Adhf lecture

1,913 views

Published on

Published in: Health & Medicine, Business
0 Comments
1 Like
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
1,913
On SlideShare
0
From Embeds
0
Number of Embeds
825
Actions
Shares
0
Downloads
19
Comments
0
Likes
1
Embeds 0
No embeds

No notes for slide

Adhf lecture

  1. 1. Congestive Heart Failure 10 Minute Review Kona Seng PGY-3 ARMC Emergency Medicin July 20, 2011
  2. 2. They Say... <ul><li>“ HF is a clinical syndrome that occurs in patients who because of an inherited or acquired abnormality of cardiac structure and/or function, develop a constellation of clinical symptoms (dyspnea and fatigue) and signs (edema and rales) that lead to frequent hospitalizations, poor quality of life, and a shortened life expectancy.” </li></ul><ul><ul><ul><ul><li>Dr. Mark Robinson </li></ul></ul></ul></ul>
  3. 3. We Say... <ul><li>“ That pt looks kind of shitty.” </li></ul><ul><ul><ul><li>Dr. Dorian Snyder </li></ul></ul></ul>
  4. 4. Epidemiology <ul><li>23 million worldwide </li></ul><ul><li>5.8 million in the US </li></ul><ul><li>Affects 6-10% over 65 years of age </li></ul><ul><li>20% of hospital admissions </li></ul><ul><li>$12 billion </li></ul>
  5. 5. ADHF <ul><li>Acute Decompensated Heart Failure </li></ul><ul><li>Dyspnea with elevated cardiac filling pressures </li></ul><ul><li>Often with accumulation of fluid in the lung’s interstitial and alveolar spaces </li></ul><ul><li>Hemodynamic stabilization, supportive oxygenation and ventilation, and symptom relief. </li></ul>
  6. 6. Dr. Dan Arellano (Resident) <ul><li>Initial insult to the heart </li></ul><ul><li>Compensatory mechanisms </li></ul><ul><li>Eventual deterioration </li></ul><ul><li>Progressive LV remodeling </li></ul>
  7. 7. Dr Dan Arellano (Attending Physician) <ul><li>Preload </li></ul><ul><li>Afterload </li></ul><ul><li>LV Dysfunction </li></ul><ul><li>It’s coming in </li></ul>
  8. 8. 5 points <ul><li>Airway </li></ul><ul><li>3591 </li></ul><ul><li>Diuretics </li></ul><ul><li>Nitrates </li></ul><ul><li>Ace-Inhibitors </li></ul>
  9. 9. Have faith in your attending
  10. 10. 5 points <ul><li>Airway </li></ul><ul><li>3591 </li></ul><ul><li>Medications: Diuretics/Nitrates/ACE </li></ul><ul><li>BNP </li></ul><ul><li>Admission Criteria </li></ul>
  11. 11. 3591 <ul><li>Cardiac arrest </li></ul><ul><li>Resp arrest </li></ul><ul><li>Encephalopathy </li></ul><ul><li>UGI Bleed </li></ul><ul><li>Hemodynamic instability </li></ul><ul><li>Unstable arrhythmia </li></ul><ul><li>Inability to cooperate/protect airway </li></ul><ul><li>Inability to clear secretions </li></ul><ul><li>High risk for aspiration </li></ul>
  12. 12. Noninvasive Ventilation in Acute Cardiogenic Pulmonary Edema: A Systematic Review and Analysis Masip J, et al. JAMA 2005 <ul><li>MEDLINE EMBASE COCHRANE </li></ul><ul><li>CPAP/BIPAP vs Standard Oxygen Therapy </li></ul><ul><li>15 trials selected </li></ul><ul><li>Decreased intubations </li></ul><ul><li>Reduced mortality by 45% </li></ul>
  13. 13. Effect of Non-invasive Positive PRessrue Ventilation on Mortality in Patients with Acute Cardiogenic Pulmonary Edema Peter JV et al. Lancet 2006 <ul><li>Metanalysis </li></ul><ul><li>Lower mortality rate </li></ul><ul><li>No difference between CPAP and BIPAP </li></ul>
  14. 14. CPAP/BIPAP <ul><li>Improvements in PaO2, FiO2, pH, RR, HR, SpO2 </li></ul><ul><li>Reduction in the need for intubation </li></ul><ul><li>Decrease short term mortality </li></ul><ul><li>Use it </li></ul><ul><li>Call for it early </li></ul>
  15. 15. 5 points <ul><li>Airway </li></ul><ul><li>3591 </li></ul><ul><li>Nitrates </li></ul><ul><li>Ace-Inhibitor </li></ul><ul><li>Diuretics </li></ul>
  16. 16. Nitrates <ul><li>Most commonly used vasodilator </li></ul><ul><li>Reduces your preload </li></ul><ul><li>Increased stroke volume and cardiac output </li></ul><ul><li>Lowers rates of intubation, ICU admissions </li></ul><ul><li>IV? 5-10mcg/min increased by 5-10mcg every 3-5min </li></ul><ul><li>PO? 400mcg </li></ul>
