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ANDREA JOHNSON Slide 2 P.C. 60 year old female Hypertensive non-compliant X 1year Slide 3 PRESENTING COMPLAINT SEVERE SOB Began while swearing & getting on bad Drank 1 bottle extra strength Codeine Then 20mls rum cream GOT WORSE !!!! Slide 4 DENIED Chest, abdominal or back pain Palpation Nausea or vomiting Diaphoresis Cough fever Previous episodes of SOB History of immobilization Slide 5 PMH NO previous admission to QEH No Diabetes Mellitus/heart disease Admission to Psyche hospital for social reasons ?!! - ? # times On no medication Given Natrilix on 1 occasion ~ 1year previously Slide 6 EXAMINATION Obvious CP distress Mm pink, hydration adequate No pedal oedema Temperature 36 o C axillary Slide 7 RESPIRATORY SYSTEM OXYGEN SAT (room air)- 78% RR 40/min, use of accessory muscles BS vesicular Creps laterally + posteriorly Wheeze throughout posteriorly Slide 8 CARDIOVASCULAR SYS Distal pulses palpable + = bilaterally JVP not elevated PULSE 107/min, regular, synchronous BP 260 / 145 mmHg Normal heart sounds No murmurs Slide 9 ABDOMEN Soft, non-tender No masses or organomegaly Normal BS Slide 10 MUSCULOSKELETAL No calf swelling or tenderness Slide 11 DIASCAN 22.3 MMOL / L Slide 12 ASSESSMENT 1. ACUTE PULMONARY OEDEMA r/o Acute Myocardial Infarction 2. Uncontrolled HTN 2 o non-compliance 3. ? Newly Diagnosed Diabetic Slide 13 PLAN Oxygen 15 L / min- nonbreather face mask GTN 2 puffs X 2 Nitroglygerin infusion @ 1mcg/kg/min (100mcg/min) Enalapril 1.25mg IV Lasix 60mg IV Aspirin 300mg stat Soluble insulin 10u IV Slide 14 ECG (RT sided leads subsequently) ABG Cardiac enzymes FBC PT PTT n/a. Urea and electrolytes CXR Urethral catheter + urinalysis Slide 15 RESULTS ECG: sinus, regular LVH with Strain ST depression II, aVF ? ST elevation vs high J point V1-V3 Right sided leads - NAD Slide 16 RESULTS CXR- fluffy opacity throughout ABG 15 L O2 O2 sat 93.2% pO2 - 74.3 pCO2 39.6 HCO3 18.1 Slide 17 RESULTS Hb 15.1 WBC 19.8 PLT 332 Sodium 137 Potassium 3.6 Chloride 101 Urea 9.9 Creatinine 125 CK 120 CKMB 41 Troponin I 0.22 Slide 18 FURTHER MX Referred To Med on Call 1 hour after seen significant improvement RR 32/ min, BP 195 / 109, pulse 85/min 2 hours later 1000 mls urine emptied Admitted to MED Slide 19 ON WARD Treated for UTI Day 4 aggressive, speaking loudly Seen by psyche Diagnosis ? Paranoid Schizophrenia vs Delusional disorder ? Hypomanic symptoms Slide 20 DISCHARGE DAY 7 F/U: MOPD + Psyche Hospital TTH: Lasix 40mg od Norvasc Tritace ASA Lipitor Diamicron MR 30mg od Complete Septrin Slide 21 ACUTE CARDIOGENIC PULMONARY OEDEMA ANDREA JOHNSON Slide 22 DEFINITION Leakage of fluid from the pulmonary capillaries and venules into the alveolar space as a result of increased hydrostatic pressure Inability of left ventricle to effectively handle its pulmonary venous return MATTU ET AL Slide 23 PATHOPHYSIOLOGY Angiotensin II Angiotensin I Angiotensinogen ( LIVER) ALDOSTERONE VASOCONSTRICTION RENIN ACE Slide 24 PATHOPHYSIOLOGY CARDIAC OUTPUT INCREASED PCWP ACTIVATION OF RENIN ANGIOTENSIN SYSTEM ACTIVATION OF S/S SYSTEM INCREASED HEART RATE INCREASED SYSTEMIC VASCULAR RESISTANCE INCREASED PRELOAD