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Acute Heart Failure

Acute Heart Failure. Definitions. • Acute Heart Failure (AHF) is defined as the rapid onset of symptoms and signs, secondary to abnormal cardiac function

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Acute Heart Failure

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  1. Acute Heart Failure

  2. Definitions • Acute Heart Failure (AHF) is defined as the rapid onset of symptoms and signs, secondary to abnormal cardiac function • Cardiac dysfunction can be related to systolic or diastolic dysfunction, to abnormalities in cardiac rhythm or to preload and afterload mismatch • It is often life threatening and requires urgent treatment

  3. Aetiology (1) Decompensation of chronic heart failure (2) Acute coronary syndromes (a) AMI / UAP / ischaemic dysfunction, (b) mechanical complications of AMI (c) right ventricular infarction (3) Hypertensive crisis (4) Acute arrhythmia (VT, VF, AF, SVT)

  4. Aetiology (5) Cardiomyopathy and myocarditis (6) Valvular regurgitation (7) Aortic stenosis (8) Acute myocarditis (9) Cardiac tamponade (10) Aortic dissection (11) Post-partum cardiomyopathy

  5. Aetiology (11) Non cardiovascular precipitating factors • (a) poor compliance for medical treatment • (b) volume overload • (c) infections, especially pneumonia, septicaemia • (d) severe brain injury • (e) major surgery • (f) reduced renal function • (f) reduced renal function • (g) asthma • (h) drug abuse • (i) alcohol abuse

  6. Aetiology (12) High output syndromes • (a) septicaemia • (b) thyrotoxicosis • (c) anaemia • (d) shunt syndromes

  7. Classification Patients with AHF present with six distinct clinical conditions

  8. Clinical Conditions Acute decompensation of CHF: Signs and symptoms are mild •Heart rate +/- •SBP +/- •CI +/- •PCWP + •Diuresis + •Hypoperfusion +/-

  9. Clinical Conditions AHF with pulmonary edema: Severe respiratory distress with rales over the lungs •Heart rate + •SBP +/- •CI - •PCWP ++ •Diuresis + •Hypoperfusion +/-

  10. Clinical Conditions Cardiogenic shock Low output syndrome: reduced BP, low urine output, tissue hypoperfusion • Heart rate + • • SBP - • • CI - • • PCWP + • • Diuresis - • • Hypoperfusion +

  11. Clinical Conditions Cardiogenic shock Severe Cardiogenic shock: low BP, organ hypoperfusion, anuria • Heart rate ++ • •SBP -- • •CI -- • •PCWP ++ • •Diuresis -- • •Hypoperfusion ++

  12. Clinical Conditions Hypertensive AHF: Signs and symptoms of AHF with high BP and preserved LVEF • •Heart rate + • • SBP ++ • • CI +/- • • PCWP + • • Diuresis +/- • • Hypoperfusion +/-

  13. Clinical Conditions • High output failure: signs of increased cardiac output with elevated heart ratewith warm periphery • Heart rate + • • SBP +/- • • CI + • • PCWP +/- • • Diuresis + • • Hypoperfusion +/-

  14. Clinical Conditions Right heart failure: low output syndrome with increased JVP, tender hepatomegaly and hypotension • •Heart rate +/- • • SBP - • • CI - • • PCWP - • • Diuresis +/- • • Hypoperfusion +/-

  15. Suspected Acute Heart Failure • Assess symptoms & signs • Heart Diseases? • ECG/BNP/X-Ray ? Normal Abnormal • Consider other diagnosis • Evaluate cardiac function by echocardiography Normal Abnormal • Heart failure • Selected tests, (angio, Haemodynamic monitoring) • Characterize type and severity

  16. Laboratory tests • Routine haematology • Platelet count Creatinine/urea always • Electrolytes • Blood Glucose • Troponin (CKMB) • CRP • D-dimer

  17. Differential Diagnosis Pulmonary Asthma

  18. Treatment goals • The goals in the treatment of heart failure are to improve clinical symptoms and outcomes • Management strategy should be based on clinical, laboratory and haemodynamic findings

  19. Initial management 􀀠 Correct hypoxia and increase cardiac output, renal perfusion, sodium excretion and urinary output. 􀀠Ultimately ultrafiltration or dialysis may be required. 􀀠Devices may be indicated such as an intraaortic balloon pump, assisted ventilation, oral circulatory assist device as temporary measure or as bridge for heart Transplantation.

  20. Initial management • 􀀠 Oxygen by face mask or CPAP (SpO2 target >95%) • 􀀠 iv morphine (2.5-5 mg prn) • 􀀠 iv loop diuretic therapy • 􀀠 Vasodilatation by nitrate or nitroprusside • 􀀠 Inotropic (digitalis)support with severe AHF or hypotension • 􀀠 iv fluids if low filling pressure • 􀀠 Concomitant metabolic conditions treated according to the diagnostic work-up and laboratory status

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