diagnosis and management of acute heart failure · pdf filediagnosis and management of acute...
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DIAGNOSIS AND MANAGEMENT OFACUTE HEART FAILURE
Mefri Yanni, MDBagian Kardiologi dan Kedokteran Vaskular
RS.DR.M.Djamil Padang
The 3rd Symcard Padang, Mei 2013
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Outline
• Diagnosis
• Treatment options
• Approach to management
• Discharge planning
Diagnosis
Management options
Discharge planning
Diagnosis
Therapeutic goals
Management options
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LABS :• Hb value (Anemia?)• Infection marker• Electrolytes• Renal function• Blood glucose• Cardiac enzyme• Blood gas analysis• Throid function – new onset HF
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Classification of AHF
ESC Guideline. For diagnosis and treatment of Acute and chronic HF. 2008
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Assessment of Hemodynamic Profile
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Therapeutic Goals in AHF
Improve patient hemodynamic status
to relief symptoms and stabilize organ function
Reduce systemic vascular resistance (SVR)
↑cardiac output (CO)
Reduce fluid volume and filling pressures
Reduce neurohormones
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Pharmacologic Options
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Fluid Challenge Inotropic drugs
Diuretic
Vasodilator
Warm
Dry
Cold
Wet
Warm/Dry
Cold/Dry
Warm/Wet
Cold/Wet
A
L C
B
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Acute Pulmonary Edema / Congestion
Intravenous bolus of loop diuretic 2-2,5 times
Hipoxemia Oxygen
Severe anxiety/distress
Consider iv opiate
Measure systolic blood pressure
SBP < 85 mmHg or shock SBP 85-110 mmHg SBP > 110 mmHg
Add non-vasodilating inotrope No additional therapy until response assessed
Consider vasodilator
Yes
Yes
No
No
ESC Guidelines of Acute and Chronic Heart Failure, 2012
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Adequate response to treatment
Reevaluation patient clinical status
SBP < 85 mmHg SpO2 < 90% Urine output < 20 ml/hr
• Stop vasodilator• Stop beta-blocker if
hypoperfused• Consider non-vasodilating
inotropes or vasopressor• Consider right heart
catheterization• Consider mechanical circulatory
support
• Bladder catheterization to confirm
• Increase dose of diuretic• Consider low dose
dopamine• Consider right-heart
catheterization• Consider ultrafiltration
No
Yes Yes Yes
No
• Oxygen• Consider NIV• Consider ETT• Consider Invasive
ventilation
Yes
No
Continue present treatment
ESC Guidelines of Acute and Chronic Heart Failure, 2012
No
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Diuretics
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VasodilatorsNitroprusside, Nitroglycerin, Nitrate family
Work by cGMP mediated smooth muscle
relaxation -> vasodilation
Decrease myocardial work by afterload and
preload reduction
May cause hypotension
May cause headache
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Intravenous Vasodilator in AHF
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Inotropic AgentsDobutamin, Dopamine, Milrinone
Indication :Peripheral hypoperfusion (hypotension, decrease renal
function) with or without congestion
ESC, Acute Heart Failure, 2012
Improve cardiac output
by directly increasing cardiac
contractility
Significant proarrhythmic effects
May precipitate ischemia
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Dopamine
ESC, Acute Heart Failure, 2012
• Effect dose dependent• In low dose (< 2 ug/kgBW/min) :
vasodilatation occurs predominantly in renal, coronary, and cerebral vascular beds.
• At doses > 5 g/kgBW/min :will increase peripheral vascular resistance via adrenergic receptors
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Dobutamine
ESC, Acute Heart Failure, 2012
• Clinical action :
Positive inotropic
Positive chronotropic effects.
• Range dosage : 2 – 20 ug/kgBW/min
• In low dose < 5 ug/kgBW/min induce arterial vasodilatation
• In higher dose induce arterial vasoconstriction
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Phosphodiesterase Inhibitors
ESC, Acute Heart Failure, 2012
• Non beta adrenergic mechanism• Inotropic• Vasodilator• Lusitropy (diastolic relaxation)
• Uses– Low cardiac output states– Downregulated/ desensitized – CHF unresponsive to diuretic – Increased SV decreased SVR
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Cardiogenic Shock
ESC, Acute Heart Failure, 2012
• A state of end organ hypoperfusion due to cardiac failure
• SBP < 80-90 mmHg or ↓ MAP >30 mmHg
• Severe ↓ cardiac index (CI) < 1.8 L/m without support, or < 2.0-2.2 L/m with support ↓
• LVEDP > 18 mmHg, or RVEDP > 10-15 mmHg
• Absent or low urine output (< 0.5 ml/kg/h)
• Evidence of organ hypoperfusion and pulmonary congestion
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Vasopressor
ESC, Acute Heart Failure, 2012
• Drugs that stimulates smooth muscle contraction of the capillaries & arteries
• Cause vasoconstriction & a consequent rise in blood pressure
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Drugs used to treat AHF ( Inotropes and vasopressor )
ESC, Acute Heart Failure, 2012
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• Considered early in patient present with restlessness, dyspnoea, anxiety, chest pain
• Morphine induces : Venodilatation Mild arterial dilatation Reduce heart rate
• Caution : hypotension, bradycardia, CO2 retention.
• Dose : 2,5-5 mg IV bolus (rate 1 mg/min.)repeated if required
Morphine and its analogues
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Monitoring patient with AHF
ESC, Acute Heart Failure, 2012
DAILY MONITORING
Weight
Intake and output
Symptoms and
exam
Renal function
and electrolytes
MORE FREQUENTLY
• Symptoms
• Vital signs
• Saturation
• Urine output
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Drug Initiation after stabilization
ESC, Acute Heart Failure, 2012
• ACE-I
• Beta blocker
• Mineralcorticoid receptor antagonist
• Digoxin
• Device therapy
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Outline
ESC Guidelines Acute and Chronic Heart Failure 2012
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Discharge Criteria
ESC, Acute Heart Failure, 2012
Near optimal volume status achieved
Transition from iv to oral medications done
No IV vasodilators or inotropes x 24 h
Oral medication regimen stable x 24 h
Near optimal oral therapy achieved
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Discharge Instructions
ESC, Acute Heart Failure, 2012
Discharge medications
Follow up clinic visit 3-5 days
Weight monitoring
Assessment of worsening heart failure
Patient and family education of risk factors and precipitating factors
Referral for further management
Salt and Fluid restriction diet
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Patient Education :What are the symptoms of heart failure ?
Think FACES ...
• Fatigue
• Activities limited
• Chest congestion
• Edema or ankle swelling
• Shortness of breath
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Conclusion
ESC, Acute Heart Failure, 2012
Rapid assessment and treatment of AHF could decreased mortality and morbidity rate
Management strategies including :
– Ensure oxygenation
– Reduce pain
– Reduce fluid volume
– Reduce preload and or afterload
– Increase cardiac output
– Identify and treat the cause of CHF
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