27th Annual Update in Emergency Medicine

Acute heart failure & all it's friends - managing the complicated CHF

patient in the ED February 24, 2014

Clare Atzema, MD MSc FRCPC Staff Physician, Sunnybrook Health Sciences Centre

Core Scientist, ICES Annals of Emergency Medicine Decision Editor

Disclosures •  No industry funding •  Funded by several Canadian federal

research agencies – Heart and Stroke Foundation of Canada – CIHR

Objectives 1)  To discuss the management of heart

failure in the setting of atrial fibrillation, in conjunction with an acute coronary syndrome, and secondary to pregnancy

2)  To review the recent evidence that is applicable to your HF patient: bolus vs drip furosemide, IABP in AMI with CHF, etc

Patient A Patient A: 70 y o!with worsening SOBOE in last few weeks •  Now ++SOB at rest •  ↑ Fatigue for a few weeks •  ? weight gain, + leg swelling •  Sleeping in a reclining chair

–  +PND, +orthopnea •  Denies chest pain, fever, cough

Patient A •  VS: hr 110, 164/101, RR 28, Sat 91% np, t36.9oC

•  Alert, sitting upright, 2-3 word sentences •  H&N: + Accessory muscle use, MMM, JVP 5 cm ASA •  Chest: Coarse crackles throughout •  CVS: No S3, + pitting edema to knees, warm extremities

Patient A •  Ddx:

•  Infectious / pneumonia •  Asthma / COPD •  ALS / neurodegenerative d/o •  Salicylate toxicity •  PE •  HF

Patient A •  Treatment

1.  Etiology? •  ACS •  Valvular disease •  HTN emergency •  Atrial fibrillation •  Cocaine •  Medication non-compliance or change •  Iatrogenic fluid overload •  Renal failure •  Hyperthyroidism, anemia

Patient A •  Treatment

–  (hr 110, 164/101, RR 28, Sat 91% np, t36.9oC) a)  Oxygen 100% by face mask b)  NPPV c)  Furosemide iv d)  Nitro spray e)  Nitro drip f)  ACE-I g)  Morphine IV

Patient A •  Treatment

a)  Oxygen 100% by face mask •  Strong recommendation if hypoxemic (CCS)

b)  Noninvasive positive pressure ventilation (NPPV) •  NPPV i need for intubation, improves dypsnea, hypercapnia,

heart rate, i hospital LOS, i ICU LOS –  RCTs, meta-analyses

?  Alert enough –  Continuous positive airway pressure (CPAP) –  Bilevel positive airway pressure (BiPAP)

»  Meta-analysis (23 RCTs) found no difference in mortality or need to intubate with BiPAP vs CPAP

Patient A •  Treatment

c)  Furosemide iv Æ  Fluid overloaded or not? •  Weight gain, leg swelling (peripheral edema), palpable liver

–  Peak diuresis at 30 minutes »  Initial effect: morphine-like venodilation

–  2.5X daily po dose, divided bid-tid –  DOSE trial (NEJM 2011, Felker et al)

»  n=308 »  Bolus vs infusion Æ no difference @ 72 hrs sx, Cr " »  High vs low dose bolus Æ better sx @ 72 hrs, no difference Cr " Θ  Enrolled within 24 hrs

•  “IV diuretics be given as first line therapy for patients with congestion” (Strong recommendation [CCS])

Patient A •  Treatment

d)  Nitroglycerin spray e)  Nitroglycerin drip

•  Vasodilator 1.  Venodilation 2.  Vasodilation ≥ 50 mcg/min –  For relief of dypsnea in SBP > 100 mg (Strong Recommendation [CCS])

•  Nitroprusside –  Vasodilation & venodilation –  Weak recommendation (CCS)

Patient A •  Treatment

– ACE Inhibitors & ARBs –  Not in the initial phase (CCS 2012 Guidelines)

»  Risk of hypotension when combined with aggressive diuretic Rx »  May worsen outcomes in setting of AMI

