Initial Management :- the patient with AHF on the ICU

THE PATIENT WITH ACUTE HEART FAILURE ON THE ICU – INITIAL

MANAGEMENT

Alain Rudiger, MDUniversity Hospital Zurich, Switzerland

Heart Failure Meeting of the ESCSevilla, May 23rd 2015

Conflict of interests

Honoraria were received from:•AOP Orphan (esmolol, vernakalant) for lectures•BAXTER (esmolol) for expert meetings and lectures•NOVARTIS (human relaxin-2) for advisory board meetings•ORION (levosimendan) for expert meetings

Case report

• 36-year old man

• History: Fatigue, dyspnoea, orthopnoea, abdominal pain

• Clinical examination: Cool periphery, T 36.6 °C, HR 110 /min, BP 110/80 mmHg, normal chest examination, tender and enlarged liver

• Elevated liver enzymes

• Ultrasound: Ascites, pleural effusions

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Echocardiography

• Dilated LV with globally impaired function (EF 14 %), moderate MR

• Dilated RV with impaired function (FAC 21 %)

Pulmonary artery catheter

• Cardiac index 1.9 l/min/m2 (with milrinone 20 g/min)

• PAP 50/40/34 mmHg

• SmvO2 41 % (SaO2 98 %)

Case report

Treatment

• Inotropes (dobutamine, milrinone)

• Vasodilators (nitroglycerin)

• IABP

• Mechanical assist device (Excor® from Berlin Heart)

Case report

From http://www.berlinheart.de

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Case report

Histology

• Inflammation (granulomas with giant cells) cardiac sarcoidosis

Case report

Treatment

• Heart transplantation one month later

Follow up

• Immunosuppression with prednison, mycofenolat mofetil, ciclosporin

• Good quality of life

• Working capacity 80%

AHF on the ICU – Initial management

□ History, clinical investigation, examinations:ØRecognition of AHF-syndromeØDiagnosis of underlying heart diseaseØIdentification of trigger for decompensationØUnderstanding the pathophysiology

□ Monitoring

□ Management

History

AHF-symptoms: Dyspnoea, fatigue, appetite loss, weight gain/loss

Causes for dyspnoea:•Pulmonary congestion•Pleural effusions•Bronchial obstructions (asthma cardiale)•Cerebral hypoxia (hypoxemia, shock)•Metabolic acidosis•Anxiety, pain

Clinical signs

• Pulse rate • Blood pressure • Cardiac auscultation• RR, lung auscultation• Skin evaluation• Neck veins, ascites• Peripheral oedema• GCS, somnolence• Body temperature

Clinical signs

• Pulse rate • Blood pressure • Cardiac auscultation• RR, lung auscultation• Skin evaluation• Neck veins, ascites• Peripheral oedema• GCS, somnolence• Body temperature

Clinical signs

• Pulse rate • Blood pressure • Cardiac auscultation• RR, lung auscultation• Skin evaluation• Neck veins, ascites• Peripheral oedema• GCS, somnolence• Body temperature

Clinical signs

• Pulse rate • Blood pressure • Cardiac auscultation• RR, lung auscultation• Skin evaluation• Neck veins, ascites• Peripheral oedema• GCS, somnolence• Body temperature

Clinical signs

• Pulse rate • Blood pressure • Cardiac auscultation• RR, lung auscultation• Skin evaluation• Neck veins, ascites• Peripheral oedema• GCS, somnolence• Body temperature

Clinical signs

• Pulse rate • Blood pressure • Cardiac auscultation• RR, lung auscultation• Skin evaluation• Neck veins, ascites• Peripheral oedema• GCS, somnolence• Body temperature

Clinical signs

• Pulse rate • Blood pressure• Cardiac auscultation• RR, lung auscultation• Skin evaluation• Neck veins, ascites• Peripheral oedema• GCS, somnolence• Body temperature

Laboratory parameters

• Chemistry• Hematology• Coagulation parameters• Serologic testing• Sampling for microbiology

Arterial blood gas analysis

Mikkelsen ME. Crit Care Med 2009; 37; 1670-7

Lactate

Rudiger A. Crit Care Med 2006: 34: 2140-4

At ICU admission (grey) and maximal value during ICU stay (black)

NT-proBNP

Shock

Nikolau M. Eur Heart J 2013; 34: 742-9

Liver transaminases and alkaline phosphatase

Additional examinations

• Electrocardiogram

• Chest X-ray

• Echocardiography

• Coronary angiogram

Underlying cardiac diseases

• Ischemic heart disease

• Valvular heart disease

• Hypertensive cardiopathy

• Infectious myocarditis

• Dilatated / hypertrophic cardiomyopathy (genetic)

• Peripartum cardiomypathy

• Drugs (alcohol, cocain)

• Scleroderma, rheumatoid arthritis; Anti-TNF therapy

• Chemotherapy, radiation therapy; Neoplasia

• Amyoloidosis, haemochromatosis, sarkoidosis

Felker GM. N Engl J Med 2000: 342: 1077-84

Triggers for decompensation

• Myocardial ischemia• Arrhythmia• High blood pressure• Infections / inflammations• Malcompliance• Disease progression• Iatrogenic causes

