what new in acute heart failure
TRANSCRIPT
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WH Ts NEW IN CUTE HE RTFAILUREINTENsIVIsTs PERsPECTIVE
Dr Mukesh Kumar Gupta(MD,FNB)
Senior consultant critical care medicine
Medanta The Medicity, Gurgaon
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DEFINITIONS OF HE RT F ILUREHeart failure is a clinical syndrome characterized by
decreased systemic perfusion, inadequate to meet
the body's metabolic demands as a result of impaired
cardiac pump function - Cleveland Clinic
A pathophysiologic state in which an abnormality of
cardiac function is responsible for failure of the heart
to pump blood at a rate commensurate with metabolic
requirements of the tissues -E Braunwald
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DEFINITION OF HF
Physiological:
Inability of the heart to pump sufficient
oxygenated blood to the metabolizing tissues
despite an adequate filling pressure.
Working Clinical Definition:
Clinical syndrome consisting of symptoms such
as breathlessness, fatigue, and swelling of
ankle caused by cardiac dysfunction.
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DEFINITION OF ACUTE HEART FAILURE
ACUTE HFis defined as a rapid onset orchange in the signs and symptoms of HF,
resulting in the need of urgent therapy
It may present as new HF or worsening HF in
presence of chronic HF
It may be associated with worsening
symptoms or signs or as a medical
emergency such as acute pulmonary edema
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TYPES OF HEART FAILURE
Chronic Heart Failure (CHF)
Acute Heart Failure (Cardiogenic Shock)
Systolic Failure (LVSD):HF-rEF
Diastolic Heart Failure (LVDD):HF-PEF
Left Heart Failure (LVF)
Right Heart Failure (Congestive CCF)
Forward Failure and Backward Failure
High output failure -Thyrotoxicosis, Paget's,Anemia, Pregnancy, A-V fistula
Low output failureforms 95% of HF
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HEART FAILURE SOME STATISTICS
Affects 10% of people over 65 years
Affects over 50% of people with 85+ years
Approx 10% of patients with HF die each yr.
Most common condition for which patients 65 +
require admission to hospital
It is NOT a single disease A syndrome
Results from any cardiac disorder that impairs
the ability of the ventricles to fill with or eject
blood
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EPIDEMIOLOGY OF HEART FAILURE
Clinical criteria Prevalence 1-2 %
Males > Females; in 65+ Prevalence 7%
50% of LVSD is asymptomatic
NEF HF varies from 15 to 50%
Incidence 0.2 to 0.3 %; es with age
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EPIDEMIOLOGY OF HEART FAILURE
Data from Framingham Heart Study per 1000 population
Prevalence
Age Men Women 5059 8 8
8089 66 79
All ages 7.4 7.7
Incidence
Age Men Women
5059 3 2
8089 27 22
All ages 2.3 1.4
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GRADING OF HEART FAILURE
NYHA classification
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GRADING OF HEART FAILURE
ACC/AHAclassification
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TWO CLASSIFICATIONS OF THE SEVERITY OF HEART FAILURE IN THE
CONTEXT OF ACUTE MYOCARDIAL INFRACTION
Killip Classification Forrester Classification
Designed to provide a clinical estimate of the severity ofcirculatory derangement in the treatment of acute
myocardial infarction
Designed to describe clinical and haemodynamicstatus in acute myocardial infarction
Stage I No heart failure
No clinical signs of cardiac decompression
1) Normal perfusion and pulmonary wedge
pressure (PCWP estimate of atrial pressure)
2) Poor perfusion and low PCWP (hypovolemic)
3) Near normal perfusion and high PCWP(pulmonary oedema)
4) Poor perfusion and high PCWP (cardiogenic
shock)
Stage II Heart failure
Diagnostic criteria include rales. S3 gallop andpulmonary venous hypertension.
Pulmonary congestion with wet rales in the
lower half of the lung fields
Stage III Severe heart failure.
