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ACUTE DECOMPENSATED HEART FAILURE 2014

ACUTE DECOMPENSATED HEART FAILURE 2014. BART COX, M.D., FACC DIRECTOR, ADVANCED HEART FAILURE PROGRAM ASSOCIATE PROFESSOR OF MEDICINE UNIVERSITY OF NEW MEXICO SCHOOL OF MEDICINE. DISCLOSURES. NONE. DEFINITIONS.

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ACUTE DECOMPENSATED HEART FAILURE 2014

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  1. ACUTE DECOMPENSATED HEART FAILURE 2014 BART COX, M.D., FACC DIRECTOR, ADVANCED HEART FAILURE PROGRAM ASSOCIATE PROFESSOR OF MEDICINE UNIVERSITY OF NEW MEXICO SCHOOL OF MEDICINE

  2. DISCLOSURES NONE

  3. DEFINITIONS • HEART FAILURE: a complex clinical syndrome resulting from any structural or functional impairment of ventricular ejection of filling. • ASYMPTOMATIC LEFT VENTRICULAR DYSFUNCTION: LVEF < 50% + NO history (ever) of HF signs and symptoms

  4. DEFINITIONS • ACUTE DECOMPENSATED HEART FAILURE: HF with a relatively rapid onset of signs and symptoms, resulting in hospitalization or an unplanned clinic or ED visit. • ACUTE HEART FAILURE SYNDROME: new-onset or gradual or rapidly worsening HF requiring urgent therapy

  5. DEFINITIONS • HEART FAILURE WITH REDUCED EJECTION FRACTION (HFrEF): signs/sx of HF + LVEF <40% • HEART FAILURE WITH PRESERVED EJECTION FRACTION (HFpEF): signs/sx of HF + LVEF >50% • HEART FAILURE WITH PRESERVED EJECTION FRACTION, BORDERLINE (HFpEF, borderline): signs/sx of HF + LVEF 41-49% • HEART FAILURE WITH PRESERVED EJECTION FRACTION, IMPROVED (HFpEF, improved): signs/sx of HF +LVEF was < 40% now is > 40%

  6. EPIDEMIOLOGY • PREVALENCE: 5.1 million in US • INCIDENCE: 650,000 new cases/year • HOSPITALIZATION: 1 million/year • Rehospitalization Rate 30 days: 25% • Rehospitalization Rate 6 month: 50% • MORTALITY: • In hospital mortality: 4% • 1 year mortality: nearly 30% • 5 year mortality: 50% • COST: $37-39 billion/year in US

  7. 10 MINUTES OF BAD MEMORIES

  8. FILLING PRESSURES • LEFT VENTRICULAR FILLING PRESSURE: THE PRESSURE IN THE LV CAVITY AT THE END OF DIASTOLE • LV END DIASTOLIC PRESSURE (LVEDP) • MEAN LA PRESSURE • PCWP • RIGHT VENTRICULAR FILLING PRESURE: THE PRESSURE IN THE RV CAVITY AT THE END OF DIASTOLE • RV END DIASTOLIC PRESSURE (RVEDP) • MEAN RIGHT ATRIAL PRESSURE • CVP

  9. LEFT VENTRICULAR FILLING PRESSURE

  10. CONGESTION AND FILLING PRESSURES • SYMPTOMATIC CONGESTION IS DUE TO INCREASED FILLING PRESSURES • ELEVATED LEFT VENTRICULAR FILLNG PRESSURES =SIGNS AND SX OF PULMONARY CONGESTION APPEAR • ELEVATED RIGHT VENTRICULAR FILLING PRESSURES = SIGNS AND SX OF SYSTEMIC CONGESTION APPEAR

  11. TO RELIEVE CONGESTION, LOWER FILLNG PRESSURES!!!

  12. 2 TYPES OF CONGESTION • PULMONARY CONGESTION • DUE TO ELEVATED LEFT HEART FILLING PRESSURES • SYSTEMIC CONGESTION • DUE TO ELEVATED RIGHT HEART FILLING PRESSURES

