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Acute Heart Failure Chief Rounds, Sept. 14, 2009 Dr. Frederic L. Ginsberg. CJTMEustaquio, MD PGY-3. Internal Medicine Cooper University Hospital. I.Introduction - Definition & Causes - General Approach II.Case 1: LS, 62M. cc: chest pain - Discussion: Management

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Acute Heart Failure Chief Rounds, Sept. 14, 2009 Dr. Frederic L. Ginsberg

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Acute Heart FailureChief Rounds, Sept. 14, 2009Dr. Frederic L. Ginsberg

CJTMEustaquio, MD

PGY-3. Internal Medicine

Cooper University Hospital


I.Introduction

- Definition & Causes

- General Approach

II.Case 1: LS, 62M. cc: chest pain

- Discussion: Management

III.Case 2: DF, 60M. cc: syncope

- Discussion: Management

IV.Case 3: DK, 63F. cc: dyspnea

- Discussion: Management

V.Conclusion


I. INTRODUCTION

  • Potentially fatal

  • Key concepts

  • Determinants of cardiac output

  • Heart failure

    - dyspnea

  • Introduction

  • Case 1

  • Case 2

  • Case 3

  • Conclusion

"demand >> supply"


  • Introduction

  • Case 1

  • Case 2

  • Case 3

  • Conclusion

Congestive Heart Failure

"volume of blood >> heart's capacity"

no congestion

congestion


  • Introduction

  • Case 1

  • Case 2

  • Case 3

  • Conclusion

  • Acute decompensated heart failure

    - Potentially fatal

  • Cardiogenic pulmonary edema

  • Flash pulmonary edema


General Approach

  • Suspect the diagnosis from S/Sx

    - HPI: cough, SOB, fatigue, chest pain/ discomfort

    - PE: RR, HR,  or BP

    accessory muscles

    wheezing

    S3, S4 gallop

    murmurs

     JVP

    pedal edema

  • Introduction

  • Case 1

  • Case 2

  • Case 3

  • Conclusion


Consider precipitating factors

CARDIAC

MI & myocardial ischemia

Atrial fibrillation, other arrhythmias

Progression of underlying cardiac dysfunction

RV pacing with dyssynchrony

NON CARDIAC

Severe HTN

Renal failure

Miscellaneous:

anemia

hypo/hyperthyroidism

toxins (cocaine, EtOH)

fever & infection

uncontrolled DM

Medications

PE

Dietary indiscretion, medication noncompliance, iatrogenic volume overload

  • Introduction

  • Case 1

  • Case 2

  • Case 3

  • Conclusion


  • Introduction

  • Case 1

  • Case 2

  • Case 3

  • Conclusion

  • Tests

    a. EKG

    b. CXR

    c. Lab data - CBC, basic chem 7, cardiac enzymes

    BNP, NT-proBNP

    Lipid profile, LFTs, TSH

    d. Echo

    e. Swan-Ganz catheter

    f. Coronary Angiography

    g. Others: EP studies

  • Treat


  • Introduction

  • Case 1

  • Case 2

  • Case 3

  • Conclusion

Case 1: LS, 62M. Cc: chest pain

  • SSCP at rest

    SOB, dyspnea on exertion

    Diaphoresis

  • HTN, DM, HPL

    CAD s/p POBA 1991

    Previous smoker

  • Metoprolol, HCTZ, Glyburide, Enalapril, Fish Oil, Lovastatin

  • 95.2F, 78, 164/83, 18, 99%RA

    No JVD. CTA b/l.

    RRR, good S1/S2, no m/r/g

    No pedal edema.


  • Introduction

  • Case 1

  • Case 2

  • Case 3

  • Conclusion

Recommendations for the Evaluation of Patients with HF


  • Introduction

  • Case 1

  • Case 2

  • Case 3

  • Conclusion

Case 1: LS, 62M. Cc: chest pain


  • Introduction

  • Case 1

  • Case 2

  • Case 3

  • Conclusion

  • Diagnoses:

  • NSTEMI

  • Chronic Systolic Heart Failure 2 to severe CAD,

  • not in acute decompensation

  • HTN, DM, HPL


  • Introduction

  • Case 1

  • Case 2

  • Case 3

  • Conclusion

Recommendations for the Evaluation of Patients with HF


  • Introduction

  • Case 1

  • Case 2

  • Case 3

  • Conclusion

Recommendations for the Evaluation of Patients with HF


  • Introduction

  • Case 1

  • Case 2

  • Case 3

  • Conclusion

The Stages of Heart Failure – NYHA Classification


  • Introduction

  • Case 1

  • Case 2

  • Case 3

  • Conclusion

  • Management: Medical + Evaluation for CABG

    - Thallium viability study: viable myocardium except distal apex

    - Discharged, then readmitted in 2 weeks for planned CABG x5:

    LIMA to D2 and LAD.

