Bimbingan AHF

Management of Acute Heart
Failure
1
Definition – Acute Heart Failure
Rapid onset of symptoms and signs of heart failure, secondary to
cardiac dysfunction
Dysfunction can be related to systolic or diastolic

dysfunction, to abnormalities in cardiac rhythm or to
preload and afterload mismatch
Often life threatening and requires urgent treatment

ESC Heart Failure Guideline, 2008
ESC Heart Failure Guideline, 2012 2
AHA Guideline 2013
Common manifestations
Features Symptoms Signs
Pulmo congestion Dyspnea, fatigue Tachypnea, lung rales, effusion,
tachycardia
Systemic congestion Dyspnea, fatigue Peripheral oedema, ↑ JVP, hepatomegaly
Cardio. shock Confusion, weakness Poor peripheral perfusion, SBP <90,

cold periphery anuria/oliguria
High BP (HT HF) Dyspnea ↑ BP, LV hypertrophy, preserved EF
Right heart failure Dyspnea, fatigue RV dysfunction, ↑ JVP, peripheral

edema, hepatomegaly, ascites

AHA Guideline 2013
3
Signs & Symptoms
Hypotension (MAP<65) ,
tachycardia, cold extremity,
↓ PERFUSION narrow pulse pressure, fatique,
confusion, restlessness, oliguria,
↑ ureum creatinine
Dyspnea, orthopnea, paroxysmal

nocturnal dyspnea, rales, neck
CONGESTION
vein distension, ascites, edema,
hepatojugular reflex
Braunwald, 2009 4
Hemodynamic profile:
Forrester classification Congestion present:
Congestion absent Pulmonary rales,
elevated JVP, orthopnea,
ascites, edema
2.2 L/min/m2
Normal
Pulmonary
edema
Cardiac index:
Hypovolemic
Cardio shock
shock
PCWP: 18 mmHg
Poor Perfusion:
- MAP <65 mmHg
- Cold extremities
- Altered
Braunwald, mental status
2009
- Oliguria 5
Clinical Classifications

7
Clinical classifications
Acute decompensation of heart failure (ADHF)
• De novo or as decompensation of chronic HF
• Signs and symptoms relatively mild
• Do not fulfil criteria for cardio shock, pulmonary edema or
hypertensive crisis
Hypertensive AHF
 Signs and symptoms of HF + high BP
 Relatively preserved LV fx
 CXR can resemble pulmonary oedema
AHA Guideline 2013
8
Pulmonary edema
• Severe respiratory distress, orthopnea
• Crackles all over the lung
• O2 sat <90% on room air prior to treatment.
• Verified by CXR
ACS and HF
 15% of ACS patients have signs & symptoms of AHF
 Frequently associated with or precipitated by an arrhythmia (bradycardia, AF, VT)
 Form: ADHF, pulmo edema, cardio shock, RHF

AHA Guideline 2013
9
Cardiogenic shock
• Evidence of organ hypoperfusion & pulm congestion
• ↓ BP (syst <90 mmHg, ↓ MAP >30 mmHg)
• Low urine output (<0.5 ml/kg/h)
• Continuum of low cardiac output syndrome.
Isolated Right HF
 Low output syndrome but no pulmonary congestion
 ↑ JVP, with or without hepatomegaly
 low LV filling pressures
AHA Guideline 2013
10
Aim of therapy
INITIAL: Improve hemodynamic status to relieve
symptoms & stabilize organs functions
– ↓ volume overload & filling pressure

– ↓ systemic vascular resistance
– ↑ cardiac output
– ↓ neurohormonal activation
SUBSEQUENT: Definitive etiologic therapy

AHA Guideline 2013
th
4 SymCARD 2014
12
Management approach – hemodynamic oriented
Diuretic, vasodilator
Fluid administration Normal BP: vasodilator

↓ BP: Inotropic drugs
13
Co-morbidities of Acute Heart Failure
Comorbid
Conditions Influencing the treatment requirement
Multiple comorbidity
Diabetes ACS Common and greatly

In developed nations, about one in four adults have at least
increase two chronic
the complexity of
conditions and more than half of older adults have three or
managing morein
disease
Renal Dysfunction Aritmia
chronic conditions patients with heart failure
Respiratory Failure Infection ESC Heart Failure Guideline, 2008

