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Acute Heart Failure
Acute Heart Failure
Acute Heart Failure
Acute Heart Failure
Acute Heart Failure
Acute Heart Failure
Acute Heart Failure
Acute Heart Failure
Acute Heart Failure
Acute Heart Failure
Acute Heart Failure
Acute Heart Failure
Acute Heart Failure
Acute Heart Failure
Acute Heart Failure
Acute Heart Failure
Acute Heart Failure
Acute Heart Failure
Acute Heart Failure
Acute Heart Failure
Acute Heart Failure
Acute Heart Failure
Acute Heart Failure
Acute Heart Failure
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Acute Heart Failure

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Transcript

  • 1. Acute heart failure AIMS
  • 2.
    • Common emergency presentation
    • High mortality & morbidity in survivors
    • Diagnosis not always straightforward
    • Classic examination findings not sensitive or specific
    • Prompt recognition & stabilization of patient- priority
  • 3.
    • At 40 yrs age- lifetime risk: 21%
    • Increasing prevalence
    • In extremis + rapid deterioration
    • Often respond very rapidly to treatment
    • Very satisfying condition to treat
    • Outlook poor despite initial clinical improvement
  • 4. Presentations
    • Acute SOB, frothy sputum
    • Collapse
    • Shock
    • Cardiac arrest
  • 5. Acute pulmonary oedema
    • SPOTTER
    • Extreme SOB, puffing, unable to speak
    • Profuse sweating, cold clammy extremities
    • Tachycardia irregularity
    • BP fall ±
    • Basal creps
    • Rarely wheeze predominant !!! ( asthma)
  • 6. Collapse/ cardiac arrest
    • Severe HF of any cause:- prone for malignant arrythmias, PE 
    • Present as collapse
    • Very poor outcomes
    • Survival to discharge ???
  • 7. Aetiology
    • CAD
    • Hypertensive heart disease
    • Fluid overload
    • Acute valvular regurgitations
    • Arrythmias
    • Pulmonary embolism
    • Acute hepatic venous thrombosis
    • IWMI+RVMI
    • Tamponade
  • 8. CAD
    • Most common cause
    • Can be the 1 st manifestation
    • SOB >>> chest pain
    • RVMI common in the setting of IWMI
    • LV > 40% infarct size
  • 9. HHD
    • 1 st presentation
    • Accelerated hypertension
    • Onset of HF lowers previously high BP
    • Diastolic dysfunction is the basis
    • Age
  • 10. Pulmonary oedema
    • Mechanisms
      • pulm capillary pressure
      • Capillary permeability
      • Oncotic pressure
  • 11. pulm capillary pressure
    • LA pressure
      • MV disease
      • Arrythmias
      • Aortic valve disease
      • Ischemia
      • cardiomyopathy
    • LVEDP
      • Accelerated HBP
      • Pericardial constriction
      • Fluid overload
      • Reno-vascular disease
      • High-output states
    • Neurogenic
      • IC bleed
      • Cerebral oedema
      • Post-ictal
    • high altitude
  • 12.
    • Capillary permeability
      • ARDS
    • Oncotic pressure fall
      • Loss:- NS, Cirrhosis
      • Production:- cirrhosis, sepsis
      • Dilution:- crystalloids
  • 13.  
  • 14. Investigations
    • ECG
    • Entirely normal # systolic HF
    • ACS
    • Arrythmias
    • Serial ECG always essential
  • 15. Cardiac enzymes
    • Essential to r/o AMI even in the absence of chest pain !!
    • Ideally tropT / trop-I : at presentation & 12 hrs later
    • BNP :- very useful in r/o AMI in a breathless patient
  • 16. CXR
    • NEVER delay treatment pending CXR
    • Portable CXR: cardiomegaly ??
    • Peri-hilar bat’s wing shadowing diagnostic
    • Look for pericardial effusion, pneumothorax, consolidation
  • 17.
    • ECHO:- preferably as early as possible
    • To identify cause
    • Assess LV function,
    • Diastolic dysfunction
    • Cardiac tamponade
  • 18. STABILIZATION
  • 19. Actions in order
    • Propped up position
    • IV Morphine
    • 100% Oxygen
    • IV Lasix
    • Monitor ECG
    • Venous access
    • Ensure optimal BP
    • Emergency blood samples
    • ABG SpO2
  • 20. Assess respiratory function
    • Wheeze: interstitial oedema
    • Aminophylline helpful- bolus
    • Indications for further support
      • Exhaustion
      • Persistent low paO2 < 8kPa
      • Rising pCO2
      • Worsening acidosis
  • 21. Hemodynamic status
    • PCWP > 18 mmHg diagnostic
    BP < 100 > 100
  • 22. Patient in shock
    • Insert central line
    • Renal dose Dopamine ( 2.5-5 µg/kg/mt)
    • Urgent ECHO for any mechanical causes
    • Increase Dopamine (but not > 10-20 )  raises pulm filling prssures
    • Nor adrenaline preferred to high dose dopamine
    • Once Bp restored add vasodilators
  • 23. SBP >100
    • Further doses of IV lasix 60-80 mg q8h or even 20-80 mg/hr infusion
    • NTG infusion at 2-10 mg/hr titrate to keep BP> 100
    • Vasodilators : ACEI
  • 24. THANK YOU

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