THE PATIENT WITH ACUTE HEART FAILURE ON THE ICU – INITIAL MANAGEMENT Alain Rudiger, MD University Hospital Zurich, Switzerland Heart Failure Meeting of the ESC Sevilla, May 23 rd 2015
THE PATIENT WITH ACUTE HEART FAILURE ON THE ICU – INITIAL
MANAGEMENT
Alain Rudiger, MDUniversity Hospital Zurich, Switzerland
Heart Failure Meeting of the ESCSevilla, May 23rd 2015
Conflict of interests
Honoraria were received from:•AOP Orphan (esmolol, vernakalant) for lectures•BAXTER (esmolol) for expert meetings and lectures•NOVARTIS (human relaxin-2) for advisory board meetings•ORION (levosimendan) for expert meetings
Case report
• 36-year old man
• History: Fatigue, dyspnoea, orthopnoea, abdominal pain
• Clinical examination: Cool periphery, T 36.6 °C, HR 110 /min, BP 110/80 mmHg, normal chest examination, tender and enlarged liver
• Elevated liver enzymes
• Ultrasound: Ascites, pleural effusions
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Echocardiography
• Dilated LV with globally impaired function (EF 14 %), moderate MR
• Dilated RV with impaired function (FAC 21 %)
Pulmonary artery catheter
• Cardiac index 1.9 l/min/m2 (with milrinone 20 g/min)
• PAP 50/40/34 mmHg
• SmvO2 41 % (SaO2 98 %)
Case report
Treatment
• Inotropes (dobutamine, milrinone)
• Vasodilators (nitroglycerin)
• IABP
• Mechanical assist device (Excor® from Berlin Heart)
Case report
From http://www.berlinheart.de
Case report
Case report
Histology
• Inflammation (granulomas with giant cells) cardiac sarcoidosis
Case report
Treatment
• Heart transplantation one month later
Follow up
• Immunosuppression with prednison, mycofenolat mofetil, ciclosporin
• Good quality of life
• Working capacity 80%
AHF on the ICU – Initial management
□ History, clinical investigation, examinations:ØRecognition of AHF-syndromeØDiagnosis of underlying heart diseaseØIdentification of trigger for decompensationØUnderstanding the pathophysiology
□ Monitoring
□ Management
History
AHF-symptoms: Dyspnoea, fatigue, appetite loss, weight gain/loss
Causes for dyspnoea:•Pulmonary congestion•Pleural effusions•Bronchial obstructions (asthma cardiale)•Cerebral hypoxia (hypoxemia, shock)•Metabolic acidosis•Anxiety, pain
Clinical signs
• Pulse rate • Blood pressure • Cardiac auscultation• RR, lung auscultation• Skin evaluation• Neck veins, ascites• Peripheral oedema• GCS, somnolence• Body temperature
Clinical signs
• Pulse rate • Blood pressure • Cardiac auscultation• RR, lung auscultation• Skin evaluation• Neck veins, ascites• Peripheral oedema• GCS, somnolence• Body temperature
Clinical signs
• Pulse rate • Blood pressure • Cardiac auscultation• RR, lung auscultation• Skin evaluation• Neck veins, ascites• Peripheral oedema• GCS, somnolence• Body temperature
Clinical signs
• Pulse rate • Blood pressure • Cardiac auscultation• RR, lung auscultation• Skin evaluation• Neck veins, ascites• Peripheral oedema• GCS, somnolence• Body temperature
Clinical signs
• Pulse rate • Blood pressure • Cardiac auscultation• RR, lung auscultation• Skin evaluation• Neck veins, ascites• Peripheral oedema• GCS, somnolence• Body temperature
Clinical signs
• Pulse rate • Blood pressure • Cardiac auscultation• RR, lung auscultation• Skin evaluation• Neck veins, ascites• Peripheral oedema• GCS, somnolence• Body temperature
Clinical signs
• Pulse rate • Blood pressure• Cardiac auscultation• RR, lung auscultation• Skin evaluation• Neck veins, ascites• Peripheral oedema• GCS, somnolence• Body temperature
Laboratory parameters
• Chemistry• Hematology• Coagulation parameters• Serologic testing• Sampling for microbiology
Arterial blood gas analysis
Mikkelsen ME. Crit Care Med 2009; 37; 1670-7
Lactate
Rudiger A. Crit Care Med 2006: 34: 2140-4
At ICU admission (grey) and maximal value during ICU stay (black)
NT-proBNP
Shock
Nikolau M. Eur Heart J 2013; 34: 742-9
Liver transaminases and alkaline phosphatase
Additional examinations
• Electrocardiogram
• Chest X-ray
• Echocardiography
• Coronary angiogram
Underlying cardiac diseases
• Ischemic heart disease
• Valvular heart disease
• Hypertensive cardiopathy
• Infectious myocarditis
• Dilatated / hypertrophic cardiomyopathy (genetic)
• Peripartum cardiomypathy
• Drugs (alcohol, cocain)
• Scleroderma, rheumatoid arthritis; Anti-TNF therapy
• Chemotherapy, radiation therapy; Neoplasia
