Management of ACS Complicated With Acute Heart Failure DR Budiana

Management of ACS complicated
with Acute Heart Failure
dr. I Putu Gede Budiana, SpJP (FIHA)
RSD Mangusada, Kabupaten Badung

6 April 2019
INTRODUCTION
• Incidence of HF among patients hospitalized for an AMI varies among

studies, ranging from 14% to 36%1
• Approximately 10% to 20% of patients with ACS have concomitant
acute HF and roughly 10% of ACS patients develop HF in-hospital2,3
• In the EuroHeart Survey II on HF, 42% of all de novo HF cases were
due to ACS
• The prognosis of ACS complicated by HF is directly related to the
Killip class.
• Compared with Killip class I patients, patients with an ACS in Killip
class II or III HF are four times more likely to die in-hospital.
• The risk goes up to 10-fold for patients with cardiogenic shock (Killip
class IV)3
1Bahit .
MC, Kochar A, Granger CB. Post-Myocardial Infarction Heart Failure. JACC Hear Fail [Internet]. 2018;6(3):179–86
2 Arrigo M, Parissis JT, Akiyama E, Mebazaa A. Understanding acute heart failure : pathophysiology and diagnosis. 2016;18 3 Montalescot G., et al.
3Mann DL, Felker GM. Heart Failure A Companion to Braunwald ’ s Heart Disease
INTRODUCTION
Jose López-Sendón and Esteban López de Sá, 2008, Acute Heart Failure in the Setting of Acute Coronary Syndromes. Springer-Verlag London .
INTRODUCTION
All STEMI NSTEMI UAP
.
Jose López-Sendón and Esteban López de Sá, 2008, Acute Heart Failure in the Setting of Acute Coronary Syndromes. Springer-Verlag London
INTRODUCTION
Clinical Decision Making Toolkit, Acute Cardiovascular Care Association , ESC, 2018
CARDIAC PERFORMANCE (CO = SV x HR)
Wolfgang Krüger, 2017, Acute Heart Failure Putting the Puzzle of Pathophysiology and Evidence Together in Daily Practice, Springer; 1-80
Pathophysiology Ventricular Remodelling
Arrigo M, Parissis JT, Akiyama E, Mebazaa A. Understanding acute heart failure : pathophysiology and diagnosis. 2016;18
Mann DL, Felker GM. Heart Failure A Companion to Braunwald ’ s Heart Disease
Neurohormonal activation
and progression of Heart Failure
Correlation CO and PCWP in HF
PATHOPHYSIOLOGY AHF
Jose López-Sendón and Esteban López de Sá, 2008, Acute Heart Failure in the Setting of Acute Coronary Syndromes. Springer-Verlag London.
SYMPTOMS SIGNS
Dyspnea Pulmonary
Orthopnea crepitations
Symptoms PND Gallops
rhythm-third
and sign Reduced exercise heart sound
of AHF tolerance
Cardiac
Wheeze murmur
Ankle swelling Tachycardia
Weight gain Tachypnea
Palpitations Raised JVP
Ascites
Peripheral
edema
• HISTORY
• PHYSICAL EXAMINATION
• CHEST X-RAY
• ECG
• LABAORATORY TESTING
DIAGNOSIS (Natriuretic peptides,
Cardiac Biomarker, Renal
of AHF functions, Electrolytes)
• ECHOCARDIOGRAPHY
• CT/MRI/PET
• CARDIAC CATHETERIZATION
• ENDOMYOCARDIAL BIOPSY
ACS
TACHYARRHYTHMIA
EXERCISE RISE IN BLOOD PRESSURE
INFECTION
NON ADHRENCE WITH SALT/FLUID OR
MEDICATIONS
TOXIC SUBSTANCES
FACTORS DRUGS (NSAID etc)
TRIGGERING EXACERBATIONS OF COPD
PULMONARY EMBOLISM
AHF
SURGERY AND PERIOPERATIVE
COMPLICATIONS
INCREASED SYMPATHETIC DRIVE
METABOLIC/HORMONAL
DERANGEMENT
CEREBROVASCULAR INSULT
ACUTE MECHANICAL CAUSE
Tejedo AA, Miró Ò. Precipitating factors in acute heart failure : a review. 2017;(Figure 1):185–93
Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JGF, Coats AJS, et al. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic
Clinical Profiles of patients with AHF
Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JGF, Coats AJS, et al. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart
failure. Eur Heart J [Internet]. 2016 Jul 14;37(27):2129–200
Initial management of patient with AHF
Management of patient with AHF
Management
of patients
with AHF
based on
clinical
profile
Management of patients with AHF
based on clinical profile
history
CARDIAC profile : This profile typically occurs in patients with a
of chronic HF, impaired LVEF, slow symptomatic deterioration,
gradual (over several days-weeks) fluid accumulations with
concomitan weight gain and dominating signs of peripheral edema,
jugular distension and hepatomegaly.
deterioration
VASCULAR profile : This profile is characterized as rapid clinical
(typically within hours), with severe dyspnea,evidence
of pulmonary congestion (in most severe cases in form of pulmonary
edema), with no (or only minimal) weight gain, where fluid
redistribution to the lung is essential for symptoms; these patients
often have preserved LVEF and present with normal or elevated
systolic blood pressure.
heart failure. Eur Heart J [Internet]. 2016 Jul 14;37(27):2129–200
Ponikowski P, Jankowska EA. Pathogenesis and Clinical Presentation of Acute Heart Failure. 2015;68(4):331–7
.
Bahit MC, Kochar A, Granger CB. Post-Myocardial Infarction Heart Failure. JACC Hear Fail [Internet]. 2018;6(3):179–86
Bahit MC, Kochar A, Granger CB. Post-Myocardial Infarction Heart Failure. JACC Hear Fail [Internet]. 2018;6(3):179–86
Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JGF, Coats AJS, et al.
2016 ESC Guidelines for the diagnosis and treatment of acute and chronic
Goals of Treatment in AHF
CONCLUSION
Flaherty JD, Bax JJ, Luca L De, Rossi JS, Davidson CJ, Filippatos G, et al. Acute Heart Failure Syndromes in Patients With Coronary Artery Disease Early
Assessment and Treatment. JAC [Internet]. 2009;53(3):254–63
CONCLUSION
CONCLUSION
Terima Kasih

Management of ACS Complicated With Acute Heart Failure DR Budiana

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Management of ACS Complicated With Acute Heart Failure DR Budiana

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Management of ACS complicated

with Acute Heart Failure

dr. I Putu Gede Budiana, SpJP (FIHA)

RSD Mangusada, Kabupaten Badung

• Incidence of HF among patients hospitalized for an AMI varies among

All STEMI NSTEMI UAP

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