Acute Heart Failure
Chief Rounds, Sept. 14, 2009
Dr. Frederic L. Ginsberg
CJTMEustaquio, MD
PGY-3. Internal Medicine
Cooper University Hospital
I. Introduction
- Definition & Causes
- General Approach
II. Case 1: LS, 62M. cc: chest pain
- Discussion: Management
III. Case 2: DF, 60M. cc: syncope
- Discussion: Management
IV. Case 3: DK, 63F. cc: dyspnea
- Discussion: Management
V. Conclusion
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Introduction
Case 1
Case 2
Case 3
Conclusion
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I. INTRODUCTION
Potentially fatal
• Key concepts
o Determinants of cardiac output
o Heart failure
- dyspnea
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Introduction
Case 1
Case 2
Case 3
Conclusion
Congestive Heart Failure
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Introduction
Case 1
Case 2
Case 3
Conclusion
o Acute decompensated heart
failure
- Potentially fatal
- Cardiogenic pulmonary edema
- Flash pulmonary edema
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Introduction
Case 1
Case 2
Case 3
Conclusion
1.
General Approach
Suspect the diagnosis from
S/Sx
- HPI: cough, SOB, fatigue,
chest pain/ discomfort
- PE: RR, HR,  or BP
accessory muscles
wheezing
S3, S4 gallop
murmurs
 JVP
pedal edema
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Introduction
Case 1
Case 2
Case 3
Conclusion
2.
Consider precipitating factors
CARDIAC
MI & myocardial ischemia
Atrial fibrillation, other
arrhythmias
Progression of underlying
cardiac dysfunction
RV pacing with dyssynchrony
NON CARDIAC
- Severe HTN
- Renal failure
- Miscellaneous:
anemia
hypo/hyperthyroidism
toxins (cocaine, EtOH)
fever & infection
uncontrolled DM
- Medications
- PE
- Dietary indiscretion, medication
noncompliance, iatrogenic volume
overload
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Introduction
Case 1
Case 2
Case 3
Conclusion
3.
Tests
a. EKG
b. CXR
c. Lab data - CBC, basic chem 7, cardiac enzymes
BNP, NT-proBNP
Lipid profile, LFTs, TSH
d. Echo
e. Swan-Ganz catheter
f. Coronary Angiography
g. Others: EP studies
4.
Treat
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Introduction
Case 1
Case 2
Case 3
Conclusion
Case 1: LS, 62M. Cc: chest pain
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SSCP at rest
SOB, dyspnea on exertion
Diaphoresis
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HTN, DM, HPL
CAD s/p POBA 1991
Previous smoker
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Metoprolol, HCTZ, Glyburide,
Enalapril, Fish Oil, Lovastatin
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95.2F, 78, 164/83, 18, 99%RA
No JVD. CTA b/l.
RRR, good S1/S2, no m/r/g
No pedal edema.
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Introduction
Case 1
Case 2
Case 3
Conclusion
Recommendations for the
Evaluation of Patients with HF
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Introduction
Case 1
Case 2
Case 3
Conclusion
Case 1: LS, 62M. Cc: chest pain
EKG
T wave inversions I, V5, AVL. No ST elevation
CXR
No infiltrate
Labs
8.8 17.9 145
49.7
Echo
3/13/09: Severe global systolic dysfxn. EF 15-20%.
Gr I diastolic dysfxn.
SwanG
N/A
Cath
4/13/09: severe, multiple vessel CAD. RCA dominant. EF 15%.
Prox RCA 50%. Distal RCA 95%.
1st R posterolat segment 100% -- L to R collaterals
Prox LAD 100% - L to L collaterals
OM1 30%
Ramus intermedius 100% -- L to L collaterals
135
3.4
95 23 200
25 0.8
CK 276
MB 15.7
Trop 0.03
ProBNP 279
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Introduction
Case 1
Case 2
Case 3
Conclusion
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Diagnoses:
NSTEMI
Chronic Systolic Heart Failure 2 to severe CAD,
not in acute decompensation
HTN, DM, HPL
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Introduction
Case 1
Case 2
Case 3
Conclusion
Recommendations for the
Evaluation of Patients with HF
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Introduction
Case 1
Case 2
Case 3
Conclusion
Recommendations for the
Evaluation of Patients with HF
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Introduction
Case 1
Case 2
Case 3
Conclusion
The Stages of Heart Failure – NYHA Classification
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Introduction
Case 1
Case 2
Case 3
Conclusion
• Management: Medical + Evaluation for CABG
- Thallium viability study: viable myocardium except distal apex
- Discharged, then readmitted in 2 weeks for planned CABG x5:
LIMA to D2 and LAD.
SVG to D1. SVG to posterior descending artery & distal RCA.
