ACUTE HEART FAILURE in the ED. Pr. Samir Nouira Emergency Department Fattouma Bourguiba University Hospital Monastir Tunisia

Transcription

1 ACUTE HEART FAILURE in the ED Pr. Samir Nouira Emergency Department Fattouma Bourguiba University Hospital Monastir Tunisia

2 ACUTE HEART FAILURE 80%

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4 Acute Heart Failure Syndrome Sensitivity Specificity Sam L et al. Crit Pathways in Cardiol 2015 Medical history Heart failure Myocardial infarction Coronary artery disease Hypertension Symptoms Paroxysmal nocturnal dyspnea Orthopnea Dyspnea on exertion Physical examination Third heart sound Jugular venous distension Rales Any murmur Lower extremity edema Wheezing Chest radiograph Pulmonary venous congestion Interstitial edema Alveolar edema Cardiomegaly Pleural effusion 12-Lead electrocardiogram Atrial fibrillation New T-wave changes Any abnormal finding

5 How to reduce diagnostic inaccuracy? BNP of course but Multiple biomarker diagnostic strategy perhaps!

6 USE OF SCORES Predictor Point value Elevated NT-proBNP* 4 Interstitial edema on C XR Orthopnea 2 Lack of fever 2 Curruent loop diuretic use Age >75 y 1 Rales on lung exam 1 Lack of cough Aron L Am Heart J 2006

7 How to reduce diagnostic inaccuracy? Use of New noninvasive tests?

8 LUS and IVC and collapsibility Poor sensitivity Excellent specificity è can t rule out AHF

9 Thoracic Fluid Content Garcia Chest 2013

10 Goals of Acute Management q Rapidly improve symptoms while preserving and organ fuction. q Determine precipitating factors. q Restore function to pre-morbid levels and optimize oral chronic therapy. q Educate patient and family. ü Reduce the risk of rehospitalization and death. ü Control costs.

11 Clinical classifications Tissue perfusion Dry and Warm Dry and Cold Wet and Warm Wet and Cold Pulmonary congestion

12 Class I, C Rapidly improve symptoms Respiratory assistance Oxygen Improves oxygen delivery and tissue perfusion Goal >90% Consider CPAP or NIV Endotracheal intubation as last resort

13 Air + O 2 PEP P + P + AI VNI CPAPvs VNI CPAP

14 Clinical classification Tissue perfusion dry and warm dry and cold PA PA nle wet and cold Pulmonary congestion

15 Hemodynamic categorization of ED patients with Acute Heart Failure Syndromes

16 qiv loop diuretics Institute early in the ER Diuresis Dose should equal or exceed PO dose For ineffective diuresis : üincrease dose/frequency üadd second diuretic (aldactone, chlorothiazide ) ürestore volume depletion (renal function?) q If all diuretic strategies are unsuccessful: Ultrafiltration is reasonable (class 2b) Low dose dopamine (class 2b) CONGESTION SIGNS +++

17 IV Vasodilators: Overview HYPERTENSION qclass IIB recommendation Hypertensive patients Pulmonary congestion not responsive to initial diuretics and standard HF therapy. q Beneficial effects: Decrease BP and improve the efficiency of cardiac work. Speed symptom relief Possibly decrease the need for mechanical ventilation No proven change in mortality Nitroglycerin, Nitropusside, Nesiritide

18 Clinical classification Tissue perfusion dry and warm dry and cold wet and warm wet and cold Pulmonary congestion

19 Traditional Inotropes short-termgains appearto be offset by highermid and long-termmortality Admission

20 AHF Precipitating Factors INFECTION

21 Events usually leading to rapid deterioration

22 Events usually leading to less rapid deterioratio n

23 Discharge Criteria ü Near optimal volume status achieved ü Transition from IV to oral medications done ü Exacerbating factors addressed ü Assess biomarkers/ Thoracic Fluid Content? ü Assess ambulation ü Patient and family education done ü Follow-up clinic visit in 7-10 days

24 Home telemonitoring

25 Early Diagnosis PAWP + TFC Fatigue Weight gain Dyspnea STABLE CHF AHF OCCULT PERIOD Khoo Khoo

26 Prehospital treatment of pulmonary edema significantly decrease d hospital mortality from 15% to 7% CCU AHF ED Observation Unit

27 Summary ü Start early treatment ü Know when and what therapy to use ü Know when to discharge ü Follow-up is key

28 THANK YOU