1.
ACUTE HEART
FAILURE IN ICU
Mohamed Elmoshey

2.
Acute Heart
Failure
• AHF is 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 Heart Failure
• 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 Heart failure
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 Heart Failure
• 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.

7.
PITTING
EDEMA

8.
Heart failure

9.
Diagnosis of Heart Failure
• 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 Heart Failure
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 Heart Failure
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 Acute Heart
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

13.
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