14
AHA Guideline 2013
Management of co-morbidities is a KEY COMPONENT of the
HOLISTIC CARE of patients with HEART FAILURE
15
• AHA Guideline 2013
Diabetes
1. Reaction of Hyperglicemic increase release of stress hormones
2. Diabetic Keto-acidocis  a complex disorder metabolic state
characterised by hyperglicemia, ketoacidosis, and ketonuria
3. Hyperosmolar Nonketotic Coma
Treatment:
- Critical ill insulin

- Fluid Monitoring Checked IVC
 non invasive method Checked Hb/Ht
and invasive Checked Ur/Cr
Evaluate osmolarity and fluid
Altabas V, Glucose metabolism disorder in coronary heart
deficit
disease, acta clin 2011 CVP
16
Hamdy O, Diabetic Ketoacidosis, 2014
Osmolarity and Fluid Deficit (the formula)
Osmolarity Body Fluid= 2xNa + Sliding scale BG + BUN
18 2,8
BUN = ureum
2,14
Fluid Deficit = Osmolarity -295x0,6xkgBW

295
Altabas V, Glucose metabolism disorder in coronary heart disease, acta clin
2011
Hamdy O, Diabetic Ketoacidosis, 2014 17
INFECTION
Heart failure can be precipitated by infection
by several mechanism
Acute inflammation can not only depress myocardial function, but it

can also increase large artery stifness and the pulse wave
reflections from peripheral middle-sized and small arteries that
return to the heart in late systole, increasing left ventricular
afterload and raising
oxygen consumption
AHA Guideline 2013 18

AHF with Infection
cont
Respiratory Tract
INFECTION Urinary Tract Infection
Soft Tissue
Marker of infection in critically ill patient:
- White blood cell count
- C-reactive protein level
- Procalcitonin  uselful marker of the severity of infection/
septicemia
Kaplan J.L et al, SIRS 2015
Andreola B, 2007, marker of infection
Wacker C, procalcitonin as a diganostc marker for sepsis, 2013 19
AHF with Infection  Haemodynamic Monitoring
SIRS  Criteria
Haemodynamic
echocardiography
Decrease SVR = (MAP-RAP)x80

CO
Kaplan J.L et al, SIRS 2015 Pump failure Decrease Ejection Fraction
Andreola B, 2007, marker of infection 20
Wacker C, procalcitonin as a diganostc marker for sepsis, 2013
AHF with infection
cont
Severe Sepsis and septic shock condition  observes

Disseminated Intravascular Coagulation :
- aPTT/PTT
- Fibrinogen
- D-Dimer
- Thrombocyte
Kaplan J.L et al, SIRS 2015

Andreola B, 2007, marker of infection
Wacker C, procalcitonin as a diganostc marker for sepsis, 2013
21
Kidney Disfunction
Acutely worsening Heart Failure or its treatment or both  may cause
acute worsening renal function ~ associated with worse survival and
prolonged hospitalization
An acute renocardiac syndrome  characterized by worsening cardiac

function secondary to volume overload resulting from acute kidney
injury
The Main Management : Limit the use of renin-angiotensin-

aldosteron system blocker and that progressive uraemia and volume
overload may necessitate renal replacement therapy 22
Marvin A, Renal function and Heart Failure
Treatment, AHA, 2011
23
AHF with Renal Dysfunction
cont
Asses renal function  Glomerulus Filtration Rate (GFR) ~ estimated
Creatinine CLearance (eCCr)
eCCR = (140-age)xMass(in kilograms)x (0,85 if female)
eCCr= (140-age)x mass (in kgBW)x (0,85 if female)
72xserum creatinin (in mg/dl)
72xserum creatinin (in mg/dl)

24
AHF with Renal Dysfunction
THERAPY cont
I.V diuretic (Force Diuretic) potential to

reduce GFR, worsen beurohumoral activation,
- Carefully monitored produce electrolyte disturbances
- Serial evaluation volume status
- Serial evaluation of systemic perfusion
- Monitoring of weight, vital signs, fluid Drugs Combination  Furosemide + Thiazid
input and output
- Asses dosis electrolyte and renal function
DOPAMIN renal dose  < 3µg/kg/min  have a
selective renal arterial vasodilator activity and
promote natriuresis, but UNCERTAIN
Continuous Renal Replacement Therapy (CRRT)

