Congestive Heart Failure10 Minute Review

Kona Seng PGY-3ARMC Emergency Medicin

July 20, 2011

Congestive Heart Failure10 Minute Review

Kona Seng PGY-3ARMC Emergency Medicin

July 20, 2011

They Say...They Say...

“HF is a clinical syndrome that occurs in patients who because of an inherited or acquired abnormality of cardiac structure and/or function, develop a constellation of clinical symptoms (dyspnea and fatigue) and signs (edema and rales) that lead to frequent hospitalizations, poor quality of life, and a shortened life expectancy.”

Dr. Mark Robinson

“HF is a clinical syndrome that occurs in patients who because of an inherited or acquired abnormality of cardiac structure and/or function, develop a constellation of clinical symptoms (dyspnea and fatigue) and signs (edema and rales) that lead to frequent hospitalizations, poor quality of life, and a shortened life expectancy.”

Dr. Mark Robinson

We Say...We Say...

“That pt looks kind of shitty.”

Dr. Dorian Snyder

“That pt looks kind of shitty.”

Dr. Dorian Snyder

EpidemiologyEpidemiology

23 million worldwide

5.8 million in the US

Affects 6-10% over 65 years of age

20% of hospital admissions

$12 billion

23 million worldwide

5.8 million in the US

Affects 6-10% over 65 years of age

20% of hospital admissions

$12 billion

ADHFADHF

Acute Decompensated Heart Failure

Dyspnea with elevated cardiac filling pressures

Often with accumulation of fluid in the lung’s interstitial and alveolar spaces

Hemodynamic stabilization, supportive oxygenation and ventilation, and symptom relief.

Acute Decompensated Heart Failure

Dyspnea with elevated cardiac filling pressures

Often with accumulation of fluid in the lung’s interstitial and alveolar spaces

Hemodynamic stabilization, supportive oxygenation and ventilation, and symptom relief.

Dr. Dan Arellano (Resident)Dr. Dan Arellano (Resident)

Initial insult to the heart

Compensatory mechanisms

Eventual deterioration

Progressive LV remodeling

Initial insult to the heart

Compensatory mechanisms

Eventual deterioration

Progressive LV remodeling

Dr Dan Arellano (Attending Physician)Dr Dan Arellano (Attending Physician)

Preload

Afterload

LV Dysfunction

It’s coming in

Preload

Afterload

LV Dysfunction

It’s coming in

5 points5 points

Airway

3591

Diuretics

Nitrates

Ace-Inhibitors

Airway

3591

Diuretics

Nitrates

Ace-Inhibitors

Have faith in your attendingHave faith in your attending

5 points5 points

Airway

3591

Medications: Diuretics/Nitrates/ACE

BNP

Admission Criteria

Airway

3591

Medications: Diuretics/Nitrates/ACE

BNP

Admission Criteria

35913591

Cardiac arrest

Resp arrest

Encephalopathy

UGI Bleed

Hemodynamic instability

Unstable arrhythmia

Inability to cooperate/protect airway

Inability to clear secretions

High risk for aspiration

Cardiac arrest

Resp arrest

Encephalopathy

UGI Bleed

Hemodynamic instability

Unstable arrhythmia

Inability to cooperate/protect airway

Inability to clear secretions

High risk for aspiration

Noninvasive Ventilation in Acute Cardiogenic Pulmonary Edema: A Systematic Review and

AnalysisMasip J, et al. JAMA 2005

Noninvasive Ventilation in Acute Cardiogenic Pulmonary Edema: A Systematic Review and

AnalysisMasip J, et al. JAMA 2005

MEDLINE EMBASE COCHRANE

CPAP/BIPAP vs Standard Oxygen Therapy

15 trials selected

Decreased intubations

Reduced mortality by 45%

MEDLINE EMBASE COCHRANE

CPAP/BIPAP vs Standard Oxygen Therapy

15 trials selected

Decreased intubations

Reduced mortality by 45%

Effect of Non-invasive Positive PRessrue Ventilation on Mortality in Patients with Acute

