Acute heart failureAcute heart failure

AIMSAIMS

• Common emergency presentationCommon emergency presentation• High mortality & morbidity in High mortality & morbidity in

survivorssurvivors• Diagnosis not always straightforwardDiagnosis not always straightforward• Classic examination findings not Classic examination findings not

sensitive or specificsensitive or specific• Prompt recognition & stabilization of Prompt recognition & stabilization of

patient- prioritypatient- priority

• At 40 yrs age- lifetime risk: 21%At 40 yrs age- lifetime risk: 21%• Increasing prevalenceIncreasing prevalence• In extremis + rapid deteriorationIn extremis + rapid deterioration• Often respond very rapidly to Often respond very rapidly to

treatmenttreatment• Very satisfying condition to treatVery satisfying condition to treat• Outlook poor despite initial clinical Outlook poor despite initial clinical

improvementimprovement

PresentationsPresentations

• Acute SOB, frothy sputumAcute SOB, frothy sputum• CollapseCollapse• ShockShock• Cardiac arrestCardiac arrest

Acute pulmonary oedemaAcute pulmonary oedema• SPOTTERSPOTTER• Extreme SOB, puffing, unable to speakExtreme SOB, puffing, unable to speak• Profuse sweating, cold clammy Profuse sweating, cold clammy

extremitiesextremities

• TachycardiaTachycardia irregularityirregularity• BP fall BP fall ±±• Basal crepsBasal creps• Rarely wheeze predominant !!! ( asthma)Rarely wheeze predominant !!! ( asthma)

Collapse/ cardiac arrestCollapse/ cardiac arrest

• Severe HF of any cause:- prone for Severe HF of any cause:- prone for malignant arrythmias, PE malignant arrythmias, PE

• Present as collapsePresent as collapse• Very poor outcomesVery poor outcomes• Survival to discharge ???Survival to discharge ???

AetiologyAetiology

• CADCAD• Hypertensive heart Hypertensive heart

diseasedisease• Fluid overloadFluid overload• Acute valvular Acute valvular

regurgitationsregurgitations• ArrythmiasArrythmias

• Pulmonary Pulmonary embolismembolism

• Acute hepatic Acute hepatic venous thrombosisvenous thrombosis

• IWMI+RVMIIWMI+RVMI• TamponadeTamponade

CADCAD

• Most common causeMost common cause• Can be the 1Can be the 1stst manifestation manifestation• SOB >>> chest painSOB >>> chest pain• RVMI common in the setting of IWMIRVMI common in the setting of IWMI• LV > 40% infarct sizeLV > 40% infarct size

HHDHHD

• 11stst presentation presentation • Accelerated hypertensionAccelerated hypertension• Onset of HF lowers previously high Onset of HF lowers previously high

BPBP• Diastolic dysfunction is the basisDiastolic dysfunction is the basis• Age Age

Pulmonary oedemaPulmonary oedema

• MechanismsMechanisms– pulm capillary pressurepulm capillary pressure

– Capillary permeabilityCapillary permeability

– Oncotic pressureOncotic pressure

pulm capillary pressurepulm capillary pressure• LA pressureLA pressure

– MV diseaseMV disease– ArrythmiasArrythmias– Aortic valve diseaseAortic valve disease– IschemiaIschemia– cardiomyopathycardiomyopathy

• LVEDPLVEDP– Accelerated HBPAccelerated HBP– Pericardial constrictionPericardial constriction– Fluid overloadFluid overload– Reno-vascular diseaseReno-vascular disease– High-output statesHigh-output states

• NeurogenicNeurogenic– IC bleedIC bleed– Cerebral oedemaCerebral oedema– Post-ictalPost-ictal

• high altitudehigh altitude

• Capillary Capillary permeabilitypermeability– ARDSARDS

• Oncotic pressure Oncotic pressure fallfall– Loss:- NS, CirrhosisLoss:- NS, Cirrhosis

– Production:- Production:- cirrhosis, sepsiscirrhosis, sepsis

– Dilution:- Dilution:- crystalloidscrystalloids

Investigations Investigations

• ECGECG• Entirely normal # systolic HFEntirely normal # systolic HF• ACSACS• Arrythmias Arrythmias • Serial ECG always essentialSerial ECG always essential

Cardiac enzymesCardiac enzymes

• Essential to r/o AMI Essential to r/o AMI even in the even in the absence of chest pain !!absence of chest pain !!

• Ideally tropT / trop-I : at presentation Ideally tropT / trop-I : at presentation & 12 hrs later& 12 hrs later

• BNPBNP :- very useful in r/o AMI in a :- very useful in r/o AMI in a breathless patientbreathless patient

CXRCXR

• NEVER delay treatment pending CXRNEVER delay treatment pending CXR

• Portable CXR: cardiomegaly ??Portable CXR: cardiomegaly ??

• Peri-hilar bat’s wing shadowing Peri-hilar bat’s wing shadowing diagnosticdiagnostic

• Look for pericardial effusion, Look for pericardial effusion, pneumothorax, consolidationpneumothorax, consolidation

• ECHO:-ECHO:- preferably as early as preferably as early as possiblepossible

• To identify causeTo identify cause• Assess LV function, Assess LV function, • Diastolic dysfunctionDiastolic dysfunction• Cardiac tamponadeCardiac tamponade

STABILIZATIONSTABILIZATION

Actions in orderActions in order

• Propped up positionPropped up position• IV MorphineIV Morphine• 100% Oxygen100% Oxygen• IV LasixIV Lasix• Monitor ECGMonitor ECG• Venous accessVenous access• Ensure optimal BPEnsure optimal BP• Emergency blood samplesEmergency blood samples• ABGABG SpO2SpO2

Assess respiratory functionAssess respiratory function

• Wheeze: interstitial oedemaWheeze: interstitial oedema• Aminophylline helpful- bolus Aminophylline helpful- bolus • Indications for further supportIndications for further support

– ExhaustionExhaustion– Persistent low paO2 < 8kPaPersistent low paO2 < 8kPa– Rising pCO2Rising pCO2– Worsening acidosisWorsening acidosis

Hemodynamic statusHemodynamic status

• PCWP > 18 mmHg diagnosticPCWP > 18 mmHg diagnostic

BP

< 100 > 100

Patient in shockPatient in shock

• Insert central lineInsert central line• Renal dose Dopamine ( 2.5-5 Renal dose Dopamine ( 2.5-5 µg/kg/mt)µg/kg/mt)• Urgent ECHO for any mechanical causesUrgent ECHO for any mechanical causes• Increase Dopamine (but not > 10-20 ) Increase Dopamine (but not > 10-20 )

raises pulm filling prssures raises pulm filling prssures• Nor adrenaline preferred to high dose Nor adrenaline preferred to high dose

dopaminedopamine• Once Bp restored add vasodilatorsOnce Bp restored add vasodilators

SBP >100SBP >100

• Further doses of IV lasix 60-80 mg Further doses of IV lasix 60-80 mg q8h or even 20-80 mg/hr infusionq8h or even 20-80 mg/hr infusion

• NTG infusion at 2-10 mg/hr titrate to NTG infusion at 2-10 mg/hr titrate to keep BP> 100keep BP> 100

• Vasodilators : ACEI Vasodilators : ACEI