Acute heart failure AIMS
<ul><li>Common emergency presentation </li></ul><ul><li>High mortality & morbidity in survivors </li></ul><ul><li>Diagnosi...
<ul><li>At 40 yrs age- lifetime risk: 21% </li></ul><ul><li>Increasing prevalence </li></ul><ul><li>In extremis + rapid de...
Presentations <ul><li>Acute SOB, frothy sputum </li></ul><ul><li>Collapse </li></ul><ul><li>Shock </li></ul><ul><li>Cardia...
Acute pulmonary oedema <ul><li>SPOTTER </li></ul><ul><li>Extreme SOB, puffing, unable to speak </li></ul><ul><li>Profuse s...
Collapse/ cardiac arrest <ul><li>Severe HF of any cause:- prone for malignant arrythmias, PE   </li></ul><ul><li>Present ...
Aetiology <ul><li>CAD </li></ul><ul><li>Hypertensive heart disease </li></ul><ul><li>Fluid overload </li></ul><ul><li>Acut...
CAD <ul><li>Most common cause </li></ul><ul><li>Can be the 1 st  manifestation </li></ul><ul><li>SOB >>> chest pain </li><...
HHD <ul><li>1 st  presentation  </li></ul><ul><li>Accelerated hypertension </li></ul><ul><li>Onset of HF lowers previously...
Pulmonary oedema <ul><li>Mechanisms </li></ul><ul><ul><li>pulm capillary pressure </li></ul></ul><ul><ul><li>Capillary per...
pulm capillary pressure <ul><li>LA pressure </li></ul><ul><ul><li>MV disease </li></ul></ul><ul><ul><li>Arrythmias </li></...
<ul><li>Capillary permeability </li></ul><ul><ul><li>ARDS </li></ul></ul><ul><li>Oncotic pressure fall </li></ul><ul><ul><...
 
Investigations  <ul><li>ECG </li></ul><ul><li>Entirely normal # systolic HF </li></ul><ul><li>ACS </li></ul><ul><li>Arryth...
Cardiac enzymes <ul><li>Essential to r/o AMI  even in the absence of chest pain !! </li></ul><ul><li>Ideally tropT / trop-...
CXR <ul><li>NEVER delay treatment pending CXR </li></ul><ul><li>Portable CXR:  cardiomegaly ?? </li></ul><ul><li>Peri-hila...
<ul><li>ECHO:-  preferably as early as possible </li></ul><ul><li>To identify cause </li></ul><ul><li>Assess LV function, ...
STABILIZATION
Actions in order <ul><li>Propped up position </li></ul><ul><li>IV Morphine </li></ul><ul><li>100% Oxygen </li></ul><ul><li...
Assess respiratory function <ul><li>Wheeze: interstitial oedema </li></ul><ul><li>Aminophylline helpful- bolus  </li></ul>...
Hemodynamic status <ul><li>PCWP  > 18 mmHg diagnostic </li></ul>BP  < 100 > 100
Patient in shock <ul><li>Insert central line </li></ul><ul><li>Renal dose Dopamine  ( 2.5-5  µg/kg/mt) </li></ul><ul><li>U...
SBP >100 <ul><li>Further doses of IV lasix 60-80 mg q8h or even 20-80 mg/hr infusion </li></ul><ul><li>NTG infusion at 2-1...
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Acute Heart Failure

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Acute Heart Failure

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

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