Acute Heart Failure

Rapid onset of s/sx secondary to abnormal cardiac function (systolic/diastolic dysfx;

arrythmias; preload & afterload mismatch)

Causes of Acute heart failure

• Acute de novo heart failure:– Myocardial Infarction

– Uncontrolled Hypertension

– Myocarditis

• Acute decompensation of chronic heart failure

Distinct clinical condition

• Acute decompensated HF• Hypertensive AHF• Pulmonary edema• Cardiogenic shock• High output failure

Congestion at Rest

LowPerfusion

at Rest

No

No Yes

Yes

Warm & Dry Warm & Wet

Cold & WetCold & Dry

Signs/symptoms of congestion Orthopnea/PND JVD Ascites Edema Rales (rare in HF)

Possible evidence of low perfusion Narrow pulse pressure Sleepy/obtunded Low serum sodium

Cool extremities Hypotension with ACE inhibitor Renal dysfunction (one cause)

Stevenson LW. Eur J Heart Fail. 1999;1:251

Hemodynamic Profile Assessment

Yes

Stevenson LW. Eur J Heart Fail. 1999;1:251

No

Warm & DryPCWP normal

CI normal (compensated)

Cold & WetPCWP elevatedCI decreased

Cold & DryPCWP low/normal

CI decreased

VasodilatorsNitroprussideNitroglycerin

Inotropic DrugsDobutamine

MilrinoneCalcium Sensitizers

Normal SVR

High SVR

Congestion at Rest

LowPerfusion

at Rest

No

Yes

Warm & WetPCWP elevated

CI normal

Natriuretic PeptideNesiritide or

Patient Selection and Treatment

Treatment of Acute Heart Failure ‘treat the cause’

• AMI:– Reperfusion therapy, if possible i.e. thrombolytic

therapy or primary PTCA• Other complications

– surgery for ruptured VSD, severe mitral regurgitation– Arrhythmias – pacing for bradycardia; cardioversion

for AF, VT– Cardiac tamponade - drainage