Cardiogenic Pulmonary EdemaPeter JV et al. Lancet 2006

Effect of Non-invasive Positive PRessrue Ventilation on Mortality in Patients with Acute

Cardiogenic Pulmonary EdemaPeter JV et al. Lancet 2006

Metanalysis

Lower mortality rate

No difference between CPAP and BIPAP

Metanalysis

Lower mortality rate

No difference between CPAP and BIPAP

CPAP/BIPAPCPAP/BIPAP

Improvements in PaO2, FiO2, pH, RR, HR, SpO2

Reduction in the need for intubation

Decrease short term mortality

Use it

Call for it early

Improvements in PaO2, FiO2, pH, RR, HR, SpO2

Reduction in the need for intubation

Decrease short term mortality

Use it

Call for it early

5 points5 points

Airway

3591

Nitrates

Ace-Inhibitor

Diuretics

Airway

3591

Nitrates

Ace-Inhibitor

Diuretics

NitratesNitrates

Most commonly used vasodilator

Reduces your preload

Increased stroke volume and cardiac output

Lowers rates of intubation, ICU admissions

IV? 5-10mcg/min increased by 5-10mcg every 3-5min

PO? 400mcg

Most commonly used vasodilator

Reduces your preload

Increased stroke volume and cardiac output

Lowers rates of intubation, ICU admissions

IV? 5-10mcg/min increased by 5-10mcg every 3-5min

PO? 400mcg

Improved CLinical OutcomesImproved CLinical Outcomes

Cotter G. Randomized trial of high dose isosorbide dinatrate plus low dose Lasix vs High Dose Lasix plus low dose isosorbide Dinaitrate. Lancet 1998

Nashed AH. IV Nitro boluses in treating pts with cardiogenic pulmonary edema. Ann Emerg Med 1997

Levy P. Treatment of Severe Decompensated Heart Failure with High-dose IV Nitro: a feasibility and outcome analysis. Ann Emerg Med 2007

Cotter G. Randomized trial of high dose isosorbide dinatrate plus low dose Lasix vs High Dose Lasix plus low dose isosorbide Dinaitrate. Lancet 1998

Nashed AH. IV Nitro boluses in treating pts with cardiogenic pulmonary edema. Ann Emerg Med 1997

Levy P. Treatment of Severe Decompensated Heart Failure with High-dose IV Nitro: a feasibility and outcome analysis. Ann Emerg Med 2007

Ace InhibitorsAce Inhibitors

No large randomized controlled trials

Short term benefit

Early use associated with rapid improvements (6-12 min)

HD patients

No large randomized controlled trials

Short term benefit

Early use associated with rapid improvements (6-12 min)

HD patients

Rapid Improvement of Acute Pulmonary Edema with Sublingual Captopril

Hamilton RJ et al. Acad Emerg Med 1996

Rapid Improvement of Acute Pulmonary Edema with Sublingual Captopril

Hamilton RJ et al. Acad Emerg Med 1996

Compared Captopril vs Placebo

Subjective improvement in clinical symptoms over first 40 minutes.

Adding Captopril to standard regiment produces more rapid results

Less intubations: 9% vs 20%

Compared Captopril vs Placebo

Subjective improvement in clinical symptoms over first 40 minutes.

Adding Captopril to standard regiment produces more rapid results

Less intubations: 9% vs 20%

DiureticsDiuretics

“Patients admitted with HF and with evidence of significant fluid overload should be treated with intravenous loop diuretics. Therapy should begin in the ED without delay.”

2009 ACCF/AHA Heart Failure Guidelines

“Patients admitted with HF and with evidence of significant fluid overload should be treated with intravenous loop diuretics. Therapy should begin in the ED without delay.”

2009 ACCF/AHA Heart Failure Guidelines

Diuretic Optimization Strategies Evaluation (DOSE)

Diuretic Optimization Strategies Evaluation (DOSE)

“Low intensification” therapy will be more efficacious and safer when compared to “high intensification” therapy.”

