Acute Heart Failure Chief Rounds, Sept. 14, 2009 Dr. Frederic L. Ginsberg

Acute Heart FailureChief Rounds, Sept. 14, 2009

Dr. Frederic L. Ginsberg

CJTMEustaquio, MD

PGY-3. Internal Medicine

Cooper University Hospital

I. Introduction

- Definition & Causes

- General Approach

II. Case 1: LS, 62M. cc: chest pain

- Discussion: Management

III. Case 2: DF, 60M. cc: syncope


IV.Case 3: DK, 63F. cc: dyspnea


V. Conclusion

I. INTRODUCTION

• Potentially fatal

• Key concepts

o Determinants of cardiac output

o Heart failure

- dyspnea

• Introduction

• Case 1

• Case 2

• Case 3

• Conclusion

Congestive Heart Failure• Introduction• Case 1• Case 2• Case 3• Conclusion

o Acute decompensated heart failure

- Potentially fatal

- Cardiogenic pulmonary edema

- Flash pulmonary edema

• Introduction• Case 1• Case 2• Case 3• Conclusion

General Approach

1. Suspect the diagnosis from S/Sx

- HPI: cough, SOB, fatigue, chest pain/ discomfort

- PE: RR, HR, or BP

accessory muscles

wheezing

S3, S4 gallop

murmurs

JVP

pedal edema

• Introduction

• Case 1

• Case 2

• Case 3

• Conclusion

2. Consider precipitating factorsCARDIAC- MI & myocardial ischemia- Atrial fibrillation, other

arrhythmias- Progression of underlying

cardiac dysfunction- RV pacing with dyssynchrony

NON CARDIAC- Severe HTN- Renal failure- Miscellaneous:

anemiahypo/hyperthyroidismtoxins (cocaine, EtOH)fever & infectionuncontrolled DM

- Medications- PE- Dietary indiscretion, medication

noncompliance, iatrogenic volume overload


3. Tests

a. EKG

b. CXR

c. Lab data - CBC, basic chem 7, cardiac enzymes

BNP, NT-proBNP

Lipid profile, LFTs, TSH

d. Echo

e. Swan-Ganz catheter

f. Coronary Angiography

g. Others: EP studies

4. Treat


Case 1: LS, 62M. Cc: chest pain

• SSCP at restSOB, dyspnea on exertionDiaphoresis

• HTN, DM, HPLCAD s/p POBA 1991Previous smoker

• Metoprolol, HCTZ, Glyburide, Enalapril, Fish Oil, Lovastatin

• 95.2F, 78, 164/83, 18, 99%RANo JVD. CTA b/l.RRR, good S1/S2, no m/r/gNo pedal edema.


Recommendations for the Evaluation of Patients with HF


Case 1: LS, 62M. Cc: chest pain

EKG T wave inversions I, V5, AVL. No ST elevation

CXR No infiltrate

Labs 8.8 17.9 145

49.7

135 95 23 200

3.4 25 0.8

CK 276

MB 15.7

Trop 0.03

ProBNP 279

Echo 3/13/09: Severe global systolic dysfxn. EF 15-20%.

Gr I diastolic dysfxn.

SwanG N/A

Cath 4/13/09: severe, multiple vessel CAD. RCA dominant. EF 15%.

Prox RCA 50%. Distal RCA 95%.

1st R posterolat segment 100% -- L to R collaterals

Prox LAD 100% - L to L collaterals

OM1 30%

Ramus intermedius 100% -- L to L collaterals


• Diagnoses:

1. NSTEMI

2. Chronic Systolic Heart Failure 2 to severe CAD,

3. not in acute decompensation

4. HTN, DM, HPL






The Stages of Heart Failure – NYHA Classification


• Management: Medical + Evaluation for CABG

- Thallium viability study: viable myocardium except distal apex

- Discharged, then readmitted in 2 weeks for planned CABG x5:

LIMA to D2 and LAD.

SVG to D1. SVG to posterior descending artery & distal RCA.


Treatment Recommendations for Patients at High Risk of Developing Heart Failure (Stage A)


Treatment Recommendations for Patients with Asymptomatic LV Systolic Dysfunction (Stage B)


Treatment Recommendations for Symptomatic LV Systolic Dysfunction (Stage C)


Treatment Recommendations for Symptomatic LV Systolic Dysfunction (Stage C)


Case 2: DF, 60M. Cc: Syncope



• OSH: light headedness & syncope

- (+) troponin

- atrial flutter

- severe hypotension – on Norepinephrine drip (Levophed)

- transferred to CUH for cardiac catheterization• PMH:

- Hepatitis C - s/p cholecystectomy

- ESRD on HD - s/p patial colectomy 2 to polyps

- NHL s/p chemo 2007 - s/p hernia repair

- HTN - s/p AV fistula

- ascites



• SH: current smoker – 43py

occasional EtOH

former IVDA, quit 1978

• PE: afebrile, 127/91, HR=98, RR=30• JVP=15 cm H20, 2+ carotid upstrokes• CTA B/L• RR, tachycardic, normal S1/S2• Hepatomegaly• No LE edema



EKG Atrial flutter. Ventricular rate 105.

CXR CT chest: no PE

Labs 5.4 13 154

49.7

133 91 63 166

5.0 23 9.5

CK 159

MB 3.3

Trop 2.8

ProBNP 2,754

Echo 7/08/09: Severe global systolic dysfxn. EF 10-15%.

