Acute heart failure gagal jantung akut

(1)

(2)

Definitioin – cu te hecrt

fcil re



Rcpid oinset of symptoms cind sigins

of hecrt fcil re, seuoindcry to

ucrdicu dysf inutioin



Dysf inutioin ucin be relcted to

systoliu or dicstoliu dysf inutioin, to

cbinormclities iin ucrdicu rhythm or

to prelocd cind cfterlocd mismctuh



Oftein life threcteiniing cind req ires

(3)

Definitioin – hecrt fcil re

Clinical syndrome with the following features:

Symptoms

typiucl of HF: brecthlessiness ct rest or

oin exeruise, fctig e, tirediness, cinkle swelliing

AND

Signs

typiucl of HF: tcuhyucrdic, tcuhypinoec, l ing

rcles, ple rcl ef sioin, ↑ JVP, periphercl oedemc,

hepctomegcly

AND

Objective evidence

of c str ut rcl or f inutioincl

cbinormclity: ucrdiomegcly, 3

rd

hecrt so ind,

(4)

Epidemiology



Prevcleinue: 10% iin >75 y.o.



78% dicginosed iin ER



80-88% AHF pts dicginosed iin ER

were cdmitted



↑ morbidity & mortclity



Poor short term proginosis



3 moinths: 61% recdmitted or died



6 moinths: 30% recdmitted, 23%

died

(5)

Poorly mcincged



Pcssive, slow cpprocuh



Time betweein crrivcl & di retiu

cdmiinistrctioin: 7.8 hrs



Time betweein crrivcl &

vcsocutive cdmiinistrctioin: 23.6

hrs



Delcyed dx & tx = worse o tuome!

(6)

Role of GP



Prompt dicginosis



Admiinister iiniticl trectmeint



Risk strctifuctioin



Perform ineuesscry uoins ltctioin &

(7)

Commoin mcinifestctioins

Features Symptoms

Signs

P lmo

uoingestioin

Dyspinec,

fctig e

Tcuhypinec, l ing

rcles, ef sioin,

tcuhyucrdic

Systemiu

uoingestioin

Dyspinec,

fctig e

Periphercl

oedemc, ↑ JVP,

hepctomegcly

Ccrdio.

shouk

Coinf sioin,

weckiness

uold periphery

Poor periphercl

perf sioin, SBP

<90,

cin ric/olig ric

High BP

(HT HF)

Dyspinec

↑ BP, LV

hypertrophy,

preserved EF

Right

hecrt

fcil re

Dyspinec,

fctig e

RV dysf inutioin, ↑

JVP, periphercl

edemc,

(8)

Sigins & symptoms

Hypoteinsioin

(MAP<65) ,

tcuhyucrdic, uold

extremity, incrrow

p lse press re,

fctiq e, uoinf sioin,

restlessiness,

olig ric, ↑ re m

urectiiniine

_orthopinec,

Dyspinec,

pcroxysmcl

inout rincl dyspinec,

rcles, ineuk veiin

disteinsioin, csuites,

edemc,

hepctoj g lcr refex

↓

PERFUSION

(9)

Cc ses cind preuipitctiing

fcutors

Ischaemic heart disease



Au te uoroincry

syindromes



Meuhciniucl uompliuctioins

of cu te MI



Right veintriu lcr

iinfcrutioin

Valvular



_{Vclve steinosis}



_{Vclv lcr reg rgitctioin}



Eindoucrditis



Aortiu disseutioin

(10)

Cc ses cind preuipitctiing

fcutors

Deuompeinsctioin of pre-existiing uhroiniu HF



Lcuk of cdhereinue



Vol me overlocd



Iinfeutioins, espeuiclly pine moinic



Cerebrovcsu lcr iins lt



S rgery



Reincl dysf inutioin



Asthmc, COPD

(11)

(12)

(13)

Cliiniucl ulcssifuctioins

Au te deuompeinsctioin of hecrt fcil re (ADHF)



De inovo or cs deuompeinsctioin of uhroiniu HF



Sigins cind symptoms relctively mild



Do inot f lfl uriteric for ucrdio shouk,

p lmoincry edemc or hyperteinsive urisis

Hyperteinsive AHF



Sigins cind symptoms of HF + high BP



Relctively preserved LV fx

(14)

Cliiniucl ulcssifuctioins

P lmoincry edemc



Severe respirctory distress, orthopinec



Crcukles cll over the l ing



O

₂

sct <90% oin room cir prior to trectmeint.



Verifed by CXR

ACS cind HF



15% of ACS pctieints hcve sigins & symptoms of

AHF



Freq eintly cssouicted with or preuipitcted by

cin crrhythmic (brcdyucrdic, AF, VT)

(15)

Cliiniucl ulcssifuctioins

Ccrdiogeiniu shouk:



Evideinue of orgcin hypoperf sioin & p lm

uoingestioin



↓ BP (syst <90 mmHg, ↓ MAP >30 mmHg)



Low riine o tp t (<0.5 ml/kg/h)



Cointiin

m of low ucrdicu o tp t syindrome.

Isolcted Right HF



Low o tp t syindrome b t ino p lmoincry

uoingestioin



↑ JVP, with or witho t hepctomegcly

(16)

DIAGNOSTIC APPROACH

OF AHF

Suspected acute heart failure

Plan tx based on hemodynamic profile & etiology Assess symptoms & signs

Abnormal ECG?

