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Cardiac Arrest
Rony Yuliwansyah
contraction
Blood ejected from heart
Diastole :
Period of ventricular
relaxation
Blood filling
Stroke Volume
The amount of blood ejected from the
heart in one beat
Average is 60 - 100 ml
Depends on preload, contractile force
and afterload
Cardiac Output
The amount of blood ejected from the
heart in one minute
Cardiac output = heart rate x stroke
volume
Definitions
Chronotropy
Inotropy
Dromotropy
velocity
Can be positive or negative
causes
Valvular heart disease
Restrictive cardiomyopathy
Pericardial constriction
LV diastolic dysfunction
Cardiac arrhythmias
Heart Failure
Definition
It is the pathophysiological process in which
the heart as a pump is unable to meet
the metabolic requirements of the tissue for
oxygen and substrates despite the venous
return to heart is either normal or increased
Definition
No limitation: ordinary physical exercise does not cause dyspnoea.
Slight limitation of physical activity: dyspnoea on walking more than 200 yards or
on stairs;
Moderate limitation of physical activity: dyspnoea walking less than 200 yards.
Class III
Class IV
Coronary heart disease statistics: heart failure supplement., BHF 2002, http://www.heartstats.org, acc
Prevalence data is from a population based study: Davies MK et al. The Lancet 2001; 358: 439-444.
B. MYOCARDIAL DAMAGE
1. Primary
a) cardiomyopathy
b) myocarditis
c) toxicity (alcohol)
d) metabolic abnormalities (hyperthyreoidism)
2. Secondary
a) oxygen deprivation (coronary heart disease)
b) inflammation (increased metabolic demands)
c) chronic obstructive lung disease
sarcoid, restrictive
Familial
Hemachromotosis
Thyroid disease
Pheocromocytoma
Chronic renal disease
Viral and HIV cardiomyopathy
Coronary artery
disease
Hypertension
Arrhythmia
Left-ventricular
injury
Pathologic
remodelling
Left-ventricular
dysfunction
Cardiomyopathy
Valvular disease
Vasoconstriction
Endothelial
dysfunction
Renal sodium
retention
Death
Pump
failure
Neurohormonal
activation
Symptoms:
Dyspnoea
Fatigue
Oedema
Heart
failure
A C U TE H EA R T
FA ILU R E
Heart J 2005;26:384-416
the single most costly medicalEursyndrome
M ortality ofAH F
In Hospital mortality ( 60 days) : 9.6%
Rehospitalization and mortality : 32,5%
1 year mortality : 30%.
Reduce
fluid
volume
Vasodilators Inotropes
Decrease
preload
and
afterload
Augment
contractilit
y
Natriuretic
peptides
Vasodilate
; reduce
fluid
volume;
counteract
RAAS/SNS
Congestion at rest
No
No
Yes
Yes
Sign of congestion:
Orthopnea,elevated
JVP,edema,pulsatile
hepatomegaly, ascites,
rales,louder S3,P2 radiation left
ward, abdomino-jugular reflex,
valsava square wave
Congestion at rest
No
No
Yes
Yes
VOLUME
LOADING
Diuretic
Vasodilator
C
Inotropic drugs :
Dobutamine
Milrinone
Levosimendan
European Heart Journal of Heart Failure,2005; 7:323-331
Clinical
PCWP < 18 mm
CO and/or SV
Symptoms
(Dyspnea and/or fatigue)
Clinical sign
Body weight
Diuresis
Oxygenation
Laboratory
Serum electrolytes normal
BUN
Plasma BNP
Blood glucose normalization
Tolerability
Low rate of with drawl from therapy
Low incidence of adverse effects
Outcome
Length of stay in ICU
Duration of hospitalization
Time to hospital readmission
Mortality
D iuretics
For achieving optimal volume status eliminate or
minimize congestion
High doses of iv diuretics 2-3 times daily
More effective with continous iv. 5-20 mg/h
Diuretics resistance is a common problem
In case of resistance:
Restrict Na/water intake and follow electrolytes
Volume repletion in hypovolaemia
Vasodilators
Nitroprusside, Nitroglycerin, Nitrate
family
Work by cGMP mediated smooth muscle
relaxation -> vasodilatation
Decrease myocardial work by afterload
and preload reduction
May cause hypotension
May cause headache
Nitrates
Not evaluated by large scale studies
Many studies shown their favorable effect
Limitation
Side effect
Nitrate Resistance
Nitrate Tolerance
Prevention
Intermittent dosing : 12 hour nitrate free
interval
Escalating dose
Concomitant use of hydralazine
Elkayam, The American Journal of Cardiology, 2005
Inotropes:
Dopamine, Dobutamine, Milrinone
Improve cardiac output by directly
increasing cardiac contractility
Significant proarrhythmic effects
May precipitate ischemia
Not recommended for routine use in AHF,
but clearly have a role in specific patients
Inotropic Doses
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