gives account on how heart fails

1. Acute heart failure
AIMS

2. • Common emergency presentation
• High mortality & morbidity in survivors
• Diagnosis not always straightforward
• Classic examination findings not sensitive
or specific
• Prompt recognition & stabilization of
patient- priority

3. • At 40 yrs age- lifetime risk: 21%
• Increasing prevalence
• In extremis + rapid deterioration
• Often respond very rapidly to treatment
• Very satisfying condition to treat
• Outlook poor despite initial clinical
improvement

4. Presentations
• Acute SOB, frothy sputum
• Collapse
• Shock
• Cardiac arrest

5. Acute pulmonary oedema
• SPOTTER
• Extreme SOB, puffing, unable to speak
• Profuse sweating, cold clammy extremities
• Tachycardia irregularity
• BP fall
• Basal creps
• Rarely wheeze predominant !!! ( asthma)

6. Collapse/ cardiac arrest
• Severe HF of any cause:- prone for
malignant arrythmias, PE 
• Present as collapse
• Very poor outcomes
• Survival to discharge ???

7. Aetiology
• CAD • Pulmonary embolism
• Hypertensive heart • Acute hepatic venous
disease thrombosis
• Fluid overload • IWMI+RVMI
• Acute valvular • Tamponade
regurgitations
• Arrythmias

8. CAD
• Most common cause
• Can be the 1st manifestation
• SOB >>> chest pain
• RVMI common in the setting of IWMI
• LV > 40% infarct size

9. HHD
• 1st presentation
• Accelerated hypertension
• Onset of HF lowers previously high BP
• Diastolic dysfunction is the basis
• Age

10. Pulmonary oedema
• Mechanisms
– pulm capillary pressure
– Capillary permeability
– Oncotic pressure

11. pulm capillary pressure
• LA pressure • LVEDP
– MV disease – Accelerated HBP
– Arrythmias – Pericardial constriction
– Aortic valve disease – Fluid overload
– Ischemia – Reno-vascular disease
– cardiomyopathy – High-output states
• Neurogenic
– IC bleed
• high altitude
– Cerebral oedema
– Post-ictal

12. • Capillary permeability • Oncotic pressure fall
– ARDS – Loss:- NS, Cirrhosis
– Production:- cirrhosis,
sepsis
– Dilution:- crystalloids

14. Investigations
• ECG
• Entirely normal # systolic HF
• ACS
• Arrythmias
• Serial ECG always essential

15. Cardiac enzymes
• Essential to r/o AMI even in the absence
of chest pain !!
• Ideally tropT / trop-I : at presentation &
12 hrs later
• BNP :- very useful in r/o AMI in a
breathless patient

16. CXR
• NEVER delay treatment pending CXR
• Portable CXR: cardiomegaly ??
• Peri-hilar bat’s wing shadowing diagnostic
• Look for pericardial effusion,
pneumothorax, consolidation

17. • ECHO:- preferably as early as possible
• To identify cause
• Assess LV function,
• Diastolic dysfunction
• Cardiac tamponade

18. STABILIZATION

19. Actions in order
• Propped up position
• IV Morphine
• 100% Oxygen
• IV Lasix
• Monitor ECG
• Venous access
• Ensure optimal BP
• Emergency blood samples
• ABG SpO2

20. Assess respiratory function
• Wheeze: interstitial oedema
• Aminophylline helpful- bolus
• Indications for further support
– Exhaustion
– Persistent low paO2 < 8kPa
– Rising pCO2
– Worsening acidosis

21. Hemodynamic status
• PCWP > 18 mmHg diagnostic
BP
< 100 > 100

22. Patient in shock
• Insert central line
• Renal dose Dopamine ( 2.5-5 µg/kg/mt)
• Urgent ECHO for any mechanical causes
• Increase Dopamine (but not > 10-20 ) 
raises pulm filling prssures
• Nor adrenaline preferred to high dose
dopamine
• Once Bp restored add vasodilators

23. SBP >100
• Further doses of IV lasix 60-80 mg q8h or
even 20-80 mg/hr infusion
• NTG infusion at 2-10 mg/hr titrate to keep
BP> 100
• Vasodilators : ACEI