DIAGNOSIS AND MANAGEMENT OF ACUTE HEART FAILURE

Transcription

1 DIAGNOSIS AND MANAGEMENT OF ACUTE HEART FAILURE Mefri Yanni, MD Bagian Kardiologi dan Kedokteran Vaskular RS.DR.M.Djamil Padang The 3rd Symcard Padang, Mei 2013

2 Outline Diagnosis Diagnosis Treatment options Approach Therapeutic to management goals Discharge planning Management options Discharge planning

3

4

5 LABS : Hb value (Anemia?) Infection marker Electrolytes Renal function Blood glucose Cardiac enzyme Blood gas analysis Throid function new onset HF

6 Classification of AHF ESC Guideline. For diagnosis and treatment of Acute and chronic HF. 2008

7 Assessment of Hemodynamic Profile

8 Therapeutic Goals in AHF Reduce fluid volume and filling pressures Improve patient hemodynamic status to relief symptoms and stabilize organ function Reduce systemic vascular resistance (SVR) cardiac output (CO) Reduce neurohormones

9

10 Pharmacologic Options

11 Dry Wet Diuretic Vasodilator Warm A B Warm/Dry Warm/Wet Cold Cold/Dry Fluid Challenge L Cold/Wet C Inotropic drugs

12 Acute Pulmonary Edema / Congestion Intravenous bolus of loop diuretic 2-2,5 times Hipoxemia Yes Oxygen No Severe anxiety/distress No Yes Measure systolic blood pressure Consider iv opiate SBP < 85 mmhg or shock SBP mmhg SBP > 110 mmhg Add non-vasodilating inotrope No additional therapy until response assessed Consider vasodilator ESC Guidelines of Acute and Chronic Heart Failure, 2012

13 Adequate response to treatment Yes No Reevaluation patient clinical status No No SBP < 85 mmhg SpO2 < 90% Urine output < 20 ml/hr Stop vasodilator Stop beta-blocker if hypoperfused Consider non-vasodilating inotropes or vasopressor Consider right heart catheterization Consider mechanical circulatory support No Yes Yes Yes Oxygen Consider NIV Consider ETT Consider Invasive ventilation Continue present treatment Bladder catheterization to confirm Increase dose of diuretic Consider low dose dopamine Consider right-heart catheterization Consider ultrafiltration ESC Guidelines of Acute and Chronic Heart Failure, 2012

14 Diuretics

15 Vasodilators Nitroprusside, Nitroglycerin, Nitrate family Work by cgmp mediated smooth muscle relaxation -> vasodilation Decrease myocardial work by afterload and preload reduction May cause hypotension May cause headache

16 Intravenous Vasodilator in AHF

17 Inotropic Agents Dobutamin, Dopamine, Milrinone Indication : Peripheral hypoperfusion (hypotension, decrease renal function) with or without congestion Improve cardiac output by directly increasing cardiac contractility Significant proarrhythmic effects May precipitate ischemia ESC, Acute Heart Failure, 2012

18 Dopamine Effect dose dependent In low dose (< 2 ug/kgbw/min) : vasodilatation occurs predominantly in renal, coronary, and cerebral vascular beds. At doses > 5 g/kgbw/min : will increase peripheral vascular resistance via adrenergic receptors ESC, Acute Heart Failure, 2012

19 Dobutamine Clinical action : Positive inotropic Positive chronotropic effects. Range dosage : 2 20 ug/kgbw/min In low dose < 5 ug/kgbw/min induce arterial vasodilatation In higher dose induce arterial vasoconstriction ESC, Acute Heart Failure, 2012

20 Phosphodiesterase Inhibitors Non beta adrenergic mechanism Inotropic Vasodilator Lusitropy (diastolic relaxation) Uses Low cardiac output states Downregulated/ desensitized CHF unresponsive to diuretic Increased SV decreased SVR ESC, Acute Heart Failure, 2012

21 Cardiogenic Shock A state of end organ hypoperfusion due to cardiac failure SBP < mmhg or MAP >30 mmhg Severe cardiac index (CI) < 1.8 L/m without support, or < L/m with support LVEDP > 18 mmhg, or RVEDP > mmhg Absent or low urine output (< 0.5 ml/kg/h) Evidence of organ hypoperfusion and pulmonary congestion ESC, Acute Heart Failure, 2012

22 Drugs that stimulates smooth muscle contraction of the capillaries & arteries Cause vasoconstriction & a consequent rise in blood pressure Vasopressor ESC, Acute Heart Failure, 2012

23 Drugs used to treat AHF ( Inotropes and vasopressor ) ESC, Acute Heart Failure, 2012

24 Morphine and its analogues Considered early in patient present with restlessness, dyspnoea, anxiety, chest pain Morphine induces : Venodilatation Mild arterial dilatation Reduce heart rate Caution : hypotension, bradycardia, CO2 retention. Dose : 2,5-5 mg IV bolus (rate 1 mg/min.) repeated if required

25 Monitoring patient with AHF MORE FREQUENTLY Symptoms Vital signs Saturation Urine output DAILY MONITORING Weight Intake and output Symptoms and exam Renal function and electrolytes ESC, Acute Heart Failure, 2012

26 Drug Initiation after stabilization ACE-I Beta blocker Mineralcorticoid receptor antagonist Digoxin Device therapy ESC, Acute Heart Failure, 2012

27 Outline ESC Guidelines Acute and Chronic Heart Failure 2012

28 Discharge Criteria Near optimal volume status achieved Near optimal oral therapy achieved Transition from iv to oral medications done No IV vasodilators or inotropes x 24 h Oral medication regimen stable x 24 h ESC, Acute Heart Failure, 2012

29 Discharge Instructions Salt and Fluid restriction diet Discharge medications Patient and family education of risk factors and precipitating factors Follow up clinic visit 3-5 days Weight monitoring Assessment of worsening heart failure Referral for further management ESC, Acute Heart Failure, 2012

30 Patient Education : What are the symptoms of heart failure? Think FACES... Fatigue Activities limited Chest congestion Edema or ankle swelling Shortness of breath

31 Conclusion Rapid assessment and treatment of AHF could decreased mortality and morbidity rate Management strategies including : Ensure oxygenation Reduce pain Reduce fluid volume Reduce preload and or afterload Increase cardiac output Identify and treat the cause of CHF ESC, Acute Heart Failure, 2012

32