Acute Heart Failure

Valentina, MD, FIHA

Acute HF (seek
ACUTE HEART FAILURE
help in HOSPITAL
emergency)

CHRONIC HEART FAILURE

(undetected in your community)
 Heart Failure
 Clinical syndrome in which the ability of the
heart to pump blood is abnormal.
 Leaving the body’s oxygen and metabolic
demands unmet.
 Usually caused by an underlying repairable heart
problem.
 Characterized by inadequate blood flow
(perfusion) to the tissues with symptoms as
fatigue but also congestion (SOB)
 Heart Failure - Definition
A syndrome in which patients have:
 Typical symptoms (e.g. breathlessness, ankle
swelling, and fatigue)
 Signs (e.g. elevated jugular venous pressure,
pulmonary crackles, and displaced apex beat)
Resulting from an abnormality of cardiac structure
or function

John J.V. McMurray et al. European Heart Journal 2012 (ESC Guideline)
PATOPHYSIOLOGY of HEART
FAILURE in ACS
 Acute Heart Failure
Rapid symptoms and signs secondary to abnormal
cardiac function (onset :hours-days).

Cardiac dysfunction can be related to systolic or

diastolic dysfunction, or to abnormalities in cardiac
rhythm, or to preload and after load mismatch.

It is often life threatening and requires urgent

treatment.
 Clinical presentation of
Acute Heart Failure

1. New HF or worsening / decompensated

Chronic HF (ADHF)
2. Acute Pulmonary Edema
3. Hipertensive AHF
4. Cardiogenic Shock
5. Isolated right heart failure
6. Heart Failure in ACS
 Classification and Common Clinical
Characteristics of Patients with Acute Heart
Failure (ESC 2005)

Nieminen MS, et al. Eur Heart J 2005 (ESC)

 General Approach of AHF
Diagnosis
Etiologies
Precipitating factors
Acute management
Long term management
 Acute Cardiogenic Pulmonary
Oedema
 Verified by chest x-ray  congestion (+)
 Accompanied by severe respiratory distress,
with crackles over the lungs and orthopnoe
 Decreased oxygen saturation usually <90% on
room air prior to treatment
 Multiple cardiac-extra cardiac pathologies
Initiation pathologic phase
Neurohormonal &
Inflammatory activation
LV  + SVR 
contractility

Afterload mismatch

CO LV pressure
Amplification phase of AHF
Neurohormonal &
Inflammatory activation
LV  + SVR 
contractility

Afterload mismatch
Alveolar
 Capillary
CO LV pressure permeability

Decreased
Wedge Fluid
pressure clearance

Pulmonary
Edema
 VICIOUS CYCLE OF HF
Neurohormonal &
Inflammatory activation
LV  + SVR 
contractility

Afterload mismatch
Alveolar
 Capillary
CO LV pressure permeability

Decreased
RV Myocardial Peripheral Fluid
Wedge
failure ischemia hypoperfusion clearance
pressure

Respiratory Reduced Pulmonary

failure Oxygenation Edema
 Warm/Dry Warm/Wet

Cold/Dry
Cold/Wet
Clinical Severtiy Classification (ESC
2005)
Clinical Severtiy Classification (ESC
2005)
 Assessment & Treatment Algorithm for
AHF
DRY WARM WET WARM WET-COLD DRY-COLD
PROFILE PROFILE PROFILE PROFILE

Initial Management Initial Management Initial Management Initial Management

Continue oral heart IV loop diuretic IV loop diuretic Evaluate SVR
failure medications. IV Vasodilator or Inotropes and / or
Decreasing SVR
Search for other pressor
IV Natriuretic peptide IV vasodilator or
causes of symptoms
Stop beta blocker
incl PE, ACS, Oxygen if indicated IV Natriuretic peptide if
depression, anemia, Admit : telemetry on highSVR Admit :ICCU or
hypothyroidism telemetry unit
observation unit Inotropes or pressor if
low SVR
Oxygen if indicated
Admit :ICCU or
telemetry unit

Optimize oral medications and discharge

Fonarow et al. Clin Cardiol 2004 ; 27 (suppl V) V1 – V9
 Acute Heart
Failure
Oxygen/CPAP
Furosemide + vasodilator
Clinical evaluation (leading to mechanistic therapy)

SBP > 100 mmHg SBP 90-100 mmHg SBP <90 mmHg
Vasodilator Vasodilator and/or Volume loading test
(NTG, nitroprusside, niseritide) Inotropic (dobutamin) Inotrope (Dopamin
> 5mcg/kg/mnt)
And/or norepinephrine

Poor response Good response

Inotropes agent Oral therapy
vassopressor Furosemide, ACE-I/ARB,
mechanical support B-blocker
Consider transplant ESC, Acute Heart Failure, 2008
 Steps of care & treatment
Acute Heart Failure

Definitive Immediate If moribund

diagnosis resuscitation BLS, ALS

YES Analgesia or
Diagnosis Patient distressed
Algorithm or in pain sedation
NO

NO Increase FiO2,
Definitive Arterial oxygen Consider CPAP,
treatment saturation > 95% NIPPV
YES
Reperfusion
therapy for Pacing,
ACS etc. NO
Normal heart rate Antiarrhythmics
and rhythm etc…
YES
ESC guidelines, Eur Heart J 2005;26:384-416
 Steps of care and treatment
YES Vasodilators
Mean BP
Consider diuresis
> 70 mmHg
if volume overload
NO

NO Fluid challenge
Adequate
preload
YES
Consider
inotropic
Adequate CO
or further afterload
reversal of acidosis NO
reduction
SvO2 > 65%
signs of adequate YES Reassess frequently
organ perfusion
ESC guidelines. Eur Heart J 2005;26:384-416
 Algorithm for Management of
Acute Pulmonary Oedema/Congestion

John J.V. McMurray et al. European Heart Journal 2012 (ESC Guideline)
 Algorithm for Management of
Acute Pulmonary Oedema/Congestion

John J.V. McMurray et al. European Heart Journal 2012 (ESC Guideline)
thankyou