Acute Heart Failure presentation by Dr Chikondi Malobe

Acute heart failure in adult

1. Acute Heart Failure
Dr. Nitta Chinyama Nayeja
FAMMED IV

2. OUTLINE
1.Disease overview
•Definition of Acute Heart Failure.
• Classification of acute heart failure
• Special general points
•Epidemiology
2. Triage findings and outcomes
3.Pertinent Hx related to Acute heart failure
4.Primary survey findings
5.Secondary survey findings
6.Investigations ( immediate and ongoing)
7.Differential diagnosis
8.Management(immediate and ongoing), definitive and supportive
9.Monitoring parameters, goals and actions, danger signs requiring consultant or escalation of care
10.Disposition-criteria and destination
11.Referral planning and communication
12.Home care instructions( and health promotion)

3. Definition of acute Heart Failure
•Acute Heart failure is a complex syndrome in which there is “
gradual or rapid change in heart failure signs and symptoms
resulting in the need for urgent therapy.

4. Causes of acute Heart Failure
•Myocardial causes
-MI, cardiomyopathy, myocarditis, dysrhythmias.
•Valvular causes
-Pulmonary valve stenosis, aortic stenosis, mitral stenosis and tricuspid
stenosis, mitral and/or aortic regurgitations.
•Restrictive causes
-cardiac tamponade, pericardial effusion, pericarditis.

5. New York Heart Classification
•Class I: physical activity is not limited, and does not cause significant fatigue,
heart palpitations, trouble breathing and chest pain.
•Class II: Physical activity is somewhat limited. Patient is comfortable at rest
but ordinary activities cause fatigue, heart palpitations, trouble breathing and
chest pain.
•Class III: Physical activity is markedly reduced.
•Class IV: All physical activity causes discomfort. Symptoms are also present
at rest. Minor physical activity makes symptoms worse.

6. Classification of Acute Heart Failure
•Hypertensive Vs. normotensive Vs. Hypotensive
•HFpEF (diastolic dysfunction) Vs. HFrEF (systolic
dysfunction)
•Right-sided vs. Left-sided
•High output Vs. low output
•Acute Vs. Acute on chronic

7. Acute Heart Failure classification.
Descriptions
Hypertensive SBP>140mmHg and DBP>90, elderly, have preserved EF,
low mortality
Hypotensive SBP<90mm Hg, 2-5% of cases, cardiogenic shock, in -
hospital mortality 15-30%
Normotensive SBP 90-140mmHg, 48-52% of cases ,usually decompensated
chronic HF with reduced EF, in-hospital mortality 8-10%

8. Acute Heart Failure Types
Systolic Vs. Diastolic

9. Acute Heart Failure classification

10. Acute Heart Failure classification

11. Special general points
•.Registries dealing with patients hospitalized with HF, mix patients with
AHF and CHF.
•Clinical trials provide a biased view of the real incidence of HFpEF in AHF
-Most of them have excluded patients with pEF
-Exclusion of patients with AF, severe renal failure or hypertension, infection,
COPD and ischemia.

12. Epidemiology in
Africa [1,2]
•In SSA, HF occurs at a young age
•Common causes of AHF include hypertensive heart disease ( 39.2%),
cardiomyopathy, (21.4%), rheumatic heart disease( 14.1%), HIV-associated
cardiomyopathy, turberculous pericardial disease, Corpulmonale and
peripartum cardiomyopathy.
•HF with systolic dysfunction is the commonest
•Hospital case fatality rates ranges 9%-12.5%.

13. Epidemiology cont..
USA & Europe
•In America and western world, acute heart failure occurs at an advanced age
( ≥ 60years of age).
•50% of the new admissions have LVEF ≤ 40%
•Estimated that by 2020, prevalence will increase by 46%
•Leading cause of AHF is cardiovascular related atherosclerosis
complications.
•Leading cause of hospitalization in the US and Europe.

14. Triage Findings and Outcomes
Presenting
complaints
Cardinal features are Dyspnea(exertionaldyspnea, PND, orthopnea) & fatigue.
Otherfeatures:peripheral edema, ascites, coughing up pink frothy sputum,
headache, insomnia, anorexia, nausea, vomiting, painful abdomen & fullness,
nocturia
Vital signs↑ RR ( >30), hypoxia ( SPO2<93%), hypotension ( SBP <90 )or hypertension ( SBP
>140mmHg) or normotensive ( SBP 90-140mmHg), extreme tachycardia (>120) or
bradycardia ( <60).
General clinical
picture
Alteredmental status or normal mental status ,cyanosis , respiratorydistress

15. Pertinent History related to Acute Heart
Failure
•Commonest presenting complaint is dyspnea ( exertional, PND, Orthopnea).
•Past medical hx: MI/angina; HTN, prior HF, connective tissue disorders, endocrine disorders,
postpartum cardiomyopathy, recent infection(viral, bacterial), contraceptive use.
•Medications: Antihypertensives (doses, frequency, duration, compliance issues )and disease control
pattern, steroid usage, cardiotoxic drugs.
•Family hx: Hypertension, diabetes mellitus, cardiovascular events & deaths, endocrine disorders,
obesity.
•Social hx: smoking, alcohol consumption, exercises, diet content.
•Psychological & impact of disease.

