ADHF ppt.pptx

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ACUTE DECOMPENSATED HEART FAILURE

ACUTE DECOMPENSATED HEART FAILURE : 2010 HFSA GUIDELINESBART COX, M.D., FACCASSOCIATE PROFESSOR OF MEDICINEUNIVERSITY OF NEW MEXICO SCHOOL OF MEDICINEDIRECTOR, ADVANCED HEART FAILURE PROGRAM

DISCLOSURESNONEOBJECTIVESUNDERSTAND THE DEFINITION OF ADHFUNDERSTAND THE 4 HEMODYNAMIC PROFILES AND HOW TO CORRELATE THERAPY TO EACH PROFILEUNDERSTAND METHODS OF DECONGESTIONUNDERSTAND THE USE OF IV VASODILATORS2010 HEART FAILURE SOCIETY OF AMERICA GUIDELINESJOURNAL OF CARDIAC FAILURE 2010; 16:475-539 (EXECUTIVE SUMMARY)JOURNAL OF CARDIAC FAILURE 2010; 16: e1-e194 (COMPLETE GUIDELINE) ACUTE DECOMPENSATED HEART FAILURE (ADHF): DEFINITIONJACOBELLIS V. OHIO (1964) AND SUPREME COURT JUSTICE POTTER STEWARTNEW ONSET OR GRADUAL OR RAPIDLY WORSENING HEART FAILURE SIGNS OR SYMPTOMS REQUIRING URGENT THERAPY.HEART FAILURE STATISTICS>5.5 MILLION HF PATIENTS IN USA>650,000 NEW HF CASES ANNUALLY ANNUAL US COST OF HF IN 2010 (DIRECT AND INDIRECT): $39.2 BILLION1 YEAR MORTALITY IS 20%5 YEAR MOTALITY IS HIGH AND WORSE FOR MALESMALES: 59%FEMALE: 45% ADHF STATISTICS1 MILLION ADHF HOSPTIAL ADMISSIONS ANNUALLYANOTHER 2 MILLION ANNUAL ADMISSIONS IN WHICH HF COMPLICATED THE PRIMARY DIAGNOSIS30-50% OF PATIENTS DISCHARGED WITH ADHF WILL BE READMITTED WITHIN 3-6 MONTHS

ADHF STATISTICS50% OF ADHF ADMISSIONS HAVE LVEF > 40%50% OF ADHF ADMISSIONS HAVE LVEF < 40%AVERAGE PATIENT ADMITTED WITH ADHF IS 75 YEARS OF AGE WITH SUBSTANTIAL COMORBIDITIESMOST COMMON CAUSE OF ADHF HOSPITALIZATION IS EXACERBATION OF CHRONIC HEART FAILUREIN HOSPITAL MORTALITY: 4%HFSA GUIDELINES: WHO SHOULD BE HOSPITALIZED WITH ADHF? EVIDENCE OF SEVELY DECOMPENSATED HFALTERED MENTATIONHYPOTENSIONWORSENING RENAL FUNCTIONDYSPNEA AT REST (RESTING 02 SAT 18 OR RA PRESSURE > 8WARM= CARDIAC INDEX> 2.2COLD= CARDIAC INDEX < 2.2RECOGNIZING THE FOUR HEMODYNAMIC PROFILES2 COMPONENTS OF DECOMPENSATED HEART FAILUREELEVATED FILLING PRESSURES (MOST COMMON)REDUCED CARDIAC INDEX (RARE)2 MINUTE ASSESSMENT AND THE 4 HEMODYNAMIC PROFILES

PRINCIPLES OF THERAPY IN A CONGESTED PATIENT: DECREASE THE FILLING PRESSURESRELIEVE CONGESTION BY REDUCING FILLING PRESSURESABSENT CRITICAL ORGAN HYPOPERFUSION THAT LIMITS REDUCING THE FILLNG PRESURES, IMPROVING CARDIAC INDEX DOES NOT WORK!!!!PRINCIPLES OF THERAPY: THE OPTIMAL FILLING PRESSURE OPTIMAL PCWP IS < 15-16 mm Hg; RA IMPROVED SVWHATS WRONG WITH ELEVATED FILLNGPRESSURES? RESPONSIBLE FOR CONGESTIVE SYMPTOMSACTIVATE NEUROHORMONES (RAS, SNS)INCREASE VALVULAR REGURGITATIONRESPONSIBLE FOR PULMONARY HTNCAUSES RIGHT VENTRICULAR DYSFUNCTIONCAUSES ABNORMAL LV FILLNG PATTERNS FILLING PRESSURES AND STROKE VOLUME (SV)

STROKE VOLUME IMPROVED BY DECREASING MITRAL REGURGITATION

Warm and dry

Warm and wet

PROFILE B: WET AND WARMMOST PATIENTS PRESENTING WITH ADHF ARE PROFILE BGOAL OF TX: SX IMPROVEMENT BY REDUCTION OF FILLING PRESSURESFOR MAJORITY, IV DIURETIC TX IS THE MAIN INTERVENTIONMAY NEED TO ADD 2.5-10 mg METOLAZONE PO OR CHLORTHIAZIDE 500-1000 mg IV PROFILE B: ROLE FOR ADJUNCTIVE AGENTS USE OF ADJUNCTIVE THERAPIES BEYOND DIURETICS HAS NOT BEEN DEMONSTRATED TO IMPROVE OUTCOMES IN HOSPITALIZED ADHF PATIENTS WITH PROFILE BINOTROPES: ISCHEMIA/ARRHYTHMIAS/ DEATHNESIRITIDE: EXPENSIVE PLACEBOENDOTHELIN ANTAGONIST: NO IMPROVEMENTVASOPRESSIN ANTAGONIST: NO SUSTAINED BENEFITPROFILE B: VERY HIGH OR VERY LOW SYSTEMIC VASCULAR RESISTANCE (SVR)VERY HIGH SVR= > 1500 dyne/sec/cm-5HOW TO RECOGNIZE HIGH SVR:HIGH BPVERY NARROW PULSE PRESSUREPA CATHETER MEASUREMENTVERY LOW SVR (WITHOUT MEDS)= LOW BP + REASONABLE PULSE PRESSURE + WARM EXTREMITIESPROFILE C: COLD AND WET

PROFILE C: COLD AND WET< 3% OF PATIENTS PRESENT WITH CARDIOGENIC SHOCKWET = CONGESTION (PCWP>18)COLD = INADEQUATE PERFUSION (CI85mm Hg: VASODILATORSBP