Acute Heart Failure

Dr. Muhammad Fadil, SpJP

Department of Cardiology and Vascular Medicine
Medicine Faculty of Universitas Andalas/ Dr. M. Djamil
Hospital
Padang

Definition Acute Heart Failure

Rapid onset of symptoms and signs of heart failure,
secondary to cardiac dysfunction
Dysfunction can be related to systolic or diastolic
dysfunction, to abnormalities in cardiac rhythm or to
preload and afterload mismatch
Often life threatening and requires urgent treatment

Role of GP
Prompt diagnosis
Administer initial treatment
Risk stratification
Perform necessary consultation & referral

Common manifestations
Features

Symptoms

Signs

Pulmo
congestion

Dyspnea, fatigue

Tachypnea, lung rales,

effusion, tachycardia

Systemic
congestion

Dyspnea, fatigue

Peripheral oedema, JVP,

hepatomegaly

Cardio. shock

Confusion, weakness
cold periphery

Poor peripheral perfusion,

SBP <90, anuria/oliguria

High BP (HT HF)

Dyspnea

BP, LV hypertrophy,
preserved EF

Right heart
failure

Dyspnea, fatigue

RV dysfunction, JVP,
peripheral edema,
hepatomegaly, ascites

Signs & Symptoms

PERFUSION

CONGESTION

Hypotension (MAP<65) ,
tachycardia, cold extremity,
narrow pulse pressure,
fatique, confusion,
restlessness, oliguria,
ureum creatinine
Dyspnea, orthopnea,
paroxysmal nocturnal
dyspnea, rales, neck vein
distension, ascites, edema,
hepatojugular reflex

Causes and precipitating factors

Ischaemic heart disease
Acute coronary syndromes
Mechanical complications of
acute MI
Right ventricular infarction

Valvular

Valve stenosis
Valvular regurgitation
Endocarditis
Aortic dissection

Hypertension
Acute arrhythmia
Circulatory failure
Septicaemia
Thyrotoxicosis
Anaemia
Shunts
Tamponade
Pulmonary embolism

Hemodynamic profile:

Cardiac index:2.2 L/min/m2

Forrester classification

Normal
Pulmonary
edema

Cardio
shock

Hypovolemic
shock

PCWP:

18 mmHg

Clinical Classifications

Clinical classifications
Acute decompensation of heart failure (ADHF)
De novo or as decompensation of chronic HF
Signs and symptoms relatively mild
Do not full criteria for cardio shock, pulmonary
edema or hypertensive crisis

Hypertensive AHF
Signs and symptoms of HF + high BP
Relatively preserved LV fx
CXR can resemble pulmonary oedema

Clinical classifications
Pulmonary edema

Severe respiratory distress, orthopnea

Crackles all over the lung
O2 sat <90% on room air prior to treatment.
Veried by CXR

ACS and HF
15% of ACS patients have signs & symptoms of AHF
Frequently associated with or precipitated by an

arrhythmia (bradycardia, AF, VT)

Form: ADHF, pulmo edema, cardio shock, RHF

Clinical classifications
Cardiogenic shock

Evidence of organ hypoperfusion & pulm congestion

BP (syst <90 mmHg, MAP >30 mmHg)
Low urine output (<0.5 ml/kg/h)
Continuum of low cardiac output syndrome.

Isolated Right HF
Low output syndrome but no pulmonary congestion
JVP, with or without hepatomegaly
low LV lling pressures

Aim of therapy
INITIAL: Improve hemodynamic status to
relieve symptoms & stabilize organs functions

volume overload & lling pressure

systemic vascular resistance
cardiac output
neurohormonal activation

SUBSEQUENT: Definitive etiologic therapy

th

4 SymCARD 2014

MANAGEMENT ALGORITHM OF AHF

ACUTE HEART FAILURE

Dx algorithm
Definitive dx

BLS, ALS

Immediate resuscitation
Distress or in pain

Definitive tx
O2 saturation >95%

Normal HR & rhythm

MAP >70 / syst >90

Adequate preload
Adequate CO, reversal of metab acidosis, SvO2 >
65%, adequate perfusion

YES

Analgesia/sedation

NO
NO

FiO2, CPAP, NIPPV

YES
NO

Pacing, antiarrhythmics

YES
YES
NO
NO

Vasodilators, diuretic if
volume overload
Fluid challenge

YES
NO

Inotropes, IABP

YES

Reassess frequently

Management approach hemodynamic oriented

Diuretic, vasodilator

Fluid administration

Normal BP: vasodilator

BP: Inotropic drugs

Diuretic
Loop diuretic: Furosemide
Reduce congestion
Achieve optimal volume status

Initial dose: iv bolus 20-40 mg, titrated depends on

response, renal fx
Onset of action: diuresis ~5 minutes
Symptomatic improvement in acute pulmonary edema: 15-20 minutes;
occurs prior to diuretic effect
Monitor urine output

Force Diuretic
Patient with significant fluid overload should be initially treated
with loop diurectic given intravenously during hospitalization

- Carefully monitored
- Serial evaluation volume
status
- Serial evaluation of systemic
perfusion
- Monitoring of weight, vital
signs, fluid input and output
- Asses dosis electrolyte and
renal function

I.V diuretic potential to reduce

GFR, worsen beurohumoral
activation, produce electrolyte
disturbances

DOPAMIN renal dose <

3g/kg/min have a selective renal

arterial vasodilator activity and promote
natriuresis, but UNCERTAIN

18. If no response to doubling of dose of

diuretic despite adequate left ventricular
filling pressure start i.v. infusion of
dopamine 2.5 g/kg/min. Higher doses
are not recommended to enhance diuresis.

Nitrate
Form: nitroglycerine (NTG)
Administration: SL, oral, iv.
Action: vascular smooth muscle relaxation of arteries & veins, more
prominent on veins.
cardiac O2 demand by preload (LV end-diastolic pressure);
reduce afterload in high dose.
Coronary artery dilation improves collateral flow to ischemic regions
Onset: SL~3 minutes; Oral ~1 hour. SL can be given up to 3 times,
in 5 min interval. IV: start 10 ug/min, titrated up to 200 ug/min

Action of Nitrates on Circulation

The major effect is on
the venous capacitance
vessels, with additional
coronary and
peripheral arteriolar
vasodilatory benet

Opie LH & Horowitz JD. Nitrates and newer antianginals. In: Drugs for the Heart. 7 th ed. Saunders Elsevier. China

HEART
FAILURE

2013 ACCF/AHA Guideline for the Management of Heart Failure, Circulation. 2013;128:e240-e327

2013 ACCF/AHA Guideline for the Management of Heart Failure, Circulation. 2013;128:e240-e327

Intra Aortic Balloon Pump (IABP)

The conventional indication for IABP to support the
circulation :
- before surgical correction of spesific acute
mechanical problems
- During severe acute myocarditis
- Selected patient with AMI before, during and after
percutaneous or surgical revscularization
There is no good evidence that an IABP is benefit in other causess of cardiogenic
shock

Non Invasive Ventilation

Continuous positive airway pressure (CPAP) and non-invasive positive
pressure ventilation (NIPPV) relieve dyspnoea and improve certain
physiological measures in patient with acute pulmonary oedema
Non-invasive ventilation may be used as adjunctive therapy to relieve
symptoms in patients with patients with pulmonary oedema and
severe respiratory distress or who fail to improve with pharmalogical
therapy

Contraindication :

Hypotension
Vomiting
Possible pneumothorax
Depressed consciousnes

THANK YOU