Dept. Anesthesiology and Intensive Care Medicine, DSMA 2008
Acute heart failure
associate professor Ahmed Elmadana
http://www.escardio.org/guidelines-surveys/esc-guidelines/
Dept . Anesthes io logy and Intens ive Care Medic ine , DSMA 2008
Physiology and pathophysiology of LV relaxation
Calcium-induced calcium release in cardiac myocytes. After electrical stimulation, calcium influx through the calcium channels (Ica) stimulates ryanodin receptors (RyR) to release more calcium from the sarcoplasmic reticulum (SR) into the cytosol. Calcium concentration falls (i) by reuptake in the SR via phospholamban (PLB) stimulation and (ii) by calcium efflux by Na+/Ca2+ exchange (NCX). The inset summarizes the time course: action potential precedes calcium influx and the peak of myocyte contraction is seen while intracellular calcium concentration falls. From Bers and Despa with permission.
http://bja.oxfordjournals.org/cgi/content/full/98/6/707
Dept . Anesthes io logy and Intens ive Care Medic ine , DSMA 2008
Heart failureEuropean Society of Cardiology Definition of HF:
Heart failure is a clinical syndrome in which patients have the following features:Symptoms typical of heart failure: breathlessness at rest or on exercise, fatigue, tiredness, ankle swelling
andSigns typical of heart failure: tachycardia, tachypnoea, pulmonary rales, pleural effusion, raised jugular venous pressure, peripheral oedema, hepatomegaly
andObjective evidence of a structural or functional abnormality of the heart at rest: cardiomegaly, third heart sound, cardiac murmurs, abnormality on the echocardiogram, raised natriuretic peptide concentration
Heart failure should never be a sole diagnosis. The cause should always be sought.
Dept . Anesthes io logy and Intens ive Care Medic ine , DSMA 2008
Chronical and Acute Heart Failure
Heart failure is a serious medical condition where the heart does not pump blood around the body as well as it should. http://www.heartfailurematters.org
Acute heart failure (AHF) is defined as a rapid onset or change in the signs and symptoms of HF, resulting in the need for urgent therapy. AHF may be either new HF or worsening of pre-existing chronic HF. Patients may present as a medical emergency such as acute pulmonary oedema.http://www.escardio.org/guidelines-surveys/esc-guidelines/
Dept . Anesthes io logy and Intens ive Care Medic ine , DSMA 2008
Common clinical manifestations of heart failureDominant clinical feature Symptoms Signs
Peripheral oedema/congestion
Breathlessness Tiredness, fatigue Anorexia
Peripheral oedemaRaised jugular venous pressurePulmonary oedemaHepatomegaly, ascitesFluid overload (congestion)Cachexia
Pulmonary oedema Severe breathlessness at rest
Crackles or rales over lungs, effusionTachycardia, tachypnoea
Cardiogenic shock (low output syndromes)
Confusion Weakness Cold periphery
Poor peripheral perfusionSBP <90 mmHgAnuria or oliguria
High blood pressure (hypertensive heart failure)
Breathlessness Usually raised BP, LV hypertrophy, and preserved EF
Right heart failure BreathlessnessFatigue
Evidence of RV dysfunctionRaised JVP, peripheral oedema, hepatomegaly, gut congestion
Dept . Anesthes io logy and Intens ive Care Medic ine , DSMA 2008
Classification of heart failure by structural abnormality (ACC/AHA), or by symptoms relating to functional capacity
(NYHA)
ACC/AH A stages of heart failure
NYHA functional classification
Stage of heart failure based on structure and damage to heart
muscle
Severity based on symptoms and physical activity
Stage A At high risk for developing heart failure. No identified structural or functional abnormality; no signs or symptoms.
Class I No limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, or dyspnoea.
Stage B Developed structural heart disease that is strongly associated with the development of heart failure, but without signs or symptoms.
Class II Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in fatigue, palpitation, or dyspnoea.
Stage C Symptomatic heart failure associated with underlying structural heart disease.
Class III Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity results in fatigue, palpitation, or dyspnoea.
Stage D Advanced structural heart disease and marked symptoms of heart failure at rest despite maximal medical therapy.
Class IV Unable to carry on any physical activity without discomfort. Symptoms at rest. If any physical activity is undertaken, discomfort is increased.