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Introduction
Case 1
Case 2
Case 3
Conclusion
Treatment Recommendations for Patients at High Risk
of Developing Heart Failure (Stage A)
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Introduction
Case 1
Case 2
Case 3
Conclusion
Treatment Recommendations for Patients with
Asymptomatic LV Systolic Dysfunction (Stage B)
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Introduction
Case 1
Case 2
Case 3
Conclusion
Treatment Recommendations for
Symptomatic LV Systolic Dysfunction (Stage C)
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Introduction
Case 1
Case 2
Case 3
Conclusion
Treatment Recommendations for
Symptomatic LV Systolic Dysfunction (Stage C)
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Introduction
Case 1
Case 2
Case 3
Conclusion
Case 2: DF, 60M. Cc: Syncope
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Introduction
Case 1
Case 2
Case 3
Conclusion
Case 2: DF, 60M. Cc: Syncope
• OSH: light headedness & syncope
- (+) troponin
- atrial flutter
- severe hypotension – on Norepinephrine drip (Levophed)
- transferred to CUH for cardiac catheterization
• PMH:
- Hepatitis C
- s/p cholecystectomy
- ESRD on HD
- s/p patial colectomy 2 to polyps
- NHL s/p chemo 2007
- s/p hernia repair
- HTN
- s/p AV fistula
- ascites
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Introduction
Case 1
Case 2
Case 3
Conclusion
Case 2: DF, 60M. Cc: Syncope
• SH: current smoker – 43py
occasional EtOH
former IVDA, quit 1978
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PE: afebrile, 127/91, HR=98, RR=30
JVP=15 cm H20, 2+ carotid upstrokes
CTA B/L
RR, tachycardic, normal S1/S2
Hepatomegaly
No LE edema
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Introduction
Case 1
Case 2
Case 3
Conclusion
Case 2: DF, 60M. Cc: Syncope
EKG
Atrial flutter. Ventricular rate 105.
CXR
CT chest: no PE
Labs
5.4 13 154
49.7
Echo
7/08/09: Severe global systolic dysfxn. EF 10-15%.
Septal dyskinesis.
SwanG
N/A
Cath
7/08/09: normal coronaries.
133 91 63 166
5.0 23 9.5
CK 159
MB 3.3
Trop 2.8
ProBNP 2,754
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Introduction
Case 1
Case 2
Case 3
Conclusion
Case 2: DF, 60M. Cc: Syncope
• Diagnoses:
- Acute Decompensated Heart Failure
- Syncope.
- NICMP EF 10-15%.
- Paroxysmal atrial flutter.
- ESRD.
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Introduction
Case 1
Case 2
Case 3
Conclusion
Recommendations for the Management of
Acute Heart Failure
• Hospitalization
– Hypotension, worsening renal function or altered mentation
– Dyspnea at rest
– Arrhythmia
– ACS
• In-patient monitoring
• Hemodynamic monitoring
• Treatment goals
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Introduction
Case 1
Case 2
Case 3
Conclusion
Goals of Initial Management of ADHF
• Hemodynamic stabilization
• Support of oxygenation and ventilation
• Symptom relief
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Introduction
Case 1
Case 2
Case 3
Conclusion
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Treatment Goals for Patients with ADHF
Improve symptoms
Optimize volume status
Identify etiology
Identify precipitating factors
Optimize chronic oral therapy
Minimize side effects
Identify patients who might benefit from revascularization
Educate
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Introduction
Case 1
Case 2
Case 3
Conclusion
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Components of Therapy for ADHF
Na and fluid restriction
Diuretics
Oxygen and assisted ventilation
Morphine
Vasodilator – nitrate, nesiritide
Inotropic agents – dobutamine, milrinone
ACE inhibitors and ARBs
Beta-blockers
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Introduction
Case 1
Case 2
Case 3
Conclusion
Case 2: DF, 60M. Cc: Syncope
• Medications:
- ASA 325 mg daily
- ISMN ER 30 mg daily
- Carvedilol 25 mg BID
- Hydralazine 10 mg TID
- Valsartan 80 mg daily
- Temazepam 30 mg daily
- Gabapentin 300 mg BID
- Percocet prn
- Warfarin 2.5 mg daily
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Introduction
Case 1
Case 2
Case 3
Conclusion
Additional Considerations in ADHF
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Arrhythmia management
Mechanical cardiac assistance
Ultrafiltration
Vasopressin receptor antagonist
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Introduction
Case 1
Case 2
Case 3
Conclusion
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Case 2: DF, 60M. Cc: Syncope
EP studies, re atrial flutter.
TEE: no A-V clot
Atrial flutter ablation & ICD placement
Anticoagulation with Warfarin.
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Introduction
Case 1
Case 2
Case 3
Conclusion
Case 2: DF, 60M. Cc: Syncope
Why the decision for an ICD during this
admission vs. waiting 3 months of max
medical therapy as in Case 1?