Frank pulmonary oedema with rales throughout
the lung fields
Stage IV Cardiogenic shock
Signs include hypotension (SBP
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SYSTOLIC HEART FAILURE (HF-REF)
Most common type of Heart Failure; 60-70% LV is usually dilated & enlarged.
Fails to contract normally due to WMA &
Ischemia
Cannot pump sufficient blood to meet needs
Normal ejection fraction (EF) is at least 50-
55%
In LVSD heart failure the EF is
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Normal Systolic Function
Systolic Dysfunction
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DIASTOLIC HEART FAILURE (HF-PEF)
Accounts for 20-40% of patients
Ventricles are normal-sized with normalemptying
But there is an impairment in the ability of theventricles to fill with blood during diastole -because of stiff myocardium due to
hypertrophy The heart fails to relax normally (relaxation
poor)
Generally affects older women
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NORMAL MITRAL INFLOW PATTERN
EA
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DIASTOLIC RELAXATION IMPAIRMENT
E- 57 cm/s
A- 117 cm/s
dtE- 257 ms
E/A 240 msec, IVRT- >90 msec
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IVRT
Normal
RelaxationDefect
Pseudo-
Normalization
Restrictive
pattern
MITRAL INFLOW PATTERNS
A
E
E/A 240 ms,
IVRT- >90 ms
E/A 0.9-1.5,
dtE- 160-240
ms,
IVRT- 2,
dtE-
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MITRAL ANNULAR TISSUE DOPPLER
e- 1.9 cm/s
Mitral inflow E/e= 67/1.9 = 30 s/o LVEDP
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CAUSES AND PRECIPITATING FACTORS OF AHF
Ischemic heart disease
Acute coronary syndromes
Mechanical complications of acute MI
Right ventricular infarction
Valvular
Valve stenosis Valvular regurgitation
Endocarditis
Aortic dissection
Myopathies
Post partum cardiomyopathy
Acute myocarditis
Hypertension / arrhythmia
Hypertension
Acute arrhythmia
Circulatory failure
Septicemia
Thyrotoxicosis
Anaemia
Shunts
Tamponade
Pulmonary embolism
Decompensation of preexisting
chronic HF
Lack of adherence
Volume overload
Infections, especially pneumonia
Cerebrovascular insult
Surgery
Renal dysfunction
Asthma, COPD
Drug abuse
Alcohol abuse
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CHANGING PATTERN OF ETIOLOGY
McMurray J J, Stewart S Heart 2000;83:596-
602
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MECHANISMS OF HEART FAILURE
Restricted Filling: MS, Restrict CM, Constr Pericarditis
Pressure Load on Ventricle: HT, AS, PS, Coarctation
Volume load on Ventricle: MR, AR, VSD, TR, PR
Myocardial Contraction: CAD, DCM, Myocarditis
Arrhythmia: Severe Brady or Tachycardia, AF, HB
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FRANK-STARLING CURVES
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PATHOPHYSIOLOGY OF HF
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Acutelydecompensated
ChronicHF
Cardiogeni
c shock
ACS
and HF
CLINICAL CLASSIFICATION OF ACUTE HEART
FAILURE
Hypertensive
AHF
Pulmonar
y oedema
Right HF
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DIAGNOSIS OF HEART FAILURE
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ALGORITHM FOR THE DIAGNOSIS OF
HEART FAILURE
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InitiaI assessment of patient with suspected acute heart failure
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E.D. EVALUATION OF ACUTE HEART FAILURE
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HYPERTENSIVE ACUTE HEART FAILURE
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HYPOTENSIVE ACUTE HEART FAILURE
