Acute heart failure in adult

1. Acute Heart Failure
Dr. Nitta Chinyama Nayeja
FAMMED IV

2. OUTLINE
1. Disease overview
• Definition of Acute Heart Failure.
• Classification of acute heart failure
• Special general points
• Epidemiology
2. Triage findings and outcomes
3. Pertinent Hx related to Acute heart failure
4. Primary survey findings
5. Secondary survey findings
6. Investigations ( immediate and ongoing)
7. Differential diagnosis
8. Management(immediate and ongoing), definitive and supportive
9. Monitoring parameters, goals and actions, danger signs requiring consultant or escalation of care
10. Disposition- criteria and destination
11. Referral planning and communication
12. Home care instructions( and health promotion)

3. Definition of acute Heart Failure
• Acute Heart failure is a complex syndrome in which there is “
gradual or rapid change in heart failure signs and symptoms
resulting in the need for urgent therapy.

4. Causes of acute Heart Failure
• Myocardial causes
- MI, cardiomyopathy, myocarditis, dysrhythmias.
• Valvular causes
-Pulmonary valve stenosis, aortic stenosis, mitral stenosis and tricuspid
stenosis, mitral and/or aortic regurgitations.
• Restrictive causes
-cardiac tamponade, pericardial effusion, pericarditis.

5. New York Heart Classification
• Class I: physical activity is not limited, and does not cause significant fatigue,
heart palpitations, trouble breathing and chest pain.
• Class II: Physical activity is somewhat limited. Patient is comfortable at rest
but ordinary activities cause fatigue, heart palpitations, trouble breathing and
chest pain.
• Class III: Physical activity is markedly reduced.
• Class IV: All physical activity causes discomfort. Symptoms are also present
at rest. Minor physical activity makes symptoms worse.

6. Classification of Acute Heart Failure
• Hypertensive Vs. normotensive Vs. Hypotensive
• HFpEF (diastolic dysfunction) Vs. HFrEF (systolic
dysfunction)
• Right- sided vs. Left- sided
• High output Vs. low output
• Acute Vs. Acute on chronic

7. Acute Heart Failure classification.
Descriptions
Hypertensive SBP>140mmHg and DBP>90, elderly, have preserved EF,
low mortality
Hypotensive SBP<90mm Hg, 2-5% of cases, cardiogenic shock, in -
hospital mortality 15-30%
Normotensive SBP 90-140mmHg, 48-52% of cases ,usually decompensated
chronic HF with reduced EF, in- hospital mortality 8-10%

8. Acute Heart Failure Types
Systolic Vs. Diastolic

9. Acute Heart Failure classification

10. Acute Heart Failure classification

11. Special general points
• .Registries dealing with patients hospitalized with HF, mix patients with
AHF and CHF.
• Clinical trials provide a biased view of the real incidence of HFpEF in AHF
- Most of them have excluded patients with pEF
- Exclusion of patients with AF, severe renal failure or hypertension, infection,
COPD and ischemia.

12. Epidemiology in
Africa [1,2]
• In SSA, HF occurs at a young age
• Common causes of AHF include hypertensive heart disease ( 39.2%),
cardiomyopathy, (21.4%), rheumatic heart disease( 14.1%), HIV- associated
cardiomyopathy, turberculous pericardial disease, Corpulmonale and
peripartum cardiomyopathy.
• HF with systolic dysfunction is the commonest
• Hospital case fatality rates ranges 9%-12.5%.

13. Epidemiology cont..
USA & Europe
• In America and western world, acute heart failure occurs at an advanced age
( ≥ 60years of age).
• 50% of the new admissions have LVEF ≤ 40%
• Estimated that by 2020, prevalence will increase by 46%
• Leading cause of AHF is cardiovascular related atherosclerosis
complications.
• Leading cause of hospitalization in the US and Europe.

14. Triage Findings and Outcomes
Presenting
complaints
Cardinal features are Dyspnea (exertional dyspnea, PND, orthopnea) & fatigue.
Other features: peripheral edema, ascites, coughing up pink frothy sputum,
headache, insomnia, anorexia, nausea, vomiting, painful abdomen & fullness,
nocturia
Vital signs ↑ RR ( >30), hypoxia ( SPO2<93%), hypotension ( SBP <90 )or hypertension ( SBP
> 140mmHg) or normotensive ( SBP 90-140mmHg), extreme tachycardia (>120) or
bradycardia ( <60).
General clinical
picture
Altered mental status or normal mental status , cyanosis , respiratory distress

15. Pertinent History related to Acute Heart
Failure
• Commonest presenting complaint is dyspnea ( exertional, PND, Orthopnea).
• Past medical hx: MI/ angina; HTN, prior HF, connective tissue disorders, endocrine disorders,
postpartum cardiomyopathy, recent infection(viral, bacterial), contraceptive use.
• Medications: Antihypertensives (doses, frequency, duration, compliance issues )and disease control
pattern, steroid usage, cardiotoxic drugs.
• Family hx: Hypertension, diabetes mellitus, cardiovascular events & deaths, endocrine disorders,
obesity.
• Social hx: smoking, alcohol consumption, exercises, diet content.
• Psychological & impact of disease.

