Acute heart failure Flashcards
What is heart failure?
Clinical syndrome caused by structural and/or functional cardiac disorder that impairs the ability of the heart to fill with or eject blood, resulting in
-> reduced cardiac output &/or
-> increased intra-cardiac pressure at rest or during stress
HF is a CLINICAL diagnosis!
Classification of Heart failure based on measurement of left ventricular ejection fraction
- HF with REDUCED EF (HFrRF): LVEF < 40%
- HF with MILDLY REDUCED EF: LVEF 40-49%
- HF with PRESERVED EF: LVEF >/= 50%
Symptoms of Left HF
- Pulmonary congestion -> pulmonary edema
- Breathless at rest
- Exertional dyspnea
- Reduced effort tolerance
- Paroxysmal nocturnal dyspnea
- Orthopnea
- Nocturnal cough, wheezing
- Frothy sputum - Cardiogenic shock (decrease CO will lead to increase SVR - squeezing vessels -> hypoperfusion)
- Dizziness
- Confusion
- Hypotension
- Tachycardia
- Cold peripheries
- AKI, Decreased urine output
- Acute mesenteric ischemic
- Lactic acidosis
Signs of HF
Vitals
- Hypertensive**
- Tachycardic
LHF:
- Wheezing
- Crepitations
LHF -> Severe pulmonary edema:
- Increased work of breathing
- Increase RR (tachypnic)
- Hypoxic (decrease SpO2)**
RHF
- Raised JVP
- S3 heart sound
- LL edema
- Abdominal distention (ascites)
- Hepatomegaly
Presentations of acute heart failure
- Acute decompensation of chronic left heart failure*
- patient already has pre-existing chronic heart failure - Acute cardiogenic pulmonary edema*
- due to acute left heart failure - Cardiogenic shock
- Hypertensive acute heart failure
- High cardiac output heart failure
- Massive vasodilation (sepsis, beri beri, thyrotoxicosis, severe anaemia) -> decrease SVR -> decrease BP -> increase CO to compensate but not enough to overcome vasodilatory effects - Isolated right heart failure
Common trigger for decompensation of chronic HF
Non-compliance to fluid or drug therapy
Common precipitant of new onset AHF
Ischaemia
Symptoms of Right HF
- Inability to fill RV -> increase central venous pressure -> fluid overloaded picture:
- Increase JVP
- Increase LL pitting edema
- Increase hepatic congestion -> hepatomegaly, liver failure
- Increase portal pressure -> ascites - Inability to eject blood -> RV dilates more -> septal shift from RV to LV) -> decrease LV filling -> decrease LV CO -> leads to systemic hypoperfusion -> cardiogenic shock (due to right MI)
Note: Right HF often occurs with left HF -> hence all the symptoms may be present
-
Precipitating causes of heart failure
Myocardial ischaemia or MI*
Non-compliance to fluid or drug therapy*
Dilated cardiomyopathy
Dysrhythmias
Valvular heart disease (aortic stenosis)
Myocarditis
Systemic infection
Systemic illness (severe HTN, anemia, thyrotoxicosis, heavy alcohol consumption)
Drugs: CCB, BB, NSAIDs, cocaine, amphetamines, excessive bronchodilators
Pregnancy
Pulmonary embolism
When diagnosis of AHF is UNCERTAIN, what test can be done in the ED?
Brain natriuretic peptide or NT-proBNP
BNP < 100pg/ml or NT-proBNP < 300pg/ml : rule out HF as a cause of dyspnea
*IF it is clear cut AHF, do not even need to do BNP
Age stratified cut-off levels for NT-proBNP as rule-in criteria for AHF
Age < 50 years: >450pg/ml
Age 50-75 years: >900pg/ml
Age >/= 75 years: >1800pg/ml
Non cardiac causes of raised NT-proBNP
- Cor pulmonale
- Pulmonary embolism
- Liver cirrhosis
- Renal failure
Investigations for ADHF
POCTs
- ECG TRO precipitating cause, ischemia
- ABG
Labs
- FBC TRO infection
- RP assess kidney function (raised creatinine -> AKI)
- Cardiac enzymes, troponin TRO MI
Imaging
- CXR TRO features of pulmonary edema, other causes of respiratory distress
Management of Acute decompensated HF
- Secure ABCs
- Manage in P1: vital signs, pulse oximetry, continuous ECG monitoring
- Position patient upright in a seated position to relieve work of breathing
- Supplemental high flow O2 via NRM
- Start NON-invasive ventilation (CPAP!!!) for respiratory distress / SpO2 < 92% despite 15L NRM
- Obtain IV access for POCTs, labs
- Imaging
- Initiate pharmacological management (refer to next card)
- Insert IDC for strict IO charting
- Fluid and salt restriction
- Disposition: Admit to GW or short stay observational unit
Discharge if no chest pain or comorbs + sx resolves:
- TCU cardiology
- SL GTN PRN
- Loop diuretics
- Fluid and salt restriction