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NORMOTENSIVE ACUTE HEART FAILURE
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A CLINICAL ASSESSMENT OF PATIENTS WITH AHF
Dry and warm Wet and warm
Dry and cold Wet and cold
Pulmonary congest ion
Tissueper
fus
ion
Clinical classi f icat ions
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ASSESSMENT OF LV FUNCTION IN AHF
Tavazzi L, Maggioni AP, Lucci D, et al: Nationwide survey on acute heart failure in
cardiology ward services in Italy. Eur Heart J 2006; 27:12071215
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ECHOCARDIOGRAPHY. EXTREMELY USEFUL
Determining LV ejection fraction
Volume and dimensions
Wall motion abnormalities
Valvular function
Presence or absence of endocarditis
With the tissue Doppler obtain an estimate of the LV end
diastolic pressure by determining the E:E ratio. When the
diagnosis of ADHF is in doubt a markedly elevated E:E ratio
suggests elevated LV enddiastolic pressure
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INVASIVE HEMODYNAMIC MONITORING
Invasive hemodynamic monitoring should be consideredin
a patient:
Who is refractory to initial therapy
Whose volume status and cardiac filling pressures are unclear
Who has clinically significant hypotension (typically SBP < 80 mm
Hg) or worsening renal function during therapy
Or who is being considered for cardiac transplant and needs
assessment of degree and reversibility of pulmon. hypertension
Or in whom documentation of an adequate hemodynamic response
to the inotropic agent is necessary because of end organ
dysfunction.
LindenfieldJ et at. HFSA 2010 Comprehensive Heart FailureGuidelines. J Card Fail 2010:16e1-e 194.
GOALS OF TREATMENT IN ACUTE HEART FAILURE
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GOALS OF TREATMENT IN ACUTE HEART FAILURE
Immediate (ED/ICU/CCU)
Improve symptoms
Restore oxygenation Improve organ perfusion and haemodynamics
Limit cardiac / renal damage
Minimize ICU length of stay
Intermediate (in hospital)
Stabilize patient and optimize treatment strategy
Initiate appropriate (life saving) pharmacological therapy
Consider device therapy in appropriate patients
Minimize hospital length of stay
Long term and pre-discharge management
Plan follow up strategy
Educate and initiate appropriate lifestyle adjustments
Provide adequate secondary prophylaxis
Prevent early readmission
Improve quality of life and survival
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INITIAL TREATMENT ALGORITHM IN AHF
Acute heart failure
Immediate symptomatic treatment
Patient distressed or in pain
Arterial oxygen saturation
Analgesia, sedation
Pulmonary congestion
Yes
Normal heart rate and rhythm
Medical therapy
Diuretic vasodilatorYes
Increase FiO2Consider CPAP,
NIPPV, mechanicalventilation
Les
s
Pacing,
Antirrhythmics
electroversionN0
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INDICATIONS AND DOSING OF DIURETICS IN AHF
Fluid retention DiureticDaily dose
(mg)
Comments
Moderate Furosemide or
Bumetanide or
Torasemide
20 40
0.5 1
10 - 20
Oral or i.v. according to clinical symptoms
Titrate dose according to clinical response
Monitor K, Na, creatinine, blood pressure
Severe Furosemide
Furosemide infusion
Bumetanide
Torasemide
40 100
5 40 mg/h
1 4
20 100
i.v. Increase dose.
Better than very high bolus doses
Oral or i.v.
Oral
Refractory or
loop diuretic
Add hydrochlorthiazide
Or metalazone
Or spironolactone
50 100
2.5 10
25 50
Combination better than very high dose of
loop diuretics
MTZ more potent if creatinine clr < 30ml/min
Spironolactone best choice if no renal failure
and normal or low serum potassium
With alkalosis Acetazolamide 0.5 mg i.v.