16. Review of systems
• Renal : oliguria, anuria, hematuria, dysuria.
• Endocrine: goiter, acromegaly signs, Cushing's syndrome signs,
pheochromocytoma signs, hyperglycemic episodes/ DM signs.
• Neuromuscular diseases: Duchene muscular dystrophy, myotonic dystrophy.
• Genitourinary: recent pregnancies
• Hematological: anemia

17. Primary Survey Findings
• A- patent or obstructed ( if altered level of consciousness)
• B- hypoxia ( SPO2< 94%), tachypnea (RR >20)
• C- hypotension (SBP<90) or hypertension (SBP>140), bradycardia( PR>60)
or tachycardia( PR >100), Or normotensive.
• D- reduced or normal level of consciousness
• E- hypothermic or normothermic

18. Secondary survey findings
General physical exam
- Mild to moderate HF : No distress except on lying flat
for more minutes.
- Severe heart failure : sitting-up, respiratory distress,
unable to finish sentence.
- Wasting , cyanosis, edema, jaundice.

19. Secondary survey Findings
Hands
• Hands: Finger clubbing, koilonychias, splinter
hemorrhages, cyanosis, nail fold infarcts, oslers nodes &
Jane way lesions.
• Wrist: radio-radio delay; collapsing pulse, irregular pulse.

20. Secondary survey findings
Head and Neck Exam
• Malar flush
• Central cyanosis
• Poor dentition
• Pulsating carotid pulse
• Raised JVP

21. Chest exam
• Precordial scars, visible sternal heave,
• Enlarged cardiac borders, apex beat shift, thrill, S3 gallop.
• Signs of pleural effusion ( stony dull percussion note, ↓ breath sounds)
• Bibasal crepitations and rales.
• Diffuse crepitations

22. Abdominal Exam and Extremities
• Distended abdomen
• Hepatomegaly which is tender and pulsatile.
• Ascites
• Sacral –edema
• Decreased bowel sounds
• Peripheral edema

23. Immediate Investigations
Other tests
• ECG
• Chest x-ray
• Echocardiogram
• Urinalysis
• Pregnancy test
Blood tests
• Random blood glucose
• Full blood count
• Urea and Creatinine
• Cardiac biomarkers
• Liver function tests
• Thyroid function tests
• HIV test

24. Chest x-ray findings (PA-upright)
• Pulmonary venous congestion
• Cardiomegaly (80%) or normal ( 20%)
• Interstitial edema
- Absence of these, does not rule out AHF.

26. Point of care USS
• Signs of pulmonary congestion
• Signs of volume overload
-IVC >2cm
-Collapsibility index <50% indicates raised central venous pressure .
• LV ejection fraction

28. Electrocardiogram
• Early recognition of
-Arrhythmias – atrial fibrillation
- Ischemic changes
- ventricular hypertrophy.

29. Cardiac Biomarkers
• Relevant when cause of dyspnea is unclear
• Markers of Cardiac necrosis
- Troponin I & T ( ≥0.01ng/ml, ≥ 0.04ng/ml )
- CK2- MB
• Markers of hemodynamic stress
- BNP: >20pmol/L, due to ventricle stretching
- ANP : due to atrial wall stretching.

30. Differential Diagnoses
Common diagnoses
• Massive pleural effusion
• Pericardial effusion/tamponade
• Pneumothorax
• Pneumonia/PCP
• Infectious myocarditis
• Acute myocardial infarction
Less common diagnoses
• Corpulmonale
• Pulmonary embolus
• Alcoholic cardiomyopathy
• Cardiac arrhythmia
• Beriberi

31. Acute Heart Failure:
Goals of Treatment
• Improve symptoms and Improve quality of life
• Reduce mortality
• Reduce re-hospitalization
• Do it safely

32. Immediate management goals
• Dyspnea relief
• Pulmonary edema reduction
• Improve oxygenation
• Restore adequate perfusion
• Precipitating factor management

33. Immediate supportive management
• A- Maintain airway patency, sitting upright.
• B- Oxygen supplement if 02 sats ≤ 93%
• C- Iv access, careful crystalloid boluses e.g. 250ccs if hypotension.
• D- IV 50% glucose ( if hypoglycemia & unconscious)

34. Oxygen supplement
• Indicated in severe hypoxaemia ( SaO2 <90%).
• In COPD, give oxygen with caution
- high O2 worsen hypercabia & cause respiratory depression. ( O2 may
cause hyperoxia-induced vasoconstriction in patients with systolic
dysfunction if given when O2 sats >90%
• CPAP & Non-invasive intermittent Positive Pressure Ventilation
- Improve dyspnea, HR, acidosis & hypercapnea.