CARDIAC ISCHAEMIA LEFT VENTRICULAR FUNCTION SYMTOMATIC DECOMPENSATION Slide 25 PRECIPITATING FACTORS Myocardial ischaemia or infarction Arrhythmias Uncontrolled HTN/HTN crisis Medication Non-compliance Thyrotoxicosis Fluid overload Anaemia Pulmonary & other infections Inappropriate medications- -ve inotropes, NSAIDS Slide 26 CLINICAL FEATURES SOB Orthopnoea - sensitivity 5% - specificity 77% PND Tachycardia BP Wheezing sensitivity 22% - specificity 58% Crepitations - sensitivity 6% - specificity 78% EMERGENCY MEDICINE PRACTICE DEC 2006 Slide 27 DIFFERENTIAL DIAGNOSIS Physicians only 80% accurate at differentiating Acute Heart Failure from other disease processes Slide 28 DIFFERENTIAL DIAGNOSIS ASTHMA COPD PULMONARY EMBOLISM PNEUMONIA Slide 29 INVESTIGATIONS 1. Blood 2. Electrocardiography 3. Radiologic Slide 30 BLOOD INVESTIGATIONS ABG FBC anaemia, infection U & Es CARDIAC MARKERS Slide 31 CARDIAC ENZYMES OTHER CARDIAC MARKERS Slide 32 B NATRIURETIC PEPTIDE (BNP) N-TERMINAL PRO BNP PRE-PRO BNP BNP + NT PRO-BNP Slide 33 B NATRIURETIC PEPTIDE (BNP) EFFECTS 1.Vasodilation 2. Diuresis 3. Natriuresis 4. Suppression of Renin Angiotensin Sys Slide 34 IMPORTANCE OF BNP IN HF 1. Useful in Diagnosis 2. Assessing Severity 3. Predicting short & long-term CVS mortality Slide 35 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 Slide 36 PROBLEMS !!! GRAY AREA: 100pg/dl 500pg/dl BNP in non-cardiac conditions Renal disease Age Pulmonary Embolism Cor pulmonale BNP in CCF OBESITY: BMI inversely related to BNP Slide 37 USEFULNESS OF BNP Does not add much when diagnosis certain from clinical presentation Uncertain diagnosis when BNP < 100pg/dl Known baseline in certain conditions 20% obese patients with acute heart failure have values < 100pg/dl Slide 38 ELECTROCARDIOGRAM Ischaemia / infarction Arrhythmia A fib LVH Prolonged QRS Slide 39 CHEST RADIOGRAPH FINDINGS IN HEART FAILURE Cardiomegaly 74% sensitive, 78% specific Vascular redistribution Interstitial oedema Pleural effusions (right sided/bilateral) Slide 40 CXR BUT !! 20% patients with Acute heart failure have none of the typical features No longstanding HF- Normal size heart Longstanding CCF lymphatics COPD minimal findings Slide 41 Other investigation Echocardiography 1.Identify reversible cause eg tamponade 2.Distinguish between systolic and diastolic dysfunction Slide 42 TREATMENT AIMS ABCs Decrease Preload (right-sided filling) Increase left-sided emptying Afterload, Cardiac output improve LV contractility inotropes Overall aim- Redistribute fluid out of lungs! Slide 43 AVAILABLE TREATMENT OXYGEN PHARMACOTHERAPY INOTROPIC RX NONINVASIVE POSITIVE PRESSURE VENTILATION Slide 44 PHARMACOTHERAPY AVAILABLE 1. NITRATES 2. DIURETICS 3. ACE INHIBITORS 4. MORPHINE 5. NATRIURETIC PEPTIDES Slide 45 NITRATES NITROGLYCERIN MECHANISM OF ACTION Venodilation (low dose) PRELOAD Arteriolar dilatation (higher dose) AFTERLOAD pulmonary hydrostatic pressure Slide 46 NITROGLYCERIN DOSE SL: 0.4mg q 5-10 min IV: titrate up to 3 5mcg /kg /min Topical: may be unreliable in poor perfusion Effect seen within minutes !!! Slide 47 NITROPRUSSIDE Afterload Useful in Pulmonary oedema unresponsive to standard therapy