Download - Acute and Chronic Heart Failure-KoAss
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HEART FAILURE
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Classification of HF
New Onset
Transient
Chronic
Recurrent or episodic
Persistent
Stable, worsening or
decompensated
First presentation
Acute or slow onset
ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure
European Heart Journal !""#
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$illip classification
Stage 1: No eart Failure
no clinical sign o! cardiac decompensation
Stage ": eart Failure
S# gallop, pulmonar$ %enous h$pertension, wet rales in the
lower hal! o! the lung !ield Stage #: Se%ere eart Failure
rales throughout the lung !ield
Stage &: Cardiogenic Shoc'
h$potension (S)P * + mmg-, peripheral %asoconstriction
(oliguria, c$anosis, sweating-
ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure
European Heart Journal !""#
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Aetiolog%
Coronar$ Arter$ .isease /al%ular eart .isease
$pertension
Cardiom$opathies (C0, .C0, RC0- .rugs ( bloc'ers, CC), Antiarrh$thmic-
To2ins (Alcohol, Cocaine, 0ercur$, Cobalt-
3ndocrine (.0, $po4h$perth$roid, Cushing-
Nutritional (.e!5 thiamine, selenium, obesit$-
6n!iltrati%e (Sarcoidosis, am$loidosis-
Others (Chagas, 6/, Peripartum, 3SR.-
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Contractilit$ Preload A!terload
Stro'e /olumeeart Rate
Cardiac
Output
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Preload: the %entricular wall tension at the end o!
diastole5
A!terload: the %entricular wall tension during contraction5 Contractilit$: propert$ o! heart muscle that accounts !or
changes in the strength o! contraction, independent o!
preload and a!terload5
Stro'e %olume: %olume o! blood e7ected !rom %entricleduring s$stole5 (S/ 8 3./ 9 3S/-
37ection !raction (3F- 8 S/ : 3./
Cardiac output: %olume o! blood e7ected !rom %entricle
per minute5 (CO 8 S/ 2 R-
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S%mptoms
&a'or s%mptoms &inor s%mptoms
.$spneaOrthopnea
Paro2$smal nocturnal d$spneaAn'le edemaPulmonar$ edemaFatigue32ercise intoleranceCache2ia
eight lossCough
NocturiaPalpitationsPeripheral c$anosis.epression
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(h%sical Findings
&a'or s%mptoms &inor s%mptoms
Tach$cardia3le%ated %enous pressure
Positi%e hepato7ugular re!lu2Pulmonar$ ralesTach$pneaThird heart soundepatomegal$An'le edema
AscitesPleural e!!usion
0itral regurgitationCardiomegal$
Splenomegal$$potensionPulsus alternans32tras$stoleAtrial !ibrillationeight loss
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)iagnostic Studies
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ECG
eart rate
Rh$thm
Conduction
6schaemic
6n!arction
$pertroph$
)))
Prolonged ;T inter%al
Perim$ocarditis
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Chest *+ra%
Should be per!orm as soon as possible
Cardiomegal$
Congestion
3!!usion 6n!iltrates
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La,orator% test
)lood count 3lectrol$te (Na, =-
>rea, creatinine
?lucoseAlbumin
epatic en@$mes
6NR Cardiac mar'ers
Natriuretic peptides ()NP NTBpro )NP-
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Arterial ,lood gas anal%sis
Assessment o! o2$genation (pO"-
Respirator$ !unction (pCO"-
AcidBbase balance (p-
Should be assessed in se%ere respirator$
distress
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Echocardiograph%
?eneral !indings:
Si@e and shape o! the %entricle
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Echocardiograph% -cont./
S$stolic d$s!unction:
Reduced
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Echocardiograph% -cont./
.iastolic d$s!unction:
Normal
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Condition associated 0ith a poor
prognosis in HF
Ad%anced age
6schaemic aetiolog$
Resuscitated sudden death
Poor compliance Renal d$s!unction
.iabetes
Anaemia
COP.