35. Immediate definitive management
• IV loop diuretics
- Depends on renal function & how rapid should the excess fluid removed. -
- In cardio-renal syndrome high doses of diuretics are may be needed
• Nitroglycerine & morphine
- vasodilators
- Decrease pre-load → ↓ venous constriction & volume redistribution
- Decrease afterload →↓ arterial vasoconstriction

36. Ongoing management
Reduce mortality & Re-hospitalization
• Use of ACE- Inhibitors e.g. enalapril, lisinopril, captopril etc
• Use of minero-corticoid antagonists e.g. Spironolactone
• Beta blockers e.g. bisoprolol, carvedilol, metoprolol

38. Special considerations
• Dialysis if severe renal failure
• Blood transfusion if severe anemia HB<8g/dl.
• Coronary revascularization in acute STEMI
• Rate/rhythm control e.g. digoxin in atrial fibrillation
• Iv Thiamine 100mg in Beriberi
• Morphine Iv 5-10mg for dyspeania relief.

39. Heart Failure Device treatment
• Biventricular Pace maker helps improve cardiac output and improve
symptoms.
• Automatic implantable defribrillilator improves survival in patients with
EF<35%.

40. Disposition Criteria
• Lack of ED-based risk
stratification tool.
• Mainly based on physical judgment,
physiological risk assessment,
assessment of barrier to successful
outpatient.
• High risk physiological markers
- Renal dysfunction
- Low BP
- Low serum sodium
- ↑ cardiac troponin and/or
natriuretic peptide

41. Monitoring Goals and Actions
• Improved perfusion ( MAP of 65-100, central arterial pressure of ):
- oxygen supplement, control high BP , correct hypotention
• Improved breathlessness:
-positioning, oxygen supplement, adjuvant morphine
• Attain good urine output:
-Cautions IV rehydration in shock, catheterization to monitor output

42. Monitoring parameters
• Oxygen sats & ↑ respiratory effort or oxygen requirement.
• Mental status
• Blood Pressure, MAP, Central Arterial pressure
• Respiratory rate
• Pulse rate.
• Urine Output

43. Danger signs requiring consultant or
escalation of care
• Clinical deterioration after optimal management
• Respiratory fatigue
• Cardiopulmonary arrest
• Shock
• Respiratory arrest
• Cardio-renal syndrome

44. Disposition to ICU
• Patient requiring invasive monitoring
• Patient requiring invasive procedures.

45. Disposition to HDU/Main Ward
- New onset AHF
- Signs of poor perfusion
- RR>30 and requiring NIV
- Comorbidities requiring urgent intervention
- Need for vasoactive drugs’ titration.
- Labs findings: Troponin, BUN >40mg/dl, creatinine >3mg/dl,Na+ <
135mEq/l , new ischemic changes on ECG.

46. Disposition to short stay ward
• Patients in the priority category
• Lower risk features →short stay (12-24 hrs.)

47. Referral planning and communication
• Prior communication to referral facility is paramount
- Prior discussion of why patient should be referred
- Establishing availability of services at the next facility
- ICU space availability
• Availability of Oxygen cylinders, reliable transport, staff to escort

48. Home care instructions & health promotion
• Medications: Types, doses, frequencies, importance of adherence, side effects
• Life style modifications: diet ( ↓ salt intake & restrict water intake), smoking,
alcohol, exercise, reduce obesity.
• Planned follow-up review in GMC (monthly) until significant improvement.

49. References
1. Bloomfield GS et al. Heart Failure in Sub-Saharan Africa .Current Cardiology Reviews, 2013, 9, 157-173 157.
2. Agbor V.N. et al .Heart failure in sub-Saharan Africa: A contemporaneous systematic review and meta-analysis. International
Journal of Cardiology 257 (2018) 207–215.
3. Queen Elizabeth Central Hospital AETC SOAP protocols. August 2011 Pages 30-31.
4. 2017 ACC/AHA/HFSA focused update of the 2013 ACC/AHA Guideline for the management of Heart Failure.
5. Tintinali’s Emergency Medicine, 8th Edition
6. Rosen’s Emergency medicine, 8th edition
7. Harrison’s principle of internal medicine, 19th edition.