Acute Heart Failure

• Dilated– Nonischemic/Familial dilated cardiomyopathy– Myocardial ischemia– Valvular disease– Peripartum cardiomyopathy– Toxin

• Non-dilated– Myocarditis– Myocardial ischemia– Valvular disease– Infiltrative cardiomyopathy– Acute stress cardiomyopathy

Differential Diagnosis

• Ischemic heart disease• Valvular heart disease

– Endocarditis• Sepsis

– immunocompromised

• Unmasked cirrhotic cardiomyopathy• Infiltrative cardiomyopathy

Clinical Assessment of Hemodynamic Status

Congestion at Rest

Signs/Symptoms of Congestion::

Orthopnea / PND Cough Dyspnea Elevated JVP Hepatomegaly Edema Rales

LowPerfusionat Rest

C

NO

NO YES

YES

L

A BWarm &

DryWarm &

Wet

Cold & Wet

Cold & Dry

(Complex)(Low Profile)

Possible Evidence of Low Perfusion:Cool extremities/poor pulses HyponatremiaDecreased mental status HypotensionNarrow pulse pressure Renal dysfunction

Nohria A et al., JAMA 2002

Hemodynamic Changes in Cirrhosis

• Increased cardiac output

9.0 ± 3.0 l/min• Decreased systemic vascular resistance

861 ± 333 dynes-sec-cm-5• Decreased mean arterial pressure

76 ± 16 mmHg• Normal wedge pressure

10 ± 5

Dig Dis Sci 2009;54:869

Cirrhotic Cardiomyopathy

• “A form of chronic cardiac dysfunction in patients with cirrhosis, characterized by blunted contractile responsiveness to stress, and/or altered diastolic relaxation with electrophysiologic abnormalities in the absence of other known cardiac disease.”

Gut 2008;57:268

Differential Diagnosis

• Ischemic heart disease• Valvular heart disease• Sepsis• Unmasked cirrhotic cardiomyopathy• Infiltrative cardiomyopathy

Infiltrative Cardiomyopathy

• Amyloidosis• Sarcoidosis• Hemochromatosis

Iron Overload

• Hereditary Hemochromatosis– C282Y homozygous– C282Y/H63D compound heterozygote

• Secondary– Anemia ± Transfusions– Liver Disease– Dietary iron overload

Porto-systemic Shunting

• Decrease in first-pass iron metabolism in the liver

• Increased duodenal iron absorption• Although rare, case reports of shunts

potentially leading to iron overload states including cardiomyopathy (1960s)

Diagnosis

• Progressive heart failure culminating in cardiogenic shock due to secondary hemochromatosis

• Potential contribution from “cirrhotic cardiomyopathy”