1. Acute heart failure is a life-threatening condition requiring urgent evaluation and treatment based on the patient's clinical profile and symptoms of fluid congestion or hypoperfusion. 2. Initial management in the hospital involves intravenous diuretics and vasodilators to reduce fluid overload, along with inotropes or vasopressors if needed to support blood pressure and organ perfusion. 3. Patients are monitored closely and stabilized through optimization of therapy before being discharged with guidelines for follow-up and enrollment in disease management programs.

1. DIAGNOSIS AND EARLY HOSPITAL
MANAGEMENT OF ACUTE HEART FAILURE

2. Definition of Heart Failure
• A complex clinical syndrome that results from any structural
or functional impairment of ventricular filling or ejection of
blood¹
• A clinical syndrome characterized by typical symptoms that
may be accompanied by signs caused by a structural and/or
functional cardiac abnormality, resulting in a reduced cardiac
output and/or elevated intracardiac pressures at rest or
during stress²
1. 2013 ACCF/AHA Guideline for the Management of Heart Failure
2. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure

3. Definition of Acute Heart Failure
AHF refers to Rapid Onset or Worsening of
Symptoms and/or Signs of HF
• De novo vs Acute Decompensation of Chronic HF
• Primary cardiac dysfunction
• Acute myocardial dysfunction (ischaemic, inflammatory or toxic)
• Acute valve insufficiency or pericardial tamponade
• (and/or) with/without known precipitant factors
• AHF might have a ‘time to therapy’ concept → ‘pre-hospital’
management is considered a critical component of care.
Mebazaa A, et al. European Heart J (2015) 17, 544-588.

4. Factors
Triggering of
Acute Heart
Failure

5. Pulmonary Edema
Acutely
Decompensated
Chronic HF
Cardiogenic
shock
Right HF
ACS &
HF
Hypertensive AHF
Clinical Presentation of Acute HF
More
Frequent
Dickstein K, et al. Eur Heart J (2008) 29, 2388-2442. doi:10.1093/eurheartj/ehn309

6. Epidemiology Acute HF
AHF patients seen early, in the pre-hospital setting or
in the ED not only have Higher Blood Pressure but
also are more frequently Female and Older

7. Haemodynamic Profile of Acute HF
(Forrester Classification)
Most Common
presentation
SHOCK
CARDIOGENIC

8. Pre-hospital and Early
Management Strategies
in Acute Heart Failure

9. Pre-Hospital Setting
•pulse oximetry, blood pressure, respiratory rate, and a
continuous ECG, instituted within minutes of patient
contact and in the ambulance if possible.
Non-invasive
monitoring
•based on clinical judgment unless SaO2 <90% in which
case oxygen therapy should be routinely administered.Oxygen therapy
• in patients with respiratory distress.Non-invasive
ventilation
•initiated based on blood pressure and/or the degree of
congestion using vasodilators and/or diuretics (i.e.
furosemide
Medical treatment
•to the nearest hospital, preferably to a site with a
cardiology department and/or CCU/ICURapid transfer
Mebazaa A, et al. European Heart J (2015) 17, 544-588.

10. Step 1:
Initial Management of Patient
With Acute Heart Failure in Hospital

12. Initial Management of
a Patient with Acute
Heart Failure.
Ponikowski P, et al. Eur Heart J
doi:10.1093/eurheartj/ehw128

13. Management of Patients with Cardiogenic Shock
Ponikowski P, et al. Eur Heart J doi:10.1093/eurheartj/ehw128

14. Recommendations for the Management of Patients with
Acute Heart Failure: Oxygen Therapy and Ventilatory Support

15. Urgent Management of “CHAMP”
“CHAMP” Management
Acute Coronary syndrome
PCI ˂2 hours from hospital admission, irrespective of ECG or biomarkers
findings
Hypertensive emergency
i.v. vasodilator and i.v. loop diuretic
Reduce BP 25% in the first few hours
Arrhythmia
Electrical cardioversion for atrial or ventricular tachyarrhythmias with
hemodynamic instability
Temporary pacing for severe bradycardia
Acute Mechanical cause Surgical or percutaneous intervention
Pulmonary embolism
Thrombolysis
Embolectomy (surgical or catheter-based)

16. STEP 2:
(Diagnosis of AHF)
“Rule-in” or “Rule-out” AHF in Patients
Presenting with Congestion and/or
Hypoperfusion

17. Symptoms and Signs
• Fluid overload (pulmonary congestion and/or
peripheral edema)
• Hypoperfusion due to low cardiac output
THE SENSITIVITY AND SPECIFICITY OF SYMPTOMS AND SIGNS
ARE OFTEN NOT SATISFACTORY
NEED ADDITIONAL INVESTIGATION

