Ahf In Ed 2008
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Ahf In Ed 2008

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  • Hemodynamic Profile Assessment The hemodynamic profiles of patients with advanced HF are shown above. The majority (90%) of patients presenting with ADHF are volume overloaded (wet). These patients may have a cardiac index that is unchanged or decreased. Most patients with a decreased cardiac index have SVR, although a minority have unchanged or low SVR. The signs and symptoms of congestion include orthopnea, jugular venous distention, and peripheral edema. Signs and symptoms of low perfusion include narrow pulse pressure, cool extremities, and decreased mental status. Stevenson LW. Eur J Heart Fail . 1999;1:251
  • Patient Selection and Treatment This quadrant diagram depicts hemodynamic profiles of patients with advanced HF. Signs and symptoms of congestion: orthopnea/paroxysmal nocturnal dyspnea, jugular venous distension, hepatomegaly, edema, rales (rare in chronic HF), elevated PA pressure, and valsalva square wave. Signs and symptoms of low perfusion: narrow pulse pressure, sleepy/obtunded, low serum sodium, cool extremities, hypotension with ACE inhibitor, renal dysfunction. The majority of patients with HF are volume overloaded or wet. These patients may have cardiac index that is unchanged or decreased. Most patients with decreased cardiac index have elevated systemic vascular resistance; however, a minority have unchanged or low SVR. Vasodilators can reduce filling pressures and improve cardiac output without risks of arrhythmia. Can transition to oral vasodilator regimen. Patients with signs of systemic hypoperfusion who are dry would be expected to have therapeutic benefits with volume loading and/or inotropic agents. Stevenson LW. Eur J Heart Fail . 1999;1:251

Ahf In Ed 2008 Ahf In Ed 2008 Presentation 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
  • Hemodynamic Profile Assessment Congestion at Rest Low Perfusion at Rest No No Yes Yes Warm & Dry Warm & Wet Cold & Wet Cold & Dry
    • Signs/symptoms
    • of congestion
    • Orthopnea/PND
    • JVD
    • Ascites
    • Edema
    • Rales (rare in HF )
    Stevenson LW. Eur J Heart Fail. 1999;1:251
    • Possible evidence of low perfusion
    • Narrow pulse pressure
    • Sleepy/obtunded
    • Low serum sodium
    • Cool extremities
    • Hypotension with ACE inhibitor
    • Renal dysfunction (one cause)
  • Patient Selection and Treatment Yes Stevenson LW. Eur J Heart Fail. 1999;1:251 No Warm & Dry PCWP normal CI normal (compensated) Cold & Wet PCWP elevated CI decreased Cold & Dry PCWP low/normal CI decreased Vasodilators Nitroprusside Nitroglycerin Inotropic Drugs Dobutamine Milrinone Calcium Sensitizers Normal SVR High SVR Congestion at Rest Low Perfusion at Rest No Yes Warm & Wet PCWP elevated CI normal Natriuretic Peptide Nesiritide or
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  • 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