Dept . Anesthes io logy and Intens ive Care Medic ine , DSMA 2008
Common causes of heart failure due to disease of heart muscle
Coronary heart disease Many manifestations
Hypertension Often associated with left ventricular hypertrophy and preserved ejection fraction
Cardiomyopathies
Familial/genetic or non-familial/non-genetic (including acquired, e.g. myocarditis)Hypertrophic (HCM), dilated (DCM), restrictive (RCM), arrhythmogenic right ventricular (ARVC), unclassified
Drugs ß-Blockers, calcium antagonists, antiarrhythmics, cytotoxic agents
Toxins Alcohol, medication, cocaine, trace elements (mercury, cobalt, arsenic)
Endocrine Diabetes mellitus, hypo/hyperthyroidism, Cushing syndrome, adrenal insufficiency, excessive growth hormone, phaeochromocytoma
Nutritional Deficiency of thiamine, selenium, carnitine. Obesity, cachexia
Infiltrative Sarcoidosis, amyloidosis, haemochromatosis, connective tissue disease
Others Chagas disease, HIV infection, peripartum cardiomyopathy, end-stage renal failure
Dept . Anesthes io logy and Intens ive Care Medic ine , DSMA 2008
Common ECG abnormalities in heart failure
Abnormality Causes Clinical implicationsSinus tachycardia
Decompensated HF, anemia, fever, hyperthyroidism
Clinical assessment Laboratory investigation
Sinus bradycardia
ß-Blockade, dîgoxîn Antî-arrhythmics Hypothyroidism Sick sinus syndrome
Evaluate drug therapyLaboratory investigation
Atrial tachycardia/flutter/ fibrillation
Hyperthyroidism, infection, mitral valve diseases Decompensated HF, infarction
Slow AV conduction, medical conversion, electroversion, catheter ablation, anticoagulation
Ventricular arrhythmias
Ischemia, infarction, cardiomyopathy, myocarditishypokalemia, hypomagnesaemia Digitalis overdose
Laboratory investigationExercise test, perfusion studies, coronary angiography, electrophysiology testing, ICD
Ischaemia/lnfarction
Coronary artery disease Echo, troponins, coronary angiography, revascularization
Q waves Infarction, hypertrophic cardiomyopathy LBBB, pre-excîtatîon
Echo, coronary angiography
LV hypertrophy Hypertension, aortic valve disease, hypertrophic cardiomyopathy
Echo/Doppler
AV block Infarction, drug toxicity, myocarditis, sarcoidosis, Lyme disease
Evaluate drug therapy, pacemaker, systemic disease
Micro voltage Obesity, emphysema, pericardial effusion, amyloidosis
Echo, chest X-ray
QRS length > 120 ms of LBBB morphology
Electrical and mechanical dysynchrony
EchoCRT-P, CRT-D
Dept . Anesthes io logy and Intens ive Care Medic ine , DSMA 2008
Common chest X-ray abnormalities in heart failure
Abnormality Causes Clinical implicationsCardiomegaly Dilated LV, RV, atria Pericardial
effusionEcho/Doppler
Ventricular hypertrophy
Hypertension, aortic stenosis, hypertrophic cardiomyopathy
Echo/Doppler
Normal pulmonary findings
Pulmonary congestion unlikely Reconsider diagnosis (if untreated) Serious lung disease unlikely
Pulmonary venous congestion
Elevated LV filling pressure Left heart failure confirmed
Interstitial oedema
Elevated LV filling pressure Left heart failure confirmed
Pleural effusions Elevated filling pressures HF likely if bilateralPulmonary infection, surgery, or malignant effusion
Consider non-cardiac aetiology if abundantIf abundant, consider diagnostic or therapeutic centres
Kerley В lines Increased lymphatic pressures Mitral stenosis or chronic HFHyperlucent lung fields
Emphysema or pulmonary embolism
Spiral CT, spirometry, Echo
Pulmonary infection
Pneumonia may be secondary to pulmonary congestion
Treat both infection and HF
Pulmonary infiltration
Systemic disease Diagnostic work-up
Dept . Anesthes io logy and Intens ive Care Medic ine , DSMA 2008
Laboratory tests
A routine diagnostic evaluation of patients with suspected includes a complete blood count (haemoglobin, leukocytes, and platelets), serum electrolytes, serum creatinine, estimated glomerular filtration rate (GFR), glucose, liver function tests, and urinalysis. Additional tests should be considered according to the clinical picture.
