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  • 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