Acute heart failure seminar Pathophysiology Classification Aetiology Diagnosis Management in Emergency (ED) Disposition decision

1. ACUTE HEART
FAILURE
Muhammad Khairulanwar Bin Muhamad Kamal
012012050-144
Emergency Medicine [Y5]

2. Overview
■ Introduction
■ Pathophysiology
■ Classification
■ Aetiology
■ Diagnosis
■ Management in Emergency (ED)
■ Disposition decision

3. Introduction
■ A complex clinical syndrome that results from any structural or functional impairment of
ventricular filling or ejection of blood
■ Heart fails to act as a pump
■ Manifested by cardinal symptoms
– Dyspnoea & fatigue  exercise intolerance
– Fluid retention  pulmonary oedema, splanchnic oedema, peripheral oedema

4. Pathophysiology
Inefficient pump
Responsive adaptations
Maladaptation
Long term disease progressions
Acute
exacerbation

5. ■ “Inefficient pump”  decrease cardiac output (CO)
– Myocardial injury
– Stress
■ “Responsive adaptations”  Neurohormonal mediated cascades
activation
– Renin angiotensin aldosterone system (RAAS)
– Sympathetic nervous system (SNS)

6. Neurohormonal mediated cascade
RAAS & Sympathetic activation
Na+ and water retention,
increased systemic vascular resistance
Maintain blood pressure and perfusion
*At the cost of increasing myocardial workload, wall
tension and myocardial oxygen demand

8. Counter regulatory response
■ Atrial natriuretic peptides (Atria)
■ B-type natriuretic peptide (Ventricle)
■ C-type natriuretic peptide (Localized in endothelium)
■ Effects:Vasodilation, natriuresis, decreased levels of endothelin, and inhibition of RAAS
and SNS
■ Importance: (Assays)
– Elevated levels portend a worse prognosis
– Attenuation provides the basis for most chronic therapies proven to delay morbidity and
mortality

9. Assays for BNP in ED use
N-t pre-pro-BNP

10. Classification*

11. Classification
■ Acute vs Chronic
■ Systolic vs Diastolic dysfunction
■ Right sided vs Left sided
■ High output vs Low output

12. Systolic vs diastolic
Systolic Diastolic
Age All ages Frequently elderly
Sex Often male Frequently female
LV EF Decrease ( <50 ) Normal ( Preserved )
LV cavity size Dilate ( increase intracardiac
volume )
Normal ( often with LVH )

13. Current categorization
■ Heart failure with a reduced ejection fraction (HFrEF) [SYSTOLIC]
■ Heart failure with preserved ejection fraction (HFpEF) [DIASTOLIC]

14. Common causes of heart failure

15. Diagnosis
■ History
■ Clinical examination
■ Fisk factors
■ Precipitating factor
■ Investigations

16. History – cardinal symptoms
■ Dyspnoea on exertion
■ Orthopnoea
■ Paroxysmal nocturnal dyspnoea
■ Edema
■ Fatigue

17. History – other symptoms
■ Cough with expectoration
■ CNS : Altered sensorium, confusion, impairment of memory, headache,
insomnia
■ GI : Anorexia, nausea, vomiting, pain abdomen, abdominal fullness
■ GU: Nocturia

18. Dyspnoea

19. ■ Differential for dyspnoea
– Exacerbation of asthma or COPD
– Pulmonary embolus
– Pneumonia
– Acute coronary syndrome
– Anaphylaxis

20. Risk factors
■ Male
■ Old ages
■ Hypertension
■ Diabetes mellitus
■ Valvular heart disease
■ obesity

21. Precipitating factors

22. General Physical Examination
■ Mild to moderate HF : No distress except when lying flat for more than a
few minutes
■ Severe HF: Must sit upright, labored breathing, unable to finish a
sentence
– Cardiac cachexia
– Cyanosis
– Edema
– Jaundice

23. Vitals
■ Sinus tachycardia
■ Pulse pressure: ↓
■ SBP: ↓
■ Cold extremities
■ ↑ JVP
– Giant v waves

24. Examination of JugularVeins

25. CVS Examination
■ Palpation:Cardiomegaly with hyperdynamic point of maximum impulse
■ Auscultation
– S₃
– PSM

26. RS Examination
■ Crepitations / Rales
■ Signs of pleural effusion

27. PA Examination & extremities
■ Hepatomegaly:Tender, pulsatile
■ Ascites
■ Peripheral edema

28. Investigations
1. Chest X-ray
2. Electrocardiogram
3. Biomarkers
4. Ultrasonography
5. Routine lab tests: CBC, RFT, LFT,TSH, electrolytes

29. Chest x-ray (upright)
– Pulmonary venous congestion
– Cardiomegaly (80%) or normal (20%)
– Interstitial edema
■ Most specific for a final diagnosis of acute heart failure but the absence
of these does not rule it out

30. ■ CardiomegalyCTR = 18/30 (>50%)
■ Upper zone vessel enlargement (1) – a sign of
pulmonary venous hypertension
■ Septal (Kerley B) lines (2) – a sign of interstitial
oedema – see next picture
■ Airspace shadowing (3) – due to alveolar
oedema – acutely in a peri-hilar (bat's wing)
distribution
■ Blunt costophrenic angles (4) – due to pleural
effusions

32. Electrocardiogram
■ Not useful for diagnosis
– Early recognition of arrhythmias – atrial fibrillation
– Signs of ischaemia or injury

33. ■ Irregularly irregular rhythm.
■ No P waves.
■ Absence of an isoelectric baseline.
■ Variable ventricular rate.
■ QRS complexes usually < 120 ms

34. Routine
■ Complete blood count to evaluate anaemia
■ Basic metabolic panel
– Electrolytes
– Renal status

35. Cardiac biomarkers
■ It is done when cause of
dyspnoea is still unclear
after standard
evaluation
■ This test will detect
ongoing myocyte injury,
which may be clinically
silent

36. Bedside ultrasound
1. Determine cause of dyspnoea e.g. tamponade
2. Determine LV function and volume status
3. RWMA
4. Valvular abnormality
Focused on
1. Signs of pulmonary congestion
2. Sign of volume overload
3. LV ejection fraction

37. Signs of pulmonary congestion
■ Sonographic B-lines
– Dx – >2 B-lines in
any sonographic
windows along the
anterior and
posterior chest

38. Signs of volume overload
■ IVC >2 cm diameter
■ Collapsibility index <50%
– Indicates raised in central venous pressure

40. Management in ED

42. Disposition decision
■ Lack of ED-based-risk stratification tool
■ Mainly based on
– Physician judgement
– Physiologic risk assessment
– Assessments of barrier to successful outpatient
High risk physiological marker
1. Renal dysfunction 3. Low serum sodium
2. Low BP 4. Increase natriuretic peptide / cardiac troponin

44. ■ High risk features  admission to ward
■ Patient required invasive monitoring / procedure  ICU
■ Lower risk features  observation unit (12-24h)

46. References
■ Tintinalli’s Emergency Medicine, 8th edition
■ Rosen’s Emergency Medicine, 8th edition
■ Harrison’s Principle of Internal Medicine, 19th edition
Thank you!