T9 - Insuficiência Cardíaca Aguda

Question 1

Acute HF - Concept?

Answer 1

Rapid onset or worsening of symptoms and/or signs of HF.

It’s life-threatening and requires urgent therapy typically leading to urgent hospitalization.

Question 2

Delay in delivery of care for AHF?

Answer 2

Associates with increases in mortality, hospital length of stay, and treatment Costs.

Question 3

AHF in Europe?

Answer 3

The main cause of hospitalization above 65y

10% of the patients admitted in European wards

Question 4

HF in-hospital mortality?

Answer 4

12.5%

Question 5

Acute Exacerbations may contribute to the Progression of HF?

Answer 5

With each event, there may be myocardial injury that may contribute to progressive ventricular dysfunction and dilatation

Question 6

Acute HF - Economic burden?

Answer 6

HF consumes 1-2% of health resources, in developed countries, where it is the single most expensive disease

Question 7

Acute Heart Failure - Subtypes?

Answer 7

‘De novo’ HF - 37%

Descompensação de HR Crónica - 63%

Question 8

Acute Heart Failure - Clinical presentations?

Answer 8

• • HF Crónica Agudamente Descompensada
• • HR Aguda Hipertensiva
• • Edema Pulmonar
• • Choque cardiogénico
• • ACS and HF
• • Right HF

Question 9

Acute Heart Failure - Clinical/Hemodynamic Classification?

Answer 9

Warm-Dry = No Congestion , No Hypoperfusion (melhor prognóstico)
Warm-Wet =  Congestion , No Hypoperfusion
Cold-Dry = No Congestion , Hypoperfusion
Cold-Wet =  Congestion , Hypoperfusion (pior prgonóstico)

Question 10

Etiology AHF?

Answer 10

Coronary artery disease is the main etiology of AHF (60-70% of patients)

Other possible causes/ precipitating factors: 
• Hypertension
• Arrhythmia
• Valvular or Congenital heart disease
• Myocarditis/cardiomyopathy
• Decompensating factors of CHF
• Others

Question 11

Main primary cardiac causes?

Answer 11

• Acute Coronary Syndromes,
• Tachy or bradyarrhythmias
• Acute cardiac mechanical cause

Question 12

Main causes of decompensation of Chronic HF?

Answer 12

• Hypertensive emergency
• Acute pulmonary embolism
• Infection
• Non-adherence to treatment/diet
• Anemia
• other

Question 13

Pathophysiology?

Answer 13

Low CO (Hypoperfusion) and congestion
Neurohormonal and Inflammatory Activation

Question 14

Frequency of Low cardiac output?

Answer 14

Low CO leading to symptomatic hypotension and hypoperfusion, is relatively rare, present in CCU/ICU and associated with a particularly poor outcome.

Question 15

The clinical presentation of AHF?

Answer 15

Most patients have normal or high BP at presentation, and are admitted with congestion.

Question 16

Most frequent mechanisms of acute congestion?

Answer 16

 acute decompensations of chronic HF

 abrupt onset of dyspnoea due to significant HTN

Question 17

Congestion - Definition?

Answer 17

Clinical congestion
• Increased LVEDP
• Signs and symptoms of HF (dyspnoea, rales, and edema).
Hemodinamic congestion
• Increased LVEDP
• No signs and symptoms of HF

Often, haemodynamic congestion precedes clinical congestion by days or even weeks.

Question 18

Congestion (Increased LVEDP) in AHF?

Answer 18

Not always due to volume overload
• Volume overload due to
o RAAS activation
o Dietary sodium
o Cardio-renal Syndrome
• Vascular mechanisms without volume overload
o Arterial stiffness
o Volume redistribution

Question 19

Arterial compliance: HFrEF vs HFpEF?

Answer 19

Compliance arterial HFpEF < HFrEF

Question 20

Resting blood volume distribution?

Answer 20

25% in splanchnic vasculature.

Under SNS control splanchnic blood volume can be recruited in seconds to effective circulatory volume.

Question 21

Acute Hypertensive HF?

Answer 21

Common and with little volume overload
Patients improve rapidly with vasodilators with minimal diuresis.
There may be a disconnect between increased LVEDP and weight gain

Question 22

Melhor preditor de mortalidade em AHF?

Answer 22

Congestion - vicious cycle

Question 23

Acute HF - Therapy?

Answer 23

AHF Is life-threatening and requires urgent therapy

Question 24

Pre-hospital management - Within minutes of patient contact in the ambulance?

Answer 24

• Non-invasive Monitoring
o pulse oximetry, BP, respiratory rate, and continuous ECG
• Oxygen therapy
o If SpO2 < 90%
o Non-invasive ventilation, in patients with respiratory distress.
• Treatment initiated based on BP and/or the degree of congestion
o vasodilators and/or
o diuretics (i.e. furosemide)
• Rapid transfer to the nearest hospital
o preferably to a site with a cardiology department and/or CCU/ICU

Question 25

Early hospital management - On arrival in the ED/CCU/ICU?

Answer 25

Initial clinical examination, investigations and treatment should be started immediately and concomitantly.

Question 26

AHF therapeutic strategy - The 3 steps?

Answer 26

A. Clinical and hemodynamic stabilization
B. Diagnostic investigation (early)
C. Definitive treatment/correction of precipitating factor

Question 27

Early hospital management - Diagnosis of AHF?

Answer 27

Dyspnea is the most common symptom in AHF.

It is largely unspecific.

Question 28

Confirmation AHF as the cause of dyspnea - 1. History and physical Examination?

Answer 28

1. Prior HF was the most useful historical parameter
2. The most relevant symptoms and signs are:
   • Paroxysmal nocturnal dyspnea and orthopnea
   • Cardiomegaly, S3, and cardiac murmurs
   • Hepatojugular reflux, jugular venous distension, and peripheral edema

Question 29

Confirmation AHF as the cause of dyspnea - 2. Ancillary examination?

Answer 29

1. Chest X-Ray:
   • up to 20% of AHF patients have no congestion on their ED chest radiograph
2. ECG:
   • not useful for diagnosis of AHF
   • but may suggest a specific cause or precipitant
3. Natriuretic Peptides:
   • They are the most established AHF diagnostic biomarkers.
4. 2D-Echo:
   • valuable in determining the etiology of dyspnea
   • assessment of LV function
   • volume status of AHF
5. Lung sonography:
   • pulmonary ultrasound is accurate in detecting AHF with sensitivities of 86%–100% and specificities of 95%-98%

Question 30

Clinical and hemodynamic - Stabilization?

Answer 30

Class I indication
• Oxygen therapy (if SpO2 < 90%)
• Diuretics (if congestion with normal/low BP is present)
Class IIa/IIb indication
• Morphine (in APE if severe anxiety/distress is present)
• Vasodilators (SBP > 110mmHg is present)
• Inotropes / Vasopressors (if congestion with low-output and SBP <90 mmHg is present)

Question 31

Using the clinical/hemodynamic classification?

Answer 31

1. Presence of congestion?

2. Adequate peripheral perfusion?

Question 32

Correction of the causal/precipitating factor?

Answer 32

1. ACS
2. Taquiarritmia (ex: FA, Taquicardia ventricular)
3. Aumento excessivo da PA
4. Infeção (ex: pneumonia, endocardite infeciosa, sepsis)
5. Non-adherence with salt/fluid intake or medications
6. Bradiarritmia
7. Toxic substances
8. Drugs
9. Exacerbation of DPOC
10. Pulmonary embolism
11. Surgery
12. Increased sympathetic drive
13. Metabolic/hormonal derangements
14. Cerebrovascular insult
15. Acute mechanical cause