Acute heart failure [MBBS]

Acute heart failure seminar

Pathophysiology
Classification
Aetiology
Diagnosis
Management in Emergency (ED)
Disposition decision

1. ACUTE HEART FAILURE Muhammad Khairulanwar Bin Muhamad Kamal 012012050-144 Emergency Medicine [Y5]

2. Overview Introduction Pathophysiology Classification Aetiology Diagnosis Management in Emergency (ED) Disposition decision

3. Introduction A complex clinical syndrome that results from any structural or functional impairment of ventricular filling or ejection of blood Heart fails to act as a pump Manifested by cardinal symptoms Dyspnoea & fatigue  exercise intolerance Fluid retention  pulmonary oedema, splanchnic oedema, peripheral oedema

4. Pathophysiology Acute exacerbation

5. “ Inefficient pump”  decrease cardiac output (CO) Myocardial injury Stress “Responsive adaptations”  Neurohormonal mediated cascades activation Renin angiotensin aldosterone system (RAAS) Sympathetic nervous system (SNS)

6. Neurohormonal mediated cascade *At the cost of increasing myocardial workload, wall tension and myocardial oxygen demand

7. Counter regulatory response Atrial natriuretic peptides (Atria) B-type natriuretic peptide (Ventricle) C-type natriuretic peptide (Localized in endothelium) Effects: Vasodilation, natriuresis, decreased levels of endothelin, and inhibition of RAAS and SNS Importance: (Assays) Elevated levels portend a worse prognosis Attenuation provides the basis for most chronic therapies proven to delay morbidity and mortality

8. Assays for BNP in ED use N-t pre-pro-BNP

9. Classification*

10. Classification Acute vs Chronic Systolic vs Diastolic dysfunction Right sided vs Left sided High output vs Low output

11. Systolic vs diastolic Systolic Diastolic Age All ages Frequently elderly Sex Often male Frequently female LV EF Decrease ( <50 ) Normal ( Preserved ) LV cavity size Dilate ( increase intracardiac volume ) Normal ( often with LVH )

12. Current categorization Heart failure with a reduced ejection fraction ( HFrEF ) [ SYSTOLIC] Heart failure with preserved ejection fraction ( HFpEF ) [DIASTOLIC]

13. Common causes of heart failure

14. Diagnosis History Clinical examination Fisk factors Precipitating factor Investigations

15. History – cardinal symptoms Dyspnoea on exertion Orthopnoea Paroxysmal nocturnal dyspnoea Edema Fatigue

16. History – other symptoms Cough with expectoration CNS : Altered sensorium, confusion, impairment of memory, headache, insomnia GI : Anorexia, nausea, vomiting, pain abdomen, abdominal fullness GU: Nocturia

17. Dyspnoea

18. Differential for dyspnoea Exacerbation of asthma or COPD Pulmonary embolus Pneumonia Acute coronary syndrome Anaphylaxis

19. Risk factors Male Old ages Hypertension Diabetes mellitus Valvular heart disease obesity

20. Precipitating factors

21. General Physical Examination Mild to moderate HF : No distress except when lying flat for more than a few minutes Severe HF: Must sit upright, labored breathing, unable to finish a sentence Cardiac cachexia Cyanosis Edema Jaundice

22. Vitals Sinus tachycardia Pulse pressure: ↓ SBP: ↓ Cold extremities ↑ JVP Giant v waves

23. Examination of Jugular Veins

24. CVS Examination Palpation: Cardiomegaly with hyperdynamic point of maximum impulse Auscultation S₃ PSM

25. RS Examination Crepitations / Rales Signs of pleural effusion

26. PA Examination & extremities Hepatomegaly: Tender, pulsatile Ascites Peripheral edema

27. Investigations Chest X-ray Electrocardiogram Biomarkers Ultrasonography Routine lab tests: CBC, RFT, LFT, TSH, electrolytes

28. Chest x-ray (upright) Pulmonary venous congestion Cardiomegaly (80%) or normal (20%) Interstitial edema Most specific for a final diagnosis of acute heart failure but the absence of these does not rule it out

29. Cardiomegaly CTR = 18/30 (>50%) Upper zone vessel enlargement ( 1 ) – a sign of pulmonary venous hypertension Septal ( Kerley B) lines ( 2 ) – a sign of interstitial oedema – see next picture Airspace shadowing ( 3 ) – due to alveolar oedema – acutely in a peri -hilar (bat's wing) distribution Blunt costophrenic angles ( 4 ) – due to pleural effusions

30. Electrocardiogram Not useful for diagnosis Early recognition of arrhythmias – atrial fibrillation Signs of ischaemia or injury

31. Irregularly irregular rhythm. No P waves. Absence of an isoelectric baseline. Variable ventricular rate. QRS complexes usually  < 120 ms

32. Routine Complete blood count to evaluate anaemia Basic metabolic panel Electrolytes Renal status

33. Cardiac biomarkers It is done when cause of dyspnoea is still unclear after standard evaluation This test will detect ongoing myocyte injury , which may be clinically silent

34. Bedside ultrasound Determine cause of dyspnoea e.g. tamponade Determine LV function and volume status RWMA Valvular abnormality Focused on 1. Signs of pulmonary congestion 2. Sign of volume overload 3. LV ejection fraction

35. Signs of pulmonary congestion Sonographic B-lines Dx – >2 B-lines in any sonographic windows along the anterior and posterior chest

36. Signs of volume overload IVC >2 cm diameter Collapsibility index <50% Indicates raised in central venous pressure

37. Management in ED

38. Disposition decision Lack of ED-based-risk stratification tool Mainly based on Physician judgement Physiologic risk assessment Assessments of barrier to successful outpatient High risk physiological marker 1. Renal dysfunction 3. Low serum sodium 2. Low BP 4. Increase natriuretic peptide / cardiac troponin

39. High risk features  admission to ward Patient required invasive monitoring / procedure  ICU Lower risk features  observation unit (12-24h)

40. References Tintinalli’s Emergency Medicine, 8 th edition Rosen’s Emergency Medicine, 8 th edition Harrison’s Principle of Internal Medicine, 19 th edition Thank you!