CARDIOLOGY UNIT PRESENTATION

Nwalozie J.C. 17/03/2014

Question A 50 year old man presents with sudden-

onset breathlessness & feeling of impending doom.

Discuss 3 differential diagnoses & describe the management of Acute Left Ventricular Failure.

Answers 3 differential diagnoses: 1. Acute Severe asthma

2. Pulmonary Embolism

3.Acute exacerbation of COPD

MANAGEMENT OF ACUTE LEFT VENTRICULAR FAILURE

Outline Introduction Precipitating factors Pathophysiology Clinical features Investigations Management Treatment Prognosis & Monitoring Follow-up Conclusion

Introduction Inability of the left ventricle to effectively

handle its pulmonary venous return with leakage of fluid from the pulmonary capillaries & venules into the alveolar space (secondary to increased hydrostatic pressure) leading to rapid onset of breathlessness.

It is a medical emergency .

It can arise de novo or on a background of chronic left ventricular failure.

PRECIPITATING FACTORS

Dietary indiscretion Uncontrolled hypertension Non adherence to drugs Myocardial ischaemia or infarction Arrhythmias Thyrotoxicosis Fluid overload Anaemia Pulmonary & other infections Inappropriate medications- -ve inotropes,

NSAIDS Acute valvular insufficiency

PATHOPHYSIOLOGY

↓ CARDIAC OUTPUTINCREASED PCWP

ACTIVATION OF RENIN ANGIOTENSINSYSTEM

ACTIVATION OF S/S SYSTEM

INCREASED HEART RATEINCREASED SYSTEMIC VASCULAR RESISTANCE

INCREASED PRELOAD

CARDIAC ISCHAEMIA↓ LEFT VENTRICULAR

FUNCTION

SYMPTOMATICDECOMPENSATION

CLINICAL FEATURES Extreme SOB with use of accessory muscles of

respiration

Sensation of drowning, chest pain, palpitations

Cough(with pink , frothy sputum)

Previous history: Of cardiac disease

Restlessness, Profuse sweating

CLINICAL FEATURES Orthopnoea(patient noticed to be sitting up in bed) - sensitivity 5% - specificity 77%

PND

Pulse(Tachycardia, Pulsus Alternans)

BP

S3

Wheezing (Cardiac ‘asthma’) – sensitivity 22% - specificity 58%

Crepitations - sensitivity 6% - specificity 78%

Other features:

-Cyanosis

-Cold skin

-Features of underlying heart disease/precipitating factor

-Features of right heart failure

INVESTIGATIONS 1.Pulse oximetry

2. Blood

3. Electrocardiography

4. Radiologic

5.Others- eg. Pulmonary arterial catheterisation

BLOOD INVESTIGATIONS ABG

FBC – anaemia, infection

U & Es

CARDIAC MARKERS

CARDIAC MARKERS

CARDIAC ENZYMES

OTHER CARDIAC MARKERS

IMPORTANCE OF BNP IN HF

1. Useful in Diagnosis

2. Assessing Severity

3. Predicting short & long-term CVS mortality

WHAT LEVELS ? NO HEART FAILURE-BNP < 100pg / dl-NT PRO-BNP < 300pg / dl

HEART FAILURE-BNP >500pg / dl-NT PRO-BNP > 1000pg / dl*80% Sensitivity for heart failure

ELECTROCARDIOGRAM Ischaemia / infarction

Arrhythmia – A fib

LVH

Prolonged QRS

CHEST RADIOGRAPH FINDINGS IN HEART FAILURE Cardiomegaly – 74% sensitive, 78% specific

Vascular redistribution

Interstitial oedema

Alveolar oedema

Pleural effusions (right sided/bilateral)

Others Echocardiography 1.Identify reversible cause eg MI,

valvular insufficiency ,tamponade 2.Distinguish between systolic and

diastolic dysfunction

• Monitor urine output

Treatment A medical emergency

Begin treatment before investigations

ABC of resuscitation , Patient to sit up

Treatment can be medical, radiological/surgical

TREATMENT AIMS OF IMMEDIATE MANAGEMENTOverall aim- Redistribute fluid out of lungs!

-Decrease Preload (right-sided filling) eg loop diuretics,morphine,tolvaptan

-Increase left-sided emptying eg ACE-I,NTG,nitroprusside

↓ Afterload, Cardiac output

-± improve LV contractility – inotropes eg dopamine,dobutamine,milrinone,levosimendan

Other measures-diet , fluid restriction , ultrafiltration , treat precipitating cause eg infection

Radiological-IABP,LV assist device , CRT

Surgical-Valve repairs , transplantation

Prognosis & monitoring Poor prognostic factors include: -Underlying heart

disease/precipitating factor -BNP>500 pg/dl -K <3mmol/l -Na < 133mmol/l -Frequent ventricular extrasystoles

Monitoring for vital signs, other signs , symptoms ,urine output ,renal function ,electrolytes.

Follow Up

Conclusion ALVF is a life-threatening medical emergency that

is as a result of LV compromise leading to accumulation of fluid in the lungs with resultant acute onset of symptoms.

It is essential to make a diagnosis( ie differentiate it from similar conditions) so that necessary interventions can be instituted as soon as possible

Management is multidisciplinary and should be individualised according to how each patient presents.

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