Acute heart failure
Clinical Case Scenario
• 60 –year old patient, with medical history of arterial hypertension on
beta-blockers, heavy smoker, otherwise without comorbidities. In the
morning he felt sudden retrosternal pressure and pain with
propagation to the neck. Ambulance was called, 12-lead ecg was
obtained.
• Immediately applied 250 mg ASA i.v., 7500 IU UFH i.v.
and 4 ml (0,2 mg) of fentanyl i.v. for pain control.
Patient immediately referred to the cathlab.
During coronarography:
• 2 biphasic 200 J discharges applied, sinus rhythm with
palpable pulses restored. Afterwards consciousness
regained.
• After 2 days the patient was hemodynamically stable,
physiotherapy was started. Then he was transferred
to a ward. The day before discharge cough with mild
elevation of inflammatory markers was observed.
• According to a pulmonary consultation antibiotics were
suggested. Otherwise he was deemed capable of
discharge with subsequent visits at a local pulmonary
physician. Medication was prescribed:
• Anopyrin 100mg 0-1-0
Clopidogrel 75mg 1-0-0
Concor COR 5mg 1-0-0
Prestarium NEO 5mg 1/2-0-0
Torvacard 40mg 0-0-1
Metformin 500mg 0-0-1
Euphylin 200mg 1-0-0
Klacid 500mg á 12 hod for 14 days
Biopron 2-0-0
• 3 days after discharge progressive increase of dyspnea.
After another 2 days ambulance was called. At the scene
respirátory failure was apparent, intubation was
performed and the patient was transferred to the ICU.
• Ventilation : fully controlled, FiO2 0,9, Vt 450 ml, RR
25/min, I:E 1:1, PEEP 14, PIP 28
• Circulation : norepinephrine infusion at a rate of 1,5 mg/h
pH 7.27
pCO2 7.2
pO2 10.6
HCO3 24.3
BD- -3.3
sO2 0.934
Urea 8.8 mmol/l
Kreat. 122 umol/l
Na 140 mmol/l
K 6.5 mmol/l
Cl 107 mmol/l
Ca 2.08 mmol/l
Bi-celk. 6.9 umol/l
AMS 0.87 ukat/l
CB 60.8 g/l
Albumin 32.3 g/l
Glukóza 10.7 mmol/l
CRP 29.6 mg/l
• Empirical ATB treatment was started (cefotaxime,
claritromycine, oseltamivir), massive fluidothorax
evacuated bilaterally.
TProtein 24.6 g/l
TAlbumin 10.7 g/l
Several hours after admission:
• Amiodaron 300 mg with furher 900 mg/day applied,
eventually very slow stabilisation of circulation, mild
decrease of NE dose, very slight respiratory
improvement.
• Sputum negative for bacteria and viruses.
• Echocardiographically Mi reg. 2-3+, EF of LV 60%.
• According to TEE partial rupture of chordae tendineae
of posterior leaflet.
• Situation was reevaluated, acute heart failure with
pulmonary oedema due to acute mitral regurgitation
was established. The patient was referred to
cardiothoracic surgery for Mi valve replacement.
Heart failure – pathophysiology:
Pressure – volume curve
Cathegories of heart failure
• Acute x chronic
• Right-sided x left-sided, bilateral
• Backward x forward (with low cardiac output)
• Systolic x diastolic
Diagnosis and evaluation
• History
• ECG
• Chest X-ray
• Laboratory
• Cardiac enzymes
• Natriuretic peptides
• Echocardiography
Principles of therapy
• Elimination of the precipitating factor – revascularisation, arrhytmia
management, valve replacement…
• Decrease of myocardial O2 consumption – beta-blockers, antipyretics,
mech. ventilation
• Increase of O2 delivery to the tissues – oxygen, vasodilators,
optimalisation of preload, decrease of afterload
Frank – Starling curve
Acute congestive left-heart failure
• Pulmonary oedema
• Diastolic failure, hypertension crisis in many cases
• Oxygen
• Diuretic (furosemid 20 – 125 mg i.v.)
• Vasodilators (nitroglycerin sublingually, ISDN i.v.)
• Opioid (for example morphin 2-5 mg i.v.)
• NIV, invasive MV
Acute right-heart failure
• Acute increase of RV aterload
• Decreasing the afterload of RV (sildenafil, prostacycline, inhalation
NO)
• Increasing afterload of LV (vasopressor)
• Reducing preload of RV – diuretic
Cardiogenic shock
• Systolic pressure < 90 mm Hg for at least 30 minutes or need of
vasopressors
• Congestion in pulmonary circulation or elevated filling pressures of LV
• Signs of organ hypoperfusion:
- mental alteration
- oliguria
- serum lactate elevation
- capillary refill time above 2 seconds, cyanosis
Causes
• Acute myocardial infarction
• Acute mitral regurgitation
• Ventricular septum defect
• Free ventricular wall rupture
• Acute myokarditis
• Arrhythmias
Support therapy
• Fluids
• Vasopressors (noradrenaline x dopamine)
• Inotropes (dobutamine, PDE inhibitors, levosimendan)
• Organ support (CRRT…)
Mechanical circulatory support
Thanks for Your attention