Approach to Cardiac Failure

Dr J Strange7th November 2013

Case• 24 year old male• Previously well• Developed shortness of breath, pyrexias over

a 5 day period• Observations– HR 130, regular– BP 87/45– O2 Sats 88% on room air

• ABG – pO2 11 pCO2 5.1 BE -12 lactate 6

• Hb 130g/L WCC 14 Platelets 180• Na 132 K 5.2 Urea 15 Creat 210 CRP 180• PT 16, elevated transaminases• Oliguric, peripheral oedema• Intubated and commenced vasopressors

TTE

• Globally reduced LV function• Estimated EF 15%• Transferred to Alfred– Noradrenaline @ .35 microgram/kg/min– MAP 68– CVP 21– PAOP 26– CI 1.7

INITIAL ASSESSMENT

Immediate assessment and resuscitation

• Resuscitation• Basic monitoring• History• Examination• Assessment of severity

How does CPAP work?

• Recruitment• Increased FRC• Improved pulmonary

compliance• Reduced transdiaphragmatic

pressure swings• Decreased work of

breathing• Reduction in ventricular

transmural pressure – reduced afterload

Circulation

• Therapies dependent on patho-physiological classification

• Maintenance of appropriate blood pressure and cardiac output essential

Key questions…

• Is the patient dyspnoeic?• De novo or on a background of cardiac

problems?• Symptoms of ACS?• Medications?

Examination

Congestion• JVP• Pulsus alternans• HJR• Parasternal lift• Displaced apex• Gallop• MR/TR murmur• Oedema• Ascites• Hepar

Low CO• Cool peripheries• Decreased LOC• Confusion• Hypotension• Low volume pulse• Inappropriate

tachycardia

Severity

• Who should be transferred to ICU?• NYHA classification

Framington Heart Study

• Life-time risk 20% for men and women• Hypertension is the biggest modifiable risk

factor• Median survival after development of 1.7

years in men and 3.2 years in women

Diagnostic category

• Pressure overload• Volume overload• Impaired ventricular filling• Myocardial diseases• Dysrhythmias

Pathophysiology

• Right and/or left• Forward/backward• Systolic and/or diastolic

Cardiogenic shock

• Oliguria• Clouded sensorium• Cool, mottled peripheries• SBP <90• HR >90• CI <2.2• PAOP >15

Forward failure

• Signs– reduced tissue perfusion

at rest with weakness– confusion and drowsiness– pallor with peripheral

cyanosis– cold clammy skin– low blood pressure– oliguria– culminating in the full

blown cardiogenic shock

• Causes– acute myocardial

infarction– acute myocarditis– acute valvular

dysfunction– pulmonary embolism– cardiac tamponade

Left heart backward failure

Right heart backward failure

• Right heart ischaemia• Syndrome of chronically elevated systemic

venous pressure

INVESTIGATIONS

ECG

• The negative predictive value of a normal ECG to exclude LV systolic dysfunction exceeds 90%

• Presence of anterior Q waves and LBBB in patients with IHD are good predictors of decreased EF

CXR

Troponin

• I or T• Increased in shock, renal failure, sepsis,

hypovolaemia• Values need to be interpreted in context

BNP

• Elevated in accordance with severity of heart failure

• High negative predictive values

ECHO

• Function• Mechanics

Other invasive monitors

• PAC• PiCCO• Oesophageal Doppler

MANAGEMENT

Reducing demand

• Reducing heart rate• Reducing afterload• 30 to 40% of cardiac output may be required

to support the work of breathing in a dyspnoeic patient

Increasing supply

• Vasodilator• Blood transfusion• Judicious inotropes

Non-specific therapy

• General care• Adequate oxygenation• Adequate heart rate• Optimise preload• Increasing cardiac output• Correct structural problems

SPECIFIC PROBLEMS

Forward acute heart failure – Cardiogenic shock

• Most commonly MI• 5 -10% of MI’s• 50 – 80% mortality• Reperfusion vital

IABP

VA - ECMO

VAD

Left heart backward failure

• ? ACS – reperfusion• Oxygen, Diuretics, Vasodilators, Morphine

Right heart backward failure

• Increased portal venous pressures• Care with volume replacement therapy• Increase in PVR can be devastating• Aim to reduce RV afterload without affecting

systemic blood pressure

Takotsubo’s cardiomyopathy

Filtration or pharmacology

• Ultrafiltration was inferior to pharmacology at 96h

• Higher creatinine level• No difference in weight loss• Higher serious adverse events

Cardiac re-synchronisation therapy

• ICD and CRT used for wide range of patients with heart rhythm disturbances

• Reduction in sudden death• Improved ventricular performance

Institution of long-term therapy

• Evidence for long-term benefit of:– ACEi– β blockers– Spironolactone

Case

• 30 yo man post arch and aortic valve replacement

• Marfan’s• Post-op– HR 86– BP 120/85– CVP 9

• 6h later– HR 125– BP 70/50– CVP 20– TR– Lactate 2 9– Cool to touch, chest clear

Tests

• ABG• LFT – elevated transaminases• Cardiac enzymes – elevated • CXR• ECG – RBBB, ST elevation II, III, aVF• ECHO – no effusion, severely dilated and

hypokinetic RV, hypertrophied LV, TR

Management

• ABCs• Further fluid may be detrimental• Drugs to increase RV contractility and

decrease RV afterload• Return to theatre• Consider PAC

• Death from any cause or hospitalization for worsening heart failure– 50.7% vs 49.5% (p=0.87)

• Stroke– 3.7% vs 2.7% (p=0.23)

• Thromboembolism– 13.5% vs 10.0% (p=0.01)

QUESTIONS?