Felker GM. N Engl J Med 2000: 342: 1077-84

The AHF syndromes

Cardiogenic shock Pulmonary edema Decompensated CHF

Typical scenario Large myocardial infarction; Fulminant myocarditis

Hypertensive emergency in diastolic HF

Malcompliance in dilated cardiomyopathy

Signs and symptoms Tissue hypoperfusion (lactate >2 mmol/l);Organ dysfunction (ecephalopathy, renal failure, liver dysfunction)

Dyspnoea at rest; Bilateral rales; Hypoxemia (SaO2 <90%)

Dyspnoea at exercise;Weight gain, ascites, peripheral oedema

Pump failure Systolic;Left and/or right

Diastolic;Left

Systolic and diastolic;Left and/or right

Diagnostic test ABGA (lactate) Chest x-ray NT-proBNP

AHF on the ICU – Initial management

□ History, clinical investigation, examinations:ØRecognition of AHF-syndromeØDiagnosis of underlying heart diseaseØIdentification of trigger for decompensationØUnderstanding the pathophysiology

□ Monitoring

□ Management

x

Basic monitoring

• Continuous SpO2

• Continuous ECG

• Non-invasive blood pressure

• Urinary catheter

• Arterial line

• Central venous catheter

AHF on the ICU – Initial management

□ History, clinical investigation, examinations:ØRecognition of AHF-syndromeØDiagnosis of underlying heart diseaseØIdentification of trigger for decompensationØUnderstanding the pathophysiology

□ Monitoring

□ Management

x

x

Managment

• Treat underlying cardiac disease and triggering factors !

• Rhythm control

• Optimisation of preload (fluid vs diuretics)

• Improvement of contractility (inotropes, ECLS)

• Optimization of afterload (vasopressors vs vasodilators)

Hochman JS. N Engl J Med 1999; 341: 625-34

Interventions and cardiac surgery

Frank Starling mechanism

Fluid management

• Excessive use of i.v. diuretics

• Increased perspiratio insensibilis

• Reduced fluid intake

Fluid management

Cardiogenic shock Pulmonary edema Decompensated CHF

Volemia Intravascular hypovolemia (low fluid intake, fluid losses, diuretics)

Fluid redistribution Hypervolemia (weight gain, ascites, peripheral oedema)

Diuretic use Contraindicated Careful (furosemide 10 mg i.v. push)

Indicated (furosemide infusion 1-10mg/h)

Fluids Fluid challenge recommended

If shock develops Fluid restriction

Fluid balance target Urine output 0.3-0.5 ml/kg/h

Depending on intravascular volemia

Negative fluid balance

Fluid management

Cardiogenic shock Pulmonary edema Decompensated CHF

Blood pressure Low (or normal) High Normal

Vasoactive drugs Vasopressors (noradrenaline, adrenaline, vasopressin)

Vasodilators (nitroprusside)

Vasodilators (nitrates)

Inotropes Indicated (dobutamine, adrenaline, levosimendan)

In selected cases In selected cases

Hemodynamic targets

MAP 60-75 mmHg, Lactate < 2.2 mmol/lSvO2 > 60%CI >2.2 l/min/m2

MAP 65-85 mmHg Individual targets

Vasoactive drugs and inotropes

Cardiogenic shock Pulmonary edema Decompensated CHF

Respiratory support Intubation and invasive ventilation

Non-invasive ventilation

Oxygen via face mask

SpO2 target 92-98 % 92-98 % 92-98 %

Potassium levels 4.5-5.5 mmol/l 4.5-5.5 mmol/l 4.5-5.5 mmol/l

Magnesium levels >1.0 mmol/l >1.0 mmol/l >1.0 mmol/l

Enteral feeding No No Yes

Blood glucose 4.5-8.5 mmol/l 4.5-8.5 mmol/l 4.5-8.5 mmol/l

Thromboprophylaxis Yes Yes Yes

Additional treatments

Singer M. PLoS Med 2005; 2: e167

Jeger RV. Ann Intern Med 2008; 149 618-26

Avoid iatrogenic harm

Summary

The correct diagnosis of the …

• Underlying heart disease• Trigger for the acute decompensation• Pathophysiology• Organ dysfunctions• Co-morbidities

… is the basis for the correct management of the patient.

Summary

Cardiogenic shock Pulmonary edema Decompensated CHF

Signs and symptoms Tissue hypoperfusion (lactate >2 mmol/l);Organ dysfunction (ecephalopathy, renal failure, liver dysfunction)

Dyspnoea at rest; Bilateral rales; Hypoxemia (SaO2 <90%)

Dyspnoea at exercise;Weight gain, ascites, periperal edema

Treatment Inotropes, vasopressors, fluidsIntubation, mechanical ventilation

Vasodilators

Non-invasive ventilation

Vasodilators, diureticsOxygen via face mask

Avoid iatrogenic harm

Thank you!

alain.rudiger@usz.ch