16. Review of systems
•Renal : oliguria, anuria, hematuria, dysuria.
•Endocrine: goiter, acromegaly signs, Cushing's syndrome signs,
pheochromocytoma signs, hyperglycemic episodes/ DM signs.
•Neuromuscular diseases: Duchene muscular dystrophy, myotonic dystrophy.
•Genitourinary: recent pregnancies
•Hematological: anemia

17. Primary Survey Findings
•A-patent or obstructed ( if altered level of consciousness)
•B-hypoxia ( SPO2< 94%), tachypnea (RR >20)
•C-hypotension (SBP<90) or hypertension (SBP>140), bradycardia( PR>60)
or tachycardia( PR >100), Or normotensive.
•D-reduced or normal level of consciousness
•E-hypothermic or normothermic

18. Secondary survey findings
General physical exam
-Mild to moderate HF : No distress except on lying flat
for more minutes.
-Severe heart failure : sitting-up, respiratory distress,
unable to finish sentence.
-Wasting , cyanosis, edema, jaundice.

19. Secondary survey Findings
Hands
•Hands: Finger clubbing, koilonychias, splinter
hemorrhages, cyanosis, nail fold infarcts, oslers nodes &
Jane way lesions.
•Wrist: radio-radio delay; collapsing pulse, irregular pulse.

20. Secondary survey findings
Head and Neck Exam
•Malar flush
•Central cyanosis
•Poor dentition
•Pulsating carotid pulse
•Raised JVP

21. Chest exam
•Precordial scars, visible sternal heave,
•Enlarged cardiac borders, apex beat shift, thrill, S3 gallop.
•Signs of pleural effusion ( stony dull percussion note, ↓ breath sounds)
•Bibasal crepitations and rales.
•Diffuse crepitations

22. Abdominal Exam and Extremities
•Distended abdomen
•Hepatomegaly which is tender and pulsatile.
•Ascites
•Sacral –edema
•Decreased bowel sounds
•Peripheral edema

23. Immediate Investigations
Other tests
•ECG
•Chest x-ray
•Echocardiogram
•Urinalysis
•Pregnancy test
Blood tests
•Random blood glucose
•Full blood count
•Urea and Creatinine
•Cardiac biomarkers
•Liver function tests
•Thyroid function tests
•HIV test

24. Chest x-ray findings (PA-upright)
•Pulmonary venous congestion
•Cardiomegaly (80%) or normal ( 20%)
•Interstitial edema
-Absence of these, does not rule out AHF.

26. Point of care USS
•Signs of pulmonary congestion
•Signs of volume overload
-IVC >2cm
-Collapsibility index <50% indicates raised central venous pressure .
•LV ejection fraction

28. Electrocardiogram
•Early recognition of
-Arrhythmias –atrial fibrillation
-Ischemic changes
-ventricular hypertrophy.

29. Cardiac Biomarkers
•Relevant when cause of dyspnea is unclear
•Markers of Cardiac necrosis
-Troponin I & T ( ≥0.01ng/ml, ≥ 0.04ng/ml )
-CK2-MB
•Markers of hemodynamic stress
-BNP: >20pmol/L, due to ventricle stretching
-ANP : due to atrial wall stretching.

30. Differential Diagnoses
Common diagnoses
•Massive pleural effusion
•Pericardial effusion/tamponade
•Pneumothorax
•Pneumonia/PCP
•Infectious myocarditis
•Acute myocardial infarction
Less common diagnoses
•Corpulmonale
•Pulmonary embolus
•Alcoholic cardiomyopathy
•Cardiac arrhythmia
•Beriberi

31. Acute Heart Failure:
Goals of Treatment
•Improve symptoms and Improve quality of life
•Reduce mortality
•Reduce re-hospitalization
•Do it safely

32. Immediate management goals
•Dyspnea relief
•Pulmonary edema reduction
•Improve oxygenation
•Restore adequate perfusion
•Precipitating factor management

33. Immediate supportive management
•A-Maintain airway patency, sitting upright.
•B-Oxygen supplement if 02 sats ≤ 93%
•C-Iv access, careful crystalloid boluses e.g. 250ccs if hypotension.
•D-IV 50% glucose ( if hypoglycemia & unconscious)

34. Oxygen supplement
•Indicated in severe hypoxaemia ( SaO2 <90%).
•In COPD, give oxygen with caution
-high O2 worsen hypercabia & cause respiratory depression. ( O2 may
cause hyperoxia-induced vasoconstriction in patients with systolic
dysfunction if given when O2 sats >90%
•CPAP & Non-invasive intermittent Positive Pressure Ventilation
-Improve dyspnea, HR, acidosis & hypercapnea.