–  After stabilization

– Morphine •  Paucity of evidence •  Some suggests adverse effects

–  ADHERE, Emerg Med J 2008 (v large doses) –  3CPO trial, QJM 2010

Æ Use if you have a good reason, low doses

Patient B Patient B: 73 y o!with sudden onset SOB, pink sputum & heavy c.p. •  No orthopnea, no PND, no weight gain •  Hx HTN (no HF) •  Meds: Nifedipine •  VS: hr 110, BP 219/115, RR 20, Sat 98% on

100%, t 36.9oC •  Alert, short sentences, MMM •  + crackles/rales to mid lung fields •  No murmur, no S3, no pitting edema

Patient B •  HF secondary to HTN

–  Hypertensive emergency •  Treatment?

a)  Oxygen 100% by face mask b)  NPPV c)  Furosemide iv d)  Nitro Spray e)  Nitro Drip f)  Morphine iv

Patient B •  Treatment

–  Oxygen 100% by face mask; hold NPPV (98%) –  Furosemide IV

–  If fluid overloaded –  Wait for nitro response

–  Nitroglycerin (Spray, Drip) •  Venodilation & vasodilation

1.  Start: 10-20 mcg/min 2.  Titrate: Increase 10 mcg/min q 5-10 minutes 3.  Usual dosage: 50-200 mcg/min (max 500 mcg/min)

•  Nitroprusside? –  Weak recommendation (CCS)

–  LMNOP

Approaches to ED HF Mgt 1)  Fluid overloaded: diuresis

–  If not, emphasis is on nitroglycerin 2)  Initial BP

– High initial BP (SBP >140 mm Hg) •  Vasodilation >> Diuresis

– Normal initial BP (SBP 100-140 mm Hg) •  Diuresis > Vasodilation

– Often patients already on diuretics –  Look volume overloaded

Patient A: With Low BP •  VS: hr 117, BP 85/55, RR 28, 90% on 100%, t

36.9oC –  Awake but drowsy, cool extremities –  JVD, coarse crackles, moderate pitting edema

bilaterally

Patient A: With Low BP •  Treatment

1.  Inotropes a.  Dobutamine

–  β agonist (inotropic) & v/d properties –  Addresses poor contractility & peripheral vasocontriction

b.  Milrinone –  Use if on beta-blockers, as nothing else will work

c.  Dopamine –  Effect varies based on dose

»  5-10 ug/kg/min, β1 stim, increase CO via SV, some hr »  > 10ug/kg/min, α stim, arterial & venous v/c

Patient D •  Treatment

2.  Vasopressors (SBP 10 mcg/kg/min) b.  Phenylephrine c.  Norepinephrine

– Temporizing on way to PCI, IABP •  IABP-SHOCK II, NEJM Oct 2012 (n=600)

–  No difference 30 d mortality » Milder cases?

Patient C Patient C: 83 y o#from nursing home, SOB • Paramedics:

–  SOB x several days –  STEMI neg on ECG –  PMedhx

•  DM •  CABG •  ‘Empyema’

• 1 word answers, ++ accessory muscle use, sounds wet • Denies c.p., any pain • Can’t tell you if orthopnea, PND

Patient B •  VS: RR 32 HR 118 88% on 50% 130/90 36.7 •  Awake, alert, but looks tired •  H&E: JVP difficult to assess, MMdry but open mouth

" JVD most sensitive & specific sign of L sided filling pressures •  But 1/3 of patients L sided filling pressures won’t have it

•  Chest: Some crackles, poor a/e at bases, exp wheeze " “Cardiac asthma”

•  Up to 1/3 of elderly patients with acute HF •  Absence of rales does not r/o acute HF

•  CVS: HS soft, no pitting edema to legs or sacrum " S3 is rare

Patient C •  ECG: Narrow (110 ms) complex QRS with LAFB •  CXR: Mild pleural effusions, ?mild increased vascular markings

–  No hyperinflated lungs, small heart

Patient C •  VS: RR 32 HR 118 88% on 50% 130/90 36.7 •  Diagnosis?