Abnormal blood gas?

X-ray cardiomegaly congestion?

↑ inctri retiu peptides?

Kinowin hecrt disecse or uhroiniu HF?

Consider pulmonary disease Evaluate by echocardiography

YES

NO

ABNORMAL

NORMAL

Confirmed heart failure

Assess type, severity, & etiology using selected investigations

Dry & warm / wet & warm / dry & cold / wet & cold

Symptoms: dyspnea, fatigue, weakness, confusion, anorexia.

Signs: tachypnea, tachycardia, rales, peripheral edema, JVP, ↑

hepatomegaly, ascites, cachexia, cold periphery, BP in HT emergency, SBP ↑

(17)

Aim of thercpy



INITIAL: Improve hemodyincmiu

stct s to relieve symptoms &

stcbilize orgcins f inutioins



↓ vol me overlocd & flliing press re



↓ systemiu vcsu lcr resistcinue



↑ ucrdicu o tp t



↓ ine rohormoincl cutivctioin



SUBSEQUENT: Definitive etiologiu

(18)

Definitive dx Dx algorithm

Definitive tx

ACUTE HEART FAILURE

Immediate resuscitation

Distress or in pain

O2 saturation >95%

Normal HR & rhythm

MAP >70 / syst >90

Adequate preload

Adequate CO, reversal of metab acidosis, SvO2 > 65%, adequate perfusion

BLS, ALS

Fl id uhclleinge

YES

NO Iinotropes, IABP

Recssess freq eintly

(19)

Mcincgemeint cpprocuh –

hemodyincmiu orieinted

Fluid administration Normcl BP: vcsodilctor ↓ BP: Inotropic drugs

(20)

Di retiu



Loop di retiu: f rosemide



Red ue uoingestioin



Auhieve optimcl vol me stct s



Iiniticl dose: iv bol s 20-40 mg, titrcted

depeinds oin respoinse, reincl fx



Oinset of cutioin: di resis ~5 miin tes



Symptomctiu improvemeint iin cu te

p lmoincry edemc: 15-20 miin tes; ouu rs

prior to di retiu efeut

(21)

Nitrcte



Form: initroglyueriine (NTG)



Admiinistrctioin: SL, orcl, iv.



Autioin: vcsu lcr smooth m sule relcxctioin of

crteries & veiins, more promiineint oin veiins.



↓ ucrdicu O2 demcind by ↓ prelocd (LV

eind-dicstoliu press re); red ue cfterlocd iin high dose.



Coroincry crtery dilctioin improves uollctercl fow

to isuhemiu regioins



Oinset: SL~3 miin tes; Orcl ~1 ho r.

SL

ucin be

(22)

Vol me problem

Administer

• Fl ids

• Blood trcinsf sioins

• Cc se-speuifu iinterveintioins

• Coinsider vcsopressors

Rcte Problem

P mp Problem

Speuifu clgorithm

Cliiniucl sigins of hypoperf sioin, uoingestive HF

BP ?

Syst 70 - 100

Sigins of shouk (+)

Syst 70-100

Sigins of shouk (-)

Syst <70

Sigins of shouk (+)

Syst <70

Sigins of shouk (+)

Syst <70

Sigins of shouk (+)

Syst <70

Sigins of shouk (+)

(23)

Nitrodilctors



Spointcineo sly

relecsiing NO (eg.

Sodi m

Nitropr sside)



Orgciniu initrctes thct

req ire cin einzymctiu

prouess to form NO

(eg. Nitroglyueriine,

isosorbide diinitrctes

http://cvpharmacology.com/vasodilator/nitro.htm

GC: guanylate cyclase

(24)

Autioin of Nitrctes oin

Ciru lctioin

The mcjor efeut

is oin the veino s

ucpcuitcinue

vessels, with

cdditioincl

uoroincry cind

periphercl

crteriolcr

vcsodilctory

beineft

Opie LH & Horowitz JD. Nitrates and newer antianginals. In: Drugs for the Heart. 7th ed. Saunders Elsevier.

(25)

Nitrctes Meuhcinism

Efeuts of initrctes iin

geinerctiing NO cind

stim lctiing

g cinylcte uyulcse to

uc se c vcsodilctioin

Opie LH & Horowitz JD. Nitrates and newer antianginals. In: Drugs for the Heart. 7th ed. Saunders Elsevier.

(26)

Nitroglyueriin vs isosorbid

diinitrcte

Nitroglycerin Isosorbide Dinitrat

Type of Nitrctes Triinitrctes (glyueryl

triinitrctes) Diinitrctes

Oinset Fcst: 1 miin tes Delcyed d e to biouoinversioin to moinoinitrcte iin liver D rctioin 3-5 miin tes

(27)

Low-dose NTG siginifucintly red ues ucrdicu flliing press res

cind improves miurovcsu lcr perf sioin iin pctieints cdmitted

(28)

Nitroglyueriin iin cu te hecrt

fcil re

(29)

Nitroglyueriin iin cu te hecrt

fcil re

(30)

2013 ACCF/AHA Guideline for the Management of Heart Failure, Circulation. 2013;128:e240-e327

(31)

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