DIAGNOSIS AND MANAGEMENT OF ACUTE HEART FAILURE · PDF fileDIAGNOSIS AND MANAGEMENT OF ACUTE...
Transcript of DIAGNOSIS AND MANAGEMENT OF ACUTE HEART FAILURE · PDF fileDIAGNOSIS AND MANAGEMENT OF ACUTE...
DIAGNOSIS AND MANAGEMENT OFACUTE HEART FAILURE
Mefri Yanni, MDBagian Kardiologi dan Kedokteran Vaskular
RS.DR.M.Djamil Padang
The 3rd Symcard Padang, Mei 2013
Outline
• Diagnosis
• Treatment options
• Approach to management
• Discharge planning
Diagnosis
Management options
Discharge planning
Diagnosis
Therapeutic goals
Management options
LABS :• Hb value (Anemia?)• Infection marker• Electrolytes• Renal function• Blood glucose• Cardiac enzyme• Blood gas analysis• Throid function – new onset HF
Classification of AHF
ESC Guideline. For diagnosis and treatment of Acute and chronic HF. 2008
Assessment of Hemodynamic Profile
Therapeutic Goals in AHF
Improve patient hemodynamic status
to relief symptoms and stabilize organ function
Reduce systemic vascular resistance (SVR)
↑cardiac output (CO)
Reduce fluid volume and filling pressures
Reduce neurohormones
Pharmacologic Options
Fluid Challenge Inotropic drugs
Diuretic
Vasodilator
Warm
Dry
Cold
Wet
Warm/Dry
Cold/Dry
Warm/Wet
Cold/Wet
A
L C
B
Acute Pulmonary Edema / Congestion
Intravenous bolus of loop diuretic 2-2,5 times
Hipoxemia Oxygen
Severe anxiety/distress
Consider iv opiate
Measure systolic blood pressure
SBP < 85 mmHg or shock SBP 85-110 mmHg SBP > 110 mmHg
Add non-vasodilating inotrope No additional therapy until response assessed
Consider vasodilator
Yes
Yes
No
No
ESC Guidelines of Acute and Chronic Heart Failure, 2012
Adequate response to treatment
Reevaluation patient clinical status
SBP < 85 mmHg SpO2 < 90% Urine output < 20 ml/hr
• Stop vasodilator• Stop beta-blocker if
hypoperfused• Consider non-vasodilating
inotropes or vasopressor• Consider right heart
catheterization• Consider mechanical circulatory
support
• Bladder catheterization to confirm
• Increase dose of diuretic• Consider low dose
dopamine• Consider right-heart
catheterization• Consider ultrafiltration
No
Yes Yes Yes
No
• Oxygen• Consider NIV• Consider ETT• Consider Invasive
ventilation
Yes
No
Continue present treatment
ESC Guidelines of Acute and Chronic Heart Failure, 2012
No
Diuretics
VasodilatorsNitroprusside, Nitroglycerin, Nitrate family
Work by cGMP mediated smooth muscle
relaxation -> vasodilation
Decrease myocardial work by afterload and
preload reduction
May cause hypotension
May cause headache
Intravenous Vasodilator in AHF
Inotropic AgentsDobutamin, Dopamine, Milrinone
Indication :Peripheral hypoperfusion (hypotension, decrease renal
function) with or without congestion
ESC, Acute Heart Failure, 2012
Improve cardiac output
by directly increasing cardiac
contractility
Significant proarrhythmic effects
May precipitate ischemia
Dopamine
ESC, Acute Heart Failure, 2012
• Effect dose dependent• In low dose (< 2 ug/kgBW/min) :
vasodilatation occurs predominantly in renal, coronary, and cerebral vascular beds.
• At doses > 5 g/kgBW/min :will increase peripheral vascular resistance via adrenergic receptors
Dobutamine
ESC, Acute Heart Failure, 2012
• Clinical action :
Positive inotropic
Positive chronotropic effects.
• Range dosage : 2 – 20 ug/kgBW/min
• In low dose < 5 ug/kgBW/min induce arterial vasodilatation
• In higher dose induce arterial vasoconstriction
Phosphodiesterase Inhibitors
ESC, Acute Heart Failure, 2012
• Non beta adrenergic mechanism• Inotropic• Vasodilator• Lusitropy (diastolic relaxation)
• Uses– Low cardiac output states– Downregulated/ desensitized – CHF unresponsive to diuretic – Increased SV decreased SVR
Cardiogenic Shock
ESC, Acute Heart Failure, 2012
• A state of end organ hypoperfusion due to cardiac failure
• SBP < 80-90 mmHg or ↓ MAP >30 mmHg
• Severe ↓ cardiac index (CI) < 1.8 L/m without support, or < 2.0-2.2 L/m with support ↓
• LVEDP > 18 mmHg, or RVEDP > 10-15 mmHg
• Absent or low urine output (< 0.5 ml/kg/h)
• Evidence of organ hypoperfusion and pulmonary congestion
Vasopressor
ESC, Acute Heart Failure, 2012
• Drugs that stimulates smooth muscle contraction of the capillaries & arteries
• Cause vasoconstriction & a consequent rise in blood pressure
Drugs used to treat AHF ( Inotropes and vasopressor )
ESC, Acute Heart Failure, 2012
• Considered early in patient present with restlessness, dyspnoea, anxiety, chest pain
• Morphine induces : Venodilatation Mild arterial dilatation Reduce heart rate
• Caution : hypotension, bradycardia, CO2 retention.
• Dose : 2,5-5 mg IV bolus (rate 1 mg/min.)repeated if required
Morphine and its analogues
Monitoring patient with AHF
ESC, Acute Heart Failure, 2012
DAILY MONITORING
Weight
Intake and output
Symptoms and
exam
Renal function
and electrolytes
MORE FREQUENTLY
• Symptoms
• Vital signs
• Saturation
• Urine output
Drug Initiation after stabilization
ESC, Acute Heart Failure, 2012
• ACE-I
• Beta blocker
• Mineralcorticoid receptor antagonist
• Digoxin
• Device therapy
Outline
ESC Guidelines Acute and Chronic Heart Failure 2012
Discharge Criteria
ESC, Acute Heart Failure, 2012
Near optimal volume status achieved
Transition from iv to oral medications done
No IV vasodilators or inotropes x 24 h
Oral medication regimen stable x 24 h
Near optimal oral therapy achieved
Discharge Instructions
ESC, Acute Heart Failure, 2012
Discharge medications
Follow up clinic visit 3-5 days
Weight monitoring
Assessment of worsening heart failure
Patient and family education of risk factors and precipitating factors
Referral for further management
Salt and Fluid restriction diet
Patient Education :What are the symptoms of heart failure ?
Think FACES ...
• Fatigue
• Activities limited
• Chest congestion
• Edema or ankle swelling
• Shortness of breath
Conclusion
ESC, Acute Heart Failure, 2012
Rapid assessment and treatment of AHF could decreased mortality and morbidity rate
Management strategies including :
– Ensure oxygenation
– Reduce pain
– Reduce fluid volume
– Reduce preload and or afterload
– Increase cardiac output
– Identify and treat the cause of CHF