  13. SYMPtoMS OF PULMONARY CONGESTION • DYSPNEA • ORTHOPNEA • PND • SUPINE COUGH

  14. SYMPTOMS OF SYSTEMIC CONGESTION • EDEMA • ABOMINAL OR HEPATIC SWELLINGAND DISCOMFORT • ANOREXIA • EARLY SATIETY

  15. SIGNS OF PULMONARY CONGESTION • RALES • WHEEZING • PLEURAL EFFUSION • HYPOXEMIA • LEFT-SIDED S3 • WORSENING MITRAL REGURGITATION

  16. SIGNS OF SYSTEMIC CONGESTION • ELEVATED JVP • ABDOMINOJUGULAR REFLUX • RIGHT-SIDED S3 • WORSENING TRICUSPID REGURGITATION • HEPATIC ENLARGEMENT/ TENDERNESS • ASCITES • EDEMA

  17. PERFUSION= CARDIAC INDEX • NORMAL PERFUSION= NORMAL CARDIAC INDEX • DIMINISHED PERFUSION = LOW CARDIAC INDEX

  18. CARDIAC OUTPUT • CARDIAC OUPUT (CO) = HR X STROKE VOLUME • 3 PARAMETERS OF STROKE VOLUME: • PRELOAD (LVEDP OR RVEDP) • CONTRACTILITY • AFTERLOAD (The arterial pressure against which the ventricle must contract; systemic vascular resistance, aortic impedance)

  19. NORMAL VALUES • NORMAL CO=5 L/MIN • NORMAL CI=3 L/MIN/SQ. METERS

  20. TO IMPROVE PERFUSION,INCREASE CARDIAC OUTPUT • OPTIMIZE HEART RATE /RHYTHM • OPTIMIZE FILLING PRESSURE • INCREASE CONTRACTILITY • DECREASE AFTERLOAD

  21. THE 4 HEMODYNAMIC PROFILES

  22. INITIAL CLINCIAL ASSESSMENT • FIRST HOSPITALIZATION PRIORITY: ASSESS LEVEL OF HEMODYNAMIC COMPROMISE • PERFUSION (CARDIAC INDEX) • CONGESTION (PCWP AND RA PRESSURE)

  23. RECOGNIZING THE FOUR HEMODYNAMIC PROFILES • CONGESTION = WET • NO CONGESTION=DRY • NORMAL PERFUSION= WARM • DIMINISHED PERFUSION=COLD

  24. PROFILES AND HEMODYNAMICS • DRY= PCWP <18 AND RA < 8 • WET = PCWP >18 OR RA > 8 • WARM= CI > 2.2 • COLD= CI < 2.2

  25. RECOGNIZING THE 4 HEMODYNAMIC PROFILES • 2 HEMODYNAMIC COMPONENTS OF DECOMPENSATED HEART FAILURE: • ELEVATED FILLING PRESSURES • REDUCED CARDIAC OUTPUT (RARE) • THESE 2 COMPONENTS MAY NOT OCCUR TOGETHER

  26. RECOGNIZING THE 4 HEMODYNAMIC PROFILES • IN THE MAJORITY OF PATIENTS, FILLING PRESSURES HAVE BEEN INCREASING FOR AT LEAST 2 WEEKS • IT’S FAR EASIER TO ACCURATELY JUDGE FILLING PRESSURE THAN PERFUSION

  27. 2 MINUTE ASSESSMENT AND 4 HEMODYNAMIC PROFILES

  28. PRINCIPLES OF THERAPY: FOCUS ON CONGESTION / FILLING PRESSURES IN WET PATIENTS • RELIEVE CONGESTION BY REDUCING FILLING PRESSURES • ABSENT CRITICAL ORGAN/RENAL/SYSTEMIC HYPOPERFUSION THAT LIMITS FILLING PRESSURE REDUCTION, IMPROVING CARDIAC OUTPUT DOES NOT WORK!!!

