DIAGNOSIS AND MANAGEMENT OF ACUTE HEART FAILURE · PDF fileDIAGNOSIS AND MANAGEMENT OF ACUTE...

DIAGNOSIS AND MANAGEMENT OFACUTE HEART FAILURE

Mefri Yanni, MDBagian Kardiologi dan Kedokteran Vaskular

RS.DR.M.Djamil Padang

The 3rd Symcard Padang, Mei 2013

Outline

• Diagnosis

• Treatment options

• Approach to management

• Discharge planning

Diagnosis

Management options

Discharge planning

Diagnosis

Therapeutic goals

Management options

LABS :• Hb value (Anemia?)• Infection marker• Electrolytes• Renal function• Blood glucose• Cardiac enzyme• Blood gas analysis• Throid function – new onset HF

Classification of AHF

ESC Guideline. For diagnosis and treatment of Acute and chronic HF. 2008

Assessment of Hemodynamic Profile

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

Pharmacologic Options

Fluid Challenge Inotropic drugs

Diuretic

Vasodilator

Warm

Dry

Cold

Wet

Warm/Dry

Cold/Dry

Warm/Wet

Cold/Wet

A

L C

B

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

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

Diuretics

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

Intravenous Vasodilator in AHF

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

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

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

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

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

Vasopressor

ESC, Acute Heart Failure, 2012

• Drugs that stimulates smooth muscle contraction of the capillaries & arteries

• Cause vasoconstriction & a consequent rise in blood pressure

Drugs used to treat AHF ( Inotropes and vasopressor )

ESC, Acute Heart Failure, 2012

• 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

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

Drug Initiation after stabilization

ESC, Acute Heart Failure, 2012

• ACE-I

• Beta blocker

• Mineralcorticoid receptor antagonist

• Digoxin

• Device therapy

Outline

ESC Guidelines Acute and Chronic Heart Failure 2012

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

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

Patient Education :What are the symptoms of heart failure ?

Think FACES ...

• Fatigue

• Activities limited

• Chest congestion

• Edema or ankle swelling

• Shortness of breath

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