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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 !