Decompensated Clinical case - … Heart Failure Clinical case Abdelfatah Elasfar MD, FACP Consultant...
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Transcript of Decompensated Clinical case - … Heart Failure Clinical case Abdelfatah Elasfar MD, FACP Consultant...
Decompensated Heart FailureDecompensated Heart FailureClinical caseClinical case
Abdelfatah Elasfar MD, FACP Consultant Cardiologist & Heart Failure/Transplant
SpecialistSpecialistPrince Salman Heart Center, King Fahad Medical
City, Riyadh,S di A biSaudi Arabia
Acute MI or Acute Decompensated HF?S f h blScope of the problem
((GheorghiadeGheorghiade M, et al. Circulation 2005;112:3958M, et al. Circulation 2005;112:3958--68)68)
Chronic Congestive Heart Failurel f l lEvolution of Clinical Stages
NORMAL
Asymptomatic LV Dysfunction
Compensated
No symptomsNormal exerciseNormal LV fxn
No symptoms CompensatedCHF
Decompensated
No symptomsNormal exerciseAbnormal LV fxn
No symptoms pCHFExercise
Abnormal LV fxnSymptoms
ExerciseRefractoryCHFAbnormal LV fxn CHF
Symptoms not controlled with treatment
Summary of the case presentedSummary of the case presented
• 69 year old male.69 year old male.• ADHF.• 6 years history of DCM6 years history of DCM.• EF 23 %.• Non compliant• Non‐compliant.• BP 105/70, HR around 100, Spo2 91 %• Severe pulmonary and peripheral congestion• Severe pulmonary and peripheral congestion• Creatinine 139, K 3.9, Na 138
Clinical caseClinical case
• A Salt restrictionA Salt restriction
• B IV Loop Diuretics
• C Resume previous treatments
• D Add new medications
• E Consider other procedures
Models For ADHFCongestion
Models For ADHF
NoNo YesYes
NoNo Warm and DryWarm and Dry Warm and WetWarm and Wet
fusi
on
YesYes Cold and DryCold and Dry Cold and WetCold and WetHyp
oper
f
YesYes Cold and DryCold and Dry Cold and WetCold and Wet
Predictors of Mortality Based on Analysis of ADHERE Database
Classification and Regression Tree (CART) analysis ofClassification and Regression Tree (CART) analysis of ADHERE data shows:
Three variables are the strongest predictors of mortality inThree variables are the strongest predictors of mortality in hospitalized ADHF patients:
BUN > 43 mg/dL
Systolic blood pressure < 115 mmHg
BUN > 43 mg/dL
Systolic blood pressure < 115 mmHg
Serum creatinine > 2.75 mg/dLSerum creatinine > 2.75 mg/dL
Fonarow GC et al. JAMA 2005;293:572-80.
HFSA 2010 Practice GuidelineAcute HF— IV diuretics are main stay therapy
• It is recommended that patients admitted with ADHF and evidence of fluid overload be treated initially with loop diuretics—usually given intravenously rather than orally.g y y
Strength of Evidence = B
Th C di l S d f HFThe Cardiorenal Syndrome of HF
Increased Morbidityand Mortality
Diuretic Therapy
Developmentof Diuretic and
NeurohormonalActivation
NatriureticResistance Diminished
Blood Flow
Impaired RenalFunction Decreased Renal
PerfusionPerfusion
HFSA 2010 Practice GuidelineAcute HF—Diuretic Alternatives
–Restricting sodium and fluid C ti i f i f l di ti–Continuous infusion of a loop diuretic
–Addition of a second type of diuretic orally (Metolazone or spironolactone)orally (Metolazone or spironolactone)
– Ultrafiltration
Strength of Evidence = C
HFSA 2010 Practice GuidelineAcute HF—IV Vasodilators
• Intravenous vasodilators (intravenous nitroglycerin , nitroprusside or Nesiritide) and diuretics are recommended for rapid symptom relief in patients with acute pulmonary edema or severe hypertensionpulmonary edema or severe hypertension.
Strength of Evidence = C
HFSA 2010 Practice GuidelineAcute HF—IV Inotropes
• Intravenous inotropes (milrinone or d b t i ) b id ddobutamine) may be considered :– LV dilation
d d–Reduced LVEF –And diminished peripheral perfusion or end organ dysfunction (low outputend‐organ dysfunction (low output syndrome)
Strength of Evidence = C
• The combination of low‐dose f id d l dfurosemide and low‐dose dopamine, although no different in producing an effective diuresisin producing an effective diuresis and symptom relief, is safer than high‐dose furosemide, because it g ,reduces the risk of WRF and is potassium sparing.
New TherapiesNew Therapies
l fil i• Ultrafiltration• Vasopressin Receptor Antagonists ( Vaptans)• Adenosine‐1 receptor antagonists• Novel natriuretic peptides (Carperitide)• Myosin activator• Low dose DopamineLow dose Dopamine
ACC/AHA 2009 Recommendations
• ACE inhibitors ARBs and BB therapy it isACE inhibitors , ARBs and BB therapy, it is recommended that these therapies be continued in most patients in the absence ofcontinued in most patients in the absence of hemodynamic instability or contraindications.
(Class I Level of Evidence: C)(Class I ,Level of Evidence: C)
ACC/AHA 2009 Recommendations
• In patients not treated with ACE inhibitors or
ACC/AHA 2009 Recommendations
In patients not treated with ACE inhibitors or ARBs and BB therapy, initiation of these therapies is recommended in stable patientstherapies is recommended in stable patients prior to hospital discharge.
(Class I Level of Evidence: B)(Class I Level of Evidence: B)