Nwalozie J.C. 17/03/2014. Question A 50 year old man presents with sudden-onset breathlessness...

CARDIOLOGY UNIT PRESENTATION

Nwalozie J.C. 17/03/2014

Question A 50 year old man presents with sudden-

onset breathlessness & feeling of impending doom.

Discuss 3 differential diagnoses & describe the management of Acute Left Ventricular Failure.

Answers

3 differential diagnoses: 1. Acute Severe asthma

2. Pulmonary Embolism

3.Acute exacerbation of COPD

MANAGEMENT OF ACUTE LEFT VENTRICULAR FAILURE

Outline Introduction Precipitating factors Pathophysiology Clinical features Investigations Management Treatment Prognosis & Monitoring Follow-up Conclusion

Introduction Inability of the left ventricle to effectively

handle its pulmonary venous return with leakage of fluid from the pulmonary capillaries & venules into the alveolar space (secondary to increased hydrostatic pressure) leading to rapid onset of breathlessness.

It is a medical emergency .

It can arise de novo or on a background of chronic left ventricular failure.

PRECIPITATING FACTORS

Dietary indiscretion Uncontrolled hypertension Non adherence to drugs Myocardial ischaemia or infarction Arrhythmias Thyrotoxicosis Fluid overload Anaemia Pulmonary & other infections Inappropriate medications- -ve inotropes,

NSAIDS Acute valvular insufficiency

PATHOPHYSIOLOGY

↓ CARDIAC OUTPUTINCREASED PCWP

ACTIVATION OF RENIN ANGIOTENSINSYSTEM

ACTIVATION OF S/S SYSTEM

INCREASED HEART RATEINCREASED SYSTEMIC VASCULAR RESISTANCE

INCREASED PRELOAD

CARDIAC ISCHAEMIA↓ LEFT VENTRICULAR

FUNCTION

SYMPTOMATICDECOMPENSATION

CLINICAL FEATURES Extreme SOB with use of accessory muscles of

respiration

Sensation of drowning, chest pain, palpitations

Cough(with pink , frothy sputum)

Previous history: Of cardiac disease

Restlessness, Profuse sweating

CLINICAL FEATURES Orthopnoea(patient noticed to be sitting up in bed) - sensitivity 5% - specificity 77%

PND

Pulse(Tachycardia, Pulsus Alternans)

BP

S3

Wheezing (Cardiac ‘asthma’) – sensitivity 22% - specificity 58%

Crepitations - sensitivity 6% - specificity 78%

Other features:

-Cyanosis

-Cold skin

-Features of underlying heart disease/precipitating factor

-Features of right heart failure

INVESTIGATIONS 1.Pulse oximetry

2. Blood

3. Electrocardiography

4. Radiologic

5.Others- eg. Pulmonary arterial catheterisation

BLOOD INVESTIGATIONS ABG

FBC – anaemia, infection

U & Es

CARDIAC MARKERS

CARDIAC MARKERS

CARDIAC ENZYMES

OTHER CARDIAC MARKERS

IMPORTANCE OF BNP IN HF

1. Useful in Diagnosis

2. Assessing Severity

3. Predicting short & long-term CVS mortality

WHAT LEVELS ? NO HEART FAILURE-BNP < 100pg / dl-NT PRO-BNP < 300pg / dl

HEART FAILURE-BNP >500pg / dl-NT PRO-BNP > 1000pg / dl*80% Sensitivity for heart failure

ELECTROCARDIOGRAM Ischaemia / infarction

Arrhythmia – A fib

LVH

Prolonged QRS

CHEST RADIOGRAPH FINDINGS IN HEART FAILURE Cardiomegaly – 74% sensitive, 78%

specific

Vascular redistribution

Interstitial oedema

Alveolar oedema

Pleural effusions (right sided/bilateral)

Others Echocardiography 1.Identify reversible cause eg MI,

valvular insufficiency ,tamponade 2.Distinguish between systolic and

diastolic dysfunction

• Monitor urine output

Treatment A medical emergency

Begin treatment before investigations

ABC of resuscitation , Patient to sit up

Treatment can be medical, radiological/surgical

TREATMENT AIMS OF IMMEDIATE MANAGEMENTOverall aim- Redistribute fluid out of lungs!

-Decrease Preload (right-sided filling) eg loop diuretics,morphine,tolvaptan

-Increase left-sided emptying eg ACE-I,NTG,nitroprusside

↓ Afterload, Cardiac output

-± improve LV contractility – inotropes eg dopamine,dobutamine,milrinone,levosimendan

Other measures-diet , fluid restriction , ultrafiltration , treat precipitating cause eg infection

Radiological-IABP,LV assist device , CRT

Surgical-Valve repairs , transplantation

Prognosis & monitoring Poor prognostic factors include: -Underlying heart

disease/precipitating factor -BNP>500 pg/dl -K <3mmol/l -Na < 133mmol/l -Frequent ventricular extrasystoles

Monitoring for vital signs, other signs , symptoms ,urine output ,renal function ,electrolytes.

Follow Up

Conclusion ALVF is a life-threatening medical emergency

that is as a result of LV compromise leading to accumulation of fluid in the lungs with resultant acute onset of symptoms.

It is essential to make a diagnosis( ie differentiate it from similar conditions) so that necessary interventions can be instituted as soon as possible

Management is multidisciplinary and should be individualised according to how each patient presents.

THANK YOU FOR LISTENING !