Dept . Anesthes io logy and Intens ive Care Medic ine , DSMA 2008
Non-medical management of Heart Failure
Self-care management
Educational topics Skills and self-care behaviorsDefinition and etiology of heart failure
Understand the cause of heart failure and why symptoms occur
Symptoms and signs of heart failure
Monitor and recognize signs and symptomsRecord daily weight and recognize rapid weight gainKnow how and when to notify healthcare providerUse flexible diuretic therapy if appropriate and recommended
Pharmacological treatment
Understand indications, dosing, and effects of drugsRecognize the common side-effects of each drug prescribed
Risk factor modification
Understand the importance of smoking cessationMonitor blood pressure if hypertensiveMaintain good glucose control if diabeticAvoid obesity
Diet recommendation Sodium restriction if prescribedAvoid excessive fluid intakeModest intake of alcoholMonitor and prevent malnutrition
Dept . Anesthes io logy and Intens ive Care Medic ine , DSMA 2008
Non-medical management of Heart Failure
Self-care management(continue)
Educational topics Skills and self-care behaviorsExerciserecommendations
Be reassured and comfortable about physical activityUnderstand the benefits of exercisePerform exercise training regularly
Sexual activity Be reassured about engaging in sex and discuss problems with healthcare professionalsUnderstand specific sexual problems and various coping strategies
Immunization Receive immunization against infections such as influenza and pneumococcal disease
Sleep and breathing disorders
Recognize preventive behavior such as reducing weight of obese, smoking cession, and abstinence from alcoholLearn about treatment options if appropriate
Adherence Understand the importance of following treatment recommendations and maintaining motivation to follow treatment plan
Psychosocial aspects Understand that depressive symptoms and cognitive dysfunction are common in patients with heart failure and the importance of social supportLearn about treatment options if appropriate
Prognosis Understand important prognostic factors and make realistic decisions Seek psychosocial support if appropriate
Dept . Anesthes io logy and Intens ive Care Medic ine , DSMA 2008
Pharmacological therapy of HF
Dept . Anesthes io logy and Intens ive Care Medic ine , DSMA 2008
Pharmacological therapy of HFAngiotensin-converting enzyme inhibitors (ACEIs)Unless contraindicated or not tolerated, an ACEI should be used in all patients with symptomatic HF and a LVEF <40%. Treatment with an ACEI improves ventricular function and patient well-being, reduces hospital admission for worsening HF, and increases survival. In hospitalized patients, treatment with an ACEI should be initiated before discharge. Class of recommendation I, level of evidence Aβ-BlockersUnless contraindicated or not tolerated, a β-blocker should be used in all patients with symptomatic HF and an LVEF <40%. β-Blockade improves ventricular function and patient well-being, reduces hospital admission for worsening HF, and increases survival. Where possible, in hospitalized patients, treatment with a β-blocker should be initiated cautiously before discharge. Class of recommendation I, level of evidence AAldosterone antagonistsUnless contraindicated or not tolerated, the addition of a low-dose of an aldosterone antagonist should be considered in all patients with an LVEF <35% and severe symptomatic HF, i.e. currently NYHA functional class III or IV, in the absence of hyperkalemia and significant renal dysfunction. Aldosterone antagonists reduce hospital admission for worsening HF and increase survival when added to existing therapy, including an ACEI. In hospitalized patients satisfying these criteria, treatment with an aldosterone antagonist should be initiated before discharge. Class of recommendation I, level of evidence B
Dept . Anesthes io logy and Intens ive Care Medic ine , DSMA 2008
Pharmacological therapy of HFAngiotensin receptor blockers (ARBs)• Unless contraindicated or not tolerated, an ARB is recommended in patients with HF and an LVEF
<40% who remain symptomatic despite optimal treatment with an ACEI and β-blocker, unless also taking an aldosterone antagonist. Treatment with an ARB improves ventricular function and patient well-being, and reduces hospital admission for worsening HF. Class of recommendation I, level of evidence A
• Treatment reduces the risk of death from cardiovascular causes.Class of recommendation lia, level of evidence B
• An ARB is recommended as an alternative in patients intolerant of an ACEI. In these patients, an ARB reduces the risk of death from a cardiovascular cause or hospital admission for worsening HF. In hospitalized patients, treatment with an ARB should be initiated before discharge. Class of recommendation I, level of evidence B
