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Systolic Dysfunction
Coronary Artery Disease
Hypertension
Valvular Heart Disease
Diastolic Dysfunction
Hypertension
Coronary artery disease
Hypertrophic obstructive cardiomyopathy (HCM)
Restrictive cardiomyopathy
Etiology
Hypotension
Fluid retention & worsening CHF
exacerbation
Pathophysiology
STARLINGS LAW
Within limits, the force of ventricular contraction is a
function of the end-diastolic length of the cardiac
muscle, which in turn is closely related to the ventricular
end-diastolic volume.
This is achieved by increasing the length of
sarcomeres in dilated heart
Increases the myocardial contractility and thereby
attempts to maintain stroke volume.
Pathophysiology
Myocardial hypertrophy
Angiotensin I
Angiotensin II
Aldosterone Secretion
Peripheral
Vasoconstriction
Salt & Water Retention
Plasma Volume
Afterload Edema
Preload
Cardiac Output
Cardiac Workload
Heart Failure
Pathophysiology
Ventricular remodeling
Altered cardiac
rhythm
Signs and symptoms of CHF
Fatigue
Activity decrease
Edema
Shortness of breath
Heart Failure
Complications
Pleural effusion
Atrial fibrillation (most common dysrhythmia)
Loss of atrial contraction (kick) -reduce CO by 10%
to 20%
Promotes thrombus/embolus formation inc. risk for
stroke
Treatment may include cardioversion,
antidysrhythmics, and/or anticoagulants
Heart Failure
Complications
**High risk of fatal dysrhythmias (e.g., sudden
cardiac death, ventricular tachycardia) with HF and
an EF <35%
Thin LV wall
Eccentric LV remodeling
Pulmonary hypertension
Diastolic dysfunction:
Normal LVEF (45%-50%)
Normal LV size
Concentric LV remodeling
Pulmonary hypertension
ACE Inhibitors
Diuretics
Inotropic Agents
Beta Blockers
-BUMETANIDE
-FUROSEMIDE
-HYDROCHLOROTHIAZIDE
-METALAZONE
DRUGS USED TO TREAT CONGESTIVE
HEART FAILURE
Beta blocker
Metoprolol
Carvidilol
Bisoprolol
Calcium channel blockers
Nifedipine
Diltiazem
Verapamil
Amlodipine
Felodipine
Treating Congestive Heart failure
Upright position
Nitrates
Lasix
Oxygen
ACE inhibitors
Digoxin
Fluids(decrease)
After load (decrease)
Sodium retention
Test (Dig level, ABGs, Potassium level)
Acute Heart Failure
Rapid onset of symptoms and signs secondary to abnormal
cardiac function
Can present as new onset and without previously known
cardiac dysfunction or ADHF
Often life threatening and requires urgent treatment
Pulmonary
congestion
ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure
European Heart Journal, 2008
Causes and precipitating factors
Ischaemic heart disease
Acute coronary syndrome
Mechanical complications of acute MI
RV infarction
Valvular
Valve stenosis
Valvular regurgitation
Endocarditis
Aortic dissection
Myopathies
Postpartum cardiomyopathy
Acute myocarditis
Hypertension/arrhythmias
Circulatory failure
Septicaemia
Thyrotoxicosis
Anaemia
Tamponade
Pulmonary embolism
Decompensation of pre-existing CHF
Volume overload
Infection
Cerebrovascular insult
Surgery
Renal dysfunction
Asthma, COPD
Drug and alcohol abuse
Diagnostic of Acute Heart Failure
Based on presenting symptoms and clinical findings
History
Physical examination
ECG
Chest X-ray
Echocardiography
Laboratory (BGA, etc)
ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure
European Heart Journal, 2008
Monitoring
Non invasive:
Vital Sign
Oxygenation
Urine output
ECG
Invasive:
Arterial line (haemodynamic unstable)
Coronary angiography
Goals of treatment
Immediate (ED/ICU/ICCU)
Improved symptom
Intermediate (hospital)
Stabilize patient & optimize treatment strategy
Education
Prevention
Quality of life
Management
Immediate symptomatic treatment
Patient distressed or in pain >> analgesia, sedation
Pulmonary congestion >> diuretic, vasodilator
Arterial oxygen saturation < 95% >> increase FiO2,
consider CPAP, NIPPV, mechanical ventilation
Heart rate and rhythm disorder >> pacing,
antiarrhythmics, electroversion
ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure
European Heart Journal, 2008
Oxygen
As early as possible in hypoxaemic patients to achieve O2
saturation 95% (> 90% in COPD).
Class I, level C
NIV with PEEP as soon as possible in every patient with acute
cardiogenic pulmonary oedema
Contraindication:
- unconscious patients
- anxiety
- immediate need ET intubation
- severe obstructive airway disease
- severe Right HF
ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure
European Heart Journal, 2008
Morphine
ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure
European Heart Journal, 2008
Loop diuretics
Diuretics are recommended in AHF patients with congestion and
volume overload.
Class I, level B
Adverse effect:
- hypokalaemia, hyponatraemia
- hyperuricaemia
- hypovolaemia and dehydration
- neurohormonal activation
- may increase hypotension following ACEI/ARB therapy
ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure
European Heart Journal, 2008
Vasodilators
Vasodilators are recommended at an early stage for AHF
without hypotension or serious obstructive valvular disease.
Class I, level B
Adverse effect:
- headache (nitrat)
- tachyphylaxis (nitrat)
- hypotension (NTG or nesiritide infusion)
ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure
European Heart Journal, 2008
Inotropic agents
Inotropic agents should be considered in low output states, in
the presence of hypoperfusion or congestion.
Dobutamine (class IIa, level B)
Dopamine (class IIb, level C)
Milrinone and enoximone (class IIb,level B)
Levosimendan (class IIa, level B)
Norepinephrine (class IIb, level C)
Cardiac glycoside (class IIb, level C)
ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure
European Heart Journal, 2008
Patient counseling
Lifestyle changes
Medications
Surgery
Patient counseling
Lifestyle changes
Stop smoking
Loose weight
Avoid or limit alcohol
Avoid or limit caffeine
Eat a low-fat, low-sodium diet
Exercise
Patient counseling
Reduce stress
Keep track of symptoms and weight
and report any changes or concern to
the doctor
Limit fluid intake
See the doctor more frequently
Conclusion