Heart Failure Acute

DEFINITION, CLASSIFICATION MONITORING, AND TREATMENT

OF ACUTE HEART FAILURE

Department of Cardiology and Vascular MedicineDivision of Cardiovascular, Department of Internal

MedicinePadjadjaran University School of Medicine

Hasan Sadikin HospitalBandung

ACUTE HEART FAILURE IS A CHALENGING DISORDER

1. Highly prevalent especially among the elderly

2. High rate of hospital readmission, early recurrent

events, and mortality

3. Progressive disorder

4. Heterogeneity in etiology and LV function

5. Characteristic, management, and outcomes have

been poorly defined

MECHANISM OF HEART

FAILURE

Vena cava

Arteri pulmonali

s

Vena pulmonal

is

Aorta

Atrium kananKatup

trikuspid

Katup mitral

Atrium kiri

Ventrikelkanan

Ventrikelkiri

Paru

SIRKULASI JANTUNG PARU

PERFORMANCE OF THE VENTRICLE

1. PRELOAD

2. CONTRACTILITY

3. AFTERLOAD

Mekanisme Frank-Starling

Volume akhir diastolik ventrikel (preload)

Isi

seku

ncup

Meningkatnya preload akan diikuti oleh meningkatnya kontraktilitas sehingga isi sekuncup akan meningkat pula

Pressure

overload

Volume

overload

Myocardial

contractility

Compensatory

mechanism

Normal pumping function

Heart failure

MECHANISM OF HEART FAILURE

adequate

failed

DEFINITION and

CLASSIFICATION of

HEART FAILURE

DEFINITION OF HEART FAILURE

The heart fails to pump blood

commensurate with the requirement of the

metabolizing tissue

orThe heart can pump blood commensurate

with the requirement of the metabolizing

tissue only from an elevated filling

pressure

HEART FAILURE

DIASTOLIC

SYSTOLIC

RA

RV

LA

LV

HEART FAILURE

BACKWARD

FORWARD

RA

RV

LA

LV

HEART FAILURE

LEFT

RIGHT

RA

RV

LA

LV

HEART FAILURE

ACUTE

CHRONIC

RA

RV

LA

LV

DEFINITION OF CHRONIC AND ACUTE HEART FAILURE

Definition of Chronic Heart Failure

• A syndrome in which patients have symptoms of HF (dyspnea and fatigue) with evidence of cardiac dysfunction and a clinical response to treatment directed to HF alone (The ESC guidelines) 1

• A clinical syndrome as a result of cardiac dysfunction that impairs the ability of the ventricle to fill and eject blood, producing symptomatic manifestation of HF (The ACC/AHA guidelines) 2

1. Remme WJ, Swedberg K. Eur Heart J 2001;22:1521-60

2. Hunt SA et al. Circulation 2001;104:2996-3007

Definition of Acute Heart Failure

Acute heart failure is characterized by a

rapid or gradual onset of sign and

symptoms of heart failure, resulting in

unplanned hospitalization or office or

emergency room visits. Nieminen MS, Harjola V-P. Am J Cardiol 2005;96(suppl):5G-10G

CLINICAL SEVERITY CLASSIFICATION(For Chronic Heart Failure: Hospitalized or

Outpatients)

PERFUSION : warm or coldCONGESTION: dry or wet

Class Classification

I Warm and dry

II Warm and wet

III Cold and dry

IV Cold and wet

Nohria A TS et al. J Am Coll Cardiol 2003;41:1797-1804

INADEQUATE PERFUSION (COLD)

• pulse pressure

• Cool extremities

• Altered mentation

• ACE-I intolerance

• Worsening renal

functionNohria A TS et al. J Am Coll Cardiol 2003;41:1797-1804

PULMONARY CONGESTION (WET)

• Orthopnea

• Rales

• JVP

• Abdominojugular reflux

• Hepatomegali

• Ascites

• EdemaNohria A et al. J Am Coll Cardiol 2003;41:1797-1804

Six-month mortality by determined hemodynamic profiles

Patient profile N (%) Six-month mortality

(%)

Dry-war 123 (27) 11

Wet-warm 222 (49) 22

Wet-cold 91 (20) 40

Dry-cold 16 (4) 17

Nohria A et al. J Am Coll Cardiol 2003;41:1797-1804

The New York Heart Association functional classification

Class ClassificationI Patients with cardiac disease but without limitation of

physical activity. Ordinary physical activity does not cause undue fatique, palpitation, dyspnea, or anginal pain

