Académique Documents
Professionnel Documents
Culture Documents
Causes of AHF
CAD, ACS
Myopathy (myocarditis, postpartum CMP)
Hypertension/arrhythmia
Non-cardiac origin (sepsis, anaemia,tamponade, pulmonary embolism,
shunt, thyreotoxicosis)
Acutely decompensated CHF due to other causes (COPD, drug
abuse, volume-overload, renal failure, infection)
Valvular (endocarditis, aortic dissection)
Acut decompensated CHF:left and right heart congestion, pulmonary
edema, hypotension
Pulmonary edema: orthopnea, tachypnea, low O2 saturation
Hypertensive attack: increased afterload, congestion
Isolated right heart failure: elevated jugular venous pressure, clear
pulmonary sounds, hepatomegalia, anasarca
ACS: during ischemia contractility worsens +/arrhythmic events may
occur (e.g. bradycardia, VT/VF)
Cardiogenic shock: forward failure (low blood pressure, tissue
hypoperfusion), backward failure (congestion), impaired contractility
Symptoms, signs
Symptoms
Signs
Cool extremities
Symptoms
Signs
drowsiness, confusion, or
difficulty concentrating
hypotension
Dizziness, presyncope, or
syncope
Sleep disturbances
S4
Palpitations
genic Shock
Cardiogenic shock
Cardiogenic shock is the most severe clinical expression of left ventricular
failure.
Causes in ACS patients: severe myocardial infarction, more vessels, LAD!,
late infarction, mechanical complications such as rupture of the ventricular
septum, a papillary muscle, or free wall with tamponade; right ventricular
infarction; or marked reduction of preload caused by conditions such as
hypovolemia.
Cardiogenic shock is characterized by marked and persistent (>30
minutes) hypotension with systolic arterial pressure less than 80 mm Hg
and a marked reduction of cardiac index (generally <1.8 liters/min/m 2) in
the face of elevated left ventricular filling pressure (pulmonary capillary
wedge pressure >18 mm Hg).
9. Usually occurs near the junction of the infarct and the normal muscle.
10. Occurs less frequently in the center of the infarct, but when rupture
occurs here, it is usually during the second rather than the first week
after the infarct.
11. Rarely occurs in a greatly thickened ventricle or in an$area of
extensive collateral vessels.
12. Most often occurs in patients without previous infarction.
13. There is no evidence that the intensity of anticoagulation influences
the occurrence of rupture.
14. Occurs more commonly in patients who received reperfusion therapy
with a fibrinolytic versus PCI.
Rupture of the free wall of the left ventricle usually leads to
hemopericardium and death from cardiac tamponade.
Diagnostic options
ECG: ischemia (ST-elevation, Q-wave), arrhythmia, conduction
disturbances (eg. LBBB)
Chest X-ray: pulmonary congestion, pleural, pericardial fluids,
cardiomegalia
Lab tests: electrolyte levels, renal&liver function, blood cell count,
ProBNP
Blood gas analysis: pH, pO2, PCO2, BE, Lactate
Echocardiography: evaluation of systolic and diastolic function,
dysynchronia, valvular disease, mechanical complications
Hemodynamic Classifications of Patients with Acute Myocardial
Infarction (Killip)
A. Based on Clinical
Examination
Cla Definition
ss
Subs Definition
et
Normal hemodynamics
PCWP < 18, CI > 2.2
II
III
II
III
Pulmonary congestion
PCWP > 18, CI > 2.2
Peripheral hypoperfusion
PCWP < 18, CI < 2.2
IV
Shock
IV
A. Based on Clinical
Examination
Cla Definition
ss
Subs Definition
et
peripheral hypoperfusion
PCWP > 18, CI < 2.2
Monitoring techniques
Non-invasive: obligatory at AHF patient (resp. rate, ECG, O2
saturation,NIBP)
Invasive: obligatory at unstable AHF patients (Noninvasive AND arterial
line,
central venous line invasive pressures)
PAC (Swan Ganz) right heart catheterisation: unstable AHF and no
reaction
to conventional treatment
Pulmonary capillary wedge pressure characterizes the enddiastolic filling
pressures (exept mitral stenosis, aorta regurgitation, pulmonary vein
occlusion,MV)
Therapy
Restoration of oxygenation and tissue perfusion
Iv. access
Monitoring invasive if needed
Positioning of the patient: sitting or half-sitting (45)
Symptom guided acute therapy
Etiology evaluation and casual therapy
Evaluation and control of fluid (volume) state of the patient (Stop of
infusion in case of left heart failure)
Stable decompensated CHF: vasodilators, loopdiuretics,
hypoperfusion:positive inotropes
Pulmonary edema: morphin, loopdiuretics, hypertension: vasodilators,
hypoperfusion: inotropes
Cardiogenic shock: fluid challenge, inotropes, vasopressors, intubation,
mechanicalventilation, IABP
Isolated right heart failure: fluids, inotropes, rapid evaluation of
etiology (pulmonary Embolism? AMI?)
Acute coronary syndrome: revascularisation (PCI,CABG)
O2 -target O2 Sat: 95% (COPD:90%) -aim: decrease of pulmonary
vasoconstriction
Morphin-aim: anxietas, dyspnea, chest pain relief
-dosage: initiating 2-4mg iv. , maitenance 2 mg in 5-15 mins
-AE: antiemetic drug needed (eg. 1mg metoclopramid)
A flexible catheter with one lumen that allows for either distal
aspiration/flushing or pressure monitoring and a second that permits
the periodic delivery and removal of helium gas to a closed balloon.
A mobile console that contains the system for helium transfer as well
as computer control of the inflation and deflation cycle.
CONTRAINDICATIONS
COMPLICATIONS
Vascular Vascular complications remain the major risk. The most
common major complications include:
Cholesterol embolization
Cerebrovascular accident is a rare complication of IABP, since the
balloon is normally positioned distal to the left subclavian artery.
Cerebral ischemia only occurs when the IABP has been placed too
proximally or has accidentally migrated proximally, or the central
balloon lumen has been flushed vigorously and dislodged a
thrombus.
Sepsis
Balloon rupture
Additional complications: fall in platelet count, hemolysis, seromas,
groin infection, and peripheral neuropathy
The graph of aortic pressure throughout the cardiac cycle displays a small dip ( the
"incisure" or "dicrotic notch") which coincides with the aortic valve closure.
impella Recover
extracorporal membrane oxigenisation (ECMO)
continuous aortic-flow-augmentation Cancion-system
TandemHeart
left-, right-or. biventricular assist device (VAD)
Temporary pacemaker therapy
antibradycardia
antitachycardia
Mechanical ventilation recovery of gas exchange, decrease work
of breathing
invasive mechanical ventilation