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John H. Burton, MD Residency Program Director Dept. Emergency Medicine Albany Medical Center

Strategies for Diagnosis, Risk Stratification and Treatment of the Acutely Decompensated Heart Failure Patient. John H. Burton, MD Residency Program Director Dept. Emergency Medicine Albany Medical Center. burtonj@ mail.amc.edu. Heart Failure.

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John H. Burton, MD Residency Program Director Dept. Emergency Medicine Albany Medical Center

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  1. Strategies for Diagnosis, Risk Stratification and Treatment of the Acutely Decompensated Heart Failure Patient John H. Burton, MD Residency Program Director Dept. Emergency Medicine Albany Medical Center

  2. burtonj@mail.amc.edu

  3. Heart Failure • Approximately 5 million Americans have CHF (male to female ratio 1:1) • Incidence of 10/1000 > 65 years of age • 550,000 new cases/year • Hospital discharges 1,000,000 (2001) • Single largest expense for Medicare • Five-year mortality rate as high as 50% AHA. 2001 Heart and Stroke Statistical Update

  4. Heart Failure Hospitalizations The number of heart failure hospitalizations is increasing in both men and women AHA, 1998 Heart and Statistical Update NCHS, National Center for Health Statistics CDC/NCHS: Hospital discharges include patients both living and dead. AHA Heart and Stroke Statistical Update 2001

  5. Hospital Visits for Congestive Heart Failure Initial Episode 21% Approximately 85% of the ED visits for CHF result in hospitalizations Repeat Visit 79% Rates of Hospital Readmission  2% within 2 days  20% within 1 month  50% within 6 months Cardiology Roundtable 1998

  6. A brief discussion of the works of this thing...

  7. The Pump: 1. A Mechanical Component 2. An Electrical Component

  8. 65% 1. A Mechanical Component 2. An Electrical Component

  9. PUMPS LESS!!!

  10. FILLS LESS!!!

  11. Filling….Pumping Problems with Filling... Problems with Pumping...

  12. Pumping Just how little pumping can one get away with? Normal - 65% No Symptoms - 40-65% Lethargy, less exercise tolerance - 30-45% Shortness of breath - 20 - 30% Incompatible with life - <15%

  13. Etiology of Acute Heart Failure • Hypertension • Ischemia • Sustained Arrhythmias • Cardiomyopathy • EtOH, infiltrative • Valvular Heart Disease • Pericardial Disease Approximately 1/4th Diastolic Dysfxn

  14. PREload Contractility AFTERload

  15. PREload

  16. AFTERload

  17. Contractility

  18. DEFINITION CHF “The situation when the heart is incapable of maintaining a cardiac output adequate to accommodate metabolic requirements and the venous return.” E. Braunwald

  19. Venous Legs swell Neck veins distend Liver congestion Lung congestion Arterial Decreased perfusion…. Brain Kidneys Everything...

  20. CHF: Diagnosis CHF is a CLINICAL diagnosis • History • Physical Exam • Chest X Ray • EKG • Echocardiogram • Laboratory testing

  21. CHF: a CLINICAL diagnosis History Physical Exam Chest X Ray Echocardiogram Laboratory testing How do you know an ED pt has Heart Failure? …. Shortness of Breath!!! ; Leg edema; weakness …. Legs: Edema; Lungs: Rales

  22. Accuracy of Diagnosis: CHF EMS : 50-65% Emergency Doc: 65-80% Cardiologist: 80-85% How do you know an ED pt has Heart Failure?

  23. OR’s for differentiating between patients with and those without CHF NEJM 02;347:161-167

  24. Ask 3 Questions: 1. History of Congestive Heart Failure? 2. RALES on Lung Examination? 3. EDEMA to Legs? How do you know an ED pt has Heart Failure? IN The Emergency Department: Do a Chest XRay

  25. Emergency Department

  26. Dyspnea at rest PND and orthopnea Spectrum of Heart Failure Dyspnea on exertion Pulmonary Edema Moderate Asymptomatic CHF Cardiogenic Shock Severe Mild

  27. Natriuretic Peptides: Origin and Stimulus of Release Peptide Primary Origin Stimulus of Release ANP Cardiac atria Atrial distension BNP Ventricular myocardium Ventricular overload CNP Endothelium Shear stress of endothelium ANP = Atrial Natriuretic Peptide BNP = B-type Natriuretic Peptide CNP = C-type Natriuretic Peptide Adapted from Burnett JC, J Hypertens 2000;17(Suppl 1):S37-S43

  28. RAAS (Renin-Angiotensin Aldosterone System) Activation of AT1 receptors Vasoconstriction Sodium retention by angiotensin II Increased aldosterone release Increased cellular growth Increased sympathetic nervous activity NPS (Natriuretic Peptide System) Vasodilation ANP, BNP Sodium excretion Decreased aldosterone levels Inhibition of RAAS Inhibition of sympathetic nervous activity Vasodilation CNP Decreased vascular smooth muscle growth Decreased aldosterone levels Adapted from Burnett JC, J Hypertens 1999;17(Suppl 1):S37-S43