25
Continuous Renal Replacement Therapy (CRRT)
26
Pannu N, Renal replacement therapy in ICU, 2011
Severe Respiratory Distress
Often fail to improve with
Respiratory Failure
pharmacological therapy
Type I  pO2 decrease < 60

Type II  pCO2 increase > 45
Non-invasive ventilation may be used as adjunctive therapy to

relieve symptoms
ESC Guideline 2013
27
Non Invasive Ventilation
Continuous positive airway pressure (CPAP) and non-invasive positive pressure
ventilation (NIPPV) relieve dyspnoea and improve certain physiological measures in
patient with acute pulmonary oedema
Non-invasive ventilation may be used as adjunctive therapy to relieve symptoms in

patients with patients with pulmonary oedema and severe respiratory distress or who
fail to improve with pharmalogical therapy
Contraindication :
- Hypotension
- Vomiting
- Possible pneumothorax
- Depressed consciousnes
28
29
30
Heart Failure in Acute Coronary Syndrome
Very high risk condition
Should be assessed and treated according to the current acute

coronary syndrome guidelines
Undergo coronary angiography and revascularization as

appropriate  radial access
AHF in ACS
cont
It should be undertaken as an urgent procedure in patients with
haemodynamci intability and as an emergency procedure in those in
cardiogenic shock
BUTUnfortunately The condition of haemodynamic instability

persists despite optimal medical treatment
An IABP should be inserted before angiography

and revascularization
Intra Aortic Balloon Pump (IABP)
The conventional indication for IABP  to support the circulation
:
- before surgical correction of spesific acute mechanical problems
- During severe acute myocarditis
- Selected patient with AMI before, during and after
percutaneous or surgical revscularization
There is no good evidence that an IABP is benefit in other causess of cardiogenic shock

IABP
IABP
Intraaortic Balloon
Pump
34
Arrhytmia
• In heart failure patient population, cardiac arrhythmias frequently
contribute to worsened symptoms, periodic decompensations,
and increased mortality
• Arrhythmia recognition and management is an important aspect

of caring for these patients
• Acute heart failure predisposes to both supraventricular and

ventricular arrhythmias
Tedrow U and Stevenson WG. Management of Atrial and Ventricular Arrhythmias in Heart Failure. Marcel Dekker New York. 2005
Monomorphic Ventricular Tachycardia
Ischemic
Mechanisme of VT
 Patients with Ischemic Cardiomyopathy typically have large
areas of infarction. Surviving myocyte bundles present within
the infarction create channels for conduction set up reentry
circuits VT
 VT is typically monomorphic, with each QRS complex resembling the

preceding and following QRS complex
Monomorphic Ventricular Tachycardia
non ischemic
Mechanisme of VT
 Patients with non Ischemic Cardiomyopathy who develop
sustained monomorphic VT, most have evidence of large areas of
ventricular scar associated with a reentry circuit
 The scar may be a consequence of replacement fibrosis from the

myopathic process itself or due to infarcts from embolism of left
ventricular or atrial thrombus to a coronary artery.
Polymorphic Ventricular Tachycardia
Associated with QT interval prolongation is referred to as torsades de pointes. Any

cause of QT interval prolongation can cause torsades de Pointes
Mechanisme of VT
 Electrophysiological changes that accompany ventricular hypertrophy in chronic
heart failure may increase susceptibility to torsades de pointes
 Torsades de pointes is often ‘‘bradycardia-dependent’’ or ‘‘pause dependent,’’

with a characteristic initiating sequence
th
McMurray JJV, et al. European Heart Journal (2012) 33, 1787–1847 SymCARD 2014
40
Symptomatic Bradycardia and Atrioventricular Block
Indication for pacing
Issues specific to 1. Before implanting a conventional pace maker in a