Severe HTN Severe mitral/aortic regurge Slide 48 NITROGLYCERIN Excellent single agent for acute pulmonary oedema !! Slide 49 ACE INHIBITORS MECHANISM OF ACTION Sublingual or IV Afterload Preload Pulmonary Capillary Wedge Pressure Down-regulate renin-angiotensin system Slide 50 ACE INHIBITORS Sublingual 12.5mg Captopril Sys BP < 110 25mg Captopril Sys BP >110 Intravenous Enalapril - 0.004mg/kg bolus - 1mg infusion over 2 hrs - 1.25 mg bolus Effect seen within 10 minutes!!!! Slide 51 CARE with ACE INHIB NOT easily titratable Long duration of action BP Slide 52 DIURETICS MOA - Furosemide EARLY 1 st 30 min Activate renin angiotensin system Activate S/S nervous system (Release of Norepinephrine) SVR (afterload), HR, BP CO Slide 53 MOA - Furosemide contd LATER (30 120 min) Decrease Preload A. Diuresis B. Direct venodilator effect Slide 54 RECOMMENDATION Give Nitrates PRIOR to Furosemide High dose Nitrate + low dose Diuretic more consistent improvement Slide 55 EVEN BETTER !?? Premedication with Nitrates + ACE Inhibitors Immediate and sustained PCWP by Furosemide Slide 56 MORPHINE Preload Anxiolysis BUT Nitrate provide better preload reduction Histamine release Slide 57 NATRIURETIC PEPTIDES NESERITIDE Recombinant form of BNP FDA approved Slide 58 NESERITIDE PROS More effective than Nitrates at 1. improving haemodynamic function 2. self reported symptoms Slide 59 NESERITIDE CONS EXPENSE: 40 x > NTG Bolus (2mcg/kg) followed by 24 - 48 hour infusion (0.01mcg/kg/min) Slide 60 OTHER NATRIURETIC PEPTIDES Undergoing research Carperitide atrial natriuretic peptide Ularitide renal natriuretic peptide Slide 61 NIPPV Continuous positive airway pressure (CPAP) Bi-level positive airway pressure (BIPAP) Slide 62 NIPPV MOA Decrease work of breathing Decrease preload & afterload Improve Cardiac output Must be used early to maximize effect !! Slide 63 ? MI with BIPAP Slide 64 INOTROPIC SUPPORT CARDIOGENIC SHOCK SYS BP < 80mmHg PCWP >18mmHg Cardiac Index < 1.8L/min/m 2 (normal 2.5 4.0 L/min/m 2 ) Slide 65 INOTROPIC SUPPORT 1. Catecholamines 2. Phosphodiesterase inhibitors 3. Calcium sensitizers (undergoing research) 3. Intra-aortic balloon pump Slide 66 Catecholamines Dopamine Dobutamine (less arrhythmogenic) Cons Increase myocardial oxygen demand Tolerance may develop requiring higher doses Slide 67 Phosphodiesterase inhibitors PREFERRED !! Work independent of adrenoreceptor activity and plasma catecholamine levels No tolerance Decrease preload and afterload ! MILRINONE ! Slide 68 DISPOSAL ALMOST ALL PATIENTS SHOULD BE ADMITTED !! Discharge only if Mild failure No increased oxygen requirement Cause: non-compliance Ischaemia ruled out No arrhythmia Normal labs Normal mental status Good follow-up Slide 69 SUMMARY ABC REDISTRIBUTE FLUID OUT OF LUNGS! 1 ST Line: Nitrates 2 ND Line: ACE Inhibitors 3 RD Line: Diuretics NIPPV use early ! Milrinone preferred inotrope Slide 70 THANK YOU Slide 71 REFERENCES 1.Mattu A. Management of Acute pulmonary edema-Pearls and Pitfalls 2.Kosowsky J, et al. Acutely decompensated heart failure: diagnostic and therapeutic Strategies. Emergency Medicine Practice Dec 2006;8(12) 3.Mattu A, et al. Pulmonary edema, cardiogenic. Emedicine