ACUTE HEART

FAILURE
OLEH:
Gusti Ayu Temi V.
Melyana

Narasumber:
dr. Daniel Tobing, SpJP (K)
 Outline
Introduction
Terminology
Definition
Classification
Precipitating factors
Pathophysiology
Clinical profiles
Sign and symptoms
Clinical presentation
Diagnosis
Management
Case ilustration
 Introduction
Acute heart failure is among the most common causes for
hospitalization in patients >65 y.o in the developed world

The number of hospitalization for HF has tripled during the past 3

decades, because:

The aging of the population

The reduction in hypertension-related mortality
The greatly improved survival after MCI
The availability of effective therapy for prevention of sudden death
The 2016 ESC guidelines for the diagnosis and treatment acute and
chronic HF has published to help health professionals to make
decisions based on the best available evidence

Braunwalds Heart disease, tenth edition

 Terminology
HF with preserved, mid-range and reduced EF
Important due to different underlying etiologies, demographics, co-morbidities
and response to therapy
Related to the time course of HF
Asymptomatic LV systolic dysfunction
Chronic HF
Stable HF in deteriorates decompensated
New onset (de novo)
Congestive HF
Related to the symptomatic severity of HF
The NYHA functional classification
Advanced HF: severe symptoms, recurrent decompensation and severe
cardiac dysfunction
ESC Guidelines 2016
ESC Guidelines 2016
 Definition

AHF refers to rapid onset or worsening of symptoms and/or

signs of HF

Life-threatening medical condition requiring urgent evaluation and treatment,

leading to urgent hospital admission

AHF may present as:

A first occurrence (de novo)
A consequences of acute decompensated of chronic HF

ESC Guidelines 2016

 Classification
A large number of overlapping classification of AHF

Based on clinical presentation at admission:

Preserved SBP (90-140 mmHg)
Elevated SBP (>140 mmHg)
Low SBP (<90 mmHg) hypotensive AHF (poor prognosis)
Based on the presence of the following precipitants:
ACS, hypertensive emergency, rapid arrhythmias, severe bradycardia/conduction
disturbance, acute mechanical cause underlying AHF or acute PE
Based on bedside physical examination (wet vs. dry ; cold vs. warm)

Pt HF complicating AMI can be classified according to Killip

ESC Guidelines 2016

 Precipitating
Factors of
AHF

ESC Guidelines 2016

Pathogenesis
 Pathophysiology

Braunwalds Heart disease, tenth edition

Pathophysiology
 Clinical
Profiles of
Patients
with
AHF

ESC Guidelines 2016

 Sign and
Symptoms

Braunwalds Heart disease,

tenth edition
 Clinical Presentation

Hypertensive AHF

Acutely
Decompensated
Chronic HF
PULMONARY
OEDEMA
ACS and
HF

Right HF
Cardiogenic
shock

ESC Guidelines 2008

 Clinical Presentation
Worsening or decompensated chronic HF (peripheral
oedema/congestion)
there is usually a history of progressive worsening of known
chronic HF on treatment, and evidence of systemic and
pulmonary congestion.
Low BP on admission is associated with a poor prognosis.
Pulmonary oedema
patients present with severe respiratory distress,
tachypnoea, and orthopnoea with rales over the lung fields.
Arterial O2 saturation is usually ,90% on room air prior to
treatment with oxygen.

ESC Guidelines 2008

 Clinical Presentation
Hypertensive HF
signs and symptoms of HF accompanied by high BP and usually
relatively preserved LV systolic function.
There is evidence of increased sympathetic tone with tachycardia
and vasoconstriction.
The patients may be euvolaemic or only mildly hypervolaemic, and
present frequently with signs of pulmonary congestion without signs
of systemic congestion.
The response to appropriate therapy is rapid, and hospital mortality
is low.

ESC Guidelines 2008

 Clinical Presentation
Cardiogenic shock
evidence of tissue hypoperfusion induced by HF after
adequate correction of preload and major arrhythmia.
no diagnostic haemodynamic parameters cardiogenic
shock is characterized by reduced systolic blood pressure
(SBP < 90 mmHg or a drop of mean arterial pressure > 30
mmHg) and absent or low urine output < 0.5 mL/kg/h).
Rhythm disturbance are common.
Evidence of organ hypoperfusion and pulmonary congestion
develop rapidly.

ESC Guidelines 2008

 Clinical Presentation
Isolated right HF
characterized by a low output syndrome in the absence of
pulmonary congestion with increased jugular venous pressure, with
or without hepatomegaly, and low LV filling pressures.

