HEART FAILURE

EMERGENCY DEPARTMENT
Liu Chenyan

heart-four charmber veiw

oxygen

carbon dioxid out

trachea
arota
pulmonary artery
pulmonary
venous
left
ventricle

Cardiac Physiology

pump to ensure CO and CI

CO 4.0~ 6.0 L/min
CI 2.5 ~ 4.0 L/min/m2 at rest.
change according to oxygen
demand

Adaptability

DO2=COCaO2
=SVHRCaO2
=EDVEFHRCaO2

oxygen demand
rest/sleeping
physical exercising
sepsis

Neurohormonal Modulation

Adaptive Mechanisms
Physiologic Mechanisms

Increase in SV
Increased SVR
Development of Cardiac Hypertrophy

Neurohormonal Modulation

Cardiac Neurohormonal Response(stimulation of

sympathetic activity)
Renal Neurohormonal Response(RAAS)
Vascular Endothelial Neurohormonal
Response(Endothelin/NO)

Preload(EDP)
the filling volume

ventricular compliance

Frank-Starling mechanism
Increased preload improves SV
irrespective of the contractile state of the ventricle.

Afterload

pressure against heart ejecting

blood
determined by the SVR and the
cardiac chamber size
SVR regulatored by neurohumoral
BP = CO SVR

HR and rhythmic
contraction

CO = HR SV
HR 150 ~ 160 bpm , CO
HR >160 bpm ,CO

cardiac natriuretic
peptides

atrial natriuretic peptide

brain natriuretic peptide
C-type natriuretic peptide

promote water and sodium

excretion
increase peripheral vasodilation
inhibit the RAAS

DEFINITION

incapable of pumping a sufficient

supply of blood to meet the
metabolic requirements of the
body

requires elevated ventricular filling

pressures to accomplish this goal

Heart failure may occur as

a result of

systolic dysfunction
diastolic dysfunction
other cardiac abnormalities, including
valvular disease, intracardiac shunting,
or arrhythmia
states in which the heart is unable to
compensate for increased peripheral
blood flow or metabolic requirements.

Clinial Evaluation of Patients

with Suspected HF

Sodium and volume excess

Systemic hypertension
Myocardial infarction or ischemia
Systemic infection
Dysrhythmias
Acute hypoxia or respiratory problems
Anemia
Pregnancy
Thyroid disorders
Acute myocarditis
Acute valvular dysfunction
Pulmonary embolus
Excess exertion or trauma
Pharmacologic complications

Pathphysiology and
Clinical Feature

pulmonary edem
systemic congestion
decreased tissue dyspnea
perfusion

edem
poor exercise
tolerance
dizzness,chronic
fatigue
tachycardia,diaphoresi

Evaluation

exercise torlerence
UCG
CR/CT
BNP
ABG
Pulmonary artery catheter(SwanGanz)

UCG

morpohologic change
LV,RV
functional change
LV Systolic function
LV Diastolic function
RV controversial?
hemodynamic information
SV,CO,PASP,HR

2.LV Systolic function 2Dsimpson

EDV
SV=EDV-ESV
EF=(EDVESV)/EDV

ESV

3.Diastolic dysfunction

Transmitral flow velocities

early diastolic filling velocity
relaxation----E
late diastolic filling velocity
compliance----A

E/A>1
EDT
19932ms
affected by preload,age and HR

Classfication of Diastolic
dysfunctionII type
III/IV type
I type

compliance

compliance
+relaxation

restrictive reversibl
ersible

E/A<1

E/A>1

E/A>2

EDT>220ms

EDT 150~220ms

EDT<150ms

CR

intersitial and
alveolar edema
with or without
cardiomegaly

CT

Kerley B

CT

ABG

hyoxemia
hypocapnia

CLASSIFICATION

Right-Sided
versus Left-Sided
Heart Failure

Systolic versus
Diastolic
Dysfunction

Acute versus
Chronic Heart
Failure

High-Output
versus LowOutput Failure

UCG

Left

Right

Manifestation of HF

left HF

right HF

congestive
HF

dyspnea
fatigue
dizziness

edema

edema
dyspnea

Left or Right

Coronary Artery Disease

Cardiomyopathy and
Myocarditis
Valvular Heart Disease
Pericardial Diseases
AMI(RV)
Pulmonary artery
hypertension

Left HF

RIGHT HF

Systolic or Diastolic
systolic dysfunction Diastolic
LVEF < 40%
dysfunction
failure of ventricular
LV dialation

relaxation with
consequent high
filling pressures
E/A>2
not with LV dialation
may exist in up to
The American Heart Association (AHA) and
half of older
American College of Cardiology (ACC)
individuals with HF
guidelines

UCG

hypofunction

regional wall motion

abnormality cardiac ischemia
difuse wall motion abnormality
myocarditis Dialated Cardiomyopathy

