Acute Heart Failure How to Mend a Broken Heart Ben Cooper 12/11/14
Chung P, Hermann L. Acute Decompensated Heart Failure: Formulating an Evidence Based Approach to Diagnosis and treatment. Mt. Sinai J of Med 2006;73(2): 506-27.
Chung P, Hermann L. Acute Decompensated Heart Failure: Formulating an Evidence Based Approach to Diagnosis and treatment. Mt. Sinai J of Med 2006;73(2): 506-27.
A QRS duration of >0.1, >0.11 or >0.12 s was highly specific (63, 90 and 98%) but less sensitive (84, 81 and 75%) for the prediction of LVSD
BNP NT pro-BNP
Age All < 50 50-70 > 70
Rule Out < 100+ < 300* < 300* < 1200₸
Sens/Spec 90%/74% 99%/85% 99%/85% 97%/55%
Rule In > 400+ >450* >900* >4500₸
Sens/Spec 81%/90% 93%/95% 91%/80% 64%/86%
*Januzzi, Jr. et al Am J Cardiol 2005 ₸Berdague et al. Am Heart J 2006 +Korenstein BMC Emerg Med 2007
Acute vs Chronic
High-Output vs Low-Output
Right vs Left Systolic
vs Diastolic
Dilated vs Hypertrophic vs
Restrictive
NT-proBNP 1574 Trop T < 0.01 BP 182/127
How much furosemide during initial management would you give this patient?
A. None
B. 20 mg IV
C. 40 mg IV
D. 60 mg IV
E. 80 mg IV
NTG + F MS + F NTG + F + MS NTG + MS
What infusion rate of nitroglycerin is appropriate for this patient?
A. Start at 5 mcg/min and titrate up
B. Start at 100 mcg/min and titrate down
C. Start at 100 mcg/min and titrate up
D. Give 1 SL NTG q 5 min
E. Apply 0.5 inch of nitro paste and cross fingers
Nitroglycerin is an oily liquid that may explode when subjected to heat, shock or flame. It is dangerously sensitive and dropping or bumping a container may cause it to explode.
– Wikipedia
↓ BiPap ↓ Intubations ↓ICU
• Preload/Afterload Reduction
• Captopril SL resulted in more rapid clinical improvement when added to standard regimen over placebo*
• Enalaprilat IV is well tolerated, and reduces PCWP**
• Should be started within 24 hours***
*Hamilton R. Acad Emerg Med 1996. **Annane D. Circulation 1996. ***Buccelletti F. Mt Sinai J of Med 2006.
Bolus 250 to 500 cc
Norepinephrine
Dobutamine
• NIPPV
• High dose NTG ggt for hypertensive
– Start @ 100 mcg/min
• NE and/or Dobutamine for hypotensive
• Just say no to furosemide