Septal dyskinesis.

SwanG N/A

Cath 7/08/09: normal coronaries.



• Diagnoses:

- Acute Decompensated Heart Failure

- Syncope.

- NICMP EF 10-15%.

- Paroxysmal atrial flutter.

- ESRD.


Recommendations for the Management of Acute Heart Failure

• Hospitalization– Hypotension, worsening renal function or altered mentation– Dyspnea at rest– Arrhythmia – ACS

• In-patient monitoring• Hemodynamic monitoring• Treatment goals


Goals of Initial Management of ADHF

• Hemodynamic stabilization• Support of oxygenation and ventilation• Symptom relief


Treatment Goals for Patients with ADHF

• Improve symptoms• Optimize volume status• Identify etiology• Identify precipitating factors• Optimize chronic oral therapy• Minimize side effects• Identify patients who might benefit from revascularization• Educate


Components of Therapy for ADHF

• Na and fluid restriction• Diuretics• Oxygen and assisted ventilation• Morphine• Vasodilator – nitrate, nesiritide• Inotropic agents – dobutamine, milrinone• ACE inhibitors and ARBs• Beta-blockers



• Medications:

- ASA 325 mg daily

- ISMN ER 30 mg daily

- Carvedilol 25 mg BID

- Hydralazine 10 mg TID

- Valsartan 80 mg daily

- Temazepam 30 mg daily

- Gabapentin 300 mg BID

- Percocet prn

- Warfarin 2.5 mg daily


Additional Considerations in ADHF

• Arrhythmia management• Mechanical cardiac assistance• Ultrafiltration• Vasopressin receptor antagonist



• EP studies, re atrial flutter.• TEE: no A-V clot• Atrial flutter ablation & ICD placement• Anticoagulation with Warfarin.



Why the decision for an ICD during this admission vs. waiting 3 months of max medical therapy as in Case 1?


Recommendations for Management of Concomitant Diseases in Patients with HF



What inotropes are recommended had he still been hypotensive on transfer to CUH?


Case 3: DK, 63F. Cc: dyspnea



• Admitted under GYN in May & June 2009, cc: Nausea, vomiting• Recent ovarian CA recurrence• Developed acute, severe SOB at rest while on the floors

ICU transfer & BIPAP

• PMH:

- Ovarian CA 1997, s/p resection

1st recurrence, 2002. s/p chemo

2nd recurrence, May 2009.

- HTN – Tenormin 80 mg daily

- DM II – Metformin 500 mg BID, Pioglitazone 45mg daily

- sulfa allergy



• FH: MI – father 75, brother 63

COPD – mother 64, sister• SH: no smoking, no EtOH• ROS: occasional palpitations, fatigue• PE: BP 124/55, HR 98

no JVD

LLL crackles

normal S1/S2, no murmurs, (+) S3 gallop

no pedal edema



EKG NSR. T-wave inversions in I, AVL. ST depressions V4-V6

CXR Pleural effusions B/L, L>R. Incg pulmonary edema b/l.

Labs 9.8

7.8 31.1 299

137 101 15 105

3.9 26 0.6

CK 187 -- 103

MB 20.1 –14.6

Trop 0.58 – 0.32

ProBNP

Echo 6/01/09: Severe global LV systolic dysfxn. EF 10%

RV systolic pressure 62 mm Hg. Mild MR, mod TR.

SwanG N/A

Cath 6/1/09: single vessel CAD. 70% RCA stenosis.

Severe LV dysfunction out of proportion to single vessel CAD.



• Diagnoses:

- Acute decompensated heart failure (with cardiogenic pulmonary edema)

- Cardiomyopathy with severe LV dysfunction, unclear etiology

- Single vessel CAD – likely not the cause of CMP

- DM II

- HTN

- Ovarian CA

- HPL



• Medical therapy for ADHF • (IV Furosemide, Carvedilol, Lisinopril , ASA, statin. NPPV)

symptomatic improvement

back to GYN floors, discharged after 15 days

• HF meds discontinued on D/C – unclear reason

• Out-patient cardiology F/U within 1 week:

- SOB much improved, only mild SOB on climbing 1 flight of stairs

- back on Tenormin; not on beta blocker, ASA, ACE-I

- Add ASA, Carvedilol.

- Repeat echo in 2 weeks.

- F/U with GYN re Tx plan for ovarian CA recurrence.



Takotsubo cardiomyopathy??


Takotsubo cardiomyopathy

• Stress-induced CMP• Apical ballooning syndrome• Broken heart syndrome

• Transient LV systolic dysfunction

• Mimics MI• No significant CAD


Takotsubo Cardiomyopathy

• Stress-induced• Acute medical illness / intense emotional stress / physical stress• Pathogenesis unknown• Catecholamine excess, coronary artery spasm, microvascular

dysfunction


Takotsubo Cardiomyopathy

• Treatment and prognosis– Supportive– Hydration– Standard HF meds

• ACE inhibitor• Beta-blocker• Diuretic• Aspirin

– MR 0 – 8 %– Recovery in 1 to 4 weeks


Conclusion

• Heart failure and ACS• ADHF in atrial flutter & ESRD• Takotsubo CMP

• Evaluation guidelines in HF• Management principles in ADHF• Management of HF in general


Documents

Acute Heart Failure Chief Rounds, Sept. 14, 2009 Dr. Frederic L. Ginsberg