EF
normal
mild decrease
moderate
decrease

value %

50~70

40~50
30~40
severe decrease <30

hyperfunction

volum deficit
dehydration massive haemorrhage

High-Output
anemia hyperthiorodism sepsis

Classfication of Diastolic
dysfunctionII type
III/IV type
I type

compliance

compliance
+relaxation

restrictive reversibl
ersible

E/A<1

E/A>1

E/A>2

EDT>220ms

EDT 150~220ms

EDT<150ms

Diastolic dysfunctionn

AMI
Hypertensive heart disease
HCM
RCM

Tips

Left HF

Right HF

systolic dysfunction
diastolic dysfunction

systolic dysfunction

hemodynamic change
pulmonary edem
systolic
dysfunction
Diastolic
dysfunction

LVEDP

High-Output or LowOutput

High-Output
CO
SVR

Low-Output
CO
SVR

BP = CO SVR

High-Output or LowOutput

Septic
anemia
Pregnancy
Thyroid
disorders

volum
deficit

High-Output

Low-Output

UCG

SEPSIS

High-Output

low-Output

Acute or Chronic
1.History
2.ventricular remodeling
3.Left+right

Acute or Chronic

Acute HF

Chronic
HF

AMI
massive PE
ischemic heart diease
rheumatic heart
disease
chronic cor pulmonale
congenital
cardiovascular disease

Evaluation of AHF

I. No evidence of HF

II. Presence of left HF,pulmonary rales

accounts for <50% lung fields

III. Pulmonary edema,pulmonary rales

accounts for >50% lung fields

IV. cardiac shock

Killip classification

Evaluation of CHF

I. Asymptomatic on ordinary physical activity

II. Symptomatic on ordinary physical activity

III. Symptomatic on less than ordinary physical

activity

IV. Symptomatic at rest

New York Heart Association Functional Classes

Diagnose of HF

Acute or Chronic
Left or Right
Systolic or Diastolic
High-Output or Low-Output

Diagnose flow chart

symptom

BNP+Tn
T
+ABG

UC
G

Left/Rig
ht
Systolic/Diasto
lic
Acute/Chronic

High-Output/LowOutput

CR/CT
ARDS?
morphologi
c diagnose
hemodynam
ic
information

etiolog
y
treatme
nt

PRIMARY DISEASE PROCESSES RESULTING

AMI
IN HF
Hypertension crisis
Acute myocarditis
Acute valvular
dysfunction
Septic Myocarditis

Acute left heart

failure

Acute right heart failure

congestive heart
failure

Pulmonary
embolus
AMI(RV)

Infection
Sodium and volume
excess
Pregnancy

Differenation of HF

cardiac
dyspnea

dependent
edema

asthma
AECOPD
ARDS
Cardiac tamponate

Constructive
pericardial

asthma

widespread bronchospasm(reversible)
not associated with exercising or position
ABG:hypercapnia
BNP:normal
UCG:RV dialation/pulmonary artery
hypertension
CT:emphysema
glucocorticoid
short-acting bronchodiator

CT

AECOPD

progressive airflow obstruction caused by

chronic bronchitis or emphysema
partially reversible
not associated with position
ABG:hypercapnia
UCG:RV dialation/pulmonary artery

hypertension
CT:emphysema

short-acting bronchodiator
glucocorticoid

ARDS

noncardiogenic pulmonary edema,

hypoxia, and diffuse lung consolidation.
not associated with position
ABG:hyoxemia,hypocapnia
UCG:mild pulmonary artery hypertension
CT:diffuse infiltration
ventilatory support
glucocorticoid?

CT

Cardiac tamponate

Pericardial effusion accumulated

rapidly
Resticts venous return and
ventricular filling
cancer,tuberculosis
UCG

Cardiac tamponate

Constructive pericardial

thickend, fibrotic,adherent
pericardium that restricts diastolic
filling pressure
tuberculosis,radiation therapy or
cardiac surgery
UCG:a thick pericardium and small
chamber
CT:pericardial calcification

CT

TREATMENT OF AHF

Acute Heart Failure with Adequate

Perfusion

case report 1

76y, male
chest comfort,dyspnea,
dizzness,weakness
worsen on supine position
hypertension
smoking

physical examination

uncomfortable,diaphoretic
BP90/62mmHg, HR112bpm R
26breath per minute, SPO293%
normal jugular venous
rales on both lung fields
tachycardia, no murmurs

ECG

ABG

Blood test

BNP elevated

UCG

CT

pulmonary edema

Diagnose

asthma
AECOPD
ARDS
PE
HF
Cardiac tamponate

case report 2

78y,female
productive cough,dyspnea,edema
worsen on supine position
COPD,OMI

physical examination

uncomfortable,diaphoretic
BP156/92mmHg, HR112bpm R
26breath per minute, SPO293%
normal jugular venous
wheels on both lung fields
tachycardia, systolic murmur on
apex

ABG

Blood test

BNP elevated

UCG

CT

Diagnose

asthma
AECOPD
ARDS
PE
HF
Cardiac tamponate

answer

case1 HF
case2 HF,AECOPD

Thanks