Hydralazine and isosorbide dinitrate (H-ISDN)• In symptomatic patients with an LVEF <40%, the combination of H-ISDN may be used as an
alternative if there is intolerance to both an ACEI and an ARB. Adding the combination of H-ISDN should be considered in patients with persistent symptoms despite treatment with an ACEI, β-blocker, and an ARB or aldosterone antagonist. Treatment with H-ISDN in these patients may reduce the risk of death.Class of recommendation IIa, level of evidence B
• Reduces hospital admission for worsening HF.Class of recommendation IIa, level of evidence B
• Improves ventricular function and exercise capacity.Class of recommendation Ha, level of evidence A
Dept . Anesthes io logy and Intens ive Care Medic ine , DSMA 2008
Pharmacological therapy of HFDigoxin• In patients with symptomatic HF and AF, digoxin may be used to slow a
rapid ventricular rate. In patients with AF and an LVEF <40% it should be used to control heart rate in addition to, or prior to a β-blocker.Class of recommendation I, level of evidence C
• In patients in sinus rhythm with symptomatic HF and an LVEF <40%, treatment with digoxin (in addition to an ACEI) improves ventricular function and patient well-being, reduces hospital admission for worsening HF, but has no effect on survival.Class of recommendation IIa, level of evidence B
DiureticsDiuretics are recommended in patients with HF and cl or symptoms of congestion.Class of recommendation I, level of evidence BAnticoagulants (vitamin K antagonists)Warfarin (or an alternative oral anticoagulant) is recommended in patients with HF and permanent, persistent, or paroxysmal AF without contraindications to anticoagulation. Adjusted-dose anticoagulation reduces the risk of thromboembolic complications including stroke.Class of recommendation I, level of evidence A
Dept . Anesthes io logy and Intens ive Care Medic ine , DSMA 2008
Pharmacological therapy of HF
Diuretic dosages in patients with heart failure
Dept . Anesthes io logy and Intens ive Care Medic ine , DSMA 2008
Pharmacological therapy of HFDosages of commonly used drugs in heart failure
Dept . Anesthes io logy and Intens ive Care Medic ine , DSMA 2008
Classification of Acute Heart Failure
Worsening or decompensated chronic HF
Pulmonary oedema Hypertensive HF Cardiogenic shock Isolated right HF Acute coronary syndrome and HF
Dept . Anesthes io logy and Intens ive Care Medic ine , DSMA 2008
Two classifications of the seventy of heart failurein the context of acute myocardial infarction
Killip classification Forrester classificationDesigned to provide a clinical estimate of the severity of circulatory derangement in the treatment of acute myocardial infarction.
Designed to describe clinical and haemodynamic status in acute myocardial infarction.
Stage I No heart failure.No clinical signs of cardiac decompensation
Stage II Heart failure. Diagnostic criteria include rales, S3 gallop, and pulmonary venous hypertension. Pulmonary congestion with wet rales in the lower half of the lung fields.
Stage III Severe heart failure.Frank pulmonary oedema with rales throughout the lung fields
Stage IV Cardiogenic shock.Signs include hypotension (SBP <90 mmHg), and evidence of peripheral vasoconstriction such as oliguria, cyanosis and sweating
1. Normal perfusion and pulmonary wedge pressure(PCWP—estimate of left atrial pressure)
2. Poor perfusion and low PCWP (hypovolaemic)
3. Near normal perfusion and high PCWP(pulmonary oedema)
4. Poor perfusion and high PCWP (cardiogenic shock)
Killip T, 3rd, Kimball JT. Treatment of myocardial infarction in a coronary care unit. A two year experience with 250 patients. Am) Cardiol 1967;20:457 464.Forrester JS, Diamond GA, Swan HJ. Correlative classification of clinical and hemodynamic function after acute myocardial infarction. Am j Cardiol 1977;39:137 145.
Dept . Anesthes io logy and Intens ive Care Medic ine , DSMA 2008
Initial treatment algorithm in AHF
Dept . Anesthes io logy and Intens ive Care Medic ine , DSMA 2008
Indications and dosing of diuretics in AHF
Dept . Anesthes io logy and Intens ive Care Medic ine , DSMA 2008
Indications and dosing of vasoactive drugs in AHF
Dosing of positive inotropic agents in acute heart failure
Indications and dosing of i.v.vasodilators in AHF
Dept . Anesthes io logy and Intens ive Care Medic ine , DSMA 2008
Another classification of AHF
Classification according to initially involved partRight Ventricular Failure
(RVF)Left Ventricular Failure
(LVF)
Pathological factors
Increase precardiac load
Decrease cardiac ejection
Increase postcardiac load
Rapidly increase circulation blood volume (hi speed I.V. infusion)
Myocardial infarctMyocardiopathyCardiotoxines
Pulmonary emboliPulmonary arteriospasmPulmonary artery hypertension
Myocardial infarctMyocardiopathyCardiotoxines
Rapidly increase circulation blood volume (neardrowning)
Systemic arteriospasmArterial hypertension