  29. 1400 1200 1000 800 600 400 200 0 BNP Levels of 250 Patients Presenting with Dyspnea P < 0.001 1076 ± 138 Mean BNP Concentration (pg/ml) 141 ± 31 38 ± 4 Asymptomatic LV Dysfunction No CHF (n=14) No CHF (n=139) CHF (n=97) Maisel A. et al. J Am Coll Cardiol 2001;37(2):379-85

  30. 2500 2000 1500 1000 500 0 BNP Concentration for the Degree of CHF Severity 2013 ± 266 BNP Concentration (pg/ml) 791 ± 165 186 ± 22 Moderate (n=34) Severe (n=36) Mild (n=27) Maisel A. et al. J Am Coll Cardiol 2001;37(2):379-85

  31. BNP Concentration for the Prediction of Clinical Events Death or Heart Failure Hospitalization 45% 40% 35% 30% BNP > 480 pg/ml 25% 20% 15% 10% BNP 230-480 pg/ml 5% BNP < 230 pg/ml 0% 0 20 40 60 80 100 120 140 160 180 Days Harrison, Maisel Ann Emerg Med 2002;39:131-138

  32. 1400 1200 1000 800 600 400 200 0 Rapid Measurement of BNP in Emergency Diagnosis of Heart FailureMultinational study at 7 centers: Baseline BNP-1586 ED dyspnea pts vs clinical judgment Mean BNP Concentration (pg/ml) No CHF (n=770) CHF (n=744) Dyspnea due to noncardiac in pt with hx of LV dysfunction (n=72) Maisel A. et al. NEJM 02;347:161-167

  33. OR’s for differentiating between patients with and those without CHF NEJM 02;347:161-167

  34. BNP Integration-Diagnostic:CHF vs COPD-CHF Risk Stratification:mild, mod, severe disposition mortality-Therapeutic Decision-Makingchange therapy cease therapy

  35. Interpretation of the BNP Assay in the Dyspneic Patient Significant Decompensated Heart Failure Mean BNP Concentration (pg/ml) 400 400 400 Mild Ventricle Stretch: HF, PE, CM, ACS, Pulm HTN 100 100 100 No Heart Failure, No Ventricle Stretch

  36. I S R S D S M S K G R L G H G F R C R S S C L K V G K P M S S V Q G You’ll also hear about Pro-BNP • Pro-BNP is the BNP precursor. It is • degraded in the liver - bnp is a • product and is ultimately cleaved • by neutral peptidase: no renal or hepatic effects

  37. Ask 3 Questions: 1. History of Congestive Heart Failure? 2. RALES on Lung Examination? 3. EDEMA to Legs? How do you know an ED pt has Heart Failure? Shoot a Chest Xray Run a BNP level

  38. Current Treatment of Acute Heart Failure

  39. Current Treatment of Acute Heart Failure Diuretics Vasodilators Inotropes Augment Contract- ility Decrease Preload And Afterload Reduce fluid volume

  40. Heart Failure Guidelines 1. ACC/AHA Task Force on Practice Guidelines. 2001 1. ACC/AHA Task Force on Practice Guidelines. 1995 2. Working Group for Heart Failure of the European Society of Cardiology. 1997 3. Advisory Council To Improve Outcomes Nationwide in Heart Failure. (ACTION – HF) 1999 4. HFSA Guidelines for Management of Patients With Heart Failure Caused by Left Ventricular Systolic Dysfunction - Pharmacological Approaches. 1999 Focus on… Omit… Stable outpatients Criteria for admission to hospital Systolic dysfunction Tailored hemodynamic treatments Decompensated patients 1. Circulation 1995;92:2764-2784, 2. Eur Heart J 1997;18:736-753, 3. Am J Cardiol 1999;83(2A):1A-38A, 4. Journal of Cardiac Failure 1999;5:357-382

  41. Current Treatment of Acute Heart Failure Vasodilators Diuretics Inotropes Decrease Preload And Afterload Augment Contract- ility Reduce fluid volume Lasix Ntg: sl, top, iv MSO4 ACEi BiPAP Lasix Dopamine

  42. Expose the Literature...

  43. Early Response of PCW but not CI Predicts Subsequent Mortality in Advanced Heart Failure Total Mortality Risk% Total Mortality Risk% 60 60 50 50 PCW > 16 mmHg 40 40 Cardiac Index > 2.6 L/min-M2 30 30 199 PCW < 16 mmHg 20 20 Cardiac Index < 2.6 L/min/M2 236 10 10 220 257 P=0.001 P=NS 0 0 0 6 12 18 24 0 6 12 18 24 Months Months Fonarow Circulation 1994;90:I-488

  44. You’ve also got to look at symptom improvement...

  45. Let’s Start with the Ntg vs. Lasix Debate

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