DEFINITION, CLASSIFICATION

MONITORING, AND TREATMENT

OF ACUTE HEART FAILURE
Department of Cardiology and Vascular Medicine
Division of Cardiovascular, Department of Internal Medicine
Padjadjaran University School of Medicine
Hasan Sadikin Hospital
Bandung
ACUTE HEART FAILURE IS A CHALENGING
DISORDER
1. Highly prevalent especially among the elderly
2. High rate of hospital readmission, early recurrent events,
and mortality
3. Progressive disorder
4. Heterogeneity in etiology and LV function
5. Characteristic, management, and outcomes have been
poorly defined
MECHANISM OF HEART
FAILURE
Vena cava
Arteri
pulmonalis
Vena
pulmonalis
Aorta
Atrium
kanan
Katup
trikuspid
Katup
mitral
Atrium
kiri
Ventrikel
kanan
Ventrikel
kiri
Paru
SIRKULASI JANTUNG PARU
PERFORMANCE OF THE VENTRICLE
1. PRELOAD
2. CONTRACTILITY
3. AFTERLOAD
Mekanisme Frank-Starling
Volume akhir diastolik ventrikel (preload)
I
s
i


s
e
k
u
n
c
u
p

Meningkatnya
preload akan diikuti
oleh meningkatnya
kontraktilitas
sehingga isi sekuncup
akan meningkat pula
Pressure
overload
Volume
overload
Myocardial
contractility
Compensatory
mechanism
Normal pumping
function
Heart failure
MECHANISM OF HEART FAILURE
adequate
failed
DEFINITION and
CLASSIFICATION of
HEART FAILURE
DEFINITION OF HEART FAILURE
The heart fails to pump blood
commensurate with the requirement of the
metabolizing tissue
or
The heart can pump blood commensurate
with the requirement of the metabolizing
tissue only from an elevated filling
pressure
HEART FAILURE
DIASTOLIC
SYSTOLIC
RA
RV
LA
LV
HEART FAILURE
BACKWARD
FORWARD
RA
RV
LA
LV
HEART FAILURE
LEFT
RIGHT
RA
RV
LA
LV
HEART FAILURE
ACUTE
CHRONIC
RA
RV
LA
LV
DEFINITION OF CHRONIC AND
ACUTE HEART FAILURE
Definition of Chronic Heart Failure
A syndrome in which patients have symptoms of HF
(dyspnea and fatigue) with evidence of cardiac
dysfunction and a clinical response to treatment
directed to HF alone (The ESC guidelines)
1
A clinical syndrome as a result of cardiac dysfunction
that impairs the ability of the ventricle to fill and eject
blood, producing symptomatic manifestation of HF
(The ACC/AHA guidelines)
2
1. Remme WJ, Swedberg K. Eur Heart J 2001;22:1521-60
2. Hunt SA et al. Circulation 2001;104:2996-3007
Definition of Acute Heart Failure
Acute heart failure is characterized by a rapid or
gradual onset of sign and symptoms of heart
failure, resulting in unplanned hospitalization or
office or emergency room visits.
Nieminen MS, Harjola V-P. Am J Cardiol 2005;96(suppl):5G-10G
CLINICAL SEVERITY CLASSIFICATION
(For Chronic Heart Failure: Hospitalized or Outpatients)
PERFUSION : warm or cold
CONGESTION: dry or wet
Class Classification
I Warm and dry
II Warm and wet
III Cold and dry
IV Cold and wet
Nohria A TS et al. J Am Coll Cardiol 2003;41:1797-1804
INADEQUATE PERFUSION (COLD)
pulse pressure
Cool extremities
Altered mentation
ACE-I intolerance
Worsening renal function
Nohria A TS et al. J Am Coll Cardiol 2003;41:1797-1804
PULMONARY CONGESTION (WET)
Orthopnea
Rales
JVP
Abdominojugular reflux
Hepatomegali
Ascites
Edema
Nohria A et al. J Am Coll Cardiol 2003;41:1797-1804
Six-month mortality by determined
hemodynamic profiles
Patient profile N (%) Six-month mortality (%)
Dry-war 123 (27) 11
Wet-warm 222 (49) 22
Wet-cold 91 (20) 40
Dry-cold 16 (4) 17
Nohria A et al. J Am Coll Cardiol 2003;41:1797-1804
The New York Heart Association functional classification
Class Classification
I Patients with cardiac disease but without limitation of physical
activity. Ordinary physical activity does not cause undue
fatique, palpitation, dyspnea, or anginal pain
II Patients with cardiac disease resulting in slight limitation of
physical activity. They are comfortable at rest. Ordinary
physical activity results in fatique, palpitation, dyspnea, or
anginal pain
III Patients with cardiac disease resulting in marked limitation of
physical activity. They are comfortable at rest. Less than
ordinary physical activity results in fatique, palpitation,
dyspnea, or anginal pain
IV Patients with cardiac disease resulting in inability to carry on
any physical activity without discomfort. Symptoms of cardiac
insufficiency or anginal syndrome may be present even at rest.
If any physical activity is undertaken, discomfort is increased
Goldman L et al. Circulation 1981;64:1227
KILLIP CLASSIFICATION
STAGE I : No clinical signs
STAGE II : Heart failure. Diagnostic criteria: rales S3
gallop and pulmonary veins hypertension.
Pulmonary congestion with wet rales in the
lower half of the lung fields
STAGE III : Severe heart failure. Frank pulmonary
edema with rales over the lung filds
STAGE IV : Cardiogenic shock. Signs: hypotension (SBP
90 mm Hg), and evidence of peripheral
vasoconstriction such as oliguria, cyanosis
and diaphoresis
FORRESTER CLASSIFICATION
Adapted from Forester et al. Am J Cardiol 1977;39:137
0,5
1
1,5
2
2,5
3
3,5
0 5 10 15 20 25 30 35 40
C
I

