Approach to Cardiac Failure
Dr J Strange7th November 2013
Case• 24 year old male• Previously well• Developed shortness of breath, pyrexias over
a 5 day period• Observations– HR 130, regular– BP 87/45– O2 Sats 88% on room air
• ABG – pO2 11 pCO2 5.1 BE -12 lactate 6
• Hb 130g/L WCC 14 Platelets 180• Na 132 K 5.2 Urea 15 Creat 210 CRP 180• PT 16, elevated transaminases• Oliguric, peripheral oedema• Intubated and commenced vasopressors
TTE
• Globally reduced LV function• Estimated EF 15%• Transferred to Alfred– Noradrenaline @ .35 microgram/kg/min– MAP 68– CVP 21– PAOP 26– CI 1.7
INITIAL ASSESSMENT
Immediate assessment and resuscitation
• Resuscitation• Basic monitoring• History• Examination• Assessment of severity
How does CPAP work?
• Recruitment• Increased FRC• Improved pulmonary
compliance• Reduced transdiaphragmatic
pressure swings• Decreased work of
breathing• Reduction in ventricular
transmural pressure – reduced afterload
Circulation
• Therapies dependent on patho-physiological classification
• Maintenance of appropriate blood pressure and cardiac output essential
Key questions…
• Is the patient dyspnoeic?• De novo or on a background of cardiac
problems?• Symptoms of ACS?• Medications?
Examination
Congestion• JVP• Pulsus alternans• HJR• Parasternal lift• Displaced apex• Gallop• MR/TR murmur• Oedema• Ascites• Hepar
Low CO• Cool peripheries• Decreased LOC• Confusion• Hypotension• Low volume pulse• Inappropriate
tachycardia
Severity
• Who should be transferred to ICU?• NYHA classification
Framington Heart Study
• Life-time risk 20% for men and women• Hypertension is the biggest modifiable risk
factor• Median survival after development of 1.7
years in men and 3.2 years in women
Diagnostic category
• Pressure overload• Volume overload• Impaired ventricular filling• Myocardial diseases• Dysrhythmias
Pathophysiology
• Right and/or left• Forward/backward• Systolic and/or diastolic
Cardiogenic shock
• Oliguria• Clouded sensorium• Cool, mottled peripheries• SBP <90• HR >90• CI <2.2• PAOP >15
Forward failure
• Signs– reduced tissue perfusion
at rest with weakness– confusion and drowsiness– pallor with peripheral
cyanosis– cold clammy skin– low blood pressure– oliguria– culminating in the full
blown cardiogenic shock
• Causes– acute myocardial
infarction– acute myocarditis– acute valvular
dysfunction– pulmonary embolism– cardiac tamponade
Left heart backward failure
Right heart backward failure
• Right heart ischaemia• Syndrome of chronically elevated systemic
venous pressure
INVESTIGATIONS
ECG
• The negative predictive value of a normal ECG to exclude LV systolic dysfunction exceeds 90%
• Presence of anterior Q waves and LBBB in patients with IHD are good predictors of decreased EF
CXR
Troponin
• I or T• Increased in shock, renal failure, sepsis,
hypovolaemia• Values need to be interpreted in context
BNP
• Elevated in accordance with severity of heart failure
• High negative predictive values
ECHO
• Function• Mechanics
Other invasive monitors
• PAC• PiCCO• Oesophageal Doppler
MANAGEMENT
Reducing demand
• Reducing heart rate• Reducing afterload• 30 to 40% of cardiac output may be required
to support the work of breathing in a dyspnoeic patient
Increasing supply
• Vasodilator• Blood transfusion• Judicious inotropes
Non-specific therapy
• General care• Adequate oxygenation• Adequate heart rate• Optimise preload• Increasing cardiac output• Correct structural problems
SPECIFIC PROBLEMS
Forward acute heart failure – Cardiogenic shock
• Most commonly MI• 5 -10% of MI’s• 50 – 80% mortality• Reperfusion vital
IABP
VA - ECMO
VAD
Left heart backward failure
• ? ACS – reperfusion• Oxygen, Diuretics, Vasodilators, Morphine
Right heart backward failure
• Increased portal venous pressures• Care with volume replacement therapy• Increase in PVR can be devastating• Aim to reduce RV afterload without affecting
systemic blood pressure
Takotsubo’s cardiomyopathy
Filtration or pharmacology
• Ultrafiltration was inferior to pharmacology at 96h
• Higher creatinine level• No difference in weight loss• Higher serious adverse events
Cardiac re-synchronisation therapy
• ICD and CRT used for wide range of patients with heart rhythm disturbances
• Reduction in sudden death• Improved ventricular performance
Institution of long-term therapy
• Evidence for long-term benefit of:– ACEi– β blockers– Spironolactone
Case
• 30 yo man post arch and aortic valve replacement
• Marfan’s• Post-op– HR 86– BP 120/85– CVP 9
• 6h later– HR 125– BP 70/50– CVP 20– TR– Lactate 2 9– Cool to touch, chest clear
Tests
• ABG• LFT – elevated transaminases• Cardiac enzymes – elevated • CXR• ECG – RBBB, ST elevation II, III, aVF• ECHO – no effusion, severely dilated and
hypokinetic RV, hypertrophied LV, TR
Management
• ABCs• Further fluid may be detrimental• Drugs to increase RV contractility and
decrease RV afterload• Return to theatre• Consider PAC
• Death from any cause or hospitalization for worsening heart failure– 50.7% vs 49.5% (p=0.87)
• Stroke– 3.7% vs 2.7% (p=0.23)
• Thromboembolism– 13.5% vs 10.0% (p=0.01)
QUESTIONS?