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Introduction
Case 1
Case 2
Case 3
Conclusion
Recommendations for Management of
Concomitant Diseases in Patients with HF
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Introduction
Case 1
Case 2
Case 3
Conclusion
Case 2: DF, 60M. Cc: Syncope
What inotropes are recommended had he
still been hypotensive on transfer to CUH?
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Introduction
Case 1
Case 2
Case 3
Conclusion
Case 3: DK, 63F. Cc: dyspnea
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Introduction
Case 1
Case 2
Case 3
Conclusion
Case 3: DK, 63F. Cc: dyspnea
• Admitted under GYN in May & June 2009, cc: Nausea, vomiting
• Recent ovarian CA recurrence
• Developed acute, severe SOB at rest while on the floors
ICU transfer & BIPAP
• PMH:
- Ovarian CA 1997, s/p resection
1st recurrence, 2002. s/p chemo
2nd recurrence, May 2009.
- HTN – Tenormin 80 mg daily
- DM II – Metformin 500 mg BID, Pioglitazone 45mg daily
- sulfa allergy
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Introduction
Case 1
Case 2
Case 3
Conclusion
Case 3: DK, 63F. Cc: dyspnea
• FH: MI – father 75, brother 63
COPD – mother  64, sister
• SH: no smoking, no EtOH
• ROS: occasional palpitations, fatigue
• PE: BP 124/55, HR 98
no JVD
LLL crackles
normal S1/S2, no murmurs, (+) S3 gallop
no pedal edema
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Introduction
Case 1
Case 2
Case 3
Conclusion
Case 3: DK, 63F. Cc: dyspnea
EKG
NSR. T-wave inversions in I, AVL. ST depressions V4-V6
CXR
Pleural effusions B/L, L>R. Incg pulmonary edema b/l.
Labs
9.8
7.8 31.1
299
137 101 15 105
3.9 26 0.6
CK 187 -- 103
MB 20.1 –14.6
Trop 0.58 – 0.32
ProBNP
Echo
6/01/09: Severe global LV systolic dysfxn. EF 10%
RV systolic pressure 62 mm Hg. Mild MR, mod TR.
SwanG
N/A
Cath
6/1/09: single vessel CAD. 70% RCA stenosis.
Severe LV dysfunction out of proportion to single vessel CAD.
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Introduction
Case 1
Case 2
Case 3
Conclusion
Case 3: DK, 63F. Cc: dyspnea
• Diagnoses:
- Acute decompensated heart failure (with cardiogenic pulmonary
edema)
- Cardiomyopathy with severe LV dysfunction, unclear etiology
- Single vessel CAD – likely not the cause of CMP
- DM II
- HTN
- Ovarian CA
- HPL
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Introduction
Case 1
Case 2
Case 3
Conclusion
Case 3: DK, 63F. Cc: dyspnea
• Medical therapy for ADHF
• (IV Furosemide, Carvedilol, Lisinopril , ASA, statin. NPPV)
 symptomatic improvement
 back to GYN floors, discharged after 15 days
• HF meds discontinued on D/C – unclear reason
• Out-patient cardiology F/U within 1 week:
- SOB much improved, only mild SOB on climbing 1 flight of stairs
- back on Tenormin; not on beta blocker, ASA, ACE-I
- Add ASA, Carvedilol.
- Repeat echo in 2 weeks.
- F/U with GYN re Tx plan for ovarian CA recurrence.
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Introduction
Case 1
Case 2
Case 3
Conclusion
Case 3: DK, 63F. Cc: dyspnea
Takotsubo cardiomyopathy??
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Introduction
Case 1
Case 2
Case 3
Conclusion
Takotsubo cardiomyopathy
• Stress-induced CMP
• Apical ballooning syndrome
• Broken heart syndrome
• Transient LV systolic
dysfunction
• Mimics MI
• No significant CAD
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Introduction
Case 1
Case 2
Case 3
Conclusion
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Takotsubo Cardiomyopathy
Stress-induced
Acute medical illness / intense emotional stress / physical stress
Pathogenesis unknown
Catecholamine excess, coronary artery spasm, microvascular
dysfunction
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Introduction
Case 1
Case 2
Case 3
Conclusion
Takotsubo Cardiomyopathy
• Treatment and prognosis
– Supportive
– Hydration
– Standard HF meds
• ACE inhibitor
• Beta-blocker
• Diuretic
• Aspirin
– MR 0 – 8 %
– Recovery in 1 to 4 weeks
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Introduction
Case 1
Case 2
Case 3
Conclusion
Conclusion
• Heart failure and ACS
• ADHF in atrial flutter & ESRD
• Takotsubo CMP
• Evaluation guidelines in HF
• Management principles in ADHF
• Management of HF in general