(
L
/
m
/
m
2
)

18
2.2
PCWP (MM Hg)
Hypovolemia Pulmonary congestion
Normal
Hypovolemic shock Cardiogenic shock
Diuretics
Vasodilators: NTG, Nitropruside
Mortality 22.4%
Mortality 55.5%
H
y
p
o
p
e
r
f
u
s
i
o
n

Fluid administration
H-I
C-I
H-II
C-II
H-III
C-III
H-IV
C-IV
Pulmonary edema
Mortality 2.2%
Mortality 10.1%
Fluid administration
Normal BP: vasodilator
Reduced BP: inotropics or
vasopressor
The routine use of invasive
hemodynamic monitoring in patients
with ADHF is not recommended.
(Strength of Evidence A)
Adams Jr, KF, Lindenfeld J, Arnold JMO, et al. Executive Summary: HFSA 2006 Comprehensive
Heart Failure Practice Guideline. J Cardiac Failure 2006;12:1038.
TREATMENT GOALS
Aim of Treatment
FEEL BETTER OR LIVE
LONGER
Clinicians want to treat AHF rapidly by adding new therapies
GOAL OF
TREATMENT
QoL
improvement
Morbidity and
mortality
reduction
Improve symptoms, especially congestion and low-output
symptoms
Optimize volume status
Identify etiology
Identify precipitating factors
Optimize chronic oral therapy
Minimize side effects
Identify patients who might benefit from revascularization
Educate patients concerning medications and self
assessment of HF
Consider and, where possible, initiate a disease
management program
Treatment Goals for Patients Admitted for ADHF
Adams Jr, KF, Lindenfeld J, Arnold JMO, et al. Executive Summary: HFSA 2006 Comprehensive
Heart Failure Practice Guideline. J Cardiac Failure 2006;12:1038.
Patient distressed or in pain
Analgesia or
sedation
Arterial O2 saturation 95%
Increase Fi02,
considered CPAP
Normal heart rate and rhythm
Pacing,
antiarrhythmics
Mean BP 70 mm Hg
Vasodilators,
consider diuresis if
volume overload
Adequate preload
Yes
No
No
Yes
No
Yes
Yes
No
No
Yes
Fluid challenge
Adequate CO, metabolic acidosis,
SvO2 65%, inadequate perfusion
No
consider inotropes or
afterload manipulation
Rapid improvement of symptoms is a
desire goal, but should not become the
only goal in managing AHF.
Many treatment modalities shown to
improve symptoms were shown to
increase mortality.
Intravenous vasodilators (intravenous
nitroglycerin or nitroprusside) and diuretics
are recommended for rapid symptom relief
in patients with acute pulmonary edema or
severe hypertension.
(Strength of Evidence C)
Adams Jr, KF, Lindenfeld J, Arnold JMO, et al. Executive Summary: HFSA 2006 Comprehensive
Heart Failure Practice Guideline. J Cardiac Failure 2006;12:1038.
Intravenous inotropes (milrinone or dobu-
tamine) are not recommended unless left
heart filling pressures are known to be
elevated based on direct measurement or clear
clinical signs. (Strength of Evidence B)
Adams, KF, Lindenfeld J, Arnold JMO, et al. Executive Summary: HFSA 2006 Comprehensive
Heart Failure Practice Guideline. J Cardiac Failure 2006;12:1038.