1)  Acute HF 2)  COPD exacerbation 3)  Both?

Patient C •  VS: RR 32 HR 118 88% on 50% 130/90 36.7

–  BiPAP/CPAP: •  Indications

1.  COPD exacerbations 2.  Cardiogenic pulmonary edema 3.  Hypoxemic respiratory failure

–  Nitroglycerin: sprays, drip –  10 mcg/min, increased q5min by 10, to 30 mcg/min

–  Furosamide –  20 mg iv lasix –  Foley

–  Ventolin/Atrovent 5.0 / 0.5 neb –  Be ready to intubation

Patient C –  VS 99%, HR 110, 120/70, 22, afebrile

•  A/E improved (after nebs?), repeat nebs •  Family arrived – he had vx several times yesterday

–  ?aspiration •  Cr, trop normal. wbc 17.9

Patient C •  BNP

–  Cardiac neurohormone •  Secreted from the ventricles in response to ventricular volume

expansion, pressure overload, & resulting ↑ wall tension •  N-terminal pro-BNP (NT-proBNP) •  Also #: LVH, RF, ACS, atrial dysrhythmia, sepsis, lung ca

–  Clinically 80% accurate for HF –  McCullough et al, Circ 2002

•  n=1500 ED patients –  In determining correct diagnosis (CHF vs no CHF), adding BNP to

clinical judgment would # diagnostic accuracy from 74% to 81% –  In participants with intermediate (21% to 79%) probability of HF,

BNP correctly classified 74% of the cases

Patient C •  ACEP clinical policy (2007)

–  Level B recommendations •  “addition of a single BNP or NT-proBNP… can

improve the diagnostic accuracy compared to standard clinical judgment alone in ED patients”

–  BNP < 100 pg/dL or NT-proBNP < 300 pg/dL to rule out HF –  BNP > 500 pg/dL or NT-proBNP > 1000 pg/dL to rule in

•  Carpenter et al, 2012, JEM (BEEM) •  Top 5 RCTs: no difference in mort, LOS, $

Θ Not available for initial management

Patient C •  Differentiating HF from other etiologies of dyspnea

•  History 1.  PMedhx HF, MI 2.  PND 3.  Orthopnea 4.  SOBOE –  Weight gain –  Fatigue –  Noctiuria

•  Physical 1.  S3 (rare) 2.  JVD & HJR 3.  Rales/Crackles 4.  Edema

Patient C •  Tests

1.  CXR: –  Vascular re-distribution (15-18 cm H20) –  Interstitial edema: Kerley B lines, cuffing (18-25 cm H20) –  Alveolar edema: Pleural effusions, consolidation (25 cm H20 +)

»  70% HF pleural effusions bilateral »  If unilateral, R > L

Θ Small hrt & hyperinflation 2.  ECG:

–  Acute coronary syndrome –  Arrhythmias: afib, bradycardias, tachycardias –  Hypertrophy (AS) Θ Normal: r/o HF LR 0.6

•  High position of the diaphragm?

•  Increased distance of the stomach air bubble to the lung base: there is a large amount of pleural fluid on both sides

Patient C •  Treatment

–  HF AND Reactive Airways Disease •  Bad?

–  β-agonists in acute HF: Singer et al, Ann Emerg Med 2008 •  n=2,317 (21% of those with no COPD hx)

–  Mechanical Ventilation: OR 1.69 [95% CI 1.21-2.37] –  Inhospital mortality: OR 1.02 [95% CI 0.67-1.56]

–  Diuretics in COPD •  Probably not bad

–  Diuretics in pneumonia… •  Not great in sepsis

Patient D •  Patient D: 68 y o # with central c.p., to L

shoulder x several hours, SOB++ diaphoresis – HF in setting of ACS

•  By definition, high-risk ACS

Patient D •  Treatment?