18. Additional Investigation For the Diagnosis of AHF
Investigation Diagnostic value
Chest x-ray:
Cardiomegaly, pulmonary
congestion, pleural effusion,
interstitial or alveolar edema
• Useful test (most specific)
• Normal in 20% of patients with ADHF
• Can identify alternative pulmonary disease
ECG • Rarely normal (high negative predictive value)
Natriuretic peptides:
BNP ˂100 pg/ml or NT-proBNP ˂300
pg/ml.
• Highly sensitive
• Positive test associated with a wide variety of cardiac
and non-cardiac causes
Immediate echocardiography • Not used for diagnosis of ADHF
Bedside thoracic ultrasound (if
expertise is available):
Interstitial edema and pleural
effusion.
May be useful

19. STEP 3:
Management of AHF Based on Symptoms
and Signs of Fluid Congestion and
Hypoperfusion

22. Intravenous Diuretic and Ultrafiltration
• Loop diuretics are recommended for all patients with congestion to
improve symptoms.
• Combination with either oral thiazide diuretic or spironolactone may
be considered in the presence of resistant edema or insufficient
symptom response
• Initial dose is 20-40 mg
• May be given as intermittent boluses or continuous infusion
• Regularly monitor renal function and electrolytes
• Ultrafiltration should be considered in patients with refractory
volume overload and acute kidney injury and may be considered in
patients with refractory congestion who fail to respond to diuretic-
based therapy

23. Diuretic sites of action

24. Mebazaa et al. EJHF (2015) 17, 544-558
Dose Recommendation For Diuretic Therapy

25. Intravenous Vasodilators
Vasodilators Dose Main side effects Other
Nitroglycerine
Start with 10–20 μg/min,
increase up to 200 μg/min
Hypotension,
headache
Tolerance on
continuous use
Isosorbide
dinitrate
Start with 1 mg/h, increase
up to 10 mg/h
Hypotension,
headache
Tolerance on
continuous use
Nitroprusside
Start with 0.3 μg/kg/min
and increase up to 5
μg/kg/min
Hypotension,
isocyanate toxicity
Light sensitive
Ponikowski P, et al. Eur Heart J doi:10.1093/eurheartj/ehw128

26. Vasodilator drugs and their sites of action

27. The renin–angiotensin system

28. Organic nitrates incite vascular
smooth muscle relaxation
• The proposed mechanism involves the conversion of
the administered drug to nitric oxide at or near the
plasma membrane of vascular smooth muscle cells.
• Nitric oxide, in turn, activates guanylate cyclase to
produce cyclic guanosine monophosphate (cGMP),
and the intracellular accumulation of cGMP leads to
smooth muscle relaxation.
• At low doses, nitroglycerin, the prototypical organic
nitrate, produces greater dilation of veins than of
arterioles.
• The venodilation results in venous pooling,
diminished venous return, and hence decreased right
and left ventricular filling.

29. Action of nitrates on circulation

30. Ponikowski P, et al. Eur Heart J doi:10.1093/eurheartj/ehw128

31. Intravenous Inotropes and Vasopressors
Inotropes/Vasopresso
rs
Bolus Infusion rate
Dobutamine No 2-20 μg/kg/min
Dopamine No
3-5 μg/kg/min (inotrope)
> 5 μg/kg/min (vasopressor)
Norepinephrine No 0.2-1 μg/kg/min
Epinephrine
1 mg can be given i.v
during resuscitation,
repeated every 3-5
minutes
0.05-0.5 μg/kg/min
Ponikowski P, et al. Eur Heart J doi:10.1093/eurheartj/ehw128

32. Ponikowski P, et al. Eur Heart J doi:10.1093/eurheartj/ehw128

33. Target Hemodynamic : Warm Dry
FLUID
RESCUCITATION
INOTROPES
DIURETICS
VASODILATOR
S
VASOPRESSOR

34. Management of Oral Therapy in Acute HF
Mebazaa A, et al. European Heart J (2015) 17, 544-588.

35. Discharge From Emergency Department
• Clinical response to initial treatment is an important indicator of likely
disposition
• Indicators of good response to initial therapy that might be considered in
discharge include :
• 1. Patient-reported subjective improvement
• 2. Resting HR < 100 bpm
• 3. No hypotension when standing up
• 4. Adequate urine output
• 5. Oxygen saturation > 95% in room air
• 6. No or moderate worsening of renal function (chronic renal disease might
be present)
Mebazaa A, et al. European Heart J (2015) 17, 544-588.

36. Discharge From Emergency Department
• Fast track discharge from ED should be considered in
hospitals with chronic disease management programs, once
the trigger for decompensation has been identified and early
management commenced
• Patients with de novo AHF should not be discharged home
from ED
Mebazaa A, et al. European Heart J (2015) 17, 544-588.

37. Criteria for Discharge
• Haemodynamically stable, euvolemic, established on evidence-based
oral medication and with stable renal function for at least 24 h before
discharge
• Once provided with tailored education and advice about self-care
• Patients should be:
• enrolled in a disease management program
• seen by their general practitioner within 1 week of discharge, by the
hospital cardiology team within 2 weeks of discharge

38. Summary
•AHF is a life-threatening medical condition requiring
evaluation and treatment
•Classification based on patients clinical profile
•Urgent evaluation and early diagnosis is important for
guiding the appropriate management
•Perform all ‘Steps’ simultaneously and urgently