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acute heart failure.pptx
- 1. ACUTE HEART FAILURE INICU Mohamed Elmoshey
- 2. Acute Heart Failure • AHFis a leading cause of hospitalizations in subjects aged >65 years and is associated with high mortality and rehospitalization rates. In- hospital mortality ranges from 4% to 10%. • post-discharge 1-year mortality can be 25-30% with up to more than 45% deaths or readmission rates
- 3. Overview of HeartFailure • Definition: a clinical syndrome characterized by a constellation of symptoms (dyspnea, orthopnea, lower limb swelling) and signs (elevated jugular venous pressure, pulmonary congestion) often caused by a structural and/or functional cardiac abnormality resulting in reduced cardiac output and/or elevated intracardiac pressures • Acute heart failure can either represent the first presentation of heart failure or decompensated heart failure for patients with known underlying heart failure • American College of Cardiology Foundation/American Heart Association (ACCF/AHA) definitions of heart failure classification • heart failure with reduced ejection fraction (HFrEF) also called systolic heart failure • ejection fraction ≤ 40% • heart failure with preserved ejection fraction (HFpEF) also called diastolic heart failure • typically, ejection fraction ≥ 50%
- 4. Classification of Heartfailure Stage Description Stage A At high risk for heart failure but without structural heart disease or symptoms of heart failure Stage B Structural heart disease but without signs or symptoms of heart failure Stage C Structural heart disease with prior or current symptoms of heart failure Stage D Refractory heart failure requiring specialized interventions ACCF/AHA Staging of Heart Failure NYHA Functional Classification NYHA Class Patient Symptoms Class I •No limitation of physical activity •Ordinary physical activity does not cause symptoms of heart failure (undue fatigue, palpitations, and dyspnea) Class II •Slight limitation of physical activity •Comfortable at rest, but ordinary physical activity results in symptoms of heart failure Class III •Significant limitation of physical activity •Comfortable at rest, but less than ordinary activity causes symptoms of heart failure Class IV •Unable to carry out any physical activity without symptoms of heart failure or symptoms of heart failure at rest
- 5. Causes of Heart Failure Myocardial infarction/ischaemia. Drugs,e.g. B-blockers, cytotoxics. Tachyarrhythmias or bradyarrhythmias. Valve dysfunction. Sepsis. Septal defect. Cardiomyopathy/myocarditis. Pericardial tamponade.
- 6. Diagnosis of HeartFailure • Clinical features Decreased forward flow leading to poor tissue perfusion • Muscle fatigue leading ultimately to hypercapnia and collapse. • Confusion, agitation, drowsiness, coma. • Oliguria. • Increasing metabolic acidosis, arterial hypoxemia, and dyspnea • . Increased venous congestion secondary to right heart failure • Peripheral oedema. • Hepatic congestion. • Splanchnic ischemia. • . Increased pulmonary hydrostatic pressure from left heart failure • Pulmonary oedema, dyspnea. • Hypoxemia.
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- 9. Diagnosis of HeartFailure • clinical suspicion is based on signs and symptoms • signs and symptoms of acute decompensated heart failure often overlap with those of other common medical conditions, no single finding is diagnostic Dyspnea Orthopnea paroxysmal nocturnal dyspnea Fatigue Abdominal swelling and pain elevated jugular venous pressure edema or ascites anorexia or early satiety rales wheezing third heart sound (S3) worsening of mitral or tricuspid regurgitation enlarged and tender liver hypoxia, tachypnea, or tachycardia hepatojugular reflex cool extremities
- 10. Diagnosis of HeartFailure Exam Possible findings Diagnostic value for AHF ECG Arrhythmias, myocardial ischemia Exclusion of ACS or arrhythmias Chest-X ray Congestion, lung infection Confirmatory Lung US Congestion Confirmatory Echocardiography Congestion, cardiac dysfunction, mechanical causes Major Natriuretic peptides (BNP, NT-proBNP, MR- proANP) Congestion High negative predictive value Serum troponin Myocardial injury Exclusion of ACS
- 11. Diagnosis of HeartFailure Exam Possible findings Diagnostic value for AHF Serum creatinine Renal dysfunction Renal dysfunction Serum electrolytes (sodium, potassium, chloride) Electrolyte disorders Electrolyte disorders Iron status (transferrin, ferritin) Iron depletion Iron depletion TSH Hypo- hyperthyroidism Hypo- hyperthyroidism D-dimer pulmonary embolism Useful to exclude pulmonary embolism Procalcitonin Pneumonia Useful to exclude Pneumonia Lactate Lactic acidosis Useful to assess perfusion status
- 12. Presentation of AcuteHeart Failure Acute decompensated heart failure Acute pulmonary oedema Isolated right ventricular failure Cardiogenic shock Main mechanisms •LV dysfunction •Sodium and water renal retention •Increased afterload and/or predominant LV diastolic dysfunction •Valvular heart disease RV dysfunction and/or pre-capillary pulmonary hypertension Severe cardiac dysfunction Main cause of symptoms Fluid accumulation, increased intraventricular pressure Fluid redistribution to the lungs and acute respiratory failure Increased central venous pressure and often systemic hypoperfusion Systemic hypoperfusion Onset Gradual (days) Rapid (hours) Gradual or rapid Gradual or rapid Main haemodynami c abnormalities •Increased LVEDP and PCWPa •Low or normal cardiac output •Normal to low SBP •Increased LVEDP and PCWPa •Normal cardiac output •Normal to high SBP •Increased RVEDP •Low cardiac output •Low SBP •Increased LVEDP and PCWPa •Low cardiac output •Low SBP
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Editor's Notes
- #13 LV = left ventricular; LVEDP = left ventricular end-diastolic pressure; MCS = mechanical circulatory support; PCWP = pulmonary capillary wedge pressure; RV = right ventricular; RVEDP = right ventricular end-diastolic pressure; RRT = renal replacement therapy; SBP = systolic blood pressure. aMay be normal with low cardiac output. bWet and cold profile with need of inotropes and/or vasopressors may rarely occu