Acute heart failure chief rounds sept 14 2009 dr frederic l ginsberg
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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

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
I. INTRODUCTION

  • Potentially fatal

  • Key concepts

  • Determinants of cardiac output

  • Heart failure

    - dyspnea

  • Introduction

  • Case 1

  • Case 2

  • Case 3

  • Conclusion

"demand >> supply"


Congestive heart failure

Congestive Heart Failure

"volume of blood >> heart's capacity"

no congestion

congestion


  • Acute decompensated heart failure

    - Potentially fatal

  • Cardiogenic pulmonary edema

  • Flash pulmonary edema


General approach
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


  • 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


Case 1 ls 62m cc chest pain

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.


Recommendations for the evaluation of patients with hf

Recommendations for the Evaluation of Patients with HF


Case 1 ls 62m cc chest pain1

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


  • Diagnoses:

  • NSTEMI

  • Chronic Systolic Heart Failure 2 to severe CAD,

  • not in acute decompensation

  • HTN, DM, HPL


Recommendations for the evaluation of patients with hf1

Recommendations for the Evaluation of Patients with HF


Recommendations for the evaluation of patients with hf2

Recommendations for the Evaluation of Patients with HF


The stages of heart failure nyha classification

The Stages of Heart Failure – NYHA Classification


  • 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.


Treatment recommendations for patients at high risk of developing heart failure stage a

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


Treatment recommendations for patients with asymptomatic lv systolic dysfunction stage b

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


Treatment recommendations for symptomatic lv systolic dysfunction stage c

Treatment Recommendations for Symptomatic LV Systolic Dysfunction (Stage C)


Treatment recommendations for symptomatic lv systolic dysfunction stage c1

Treatment Recommendations for Symptomatic LV Systolic Dysfunction (Stage C)


Case 2 df 60m cc syncope

Case 2: DF, 60M. Cc: Syncope


Case 2 df 60m cc syncope1

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


Case 2 df 60m cc syncope2

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


Case 2 df 60m cc syncope3

Case 2: DF, 60M. Cc: Syncope


Case 2 df 60m cc syncope4

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


Recommendations for the management of acute heart failure

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


Goals of initial management of adhf

Goals of Initial Management of ADHF

  • Hemodynamic stabilization

  • Support of oxygenation and ventilation

  • Symptom relief


Treatment goals for patients with adhf

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


Components of therapy for adhf

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


Case 2 df 60m cc syncope5

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


Additional considerations in adhf

Additional Considerations in ADHF

  • Arrhythmia management

  • Mechanical cardiac assistance

  • Ultrafiltration

  • Vasopressin receptor antagonist


Case 2 df 60m cc syncope6

Case 2: DF, 60M. Cc: Syncope

  • EP studies, re atrial flutter.

  • TEE: no A-V clot

  • Atrial flutter ablation & ICD placement

  • Anticoagulation with Warfarin.


Case 2 df 60m cc syncope7

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?


Recommendations for management of concomitant diseases in patients with hf

Recommendations for Management of Concomitant Diseases in Patients with HF


Case 2 df 60m cc syncope8

Case 2: DF, 60M. Cc: Syncope

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


Case 3 dk 63f cc dyspnea

Case 3: DK, 63F. Cc: dyspnea


Case 3 dk 63f cc dyspnea1

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


Case 3 dk 63f cc dyspnea2

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


Case 3 dk 63f cc dyspnea3

Case 3: DK, 63F. Cc: dyspnea


Case 3 dk 63f cc dyspnea4

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


Case 3 dk 63f cc dyspnea5

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.


Case 3 dk 63f cc dyspnea6

Case 3: DK, 63F. Cc: dyspnea

Takotsubo cardiomyopathy??


Takotsubo cardiomyopathy

Takotsubo cardiomyopathy

  • Stress-induced CMP

  • Apical ballooning syndrome

  • Broken heart syndrome

  • Transient LV systolic dysfunction

  • Mimics MI

  • No significant CAD


Takotsubo cardiomyopathy1

Takotsubo Cardiomyopathy

  • Stress-induced

  • Acute medical illness / intense emotional stress / physical stress

  • Pathogenesis unknown

  • Catecholamine excess, coronary artery spasm, microvascular dysfunction


Takotsubo cardiomyopathy2

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


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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