HF patient with HF-REF, consider whether there is an
indication for ICD, CRT-P or CRT-D
2. Because Right ventricular pacing may induced
dysyncrony and worsen symptoms, CRT should be
considered instead of conventional pacing in patient
with HF-REF
th
SymCARD 2014
42
ECG in 3rd degree AV block
THANK YOU
44
Role of GP
Prompt diagnosis
Administer initial treatment
Risk stratification
Perform necessary consultation & referral
45
Acute Heart Failure and Its Comorbidities
- AHF with ACS
- AHF with Respiratory Failure
- AHF with Renal Dysfunction
- AHF with Ketoacidosis Diabeticum/KHONK
- AHF with Infection
46
Metabolic Acidosis
Acidemia is common in severe pulmonary edema due to
acute heart failure
Both the severity of the acidemia and the lowering of the

plasma bicarbonate concentration were closely related to
the plasma lactate concentration
47
HYPERTENSION Blood pressure should be reduced gradually by no more
thn 20 mmHg at a time
Cardiovascular event can occur if the diastolic

pressure is reuced below the level needed to
maintain perfusion to vital organs
It is advisable to maintain a minimum

post-treatment diastolic pressure of 60
mmHg or 65 mmHg in patient with
known CAD
48
Frequent finding
ANEMIA in adults with SOLVD Trial  22% of patients
HF had a hematocrit less than or
equal to 39% and 4% had
values below 35%
Symptoms from reduced oxygen delivery due to anemia
generally occur only wuth severe anemia but may occur at
less severely reduced hemoglobin levels in patient with heart
failure
Increase mortality associated with Hb

level < 13-13gr/dl
49
50
ACUTE HEART FAILURE MANAGEMENT ALGORITHM OF AHF
Dx algorithm Immediate resuscitation BLS, ALS
YES Analgesia/sedation
Definitive dx Distress or in pain
NO
Definitive tx ↑ FiO2, CPAP, NIPPV
NO
O2 saturation >95%
YES
NO Pacing, antiarrhythmics
Normal HR & rhythm
YES
Vasodilators, diuretic if volume
YES
MAP >70 / syst >90 overload
NO
NO Fluid challenge
Adequate preload
YES
NO Inotropes, IABP
Adequate CO, reversal of metab acidosis, SvO2 > 65%,
adequate perfusion YES Reassess frequently
51
Common manifestations
Features Symptoms Signs
Pulmo Dyspnea, fatigue Tachypnea, lung rales,
congestion effusion, tachycardia
Systemic Dyspnea, fatigue Peripheral oedema, ↑ JVP,
congestion hepatomegaly
Cardio. shock Confusion, weakness Poor peripheral perfusion,
cold periphery SBP <90, anuria/oliguria
High BP (HT HF) Dyspnea ↑ BP, LV hypertrophy,
preserved EF
Right heart Dyspnea, fatigue RV dysfunction, ↑ JVP,
failure peripheral edema,
hepatomegaly, ascites
AHA Guideline 2013
Causes and precipitating factors
Ischaemic heart disease Hypertension

• Acute coronary syndromes
• Mechanical complications of acute
Acute arrhythmia
MI Circulatory failure
• Right ventricular infarction • Septicaemia
• Thyrotoxicosis
Valvular • Anaemia
• Valve stenosis
• Valvular regurgitation • Shunts
• Endocarditis • Tamponade
• Aortic dissection • Pulmonary embolism
AHA Guideline 2013
Acute decompensation of heart failure (ADHF)
• De novo or as decompensation of chronic HF
• Signs and symptoms relatively mild
• Do not fulfil criteria for cardio shock, pulmonary edema or
hypertensive crisis
Hypertensive AHF
 Signs and symptoms of HF + high BP
 Relatively preserved LV fx
 CXR can resemble pulmonary oedema ESC Heart Failure Guideline, 2008
AHA Guideline 2013
Pulmonary edema
• Severe respiratory distress, orthopnea
• Crackles all over the lung
• O2 sat <90% on room air prior to treatment.
• Verified by CXR
ACS and HF
 15% of ACS patients have signs & symptoms of AHF
 Frequently associated with or precipitated by an arrhythmia
(bradycardia, AF, VT)
 Form: ADHF, pulmo edema, cardio shock, RHF
AHA Guideline 2013
Cardiogenic shock
• Evidence of organ hypoperfusion & pulm congestion
• ↓ BP (syst <90 mmHg, ↓ MAP >30 mmHg)
• Low urine output (<0.5 ml/kg/h)
• Continuum of low cardiac output syndrome.
Isolated Right HF
 Low output syndrome but no pulmonary congestion
 ↑ JVP, with or without hepatomegaly
 low LV filling pressures
AHA Guideline 2013
Diuretic
Loop diuretic: Furosemide
 Reduce congestion
Achieve optimal volume status
Initial dose: iv bolus 20-40 mg, titrated depends on

response, renal fx
• Onset of action: diuresis ~5 minutes
• Symptomatic improvement in acute pulmonary edema: 15-20 minutes;
occurs prior to diuretic effect
• Monitor urine output

