; Acute heart failure Martin Radvan What we will talk about? • Patophysiology • Clinical signs • Diagnosis • Therapy Definition • Acute heart failure (AHF) is generally defined as the rapid development or change of symptoms and signs of heart failure that requires urgent medical attentionis • No new mediaction for last 30 years Definition • Symptoms related to pulmonary congestion due to elevated left ventricle filling pressures with or without low cardiac output Definition • De novo x acute decompensation of chronic heart failure • Cardiogenic shock Epidemiology • No1 reason for hospitalisation in people older than 65 years • 65-75% known HF before hospitalisation • 25-55% preserved ejection fraction (HFpEF) Diagnosis • Anamnesis • Clinical signs • Examination: perfusion and volume status • ECG • Echocardiography • Labs • X-ray, CT, coronarography, etc. Signs and symptoms • noisy syndrome, rapid developement • elevated jugular venous pressure • pulmonary edema • +S3 (gallop) • pulmonary crackles • peripheral oedema • orthopnoe Signs and symptoms • Noisy syndrome, rapid developement • elevated jugular venous pressure • Pulmonary edema • +S3 (gallop) • pulmonary crackles • oedema • orthopnoe Pathopysiology Dry-warm Wet –warm Wet-cold Dry-cold Pathopysiology Dry-warm Well perfused, normovolemic Wet –warm Congestion, well perfused Wet-cold Congested, hypoperfused Dry-cold Hypoperfused, hypovolemic Pathopysiology Dry-warm Well perfused, normovolemic Wet –warm Congestion, well perfused Wet-cold Congested, hypoperfused Dry-cold Hypoperfused, hypovolemic Pathopysiology Dry-warm Well perfused, normovolemic Wet –warm Congestion, well perfused Wet-cold Congested, hypoperfused Dry-cold Hypoperfused, hypovolemic Pathopysiology Dry-warm Well perfused, normovolemic Wet –warm Congestion, well perfused Duiretics, vasodilatators Wet-cold Congested, hypoperfused Inotropes, MCS Dry-cold Hypoperfused, hypovolemic Water challenge, inotropes Pathopysiology – Forrester classification (PCWP, CI) Dry-warm Well perfused, normovolemic Wet –warm Congestion, well perfused Duiretics, vasodilatators 90-95% Wet-cold Congested, hypoperfused Inotropes, MCS 5-10% Dry-cold Hypoperfused, hypovolemic Water challenge, inotropes PCWP, CI PCWP Invasive vs. non-invasive measurment Pressure in left atrium Volume status Cardiac index Invasive vs. Non-invasive measurment 2,2L/min/m2 Cardiac output Degree of perfusion PCWP, CI PCWP Invasive vs. non-invasive measurment Pressure in left atrium Volume status Cardiac index Invasive vs. noninvasive measurment 2,2L/min/m2 Cardiac output Degree of perfusion PCWP, CI PCWP Invasive vs. non-invasive measurment Pressure in left atrium Volume status Cardiac index Invasive vs. noninvasive measurment 2,2L/min/m2 Cardiac output Degree of perfusion PCWP, CI PCWP Invasive vs. non-invasive measurment Pressure in left atrium Volume status Cardiac index Invasive vs. non-invasive measurment 2,2L/min/m2 Cardiac output Degree of perfusion Labs • ECG – rarely normal • X-ray: congestion, normal heart size • Echocardiography – heart, lungs • BNP, NT-proBNP, troponin Labs • ECG • X-ray: congestion, normal heart size • BNP, NT-proBNP, troponin Labs • ECG • X-ray: congestion, normal heart size • BNP, NT-proBNP, troponin Clinical course Pulmonary aedema Therapy of pulmonary aedema? Therapy of pulmonary aedema • Oxygen • Morphin • Vasodilatation (blood presure control) • Furosemide • Therapy of the cause Classifications Cardiogenic shock • Acute HF in naive patients • Myocardial injury • Arrythmia • Valvular disease • Obstructive shock • Tamponade • … Diagnosis Pharmacotherapy of cardiogenic shock • Inotropes: noradrenalin, dobutamin, adrenalin, milrinon, levosimendan • Ultrafiltration • Furosemide • Therapy of the cause MCS • Intra-aortic balloon counterpulsation • LVAD • Total artificial heart • ECMO • Impella • Bridge to recovery/decision/transplantation • Destinantion therapy MCS • Intraaortic balloon contrapulsation • LVAD • Total artificial heart • ECMO • Impella • Bridge to recovery/decision/transplantation • Destinantion therapy IABC ECMO ECMO ECMO Impella LVAD Transplantation • Age? • Life expectancy (except heart) • Spiroergometry VO2max • Imunosupression • Rejection, infection • Vasculopathy of the graft Conclusions • Acute HF in naive patients • Acute decompensation of chronic HF • Fluid and perfusion status • Cause of HF/decompensation • Early goal directed echocardiography • Early therapy • Early recognition of therapy failure Thanks for the attention