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