Opie, 2011
18. If no response to doubling of dose of diuretic
despite adequate left ventricular filling pressure 
start i.v. infusion of dopamine 2.5 μg/kg/min. Higher
doses are not recommended to enhance diuresis.
58
Nitrate
Form: nitroglycerine (NTG)
Administration: SL, oral, iv.
Action: vascular smooth muscle relaxation of arteries & veins, more
prominent on veins.
• ↓ cardiac O2 demand by ↓ preload (LV end-diastolic pressure); reduce

afterload in high dose.
• Coronary artery dilation improves collateral flow to ischemic regions
• Onset: SL~3 minutes; Oral ~1 hour. SL can be given up to 3 times, in 5 min
interval. IV: start 10 ug/min, titrated up to 200 ug/min
AHA Guideline 2013
Action of Nitrates on Circulation
The major effect is on the

venous capacitance vessels,
with additional coronary and
peripheral arteriolar
vasodilatory benefit
60
Opie LH & Horowitz JD. Nitrates and newer antianginals. In: Drugs for the Heart. 7th ed. Saunders Elsevier. China
HEART
FAILURE
61
2013 ACCF/AHA Guideline for the Management of Heart Failure, Circulation. 2013;128:e240-e327
62
2013 ACCF/AHA Guideline for the Management of Heart Failure, Circulation. 2013;128:e240-e327

Bimbingan AHF

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Management of Acute Heart

Dysfunction can be related to systolic or diastolic

Often life threatening and requires urgent treatment

Cardio. shock Confusion, weakness Poor peripheral perfusion, SBP <90,

Right heart failure Dyspnea, fatigue RV dysfunction, ↑ JVP, peripheral

ESC Heart Failure Guideline, 2008

Dyspnea, orthopnea, paroxysmal

ESC Heart Failure Guideline, 2008

ESC Heart Failure Guideline, 2008

– ↓ volume overload & filling pressure

SUBSEQUENT: Definitive etiologic therapy

Fluid administration Normal BP: vasodilator

Diabetes ACS Common and greatly

Respiratory Failure Infection ESC Heart Failure Guideline, 2008

- Critical ill insulin

Fluid Deficit = Osmolarity -295x0,6xkgBW

Acute inflammation can not only depress myocardial function, but it

AHA Guideline 2013 18

Decrease SVR = (MAP-RAP)x80

Severe Sepsis and septic shock condition  observes

Kaplan J.L et al, SIRS 2015

An acute renocardiac syndrome  characterized by worsening cardiac

The Main Management : Limit the use of renin-angiotensin-

Marvin A, Renal function and Heart Failure

I.V diuretic (Force Diuretic) potential to

Continuous Renal Replacement Therapy (CRRT)

Type I  pO2 decrease < 60

Non-invasive ventilation may be used as adjunctive therapy to

Non-invasive ventilation may be used as adjunctive therapy to relieve symptoms in

Very high risk condition

Should be assessed and treated according to the current acute

Undergo coronary angiography and revascularization as

BUTUnfortunately The condition of haemodynamic instability

An IABP should be inserted before angiography

ESC Heart Failure Guideline, 2012 33

• Arrhythmia recognition and management is an important aspect

• Acute heart failure predisposes to both supraventricular and

 VT is typically monomorphic, with each QRS complex resembling the

 The scar may be a consequence of replacement fibrosis from the

Associated with QT interval prolongation is referred to as torsades de pointes. Any

 Torsades de pointes is often ‘‘bradycardia-dependent’’ or ‘‘pause dependent,’’

Indication for pacing

Issues specific to 1. Before implanting a conventional pace maker in a

Administer initial treatment

Perform necessary consultation & referral

Both the severity of the acidemia and the lowering of the

Cardiovascular event can occur if the diastolic

It is advisable to maintain a minimum

Increase mortality associated with Hb

Dx algorithm Immediate resuscitation BLS, ALS

Ischaemic heart disease Hypertension

Initial dose: iv bolus 20-40 mg, titrated depends on

ESC Heart Failure Guideline, 2008

• ↓ cardiac O2 demand by ↓ preload (LV end-diastolic pressure); reduce

The major effect is on the

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