Acute heart failure, ESC 2021 GL

1. Acute Heart Failure
(ESC 2021 Guidelines)
ICC-CME 2022
Dr. Awad Youssef Zeid, MSc.
Cardiologist
ICC, Alexandria.

2. Road map

3. • 32 year male patient.
• DCM (LVEF=20%, moderate MR, severe TR, ESPAP=60mmHg.
• NYHA class 2 “2 years ago”.
Presentation:
• Flu symptoms 1 week ago.
• Then shortness of breath NYHA class 4, orthopnea and LL oedema.

4. Examination on admission:
• Orthopnea.
• HR 100 Bpm SR, SPO2=96%.
• BP 100/70 mmHg, well felt pedal pulsations.
• JVP elevated upto angle of mandible, systolic expansion.
• Bilateral LL oedema up to both knees.
• Chest auscultation: diminished air entry over right lower 1/3, bilateral
basal fine inspiratory crepitations.
• Precordial auscultation: S3 gallop, accentuated P2, soft pansystolic
murmur over apex.

5. • ECG: NSR “QRS duration 120 msec”.
• LAB:
• Hb 11 gm/dl. Uric acid 7.1mg/dl.
• Na 126 meq/L SGPT 84 mg/dl
• K 4.6 meq/L SGOT 75 mg/dl
• Urea 72 mg/dl Albumin 3.4 mg/dl
• Creatinine 1.3 mg/dl INR 1.2

6. Medications:
• Ramipril 5 mg tab. OD
• Torsamide 20 mg tab. OD
• Carvidilol 12.5 mg tab. Bid
• Ivabradine 5 mg tab. Bid
• Eplernone 25 mg tab. OD
• Pantoprazole 40 mg tab. OD

7. Metro this way ..…….
Management this way ………

8. Question 1
Which clinical profile fit this patient?
1- Warm-dry
2- Warm-wet
3- Cold-dry
4- Cold-wet

10. 4 Clinical presentations of AHF:

11. Question 1
Which clinical profile fit this patient?
2- Warm-wet

14. Question 2
• What is the initial pharmacological management:
• 1- Increase dose of oral Torsamide.
• 2- Shift to IV Torsamide or Furosamide.
• 3- Stop Carvidilol.
• 4- Increase Ramipril dose.
• 5- Stop Ramipril and start Sacubitril/Valsartan.

18. Question 2
• What is the intial pharmacological management:
• 2- Shift to IV Torsamide or Furosamide.

22. Question: 3
• Which strategy?
• 1- IV continuous infusion.
• 2- IV intermittent boluses.

25. Question: 3
• Which strategy?
• 1- IV continuous infusion.
• 2- IV intermittent boluses.
Both are true

26. IV continuous infusion
• Plasma diuretic concentration is above the threshold most of the
time.
• Borderline blood pressure.
• Inadequate response to intermittent boluses administration.

27. Question: 4
• In this patient what is the starting dose of iv furosemide?
1- 20 mg and evaluate after 6 hours.
2- 20 mg every 8 hours and evaluate after 24 hours.
3- 40 mg every 8 hours and evaluate after 24 hours.
4- 40-80 mg and evaluate after 6 hours.

29. Question: 4
• In this patient what is the starting dose of iv furosemide?
1- 20 mg and evaluate after 6 hours.
2- 20 mg every 8 hours and evaluate after 24 hours.
3- 40 mg every 8 hours and evaluate after 24 hours.
4- 40-80 mg and evaluate after 6 hours.

30. Question: 5
Within 6 hours, dyspnea mildly improved and UOP reached 1 L, what to
do next?
1- Give another furosamide dose after 6 hours of the intial dose.
2- Continue IV furosemide once daily.
3- Give another IV bolus of furosemide 40 mg now.

31. Monitor “on daily basis”
• Symptoms and clinical signs of
congestion.
• Weight.
• UOP and fluid balance.
• Serum electrolytes.
• Rend functions.

34. Diuretic resistence

35. Question: 6
How to manage sodium level?
1- Salt restriction.
2- Increase salt intake.
3- Fluid restriction.
4- Hypertonic saline.

36. Question: 6
How to manage sodium level?
1- Salt restriction.
2- Increase salt intake.
3- Fluid restriction.
4- Hypertonic saline.

37. Question: 7
Transition to oral?
1- Torsamide 10mg OD
2- Torsamide 20 mg OD
3- Torsamide 40 mg OD
4- Torsamide 60 mg OD

39. Question: 8
What to do else pre-discharge?
1-
2-
3-
………….

41. Definition:
AHF refers to rapid or gradual onset of symptoms and/or signs of HF, severe
enough for the patient to seek urgent medical attention, leading to an
unplanned hospital admission or an emergency department visit.
4 Clinical presenttions:
1- acute decompensated heart failure.
2- acute pulmonary oedema.
3- Acute right ventricular failure.
4- Cardiogenic shock.

47. What is the next?...
• Vasopressors and inotropes.
• Non invasive ventilation.
• RRT.
• LUS.

48. Thank You