1. Approach to Cardiac Failure
Dr J Strange
7th November 2013

2. Case
• 24 year old male
• Previously well
• Developed shortness of breath, pyrexias over
a 5 day period
• Observations
– HR 130, regular
– BP 87/45
– O2 Sats 88% on room air

4. • ABG
– pO2 11 pCO2 5.1 BE -12 lactate 6
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Hb 130g/L WCC 14 Platelets 180
Na 132 K 5.2 Urea 15 Creat 210 CRP 180
PT 16, elevated transaminases
Oliguric, peripheral oedema
Intubated and commenced vasopressors

5. TTE
• Globally reduced LV function
• Estimated EF 15%
• Transferred to Alfred
– Noradrenaline @ .35 microgram/kg/min
– MAP 68
– CVP 21
– PAOP 26
– CI 1.7

7. INITIAL ASSESSMENT

8. Immediate assessment and
resuscitation
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Resuscitation
Basic monitoring
History
Examination
Assessment of severity

9. How does CPAP work?
• Recruitment
• Increased FRC
• Improved pulmonary
compliance
• Reduced
transdiaphragmatic
pressure swings
• Decreased work of
breathing
• Reduction in ventricular
transmural pressure –
reduced afterload

10. Circulation
• Therapies dependent on patho-physiological
classification
• Maintenance of appropriate blood pressure
and cardiac output essential

11. Key questions…
• Is the patient dyspnoeic?
• De novo or on a background of cardiac
problems?
• Symptoms of ACS?
• Medications?

12. Examination
Congestion
• JVP
• Pulsus alternans
• HJR
• Parasternal lift
• Displaced apex
• Gallop
• MR/TR murmur
• Oedema
• Ascites
• Hepar
Low CO
• Cool peripheries
• Decreased LOC
• Confusion
• Hypotension
• Low volume pulse
• Inappropriate tachycardia

13. Severity
• Who should be transferred to ICU?
• NYHA classification

15. Framington Heart Study
• Life-time risk 20% for men and women
• Hypertension is the biggest modifiable risk
factor
• Median survival after development of 1.7
years in men and 3.2 years in women

16. Diagnostic category
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Pressure overload
Volume overload
Impaired ventricular filling
Myocardial diseases
Dysrhythmias

17. Pathophysiology
• Right and/or left
• Forward/backward
• Systolic and/or diastolic

18. Cardiogenic shock
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Oliguria
Clouded sensorium
Cool, mottled peripheries
SBP <90
HR >90
CI <2.2
PAOP >15

19. Forward failure
• Signs
– reduced tissue perfusion at
rest with weakness
– confusion and drowsiness
– pallor with peripheral
cyanosis
– cold clammy skin
– low blood pressure
– oliguria
– culminating in the full
blown cardiogenic shock
• Causes
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acute myocardial infarction
acute myocarditis
acute valvular dysfunction
pulmonary embolism
cardiac tamponade

20. Left heart backward failure

21. Right heart backward failure
• Right heart ischaemia
• Syndrome of chronically elevated systemic
venous pressure

22. INVESTIGATIONS

23. ECG
• The negative predictive value of a normal ECG
to exclude LV systolic dysfunction exceeds 90%
• Presence of anterior Q waves and LBBB in
patients with IHD are good predictors of
decreased EF

24. CXR

25. Troponin
• I or T
• Increased in shock, renal failure, sepsis,
hypovolaemia
• Values need to be interpreted in context

26. BNP
• Elevated in accordance with severity of heart
failure
• High negative predictive values

27. ECHO
• Function
• Mechanics

28. Other invasive monitors
• PAC
• PiCCO
• Oesophageal Doppler

29. MANAGEMENT

30. Reducing demand
• Reducing heart rate
• Reducing afterload
• 30 to 40% of cardiac output may be required
to support the work of breathing in a
dyspnoeic patient

31. Increasing supply
• Vasodilator
• Blood transfusion
• Judicious inotropes

32. Non-specific therapy
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General care
Adequate oxygenation
Adequate heart rate
Optimise preload
Increasing cardiac output
Correct structural problems

33. SPECIFIC PROBLEMS

34. Forward acute heart failure –
Cardiogenic shock
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Most commonly MI
5 -10% of MI’s
50 – 80% mortality
Reperfusion vital

35. IABP

39. VA - ECMO

40. VAD

41. Left heart backward failure
• ? ACS – reperfusion
• Oxygen, Diuretics, Vasodilators, Morphine

44. Right heart backward failure
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Increased portal venous pressures
Care with volume replacement therapy
Increase in PVR can be devastating
Aim to reduce RV afterload without affecting
systemic blood pressure

46. Takotsubo’s cardiomyopathy

48. Filtration or pharmacology
• Ultrafiltration was inferior to pharmacology at
96h
• Higher creatinine level
• No difference in weight loss
• Higher serious adverse events

50. Cardiac re-synchronisation therapy
• ICD and CRT used for wide range of patients
with heart rhythm disturbances
• Reduction in sudden death
• Improved ventricular performance

51. Institution of long-term therapy
• Evidence for long-term benefit of:
– ACEi
– β blockers
– Spironolactone

52. Case
• 30 yo man post arch and aortic valve
replacement
• Marfan’s
• Post-op
– HR 86
– BP 120/85
– CVP 9

53. • 6h later
– HR 125
– BP 70/50
– CVP 20
– TR
– Lactate 2  9
– Cool to touch, chest clear

54. Tests
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ABG
LFT – elevated transaminases
Cardiac enzymes – elevated
CXR
ECG – RBBB, ST elevation II, III, aVF
ECHO – no effusion, severely dilated and
hypokinetic RV, hypertrophied LV, TR

55. Management
• ABCs
• Further fluid may be detrimental
• Drugs to increase RV contractility and
decrease RV afterload
• Return to theatre
• Consider PAC

57. • Death from any cause or hospitalization for
worsening heart failure
– 50.7% vs 49.5% (p=0.87)
• Stroke
– 3.7% vs 2.7% (p=0.23)
• Thromboembolism
– 13.5% vs 10.0% (p=0.01)

58. QUESTIONS?