis if volume overload
Adequate preload
Yes
No
No
Yes
No
Yes
Yes
No
No
Yes
Fluid challenge
Adequate CO, metabolic acidosis, SvO2 65%, inadequate perfusion
No consider inotropes or afterload manipulation
Rapid improvement of symptoms is
a desire goal, but should not
become the only goal in managing
AHF.
Many treatment modalities shown
to improve symptoms were shown
to increase mortality.
Intravenous vasodilators (intravenous
nitroglycerin or nitroprusside) and
diuretics are recommended for rapid
symptom relief in patients with acute
pulmonary edema or severe
hypertension.
(Strength of Evidence C)Adams Jr, KF, Lindenfeld J, Arnold JMO, et al. Executive Summary: HFSA 2006 ComprehensiveHeart Failure Practice Guideline. J Cardiac Failure 2006;12:10–38.
Intravenous inotropes (milrinone or
dobu-tamine) are not recommended
unless left heart filling pressures are
known to be elevated based on direct
measurement or clear clinical signs.
(Strength of Evidence B)Adams, KF, Lindenfeld J, Arnold JMO, et al. Executive Summary: HFSA 2006 Comprehensive
Heart Failure Practice Guideline. J Cardiac Failure 2006;12:10–38.