    SVG to D1. SVG to posterior descending artery & distal RCA.


  • Introduction

  • Case 1

  • Case 2

  • Case 3

  • Conclusion

Treatment Recommendations for Patients at High Risk of Developing Heart Failure (Stage A)


  • Introduction

  • Case 1

  • Case 2

  • Case 3

  • Conclusion

Treatment Recommendations for Patients with Asymptomatic LV Systolic Dysfunction (Stage B)


  • Introduction

  • Case 1

  • Case 2

  • Case 3

  • Conclusion

Treatment Recommendations for Symptomatic LV Systolic Dysfunction (Stage C)


  • Introduction

  • Case 1

  • Case 2

  • Case 3

  • Conclusion

Treatment Recommendations for Symptomatic LV Systolic Dysfunction (Stage C)


  • Introduction

  • Case 1

  • Case 2

  • Case 3

  • Conclusion

Case 2: DF, 60M. Cc: Syncope


  • Introduction

  • Case 1

  • Case 2

  • Case 3

  • Conclusion

Case 2: DF, 60M. Cc: Syncope

  • OSH: light headedness & syncope

    - (+) troponin

    - atrial flutter

    - severe hypotension – on Norepinephrine drip (Levophed)

    - transferred to CUH for cardiac catheterization

  • PMH:

    - Hepatitis C- s/p cholecystectomy

    - ESRD on HD- s/p patial colectomy 2 to polyps

    - NHL s/p chemo 2007- s/p hernia repair

    - HTN- s/p AV fistula

    - ascites


  • Introduction

  • Case 1

  • Case 2

  • Case 3

  • Conclusion

Case 2: DF, 60M. Cc: Syncope

  • SH: current smoker – 43py

    occasional EtOH

    former IVDA, quit 1978

  • PE: afebrile, 127/91, HR=98, RR=30

  • JVP=15 cm H20, 2+ carotid upstrokes

  • CTA B/L

  • RR, tachycardic, normal S1/S2

  • Hepatomegaly

  • No LE edema


  • Introduction

  • Case 1

  • Case 2

  • Case 3

  • Conclusion

Case 2: DF, 60M. Cc: Syncope


Diagnoses:

- Acute Decompensated Heart Failure

- Syncope.

- NICMP EF 10-15%.

- Paroxysmal atrial flutter.

- ESRD.

  • Introduction

  • Case 1

  • Case 2

  • Case 3

  • Conclusion

Case 2: DF, 60M. Cc: Syncope


  • Introduction

  • Case 1

  • Case 2

  • Case 3

  • Conclusion

Recommendations for the Management of Acute Heart Failure

  • Hospitalization

    • Hypotension, worsening renal function or altered mentation

    • Dyspnea at rest

    • Arrhythmia

    • ACS

  • In-patient monitoring

  • Hemodynamic monitoring

  • Treatment goals


  • Introduction

  • Case 1

  • Case 2

  • Case 3

  • Conclusion

Goals of Initial Management of ADHF

  • Hemodynamic stabilization

  • Support of oxygenation and ventilation

  • Symptom relief


  • Introduction

  • Case 1

  • Case 2

  • Case 3

  • Conclusion

Treatment Goals for Patients with ADHF

  • Improve symptoms

  • Optimize volume status

  • Identify etiology

  • Identify precipitating factors

  • Optimize chronic oral therapy

  • Minimize side effects

  • Identify patients who might benefit from revascularization

  • Educate


  • Introduction

  • Case 1

  • Case 2

  • Case 3

  • Conclusion

Components of Therapy for ADHF

  • Na and fluid restriction

  • Diuretics

  • Oxygen and assisted ventilation

  • Morphine

  • Vasodilator – nitrate, nesiritide

  • Inotropic agents – dobutamine, milrinone

  • ACE inhibitors and ARBs

  • Beta-blockers


  • Introduction

  • Case 1

  • Case 2

  • Case 3

  • Conclusion

Case 2: DF, 60M. Cc: Syncope

  • Medications:

    - ASA 325 mg daily

    - ISMN ER 30 mg daily

    - Carvedilol 25 mg BID

    - Hydralazine 10 mg TID

    - Valsartan 80 mg daily

    - Temazepam 30 mg daily

    - Gabapentin 300 mg BID

    - Percocet prn

    - Warfarin 2.5 mg daily


  • Introduction

  • Case 1

  • Case 2

  • Case 3

  • Conclusion

Additional Considerations in ADHF

  • Arrhythmia management

  • Mechanical cardiac assistance

  • Ultrafiltration

  • Vasopressin receptor antagonist


  • Introduction

  • Case 1

  • Case 2

  • Case 3

  • Conclusion

Case 2: DF, 60M. Cc: Syncope

  • EP studies, re atrial flutter.

