Acute Heart Failure How to Mend a Broken Heart Ben Cooper 12/11/14

Chung P, Hermann L. Acute Decompensated Heart Failure: Formulating an Evidence Based Approach to Diagnosis and treatment. Mt. Sinai J of Med 2006;73(2): 506-27.

Chung P, Hermann L. Acute Decompensated Heart Failure: Formulating an Evidence Based Approach to Diagnosis and treatment. Mt. Sinai J of Med 2006;73(2): 506-27.

A QRS duration of >0.1, >0.11 or >0.12 s was highly specific (63, 90 and 98%) but less sensitive (84, 81 and 75%) for the prediction of LVSD

BNP NT pro-BNP

Age All < 50 50-70 > 70

Rule Out < 100+ < 300* < 300* < 1200₸

Sens/Spec 90%/74% 99%/85% 99%/85% 97%/55%

Rule In > 400+ >450* >900* >4500₸

Sens/Spec 81%/90% 93%/95% 91%/80% 64%/86%

*Januzzi, Jr. et al Am J Cardiol 2005 ₸Berdague et al. Am Heart J 2006 +Korenstein BMC Emerg Med 2007

Acute vs Chronic

High-Output vs Low-Output

Right vs Left Systolic

vs Diastolic

Dilated vs Hypertrophic vs

Restrictive

NT-proBNP 1574 Trop T < 0.01 BP 182/127

How much furosemide during initial management would you give this patient?

A. None

B. 20 mg IV

C. 40 mg IV

D. 60 mg IV

E. 80 mg IV

NTG + F MS + F NTG + F + MS NTG + MS

What infusion rate of nitroglycerin is appropriate for this patient?

A. Start at 5 mcg/min and titrate up

B. Start at 100 mcg/min and titrate down

C. Start at 100 mcg/min and titrate up

D. Give 1 SL NTG q 5 min

E. Apply 0.5 inch of nitro paste and cross fingers

Nitroglycerin is an oily liquid that may explode when subjected to heat, shock or flame. It is dangerously sensitive and dropping or bumping a container may cause it to explode.

– Wikipedia

↓ BiPap ↓ Intubations ↓ICU

• Preload/Afterload Reduction

• Captopril SL resulted in more rapid clinical improvement when added to standard regimen over placebo*

• Enalaprilat IV is well tolerated, and reduces PCWP**

• Should be started within 24 hours***

*Hamilton R. Acad Emerg Med 1996. **Annane D. Circulation 1996. ***Buccelletti F. Mt Sinai J of Med 2006.

Bolus 250 to 500 cc

Norepinephrine

Dobutamine

• NIPPV

• High dose NTG ggt for hypertensive

– Start @ 100 mcg/min

• NE and/or Dobutamine for hypotensive

• Just say no to furosemide