heart failure

1. Management of ADHF
Dr.Nishanth
Dr. Srishti

2. Diagnosing Heart Failure
HISTORY
• Prior HF/myocardial injury
• DOE, orthopnea, PND
• Fatigue
• Edema
• Family history

3. EXAMINATION
• Congestion
• Perfusion
• Tachy/brady arrhytmias

4. CXR findings

5. Lung USG findings
▸ Sliding present
▸ Diffuse B lines
(≥3 in ≥2 zones B/L)
▸ Pleural effusion

7. Treating Heart failure
GOALS
1. Initial stabilization
2. Relieve symptoms: congestion and low output
3. Identify etiology
4. Identify precipitating factors
5. Minimize side effects

9. 1.Initial Stabilization
• O2 – to prevent hypoxia <90% Spo2 (NOT
routinely)
• NIV indications
Respiratory distress
Respiratory acidosis
Hypoxia despite O2

10. NIV
Respiratory support
-Increases tidal volume
-Unloads respiratory muscles
-Decreases dead space ventilation
Hemodynamic support
-Alters cardiac transmural pressures
-Decreases preload (venous return) and afterload
-No change in cardiac index

12. 2. Symptoms management
1. Optimize preload - Diuretics
2. Decrease Afterload - Vasodilators
3. Augment contractility – Inotropes and
vasopressors , Mechanical Circulatory support

13. Overview
Allen LA, O'Connor CM. CMAJ. 2007 Mar 13;176(6):797-805

14. DIURETICS
• Reduce congestion by increasing excretion of
Na and water
• Preferred - Loop diuretics (Furosemide)
• IV route better
Gut wall edema
Reduced blood flow

16. VASODILATORS
• Reduce filling pressures
• Reduce afterload
• Commonly used:
NTG
Nitroprusside

17. NITROGLYCERINE NITROPRUSSIDE
Stimulates guanylate
cyclase
Equipotent venous and
arteriolar dilation
Dose dependent venous
> arteriole dilatation
Useful for HTN, valvular
dysfunction (AR, MR)
Decreases filling pressures Short half life
Headache Methemoglobinaemia
Nitrate tolerance Cyanide toxicity

18. INOTROPES
• Reserved for low output HF (wet and cold)
• Evidence of hypotension and poor tissue
perfusion despite adequate filling pressures
• Poor response to diuretics with worsening
renal function
• Unresponsive or intolerant to vasodilators
• Short term with lowest dose

19. Mechanism of action
Pagel, P., & Warltier, D. 2011 (pp. 706-723)

21. DOBUTAMINE MILRINONE LEVOSIMENDAN
Initial agent in low CO
with maintained BP
Alternative for short
term CO augmentation
Sensitises the cardiac
myocytes to calcium
Add on with Norad in
case of hypotension
Accumulates in renal
failure
Enhance myocardial
contractility at a given
calcium concentration
Increases contractility
and rate
Increases Contractility
and at higher doses HR
Have intrinsic PDE inh
property
Can cause hypotension
and arrhythmia
Can cause hypotension
and arrhythmia

22. INOTROPES AND HARM
• Increase HR and Arrhythmias
• Increase myocardial oxygen demand
• Direct toxic effect to myocardium: accelerated
apoptosis

23. VASOPRESSORS
• To increase blood pressure and vital organ
perfusion in cardiogenic shock
• Preferably Noradrenaline
• Monitor ECG and blood pressure
• Intra-arterial blood pressure measurement
may be considered.

24. MECHANICAL CIRCULATORY DEVICES

25. Types

26. IABP
• Inflates in diastole - increases coronary
perfusion
• Deflates in systole - decreases afterload &
increases LV stroke volume
• Trigger
ECG - inflation -middle of T-wave & deflation -
peak of R wave
Pressure - inflation - dicrotic notch and deflates
based on elapsed time

28. Contraindications
• Uncontrolled bleeding diathesis.
• Moderate to severe aortic regurgitation.
• An aortic aneurysm or aortic dissection.
• Severe peripheral artery disease
Complications
• Limb ischemia - monitor distal pulses
• Positioning- monitor UO , CXR
• Bleeding, hematoma - monitor sheath site,
coagulopathy

30. VA ECMO

31. • Deoxygenated venous blood - extracorporeal
centrifugal pump - oxygenated blood to iliac
artery
• Continuous flow via centrifugal pump
Complications
• Haemolysis
• Limb ischemia
• Bleeding

32. Contrindications
• Severe aortic insufficiency
• Aortic dissection
• Intolerant to systemic anticoagulation

33. 3. Identifying and management of etiology

34. 4. Common precipitating factors
INCREASED METABOLIC
DEMANDS
Fever, anemia, infection,
tachycardia,
hyperthyroidism, pregnancy
INCREASED CIRCULATING
VOLUME
Excessive salt or fluid in diet
Renal failure
INCREASED AFTERLOAD
Hypertension
PE
IMPAIRED CONTRACTILITY
Negative inotropes
Ischemia
Failure to take medications