Acute and Chronic Heart Failure-KoAss

7/25/2019 Acute and Chronic Heart Failure-KoAss

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HEART FAILURE


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Classification of HF

New Onset

Transient

Chronic

Recurrent or episodic

Persistent

Stable, worsening or

decompensated

First presentation

Acute or slow onset

ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure

European Heart Journal !""#


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$illip classification

Stage 1: No eart Failure

no clinical sign o! cardiac decompensation

Stage ": eart Failure

S# gallop, pulmonar$ %enous h$pertension, wet rales in the

lower hal! o! the lung !ield Stage #: Se%ere eart Failure

rales throughout the lung !ield

Stage &: Cardiogenic Shoc'

h$potension (S)P * + mmg-, peripheral %asoconstriction

(oliguria, c$anosis, sweating-




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Aetiolog%

Coronar$ Arter$ .isease /al%ular eart .isease

$pertension

Cardiom$opathies (C0, .C0, RC0- .rugs ( bloc'ers, CC), Antiarrh$thmic-

To2ins (Alcohol, Cocaine, 0ercur$, Cobalt-

3ndocrine (.0, $po4h$perth$roid, Cushing-

Nutritional (.e!5 thiamine, selenium, obesit$-

6n!iltrati%e (Sarcoidosis, am$loidosis-

Others (Chagas, 6/, Peripartum, 3SR.-


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Contractilit$ Preload A!terload

Stro'e /olumeeart Rate

Cardiac

Output


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Preload: the %entricular wall tension at the end o!

diastole5

A!terload: the %entricular wall tension during contraction5 Contractilit$: propert$ o! heart muscle that accounts !or

changes in the strength o! contraction, independent o!

preload and a!terload5

Stro'e %olume: %olume o! blood e7ected !rom %entricleduring s$stole5 (S/ 8 3./ 9 3S/-

37ection !raction (3F- 8 S/ : 3./

Cardiac output: %olume o! blood e7ected !rom %entricle

per minute5 (CO 8 S/ 2 R-


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S%mptoms

&a'or s%mptoms &inor s%mptoms

.$spneaOrthopnea

Paro2$smal nocturnal d$spneaAn'le edemaPulmonar$ edemaFatigue32ercise intoleranceCache2ia

eight lossCough

NocturiaPalpitationsPeripheral c$anosis.epression


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(h%sical Findings

&a'or s%mptoms &inor s%mptoms

Tach$cardia3le%ated %enous pressure

Positi%e hepato7ugular re!lu2Pulmonar$ ralesTach$pneaThird heart soundepatomegal$An'le edema

AscitesPleural e!!usion

0itral regurgitationCardiomegal$

Splenomegal$$potensionPulsus alternans32tras$stoleAtrial !ibrillationeight loss


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)iagnostic Studies


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ECG

eart rate

Rh$thm

Conduction

6schaemic

6n!arction

$pertroph$

)))

Prolonged ;T inter%al

Perim$ocarditis


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Chest *+ra%

Should be per!orm as soon as possible

Cardiomegal$

Congestion

3!!usion 6n!iltrates


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La,orator% test

)lood count 3lectrol$te (Na, =-

>rea, creatinine

?lucoseAlbumin

epatic en@$mes

6NR Cardiac mar'ers

Natriuretic peptides ()NP NTBpro )NP-


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Arterial ,lood gas anal%sis

Assessment o! o2$genation (pO"-

Respirator$ !unction (pCO"-

AcidBbase balance (p-

Should be assessed in se%ere respirator$

distress


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Echocardiograph%

?eneral !indings:

Si@e and shape o! the %entricle


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Echocardiograph% -cont./

S$stolic d$s!unction:

Reduced


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Echocardiograph% -cont./

.iastolic d$s!unction:

Normal


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Condition associated 0ith a poor

prognosis in HF

Ad%anced age

6schaemic aetiolog$

Resuscitated sudden death

Poor compliance Renal d$s!unction

.iabetes

Anaemia

COP.