  • TEE: no A-V clot

  • Atrial flutter ablation & ICD placement

  • Anticoagulation with Warfarin.


  • Introduction

  • Case 1

  • Case 2

  • Case 3

  • Conclusion

Case 2: DF, 60M. Cc: Syncope

Why the decision for an ICD during this admission vs. waiting 3 months of max medical therapy as in Case 1?


  • Introduction

  • Case 1

  • Case 2

  • Case 3

  • Conclusion

Recommendations for Management of Concomitant Diseases in Patients with HF


  • Introduction

  • Case 1

  • Case 2

  • Case 3

  • Conclusion

Case 2: DF, 60M. Cc: Syncope

What inotropes are recommended had he still been hypotensive on transfer to CUH?


  • Introduction

  • Case 1

  • Case 2

  • Case 3

  • Conclusion

Case 3: DK, 63F. Cc: dyspnea


  • Introduction

  • Case 1

  • Case 2

  • Case 3

  • Conclusion

Case 3: DK, 63F. Cc: dyspnea

  • Admitted under GYN in May & June 2009, cc: Nausea, vomiting

  • Recent ovarian CA recurrence

  • Developed acute, severe SOB at rest while on the floors

    ICU transfer & BIPAP

  • PMH:

    - Ovarian CA 1997, s/p resection

    1st recurrence, 2002. s/p chemo

    2nd recurrence, May 2009.

    - HTN – Tenormin 80 mg daily

    - DM II – Metformin 500 mg BID, Pioglitazone 45mg daily

    - sulfa allergy


  • Introduction

  • Case 1

  • Case 2

  • Case 3

  • Conclusion

Case 3: DK, 63F. Cc: dyspnea

  • FH: MI – father 75, brother 63

    COPD – mother  64, sister

  • SH: no smoking, no EtOH

  • ROS: occasional palpitations, fatigue

  • PE: BP 124/55, HR 98

    no JVD

    LLL crackles

    normal S1/S2, no murmurs, (+) S3 gallop

    no pedal edema


  • Introduction

  • Case 1

  • Case 2

  • Case 3

  • Conclusion

Case 3: DK, 63F. Cc: dyspnea


  • Introduction

  • Case 1

  • Case 2

  • Case 3

  • Conclusion

Case 3: DK, 63F. Cc: dyspnea

  • Diagnoses:

    - Acute decompensated heart failure (with cardiogenic pulmonary edema)

    - Cardiomyopathy with severe LV dysfunction, unclear etiology

    - Single vessel CAD – likely not the cause of CMP

    - DM II

    - HTN

    - Ovarian CA

    - HPL


  • Introduction

  • Case 1

  • Case 2

  • Case 3

  • Conclusion

Case 3: DK, 63F. Cc: dyspnea

  • Medical therapy for ADHF

  • (IV Furosemide, Carvedilol, Lisinopril , ASA, statin. NPPV)

     symptomatic improvement

     back to GYN floors, discharged after 15 days

  • HF meds discontinued on D/C – unclear reason

  • Out-patient cardiology F/U within 1 week:

    - SOB much improved, only mild SOB on climbing 1 flight of stairs

    - back on Tenormin; not on beta blocker, ASA, ACE-I

    - Add ASA, Carvedilol.

    - Repeat echo in 2 weeks.

    - F/U with GYN re Tx plan for ovarian CA recurrence.


  • Introduction

  • Case 1

  • Case 2

  • Case 3

  • Conclusion

Case 3: DK, 63F. Cc: dyspnea

Takotsubo cardiomyopathy??


  • Introduction

  • Case 1

  • Case 2

  • Case 3

  • Conclusion

Takotsubo cardiomyopathy

  • Stress-induced CMP

  • Apical ballooning syndrome

  • Broken heart syndrome

  • Transient LV systolic dysfunction

  • Mimics MI

  • No significant CAD


  • Introduction

  • Case 1

  • Case 2

  • Case 3

  • Conclusion

Takotsubo Cardiomyopathy

  • Stress-induced

  • Acute medical illness / intense emotional stress / physical stress

  • Pathogenesis unknown

  • Catecholamine excess, coronary artery spasm, microvascular dysfunction


  • Introduction

  • Case 1

  • Case 2

  • Case 3

  • Conclusion

Takotsubo Cardiomyopathy

  • Treatment and prognosis

    • Supportive

    • Hydration

    • Standard HF meds

      • ACE inhibitor

      • Beta-blocker

      • Diuretic

      • Aspirin

    • MR 0 – 8 %

    • Recovery in 1 to 4 weeks


  • Introduction

  • Case 1

  • Case 2

  • Case 3

  • Conclusion

Conclusion

  • Heart failure and ACS

  • ADHF in atrial flutter & ESRD

  • Takotsubo CMP

  • Evaluation guidelines in HF

  • Management principles in ADHF

  • Management of HF in general


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