DIAGNOSIS AND MANAGEMENT OF ACUTE HEART FAILURE Mefri Yanni, MD - - PowerPoint PPT Presentation

DIAGNOSIS AND MANAGEMENT OF ACUTE HEART FAILURE

Mefri Yanni, MD

Bagian 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

Vasodilators

Nitroprusside, 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 Agents

Dobutamin, 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