  29. PRINCIPLES OF THERAPY: THE OPTIMAL FILLING PRESSURE • WITH LOW EF, OPTIMAL PCWP < 15-16 • LOWERING FILLING PRESSURES -> IMPROVED STROKE VOLUME • ELEVATED FILLING PRESSURES: • RESPONSIBLE FOR SX OF CONGESTION • ACTIVATE NEUROHORMONES (RAS, SNS) • INCREASE VALVULAR REGURGITATION • RESPONSIBLE FOR PULMONARY HYPERTENSION • CAUSE RIGHT VENTRICULAR DYSFUNCTION • CAUSE ABNORMAL LV FILLING PATTERNS

  30. FILLING PRESSURES AND STROKE VOLUME

  31. STROKE VOLUME IMPROVED BY DECREASING MR

  32. PROFILE A: WARM AND DRY

  33. PROFILE B: WARM AND WET

  34. PROFILE B: WET AND WARM • MOST PATIENTS PRESENTING WITH ADHF ARE PROFILE B • GOAL OF TX: SX IMPROVEMENT BY REDUCTION IN FILLING PRESSURES • ELEVATED FILLING PRESSURES ARE DUE TO: • INCREASED INTRAVASCULAR VOLUME • INCREASED SVR • DECREASED VENTRICULAR COMPLIANCE • FOR MAJORITY, IV DIURETIC TX IS THE MAIN INTERVENTION • MAY REQUIRE ADDITION OF METOLAZONE OR IV CHLORTHIAZIDE

  35. PROFILE B: ROLE FOR ADJUNCTIVE AGENTS • USE OF ADJUNCTIVE THERAPIES BEYOND DIURETICS HAS NOT BEEN DEMONSTRATED TO IMPROVE OUTCOMES IN HOSPITALIZED ADFH PATIENTS IN PROFILE B • INOTROPES: ISCHEMIA, ARRHYTHMIAS, POSSIBLY DEATH • NTG: NEUTRAL OUTCOMES • NESIRITIDE: EXPENSIVE PLACEBO • ENDOTHELIN ANTAGONIST: NO IMPROVEMENT • VASOPRESSIN ANTAGONISTS: NEGATIVE FLUID BALANCE NOT SUSTAINED LONG-TERM

  36. PROFILE B: VERY HIGH OR VERY LOW SYSTEMIC VASCULAR RESISTANCE(SVR) • VERY HIGH SVR > 2000 dyne/sec/cm-5 • RECOGNITION OF HIGH SVR: • HIGH BP • VERY NARROW PULSE PRESSURE • PA CATHETER MEASUREMENT • VERY LOW SVR (WITHOUT MEDS): LOW BP + REASONABLE PULSE PRESSURE + WARM EXTREMITIES

  37. PROFILE C: COLD AND WET

  38. PROFILE C: WET AND COLD • <3% OF PATIENTS PRESENT WITH CARDIOGENIC SHOCK • WET=CONGESTION • COLD=INADEQUATE PERFUSION • TX: MAY NEED TO WARM THEM UP BEFORE DRYING THEM OUT • DIURESIS WILL IMPROVE CARDIAC OUTPUT • IN MANY CASES, DIURESIS IS NOT POSSIBLE IF RENAL PERFUSION SEVERLY COMPROMISED

  39. PROFILE C: IV VASODILATORS OR INOTROPES? • CHOICE OF THERAPY DEPENDS ON SYSTEMIC VASCULAR RESISTANCE • IF SVR SIGNIFICANTLY ELEVATED: VASODILATOR • IF SVR NORMAL-LOW: INOTROPE • IF INOTROPES USED, KEEP THE DOSE AS LOW AS POSSIBLE