.epression
ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure
European Heart Journal !""#
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&anagement
Non Pharmacological: Sel! care management
S$mptom recognition
eight monitoring
.iet and nutrition Fluid inta'e (restriction o! 15EB"
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Pharmacological
Ob7ecti%e
Prognosis
0orbidit$
Pre%ention
Reduce mortalit$
Relie%e s$mptom and sign
6mpro%e Hualit$ o! li!e
3liminate oedema
Reduce !atigue and d$spnea
Reduce need hospitali@ation
Occurrence m$ocardial damage
Progression m$ocardial damage
Remodelling m$ocardium
Reoccurence s$mptom
ospitali@ation
ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure
European Heart Journal !""#
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1ormalAs%mptomaticL2 d%sfunctionEF 34"5
S%mptomatic CHF
16HA II
S%mptomatic CHF16HA + I2
S%mptomatic CHF16HA + III
Secondar$ pre%ention
0odi!ication o! ph$sical acti%it$
6notropes
Speciali@ed therap$
Transplant
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Rapid onset o! s$mptoms and signs secondar$ toabnormal cardiac !unction
Can present as new onset and without pre%iousl$'nown cardiac d$s!unction or A.F
O!ten li!e threatening and reHuires urgent treatment
AF ma$ present with one or se%eral clinical
conditions:15 orsening or .ecompensated Chronic eart Failure
"5 $pertensi%e eart Failure
#5 Pulmonar$ Oedema
&5 Cardiogenic Shoc'
E5 6solated Right F
J5 ACS and F
Acute Heart Failure
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Causes and precipitating factors
6schaemic heart disease Acute coronar$ s$ndrome
0echanical complications o! acute 06
R/ in!arction
/al%ular /al%e stenosis
/al%ular regurgitation
3ndocarditis
Aortic dissection
0$opathies Postpartum cardiom$opath$
Acute m$ocarditis
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$pertension4arrh$thmias
Circulator$ !ailure Septicaemia
Th$roto2icosis
Anaemia
Shunts
Tamponade
Pulmonar$ embolism
.ecompensation o! preBe2isting CF /olume o%erload
6n!ection
Cerebro%ascular insult Surger$
Renal d$s!unction
Asthma, COP.
.rug and alcohol abuse
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)iagnostic of Acute Heart Failure
)ased on presenting s$mptoms and clinical
!indings
istor$
Ph$sical e2amination
3C?
Chest KBra$
3chocardiograph$
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&onitoring
Non in%asi%e:
/ital Sign
O2$genation
>rine output
3C?
6n%asi%e:
Arterial line (haemod$namic unstable-
Central %enous lines
Pulmonar$ arter$ catheter
Coronar$ angiograph$
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Goals of treatment6mmediate (3.46C>46CC>-
6mpro%ed s$mptom Restore o2$genation and impro%e organ per!usion
length o! sta$
6ntermediate (hospital-
Stabili@e patient optimi@e treatment strateg$
6nitiate appropriate pharmacolog$ therap$
Consider de%ice therap$
0inimi@e hospital length o! sta$
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&anagement
6mmediate s$mptomatic treatment Patient distressed or in pain LL analgesia,
sedation
Pulmonar$ congestion LL diuretic, %asodilator Arterial o2$gen saturation * +E LL increase
FiO", consider CPAP, N6PP/, mechanical
%entilation
eart rate and rh$thm disorder LL pacing,
antiarrh$thmics, electro%ersion
ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure
European Heart Journal !""#
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78%gen
As earl$ as possible in h$po2aemic patients to achie%eO"saturation G +E (L + in COP.-5
Class 6, le%el C
N6/ with P33P as soon as possible in e%er$ patient with
acute cardiogenic pulmonar$ oedema Contraindication:
B unconscious patients
B an2iet$
B immediate need 3T intubation
B se%ere obstructi%e airwa$ disease
B se%ere Right F
ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure
European Heart Journal !""#
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&orphine
0orphine should be considered in the earl$ stage o!
se%ere AF with restlessness, d$spnoea, an2iet$, chest
pain5
Respiration should be monitored
Caution: h$potension, brad$cardia, ad%anced A/ bloc',
CO"retention
ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure
European Heart Journal !""#
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Loop diuretics
.iuretics are recommended in AF patients withcongestion and %olume o%erload5
Class 6, le%el )
Ad%erse e!!ect:
B h$po'alaemia, h$ponatraemiaB h$peruricaemia
B h$po%olaemia and deh$dration
B neurohormonal acti%ation
B ma$ increase h$potension !ollowing AC364AR) therap$
ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure
European Heart Journal !""#
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2asodilators
/asodilators are recommended at an earl$ stage !or AFwithout h$potension or serious obstructi%e %al%ular
disease5
Class 6, le%el )
Ad%erse e!!ect:
B headache (nitrat-
B tach$ph$la2is (nitrat-
B h$potension (NT? or nesiritide in!usion-
ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure
European Heart Journal !""#
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Inotropic agents
6notropic agents should be considered in low outputstates, in the presence o! h$poper!usion or congestion5
.obutamine (class 66a, le%el )-
.opamine (class 66b, le%el C-
0ilrinone and eno2imone (class 66b,le%el )-