1)  Treat ACS "  IF STEMI:

•  Cath lab if ≤ 90 minutes •  If > 90 minutes, fibrinolytics + early cath

Patient D •  Treatment?

!IF NSTEMI •  160 mg ASA •  Ticagrelor 180 mg (Clopidogrel) •  Fondaparinux 2.5 mg sq (Enox) •  Early angiography with revascularization intent

–  2009 focused update ACC/AHA HF guidelines i.  Hemodynamic instability ii.  Refractory or recurrent angina iii.  Signs/sx of HF iv.  Reduced LV fxn (LVEF < 40%)

Patient D •  Treatment?

2)  Treat HF •  Oxygen, +/- NPPV •  Nitroglycerin if SBP > 100

–  To relieve ischemic pain •  Diuretic

–  To tx pulmonary congestion if volume overload –  Caution

•  Morphine –  To relieve ischemic PAIN (add on to nitroglycerin)

Patient E •  67 y o with no PMedhx: 1 wk palpitations, presyncope •  VS: RR 30 HR 160s 93% on 100% 90/68 36.7 •  ECG: afib •  Exam: JVP normal, coarse crackles, no edema

" Guidelines: •  “Unstable afib” = hypotension, HF, etc Æ Cardiovert

Figure 1 A management strategy for patients with recent-onset AF/AFL.

Patient E •  Hemodynamically unstable requires cardioversion

Æ Heparin before cardioversion •  IV unfractionated heparin or subcutaneous heparin

–  IV has faster onset

– AP pad placement (sandwich) – Sedation?

•  Etomidate •  Ketamine •  Fentanyl

Patient E •  Or, attempt rate control first:

1)  Amiodarone 2)  Digoxin

•  No hypotension •  Slow but some effect within 30 minutes •  Load 0.25-0.5 mg iv, then 0.125 – 0.25 mg Q 2-6h

"  2011 ACCF/AHA/HRS Guidelines 1)  Diltiazam

•  Go v slow (2.5-5mg/2 min) •  Be ready with calcium •  Be ready with a vasopressor •  Be ready with defibrillator pads on

Patient F Patient E: 31 y o! 10 days post-partum, SOB x 2 days

–  Orthopnea & PND –  Leg swelling improving post-partum –  Central c.p. on exertion, not pleuritic

•  VS: hr 105, 183/105, RR 26, 91% RA, t 36.9oC –  Alert, full sentences but SOB –  MMM, JVD –  Rales / coarse crackles to mid lung field bilaterally –  No murmurs, moderate pitting edema

Patient F •  Ddx

–  PE –  Infection / pneumonia –  Amniotic fluid embolism –  AMI –  Peripartum cardiomyopathy

1.  Development of HF in last month of pregnancy or within 5 month of delivery

2.  Absence of other cause for HF 3.  Absence of heart disease prior to last month of pregnancy 4.  LV systolic dysfunction

Patient F •  Treatment

–  Diuretics •  Which kind?

–  Vasodilators •  Which kind?

–  Other

Patient F •  Treatment

–  Diuretics •  Loop diuretics preferred over thiazide or potassium sparing •  Potential risk to fetus if volume contraction & reduced placental perfusion

–  Vasodilators •  Hydralazine if mild •  Nitroglycerin if severe

–  Especially if associated with HTN

–  Other •  Digoxin

–  Breast-feeding – prolactin byproduct ?etiology

Take Home Points 1.  NPPV, NPPV, NPPV 2.  Decide if fluid overloaded: emphasis on vasodilator vs

diuretic 3.  HF vs COPD

–  BNP helpful if you have it –  Giving both Rx (gingerly) probably ok, your colleagues are doing it too

4.  HF & ACS needs revascularization –  Emphasis on vasodilator (nitro) over diuretic

5.  HF & Afib: amio/dig/?dilt vs cardiovert (iv hep) 6.  Peripartum cardiomyopathy: Loop diuretics, +/-

hydralazine or nitroglycerin –  Digoxin

Questions?