35. Immediate definitive management
•IV loop diuretics
-Depends on renal function & how rapid should the excess fluid removed. -
-In cardio-renal syndrome high doses of diuretics are may be needed
•Nitroglycerine & morphine
-vasodilators
-Decrease pre-load → ↓ venous constriction & volume redistribution
-Decrease afterload →↓ arterial vasoconstriction

36. Ongoing management
Reduce mortality & Re-hospitalization
•Use of ACE-Inhibitors e.g. enalapril, lisinopril, captopril etc
•Use of minero-corticoid antagonists e.g. Spironolactone
•Beta blockers e.g. bisoprolol, carvedilol, metoprolol

38. Special considerations
•Dialysis if severe renal failure
•Blood transfusion if severe anemia HB<8g/dl.
•Coronary revascularization in acute STEMI
•Rate/rhythm control e.g. digoxin in atrial fibrillation
•Iv Thiamine 100mg in Beriberi
•Morphine Iv 5-10mg for dyspeania relief.

39. Heart Failure Device treatment
•Biventricular Pace maker helps improve cardiac output and improve
symptoms.
•Automatic implantable defribrillilator improves survival in patients with
EF<35%.

40. Disposition Criteria
•Lack of ED-based risk
stratification tool.
•Mainly based on physical judgment,
physiological risk assessment,
assessment of barrier to successful
outpatient.
•High risk physiological markers
-Renal dysfunction
-Low BP
-Low serum sodium
-↑ cardiac troponin and/or
natriuretic peptide

41. Monitoring Goals and Actions
•Improved perfusion ( MAP of 65-100, central arterial pressure of ):
-oxygen supplement, control high BP , correct hypotention
•Improved breathlessness:
-positioning, oxygen supplement, adjuvant morphine
•Attain good urine output:
-Cautions IV rehydration in shock, catheterization to monitor output
-

42. Monitoring parameters
•Oxygen sats & ↑ respiratory effort or oxygen requirement.
•Mental status
•Blood Pressure, MAP, Central Arterial pressure
•Respiratory rate
•Pulse rate.
•Urine Output

43. Danger signs requiring consultant or
escalation of care
•Clinical deterioration after optimal management
•Respiratory fatigue
•Cardiopulmonary arrest
•Shock
•Respiratory arrest
•Cardio-renal syndrome

44. Disposition to ICU
•Patient requiring invasive monitoring
•Patient requiring invasive procedures.

45. Disposition to HDU/Main Ward
-New onset AHF
-Signs of poor perfusion
-RR>30 and requiring NIV
-Comorbidities requiring urgent intervention
-Need for vasoactive drugs’ titration.
-Labs findings: Troponin, BUN >40mg/dl, creatinine >3mg/dl,Na+ <
135mEq/l , new ischemic changes on ECG.

46. Disposition to short stay ward
•Patients in the priority category
•Lower risk features →short stay (12-24 hrs.)

47. Referral planning and communication
•Prior communication to referral facility is paramount
-Prior discussion of why patient should be referred
-Establishing availability of services at the next facility
-ICU space availability
•Availability of Oxygen cylinders, reliable transport, staff to escort

48. Home care instructions &health promotion
•Medications: Types, doses, frequencies, importance of adherence, side effects
•Life style modifications: diet ( ↓ salt intake & restrict water intake), smoking,
alcohol, exercise, reduce obesity.
•Planned follow-up review in GMC (monthly) until significant improvement.

49. References
1.Bloomfield GS et al. Heart Failure in Sub-Saharan Africa .Current Cardiology Reviews, 2013, 9, 157-173 157.
2.Agbor V.N. et al .Heart failure in sub-Saharan Africa: A contemporaneous systematic review and meta-analysis. International
Journal of Cardiology 257 (2018) 207–215.
3.Queen Elizabeth Central Hospital AETC SOAP protocols. August 2011 Pages 30-31.
4.2017 ACC/AHA/HFSA focused update of the 2013 ACC/AHA Guideline for the management of Heart Failure.
5.Tintinali’s Emergency Medicine, 8
th
Edition
6.Rosen’s Emergency medicine, 8
th
edition
7.Harrison’s principle of internal medicine, 19
th
edition.