Acute heart failure

In this presentation, I have briefly described the acute heart failure, with its symptoms, diagnosis and treatment.

1. Acute Heart Failure
Ilkin Bakirli

2. Content
Definition
Pathophysiology
Classification
NYHA functional classes
Causes
Clinical symptoms and signs
Diagnosis
Treatment

3. Definition
Acute heart failure is a syndrome of any functional or structural impairmentof
ventricular filling or ejection or blood (cardiac output)
De novo or acute on chronic (ADHF)
Dyspnoea at rest progressing to acute respiratory distress

4. Pathophysiology
Inefficient pump (decreased cardiac output)
adaption with increased activity of RAAS and SNS
maladaptation disease progression acute heart failure
Counter-regulation: increased activity of ANP, BNP
prolonged compensationmyocyte hypertrophy, apoptosis and necrosis 
RAAS inhibition

5. Classification
Acute vs chronic
Systolic (reduced CO) vs diastolic (reduced filling)
1.Left-sided heart failure (LHF): reduction in LV output and/or an increase in the left
atrial or pulmonary venous pressure
2.Right-sided heart failure (RHF): reduction in RV output in any given right atrial
pressure
3.Biventricular heart failure (BVF): either due to a disease affecting both the ventricles
or because LHF leads to chronic elevation of left atrial pressure, pulmonary
hypertension and eventually RHF as well

6. NYHA functional classes
Class I heart failure: which is defined as a person who experiences no limitation in
any activities and has no symptoms from ordinary activities.
Class II heart failure: mild limitation with everyday activities; the person is
comfortable at rest or with mild exertion.
Class III heart failure: there is marked limitation with any activity; the person is
comfortable only at rest.
Class IV heart failure: symptomatic at rest and becomes quite uncomfortable with
any physical activity.

7. Causes
1.Reduced ventricular contractility –MI, myocarditis, cardiomyopathy
2.Ventricular outflow obstruction –hypertension, aortic stenosis (LHF), pulmonary
hypertension, pulmonary valve stenosis (RHF)
3.Ventricular inflow obstruction –mitral stenosis, tricuspid stenosis
4.Ventricular volume overload –mitral/aortic regurgitation (LV overload), ventricular
septal defect, atrial septal defect (RV overload)
5.Arrhythmia –complete heart block
6.Diastolic dysfunction –pericarditis, restrictive cardiomyopathy, LV hypertrophy,
cardiac tamponade

8. Clinical symptoms and signs
Left-sidedheart failure Right-sided heart failure
Dyspnoea Peripheral oedema
Tachypnoea Ascites
Pulmonary congestion Hepatomegaly
Fatigability Increased jugular venous pressure
Exercise intolerance Tachycardia
Paleness
Cold peripheries
Agitation
Tachycardia

9. Diagnosis
History: recent MI, easy fatigability, confusion
General physical exam: cyanosis, oedema, paleness
Palpation: cardiomegaly, hepatomegaly, ascites
Auscultation: rales, crepitus
Vitals: tachycardia, hypotension, cold
Investigations
CXR cardiomegaly, pulmonary congestion, Kerley lines
ECG no P wave, variable HR, broad QRS
EchocardiographySV, EDV, pulmonary oedema
Hyponatremia, elevated vasopressin,
Cardiac biomarkers (elevated BNP, troponins)

10. Treatment
Treat the cause
ADHF ABC, nitroglycerin, furosemide, NIPPV
Renal failure haemodialysis, diuretics, hydralazine, isosorbide dinitrate
Respiratory failure supplemental oxygen, nitrates, diuretics
Circulatory failure inotropics (diogoxin), adrenaline/ dobutamine, milrinone, beta
blockers, ACEI/ARB, monitor CBC
Lifestyle modification fluid and salt restriction
Implant an automatic cardioverter defibrillator in patients with severe
cardiomyopathy, recurrent VT or other malignant arrhythmias
Ventricular assist devices for severe heart failure
Heart transplantation