.epression




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&anagement

Non Pharmacological: Sel! care management

S$mptom recognition

eight monitoring

.iet and nutrition Fluid inta'e (restriction o! 15EB"


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Pharmacological

Ob7ecti%e

Prognosis

0orbidit$

Pre%ention

Reduce mortalit$

Relie%e s$mptom and sign

6mpro%e Hualit$ o! li!e

3liminate oedema

Reduce !atigue and d$spnea

Reduce need hospitali@ation

Occurrence m$ocardial damage

Progression m$ocardial damage

Remodelling m$ocardium

Reoccurence s$mptom

ospitali@ation




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1ormalAs%mptomaticL2 d%sfunctionEF 34"5

S%mptomatic CHF

16HA II

S%mptomatic CHF16HA + I2

S%mptomatic CHF16HA + III

Secondar$ pre%ention

0odi!ication o! ph$sical acti%it$

6notropes

Speciali@ed therap$

Transplant


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Rapid onset o! s$mptoms and signs secondar$ toabnormal cardiac !unction

Can present as new onset and without pre%iousl$'nown cardiac d$s!unction or A.F

O!ten li!e threatening and reHuires urgent treatment

AF ma$ present with one or se%eral clinical

conditions:15 orsening or .ecompensated Chronic eart Failure

"5 $pertensi%e eart Failure

#5 Pulmonar$ Oedema

&5 Cardiogenic Shoc'

E5 6solated Right F

J5 ACS and F

Acute Heart Failure


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Causes and precipitating factors

6schaemic heart disease Acute coronar$ s$ndrome

0echanical complications o! acute 06

R/ in!arction

/al%ular /al%e stenosis

/al%ular regurgitation

3ndocarditis

Aortic dissection

0$opathies Postpartum cardiom$opath$

Acute m$ocarditis


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$pertension4arrh$thmias

Circulator$ !ailure Septicaemia

Th$roto2icosis

Anaemia

Shunts

Tamponade

Pulmonar$ embolism

.ecompensation o! preBe2isting CF /olume o%erload

6n!ection

Cerebro%ascular insult Surger$

Renal d$s!unction

Asthma, COP.

.rug and alcohol abuse


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)iagnostic of Acute Heart Failure

)ased on presenting s$mptoms and clinical

!indings

istor$

Ph$sical e2amination

3C?

Chest KBra$

3chocardiograph$


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&onitoring

Non in%asi%e:

/ital Sign

O2$genation

>rine output

3C?

6n%asi%e:

Arterial line (haemod$namic unstable-

Central %enous lines

Pulmonar$ arter$ catheter

Coronar$ angiograph$


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Goals of treatment6mmediate (3.46C>46CC>-

6mpro%ed s$mptom Restore o2$genation and impro%e organ per!usion

length o! sta$

6ntermediate (hospital-

Stabili@e patient optimi@e treatment strateg$

6nitiate appropriate pharmacolog$ therap$

Consider de%ice therap$

0inimi@e hospital length o! sta$


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&anagement

6mmediate s$mptomatic treatment Patient distressed or in pain LL analgesia,

sedation

Pulmonar$ congestion LL diuretic, %asodilator Arterial o2$gen saturation * +E LL increase

FiO", consider CPAP, N6PP/, mechanical

%entilation

eart rate and rh$thm disorder LL pacing,

antiarrh$thmics, electro%ersion




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78%gen

As earl$ as possible in h$po2aemic patients to achie%eO"saturation G +E (L + in COP.-5

Class 6, le%el C

N6/ with P33P as soon as possible in e%er$ patient with

acute cardiogenic pulmonar$ oedema Contraindication:

B unconscious patients

B an2iet$

B immediate need 3T intubation

B se%ere obstructi%e airwa$ disease

B se%ere Right F




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&orphine

0orphine should be considered in the earl$ stage o!

se%ere AF with restlessness, d$spnoea, an2iet$, chest

pain5

Respiration should be monitored

Caution: h$potension, brad$cardia, ad%anced A/ bloc',

CO"retention




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Loop diuretics

.iuretics are recommended in AF patients withcongestion and %olume o%erload5

Class 6, le%el )

Ad%erse e!!ect:

B h$po'alaemia, h$ponatraemiaB h$peruricaemia

B h$po%olaemia and deh$dration

B neurohormonal acti%ation

B ma$ increase h$potension !ollowing AC364AR) therap$




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2asodilators

/asodilators are recommended at an earl$ stage !or AFwithout h$potension or serious obstructi%e %al%ular

disease5

Class 6, le%el )

Ad%erse e!!ect:

B headache (nitrat-

B tach$ph$la2is (nitrat-

B h$potension (NT? or nesiritide in!usion-




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Inotropic agents

6notropic agents should be considered in low outputstates, in the presence o! h$poper!usion or congestion5

.obutamine (class 66a, le%el )-

.opamine (class 66b, le%el C-

0ilrinone and eno2imone (class 66b,le%el )-

Acute and Chronic Heart Failure-KoAss

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