“Continuous infusion diuretic therapy will be more efficacious when compared with twice daily bolus therapy”

Among pts with ADHF, there were no significant differences in pts’ global assessment of symptoms or in the change in renal function when diuretic therapy was administered by bolus as compared with continuous infusion or at a high dose as compared to a low dose.

N Engl J Med 2011; 364:797-805

“Low intensification” therapy will be more efficacious and safer when compared to “high intensification” therapy.”

“Continuous infusion diuretic therapy will be more efficacious when compared with twice daily bolus therapy”

Among pts with ADHF, there were no significant differences in pts’ global assessment of symptoms or in the change in renal function when diuretic therapy was administered by bolus as compared with continuous infusion or at a high dose as compared to a low dose.

N Engl J Med 2011; 364:797-805

The Dark Side of Diuretics?The Dark Side of Diuretics?

High quality data support for safety and efficacy are sparse

Activation of RAA system?

Increased SVR?

Worsening renal function? Electrolyte abnormalities?

Increased Mortality?

High quality data support for safety and efficacy are sparse

Activation of RAA system?

Increased SVR?

Worsening renal function? Electrolyte abnormalities?

Increased Mortality?

Prehospital management of Congestive Heart Fialure

Mattu A et al. Heart Failure Clin 2009

Prehospital management of Congestive Heart Fialure

Mattu A et al. Heart Failure Clin 2009

“Renewed focus on aggressive use of nitrates, optimization of airway support,and rapid transport.”

“The use of Lasix and Morphine has become de-epmhasized.”

“Renewed focus on aggressive use of nitrates, optimization of airway support,and rapid transport.”

“The use of Lasix and Morphine has become de-epmhasized.”

DiureticsDiuretics

Probably not 1st line medication

Diuresis occurs in 90 minutes

Questions as to whether it worsens cardiac parameters early on

Make IM happy....

Probably not 1st line medication

Diuresis occurs in 90 minutes

Questions as to whether it worsens cardiac parameters early on

Make IM happy....

Acutely Decompensated Heart Failure in a county ED: A double-blind randomized

controlled comparison of Nesiritide vs Placebo for Treatment

Miller, AH et al. Ann Emerg Med 2008

Acutely Decompensated Heart Failure in a county ED: A double-blind randomized

controlled comparison of Nesiritide vs Placebo for Treatment

Miller, AH et al. Ann Emerg Med 2008

• 100 patients

• NYHA Class II to IV

• Administration of nesiritide was not better than standard therapy alone for return to the ED or hospitalization at 30 days.

• 100 patients

• NYHA Class II to IV

• Administration of nesiritide was not better than standard therapy alone for return to the ED or hospitalization at 30 days.

NesiritideNesiritide

“Routine use of Nesiritide for the management of acute decompensated heart failure in the ED is not recommended.”

EMedHome 7/1/2011

“Routine use of Nesiritide for the management of acute decompensated heart failure in the ED is not recommended.”

EMedHome 7/1/2011

SummarySummary

Preload, Afterload, LV Dysfunction

Must haves: CPAP/Nitro/Ace-Inhibitors

Maybe haves: Diuretics

Must not haves: Nesiritide

Preload, Afterload, LV Dysfunction

Must haves: CPAP/Nitro/Ace-Inhibitors

Maybe haves: Diuretics

Must not haves: Nesiritide

Colin MacNeil Linebacker

Colin MacNeil Linebacker

Born 4/5/83

First Team All-CIF Honors

3 time First Team All SCIAS

Occidental Coaches Award in 02’ 03’ and 04’

Neurophysiology research grant in 2003

ESPN Academic All-America 2004

John Zinda Award 2004

Wine Consultant in Valencia, CA

Volunteer Guatemala

Considering fields of IM, GSurg, or EM

Born 4/5/83

First Team All-CIF Honors

3 time First Team All SCIAS

Occidental Coaches Award in 02’ 03’ and 04’

Neurophysiology research grant in 2003

ESPN Academic All-America 2004

John Zinda Award 2004

Wine Consultant in Valencia, CA

Volunteer Guatemala

Considering fields of IM, GSurg, or EM