• Amyoloidosis, haemochromatosis, sarkoidosis
Felker GM. N Engl J Med 2000: 342: 1077-84
Triggers for decompensation
• Myocardial ischemia• Arrhythmia• High blood pressure• Infections / inflammations• Malcompliance• Disease progression• Iatrogenic causes
Felker GM. N Engl J Med 2000: 342: 1077-84
The AHF syndromes
Cardiogenic shock Pulmonary edema Decompensated CHF
Typical scenario Large myocardial infarction; Fulminant myocarditis
Hypertensive emergency in diastolic HF
Malcompliance in dilated cardiomyopathy
Signs and symptoms Tissue hypoperfusion (lactate >2 mmol/l);Organ dysfunction (ecephalopathy, renal failure, liver dysfunction)
Dyspnoea at rest; Bilateral rales; Hypoxemia (SaO2 <90%)
Dyspnoea at exercise;Weight gain, ascites, peripheral oedema
Pump failure Systolic;Left and/or right
Diastolic;Left
Systolic and diastolic;Left and/or right
Diagnostic test ABGA (lactate) Chest x-ray NT-proBNP
AHF on the ICU – Initial management
□ History, clinical investigation, examinations:ØRecognition of AHF-syndromeØDiagnosis of underlying heart diseaseØIdentification of trigger for decompensationØUnderstanding the pathophysiology
□ Monitoring
□ Management
x
Basic monitoring
• Continuous SpO2
• Continuous ECG
• Non-invasive blood pressure
• Urinary catheter
• Arterial line
• Central venous catheter
AHF on the ICU – Initial management
□ History, clinical investigation, examinations:ØRecognition of AHF-syndromeØDiagnosis of underlying heart diseaseØIdentification of trigger for decompensationØUnderstanding the pathophysiology
□ Monitoring
□ Management
x
x
Managment
• Treat underlying cardiac disease and triggering factors !
• Rhythm control
• Optimisation of preload (fluid vs diuretics)
• Improvement of contractility (inotropes, ECLS)
• Optimization of afterload (vasopressors vs vasodilators)
Hochman JS. N Engl J Med 1999; 341: 625-34
Interventions and cardiac surgery
Frank Starling mechanism
Fluid management
• Excessive use of i.v. diuretics
• Increased perspiratio insensibilis
• Reduced fluid intake
Fluid management
Cardiogenic shock Pulmonary edema Decompensated CHF
Volemia Intravascular hypovolemia (low fluid intake, fluid losses, diuretics)
Fluid redistribution Hypervolemia (weight gain, ascites, peripheral oedema)
Diuretic use Contraindicated Careful (furosemide 10 mg i.v. push)
Indicated (furosemide infusion 1-10mg/h)
Fluids Fluid challenge recommended
If shock develops Fluid restriction
Fluid balance target Urine output 0.3-0.5 ml/kg/h
Depending on intravascular volemia
Negative fluid balance
Fluid management
Cardiogenic shock Pulmonary edema Decompensated CHF
Blood pressure Low (or normal) High Normal
Vasoactive drugs Vasopressors (noradrenaline, adrenaline, vasopressin)
Vasodilators (nitroprusside)
Vasodilators (nitrates)
Inotropes Indicated (dobutamine, adrenaline, levosimendan)
In selected cases In selected cases
Hemodynamic targets
MAP 60-75 mmHg, Lactate < 2.2 mmol/lSvO2 > 60%CI >2.2 l/min/m2
MAP 65-85 mmHg Individual targets
Vasoactive drugs and inotropes
Cardiogenic shock Pulmonary edema Decompensated CHF
Respiratory support Intubation and invasive ventilation
Non-invasive ventilation
Oxygen via face mask
SpO2 target 92-98 % 92-98 % 92-98 %
Potassium levels 4.5-5.5 mmol/l 4.5-5.5 mmol/l 4.5-5.5 mmol/l
Magnesium levels >1.0 mmol/l >1.0 mmol/l >1.0 mmol/l
Enteral feeding No No Yes
Blood glucose 4.5-8.5 mmol/l 4.5-8.5 mmol/l 4.5-8.5 mmol/l
Thromboprophylaxis Yes Yes Yes
Additional treatments
Singer M. PLoS Med 2005; 2: e167
Jeger RV. Ann Intern Med 2008; 149 618-26
Avoid iatrogenic harm
Summary
The correct diagnosis of the …
• Underlying heart disease• Trigger for the acute decompensation• Pathophysiology• Organ dysfunctions• Co-morbidities
… is the basis for the correct management of the patient.
Summary
Cardiogenic shock Pulmonary edema Decompensated CHF
Signs and symptoms Tissue hypoperfusion (lactate >2 mmol/l);Organ dysfunction (ecephalopathy, renal failure, liver dysfunction)
Dyspnoea at rest; Bilateral rales; Hypoxemia (SaO2 <90%)
Dyspnoea at exercise;Weight gain, ascites, periperal edema
Treatment Inotropes, vasopressors, fluidsIntubation, mechanical ventilation
Vasodilators
Non-invasive ventilation
Vasodilators, diureticsOxygen via face mask
Avoid iatrogenic harm
Thank you!