  40. PROFILE L: COLD AND DRY

  41. PROFILE L: DRY AND COLD • EXTEMELY RARE PRESENTATION • REQUIRE PA CATHETER PLACEMENT TO EVALUATE FILLING PRESSURES • IF PCWP<12 OR RA PRESSURE <8: PO FLUID REPLACEMENT + DC DIURETICS • IF PCWP>16: PROFILE C • IF PCWP 12-16 + NORMAL RA PRESSURE: LIMITED OPTIONS • INOTROPES AND VASODILATORS ONLY TEMPORARY FIX; • MCS/ TRANSPLANT • BETA BLOCKERS MAY LEAD TO LATER IMPROVEMENT IN LV FUNCTION

  42. 2013 ACCF/AHA HF GUIDELINES (CLASS I) : PRECIPITATING FACTORS • ACS precipitating acute HF decompensation should be promptly identified by ECG and serum biomarkers, including cardiac troponin testing, and treated optimally as appropriate to the overall condition and prognosis of the patient. • Common precipitating factors for acute HF should be considered during initial evaluation, as recognition of these conditions is critical to guide appropriate therapy.

  43. PRECIPITANTS OF ADHF • Myocardial Ischemia or Infarction • Hypertension, Hypoxia, High Output HF • Endocrine (DM, hypo-or- hyperthyroidism) • Arrhythmia (especially a fib), Anemia • Reduction in therapy, Renal disease • Too much Na+ and fluid, Too little medication • Second Heart Disease: (e.g., aortic dissection, endocarditis, acute MI)

  44. PRECIPITANTS OF ADHF • Drugs, Doc, Depressants • Infection (e.g., pneumonia, viral illness) • Embolism (PE)

  45. ADMISSION ORDERS • Na restriction is 2-3 grams/daily • Fluid restriction is 2 liters/daily. • Labs: NTproBNP, CBC with differential, chem 7, TSH, UA, uric acid, LFT, FLP, Mg, Ca, Phos, troponin • IV loop diuretic is either continuous infusion or intermittent bolus scheduled BID or TID • Daily chem 7 and Mg while receiving IV diuretics or uptitrating meds • Daily weights on their HOME scale • Daily orthostatic vitals while receiving IV diuretics or uptitrating meds

  46. ADMISSION ORDERS • Chest Xray: PA and Lateral- NOT Portable!!! • ECG: look at rhythm, evidence of ACS, and, if HFrEF, look at the QRS duration • IF CRT-D, ask for interrogation. Has biventricular pacing been > 95%? • Has ischemia evaluation ever been performed? • Therapy will depend on hemodynamic profile • If on digoxin, obtain trough dig level and ensure its between 0.5-0.9

  47. ADMISSION ORDERS • Activate the HF power plan • Activate the HF power plan • Activate the HF power plan • Activate the HF power plan • Activate the HF power plan • Activate the HF power plan • Activate the HF power plan • Activate the HF power plan

  48. HEART FAILURE WITH PRESERVED EJECTION FRACTION • Signs/symptoms of HF + LVEF > 50% (perhaps > 41%) • Pathophysiology: • Systolic (especially with exercise) and Diastolic Dysfunction • Chronotropic Incompetence • Left Atrial Dilation-> AF • Combined Ventricular-Arterial Stiffening • Prognosis: Mortality about = to HFrEF, but HFpEF patients die of non CV causes • Prevalence: About 50% of HF is HFpEF

  49. HFpEF • Female:male = 2:1 • More commonly associated with age, hypertension, anemia, AF, obesity, DM • Diagnosis of exclusion: Must rule out both CV and non-CV diseases that masquerade as HFpEF • Signs/Sx of HF + preserved LVEF + all other diseases excluded= HFpEF • Gold standard way to diagnose HFpEF: exercise in the cath lab with PA catheter in place: • Normal hemodynamics at rest, SIGNIFICANTLY elevated filling pressures with exercise

  50. HFpEF: DIFFERENTIAL DIAGNOSIS: CV DISEASES • Constrictive Pericarditis • CAD • Hypertrophic Cardiomyopathy • Infiltrarive or Restrictive Cardiomyopathy • RV myopathy • Valvular Heart Disease • High Output HF • PAH • PE

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