Refractory to
loop diuretics
and thaizides
Add dopamine (renal
vasodilation) or
dobutamine
Consider ultrafiltration or haemodialysis if co-
existing renal failure
Hyponatraemia
INTRAVENOUS VASODILATORS USED TO TREAT
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INTRAVENOUS VASODILATORS USED TO TREAT
ACUTE HF
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DOSING OF POSITIVE INOTROPIC AGENTS IN AHF
* This agent also has vasodilator properties
** In hypotensive patients (SBP < 100 mmHg) initiation of therapy without a bolus is recommended
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TREATMENT STRATEGY IN AHF ACCORDING TO LV FILLING
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TREATMENT STRATEGY IN AHF ACCORDING TO LV FILLING
PRESSURE
Pulmonary congestion andSBP > 90 mmHg
Adequate CO
Reversal of acidosis
SvO2 > 65%
Adequate organ perfusion
Vasodilators, diuretics
if volume overload
Adequate filling pressure
Yes
Fluid challengeNo
Increase FiO2Consider CPAP,
NIPPV, mechanical
ventilation
No
Reassess frequentlyYes
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DEVICES IN MANAGING HEART FAILURE
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CIRCULATORY ASSIST DEVICES
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CURRENT AHA RECOMMENDATIONS OF
IABP
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PROS AND CONS OF IABP
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IABP IN HIGH RISK STEMI
IABP did not show any benefit in Mortality but
showed an increase in strokes
And bleeding.
CRITERIA FOR IMPLANTATION OF A VENTRICULAR
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CRITERIA FOR IMPLANTATION OF A VENTRICULAR
ASSIST DEVICE
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PERCUTANEOUS LVAD
Left Ventricular Assist Device
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ADVANTAGES AND DISADVANTAGES OF
LVAD
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IABP VERSUS LVAD
30 Day Mortality was not superior to IABP
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EXTRACORPOREAL MEMBRANE
OXYGENATION
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DEVICES IN ADHF - SUMMARY
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HEART TRANSPLANTATION
IINDICATIONS
HEART TRANSPLANTATION
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HEART TRANSPLANTATION
cCONTRA INDICATIONS
TREATMENT GOALS AND STRATEGIES
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TREATMENT GOALS AND STRATEGIES
DURING THE COURSE OF THE PATIENTS JOURNEY
Phase Diagnostic strategy Action Goals Players
Acute Assess clinical status
Identify cause of
symptoms
Treat and stabilize
Initiate monitoring
Plan required interventions
Stabilze, admit and
triage to
appropriate
department
Paramedics
Primary care/ER
physicians
Intensivists
Nurses
Cardiologists
Subacute Assess cardiac function
Identify aetiology and
co-morbidities
Initiate chronic medical
treatment
Perform additional
diagnostics
Perform indicated
procedures
Shorten
hospitalization
Plan post
discharge follow
up
Hospital physicians
Cardiologists
CV nurses
HF management team
Chronic Target symptoms,adherence and
prognosisIdentify decompensation
early
Optimize pharmacological
and device treatment
Support self care behaviourRemote monitoring
Reduce morbidity
and mortality
Primary care
physicians
HF management teamCardiologists
End of life Identify patient concernsand symptoms
Symptomatic treatment
Plan for long term care
Palliation
Provide support
for patients and
family
Palliative care team
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RECOMMENDED COMPONENTSOF HF M N GEMENT PROGR MMES
Multidisciplinary approach frequently led by HF nurses in collaboration with
physicians and other related services
First contact during hospitalization, early follow-up after discharge through
clinic and home based visits, telephone support and remote monitoring
Target high risk symptomatic patients
Increased access to health care (telephone, remote monitoring and follow up)
Facilitate access during episodes of decompensation
Optimised medical management
Access to advanced treatment options
Adequate patient education with special emphasis on adherence and self caremanagement
Patient involvement in symptom monitoring and flexible diuretic use
Psychosocial support to patients and family and/or caregiver
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CONCLUSION
Heart failure remains a major contributor to
hospitalizations, morbidity and mortality in India and
worldwide.
Early recognition, understanding pathophysiology
and prompt treatment of AHF would help in
management and improve long term outcome.
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THANK YOU