Acute Heart Failure:

From Pathophysiology to Practice

Essential
An Aldia Asrial, MD, FIHA
Introduction

Definition

Classification

Pathophysiology

Clinical profile

Diagnosis

Management
Introduction
• Acute Heart Failure (AHF) is a leading cause of
hospitalization with poor outcomes in both short and
long term.
• In hospital mortality 4-11% and in those patients
surviving to discharge 50% will be re-admitted and one
third will die within 12 months.
• Understanding the basic pathophysiology and applying
it in daily clinical practice are essential to improving
patients prognosis.

Cardiac Failure Review (2015) 1 (2),69-74

European Heart Journal (2016) 37, 2129-2200
 Definition

Heart failure
• Clinical
→ syndrome
Clinical syndrome characterized
characterized by typical
by symptoms and signsymptoms and
→ signs
Causedcaused by a structural
by a structural and/or
and/or functional functional
cardiac cardiac
abnormality
→ abnormality, resulting
Resulting in a reduced inoutput
cardiac a reduced cardiac intracardiac
and or/elevated output and/ or
pressures atintracardiac
elevated rest or during stress
pressures at rest or during stress.

Acute heart failure

• The
→ rapid
The rapid development
development or change
or change of symptoms
of symptoms and signs
and signs of heart failure
of
thatheart failure
requires urgentthat requires
medical urgent medical attention
attention
→ Condition with
• Condition an adverse
with prognosis,
an adverse characterized
prognosis, by high mortality
characterized and
by high
rehospitalization rates
mortality and rehospitalization rates

European Heart Journal (2016) 37, 2129-2200

 Acute heart failure Classification:
Acutely Decompensated Chronic Heart Failure (ADCHF)
→ WITH history of heart failure
→ 65-75% of AHF
→ precipitating factors as a trigger of worsening
→ gradual disruption of cardiac function and haemodynamics

De novo Acute Heart Failure

→WITHOUT past history of heart failure
→Rapid development of symptoms and signs
→One third or less of AHF cases
→ACS as the frequent cause

Tubaro M, et al. The ESC Textbook of Intensive and Acute Cardiovascular Care (2 ed). 2018
 Clinical classification of AHF

Hypertensive
AHF

Acute Decompensated
Pulmonary Chronic HF
edema
ACS and
AHF
Cardiogenic
shock
Right HF

Reflect a spectrum of overlapping presentation

Gheorghiade et al. Circulation 2005;112;3958-68

Preload: Blood volume, blood available for pumping
Afterload: Resistance, against which the heart must pump
Contractility: Performance of the heart muscle
 • Salt and water intake ↑ • Uncontrolled
• Poor compliance hypertension
• Renal dysfunction • Acute pulmonary
• Acute valvular embolism
regurgitation
• Fever
• Hyperthyroid

↑Preload ↑Afterload
(Volume (Pressure
overload) overload)

↓Contractility ↓ Preload
(Myocardial (Impaired
loss) ventricular
filling
• Acute myocardial • Tachycardia
infarction • Pericardial diseases
• Drug toxicity

Tubaro M, et al. The ESC Textbook of Intensive and Acute Cardiovascular Care (2 ed). 2018
 Normal heart function Forward failure ≈ - Cold sweated
Hypoperfusion extremities
- Oligouria
- Mental confusion
- Dizziness
- Narrow pulse
pressure

Jugular
venous
dilatation

Pulmonary
congestion
“rales”

Backward failure ≈
Congestion

- Ascites
- Congested
hepatomegaly
- Peripheral (bilateral)
oedema
 AHF-
Suspected
Making the Diagnosis acute heart failure

Examination
History • Vital sign-SpO2
• Risk factors • Congestion
• Typical symptoms (JVP↑, oedema, rales, HJR)
(Dyspnoea, OP, PND) • Low cardiac output
• Atypical symptoms (Cool extremities, oligouria,
narrow pulse pressure

ECG
Multiple possible
Chest radiograph abnormalities: Ischaemia,
(Highly specific but aritmia, LV hypertrophy, Echocardiography
insenstive infark, etc • TTE within 48 hours
• ↑ vascular pattern Laboratory • Cardiac function and
• Interstitial and alveolar • BNP structure
oedema • Ureum/creatinine,
electrolytes
• Troponin
• TSH

Confirm
Adapted From Cardiac Failure Review (2015) 1 (2),69-74 acute heart failure
ST elevation (evolution)

Wide complex tachycardia

Ischemic pattern

Bradycardia significant
Narrow complex tachycardia
 “Redistribution” Interstitial edema
“Perihiliar haze”

Alveolar edema
Adapted From radiologyassistant.nl/chest/chest-x-ray/heart-failure
Clinical profile of AHF
based on congestion and hypoperfusion status

Pulmonary congestion
Orthopnoea/paroxysmal
Congestion nocturnal dyspnoea
(-) (+) Peripheral (bilateral) oedema
Dry Wet Jugular venous dilatation
Congested hepatomegaly, gut
congestion, ascites
Hepatojugular reflux

Warm & Dry Warm & Wet

(-) (Forrester class I) (Forrester
Warm Mortality < 3% class II)
Hypoperfusion

Mortality 9%

Cold & Dry Cold & Wet

Cold sweated extremities (+)
Oliguria Cold
(Forrester (Forrester
Mental confusion
Dizziness
class III) class IV)
Narrow pulse pressure Mortality 23% Mortality 51%

Hypoperfusion is not synonymous with hypotension, but often is accompanied by hypotension

Adapted from Forrester 1976 PMID 790191. Mortality is probably lower today
 Management
Step
1
Identification and treat cardiopulmonary instability

Step Identification and treat acute aetiology

2 /precipitants

Step Confirm AHF diagnosis, assest clinical profile and

3 select optimal management

Step
Monitoring and reassesment
4

Rudiger A. and Arrigo M. Cardiovascular Medicine. 2017; 20(10): 229-235

AHF Management
Based on clinical profile

Rudiger A. and Arrigo M. Cardiovascular Medicine. 2017; 20(10): 229-235

Monitoring
Recommendation Class Level
Standard non-invasive monitoring of heart rate, oxygen I C
saturation and blood pressure is recommended.
It is recommended that patients should be weighed daily and I C
have an accurate fluid balanced.
It is recommended to evaluate sign and symptoms relevant to HF I C
(e.g. dyspnoea, pulmonary rales, peripheral oedema) daily to
assess correction of fluid overload.
Frequent measurement of renal function (BUN, creatinine) and I C
electrolyctes (potassium, sodium) during iv therapy and when
RAAS antagonists agents are initiated is recommended.

European Heart Journal (2016) 37, 2129-2200