II Patients with cardiac disease resulting in slight limitation of physical activity. They are comfortable at rest. Ordinary physical activity results in fatique, palpitation, dyspnea, or anginal pain

III Patients with cardiac disease resulting in marked limitation of physical activity. They are comfortable at rest. Less than ordinary physical activity results in fatique, palpitation, dyspnea, or anginal pain

IV Patients with cardiac disease resulting in inability to carry on any physical activity without discomfort. Symptoms of cardiac insufficiency or anginal syndrome may be present even at rest. If any physical activity is undertaken, discomfort is increased

Goldman L et al. Circulation 1981;64:1227

KILLIP CLASSIFICATION

STAGE I : No clinical signs

STAGE II : Heart failure. Diagnostic criteria: rales S3 gallop and pulmonary veins hypertension. Pulmonary congestion with wet rales in the lower half of the lung fields

STAGE III : Severe heart failure. Frank pulmonary edema with rales over the lung filds

STAGE IV : Cardiogenic shock. Signs: hypotension (SBP 90 mm Hg), and evidence of peripheral vasoconstriction such as oliguria, cyanosis and diaphoresis

FORRESTER CLASSIFICATION

Adapted from Forester et al. Am J Cardiol 1977;39:137

0,5

1

1,5

2

2,5

3

3,5

0 5 10 15 20 25 30 35 40

CI (

L/m

/m2 )

18

2.2

PCWP (MM Hg)

Hypovolemia Pulmonary congestion

Normal

Hypovolemic shock

Cardiogenic shock

DiureticsVasodilators: NTG, Nitropruside

Mortality 22.4% Mortality 55.5%

Hyp

oper

fusi

on

Fluid administration

H-I C-I

H-II C-II

H-III C-III

H-IV C-IV

Pulmonary edema

Mortality 2.2% Mortality 10.1%

Fluid administration

Normal BP: vasodilatorReduced BP: inotropics or vasopressor

The routine use of invasive

hemodynamic monitoring in

patients with ADHF is not

recommended. (Strength of

Evidence A)Adams Jr, KF, Lindenfeld J, Arnold JMO, et al. Executive Summary: HFSA 2006 Comprehensive

Heart Failure Practice Guideline. J Cardiac Failure 2006;12:10–38.

TREATMENT GOALS

Aim of Treatment

FEEL BETTER OR

LIVE LONGER

Clinicians want to treat AHF rapidly by adding new therapies

GOAL OF TREATMEN

T

QoL improvement

Morbidity and mortality reduction

• Improve symptoms, especially congestion and low-output symptoms

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

revascularization• Educate patients concerning medications and self

assessment of HF• Consider and, where possible, initiate a disease

management program

Treatment Goals for Patients Admitted for ADHF

Adams Jr, KF, Lindenfeld J, Arnold JMO, et al. Executive Summary: HFSA 2006 ComprehensiveHeart Failure Practice Guideline. J Cardiac Failure 2006;12:10–38.

Patient distressed or in pain

Analgesia or sedation

Arterial O2 saturation 95%Increase Fi02, considered CPAP

Normal heart rate and rhythm

Pacing, antiarrhythmics

Mean BP 70 mm Hg

Vasodilators, consider diuresis if volume overload

Adequate preload

Yes

No

No

Yes

No

Yes

Yes

No

No

Yes

Fluid challenge

Adequate CO, metabolic acidosis, SvO2 65%, inadequate perfusion

No consider inotropes or afterload manipulation

Rapid improvement of symptoms is

a desire goal, but should not

become the only goal in managing

AHF.

Many treatment modalities shown

to improve symptoms were shown

to increase mortality.

Intravenous vasodilators (intravenous

nitroglycerin or nitroprusside) and

diuretics are recommended for rapid

symptom relief in patients with acute

pulmonary edema or severe

hypertension.

(Strength of Evidence C)Adams Jr, KF, Lindenfeld J, Arnold JMO, et al. Executive Summary: HFSA 2006 ComprehensiveHeart Failure Practice Guideline. J Cardiac Failure 2006;12:10–38.

Intravenous inotropes (milrinone or

dobu-tamine) are not recommended

unless left heart filling pressures are

known to be elevated based on direct

measurement or clear clinical signs.

(Strength of Evidence B)Adams, KF, Lindenfeld J, Arnold JMO, et al. Executive Summary: HFSA 2006 Comprehensive

Heart Failure Practice Guideline. J Cardiac Failure 2006;12:10–38.