  17. 17. Improved CLinical Outcomes <ul><li>Cotter G. Randomized trial of high dose isosorbide dinatrate plus low dose Lasix vs High Dose Lasix plus low dose isosorbide Dinaitrate. Lancet 1998 </li></ul><ul><li>Nashed AH. IV Nitro boluses in treating pts with cardiogenic pulmonary edema. Ann Emerg Med 1997 </li></ul><ul><li>Levy P. Treatment of Severe Decompensated Heart Failure with High-dose IV Nitro: a feasibility and outcome analysis. Ann Emerg Med 2007 </li></ul>
  18. 18. Ace Inhibitors <ul><li>No large randomized controlled trials </li></ul><ul><li>Short term benefit </li></ul><ul><li>Early use associated with rapid improvements (6-12 min) </li></ul><ul><li>HD patients </li></ul>
  19. 19. Rapid Improvement of Acute Pulmonary Edema with Sublingual Captopril Hamilton RJ et al. Acad Emerg Med 1996 <ul><li>Compared Captopril vs Placebo </li></ul><ul><li>Subjective improvement in clinical symptoms over first 40 minutes. </li></ul><ul><li>Adding Captopril to standard regiment produces more rapid results </li></ul><ul><li>Less intubations: 9% vs 20% </li></ul>
  20. 20. Diuretics <ul><li>“ Patients admitted with HF and with evidence of significant fluid overload should be treated with intravenous loop diuretics. Therapy should begin in the ED without delay.” </li></ul><ul><ul><ul><ul><ul><li>2009 ACCF/AHA Heart Failure Guidelines </li></ul></ul></ul></ul></ul>
  21. 21. Diuretic Optimization Strategies Evaluation (DOSE) <ul><li>“ Low intensification” therapy will be more efficacious and safer when compared to “high intensification” therapy.” </li></ul><ul><li>“ Continuous infusion diuretic therapy will be more efficacious when compared with twice daily bolus therapy” </li></ul><ul><li>Among pts with ADHF, there were no significant differences in pts’ global assessment of symptoms or in the change in renal function when diuretic therapy was administered by bolus as compared with continuous infusion or at a high dose as compared to a low dose. </li></ul><ul><ul><ul><ul><ul><li>N Engl J Med 2011; 364:797-805 </li></ul></ul></ul></ul></ul>
  22. 22. The Dark Side of Diuretics? <ul><li>High quality data support for safety and efficacy are sparse </li></ul><ul><li>Activation of RAA system? </li></ul><ul><li>Increased SVR? </li></ul><ul><li>Worsening renal function? Electrolyte abnormalities? </li></ul><ul><li>Increased Mortality? </li></ul>
  23. 23. Prehospital management of Congestive Heart Fialure Mattu A et al. Heart Failure Clin 2009 <ul><li>“ Renewed focus on aggressive use of nitrates, optimization of airway support,and rapid transport.” </li></ul><ul><li>“ The use of Lasix and Morphine has become de-epmhasized.” </li></ul>
  24. 24. Diuretics <ul><li>Probably not 1st line medication </li></ul><ul><li>Diuresis occurs in 90 minutes </li></ul><ul><li>Questions as to whether it worsens cardiac parameters early on </li></ul><ul><li>Make IM happy.... </li></ul>
  25. 25. Acutely Decompensated Heart Failure in a county ED: A double-blind randomized controlled comparison of Nesiritide vs Placebo for Treatment Miller, AH et al. Ann Emerg Med 2008 <ul><li>100 patients </li></ul><ul><li>NYHA Class II to IV </li></ul><ul><li>Administration of nesiritide was not better than standard therapy alone for return to the ED or hospitalization at 30 days. </li></ul>
  26. 26. Nesiritide <ul><li>“ Routine use of Nesiritide for the management of acute decompensated heart failure in the ED is not recommended.” </li></ul><ul><ul><ul><ul><ul><li>EMedHome 7/1/2011 </li></ul></ul></ul></ul></ul>
  27. 27. Summary <ul><li>Preload, Afterload, LV Dysfunction </li></ul><ul><li>Must haves: CPAP/Nitro/Ace-Inhibitors </li></ul><ul><li>Maybe haves: Diuretics </li></ul><ul><li>Must not haves: Nesiritide </li></ul>
  28. 28. Colin MacNeil Linebacker <ul><li>Born 4/5/83 </li></ul><ul><li>First Team All-CIF Honors </li></ul><ul><li>3 time First Team All SCIAS </li></ul><ul><li>Occidental Coaches Award in 02’ 03’ and 04’ </li></ul><ul><li>Neurophysiology research grant in 2003 </li></ul><ul><li>ESPN Academic All-America 2004 </li></ul><ul><li>John Zinda Award 2004 </li></ul><ul><li>Wine Consultant in Valencia, CA </li></ul><ul><li>Volunteer Guatemala </li></ul><ul><li>Considering fields of IM, GSurg, or EM </li></ul>

×