ACS and HF
many patients with AHF present with a clinical picture and
laboratory evidence of an ACS.
Approximately 15% of patients with an ACS have signs and
symptoms of HF.
Episodes of acute HF are frequently associated with or precipitated
by an arrhythmia (bradycardia, AF, VT).
ESC Guidelines 2008
 Diagnosis
Needs to be started in the pre-hospital setting and
continued in the emergency department

Initial diagnosis of AHF should be based on a

thorough history assessing symptoms, prior
cardiovascular history and potential cardiac and non-
cardiac precipitants
As well as on the assessment of signs/symptoms of
congestion and/or hypoperfusion by physical
examination and further additional investigation

ESC Guidelines 2016

Diagnostic Measurements

ESC Guidelines 2016

ECG Analysis

ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012
Laboratory test

ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012
Laboratory test : cont

ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012
 Chest X Ray
In chronic HF usually
demonstrates increased
heart size , but
cardiomegaly sometimes
absent in acute HF
Progression of pulmonary
congestion:
first: Cephalization
second : Interstitial
edema
third: Pulmonary
(alveolar) edema
 Echocardiography
Evaluate:
Chamber dimension
Valvular structure
Ventricular function
global & regional
Mechanical
complicating AMI
Pericardial pathology
Management of Acute
Heart Failure
 Goal of Treatment
In
Acute Heart
Failure

ESC. 2016 ESC Guidelines for the diagnosis and treatment of

acute and chronic heart failure. Eurheartj. 2016;2183
 Initial
Management
of Acute Heart
Failure
The criteria for ICU/CCU
admission:
need for intubation (or already
intubated)
signs/symptoms of
hypoperfusion
oxygen saturation (SpO2) <
90% (despite supplemental
oxygen)
use of accessory muscles for
breathing, respiratory rate
> 25/min
heart rate <40 or >130 bpm,
SBP <90 mmHg
ESC. 2016 ESC Guidelines for the diagnosis and treatment of
acute and chronic heart failure. Eurheartj. 2016;2174-2177
Rapid Assessment of Haemodynamic
Profile
 Congestion at rest?
No Yes
Low perfusion at rest

No A B
Warm & dry Warm & wet

Cold & Wet

Cold & dry

L
Right heart failure
Dehydration Fluid loading
C
Yes
Excessive diuretics Inotropic

European Heart Journal of Heart Failure,2005;

March. Vol 7:323-331
 Congestion at rest?
No Yes Diuretics
Low perfusion at rest
Vasodilator(nitrat)

ADHF
No A B
Acute pulmonary
edema
Hypertensive HF
Warm & dry Warm & wet

Cold & Wet

Cold & dry

L C
Yes

European Heart Journal of Heart Failure,2005;

March. Vol 7:323-331
 Congestion at rest?
Yes
Diuretic
No
Low perfusion at rest
Vasodilator

No A B
Warm & dry Warm & wet

Cold & Wet

Cold & dry

L C
Syok Kardiogenik
STEMI akut Killip 4
Yes
Inotropic drugs :
Dobutamine
Milrinon
Norepinephrine
IABP
European Heart Journal of Heart Failure,2005;
March. Vol 7:323-331
 Management
Based of
Hemodynamic
Profile

ESC. 2016 ESC Guidelines for the diagnosis and

treatment of acute and chronic heart failure. Eurheartj.
2016;2178
Pharmacological agents
and supportive
instruments
 Pharmacological Agents:
Acute Treatment
Oxygen

May be given to treat hypoxaemia (SpO2 < 90%)

Should not be used routinely in non-hypoxaemic

vasoconstriction

ESC. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure.
Eurheartj. 2016;
Recommendation For Oxygen Therapy

ESC. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure.
ESC. 2016
Eurheartj. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure.
2016;
Eurheartj. 2016;
 Pharmacological Agents:
Acute Treatment
Diuretic

Mechanism :

Increase renal salt and water excretion

vasodilatory effect.
diuretics should be avoided before adequate perfusion is
attained.

The initial i.v. dose should be at least equal to the preexisting

oral dose used at home.

ESC. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure.
Eurheartj. 2016;
Pharmacological Agent

Diuretic

ESC. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart
failure. Eurheartj. 2016;
 Pharmacological Agents:
Acute Treatment
Opiates
Mechanism :

Reduce anxiety
Relieve distress associated with dyspnoea
Venodilators characteristic
Reducing preload
Reducing sympathetic drive

Side effects :
Respiratory distress
Nausea

ESC. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eurheartj.
 Pharmacological Agents:
Acute Treatment
Vasodilators
Mechanism : Reduce preload and afterload and
increase stroke volume
Most useful in patients with hypertension
Should be avoided in patients SBP < 90 mmHg.
Avoid excessive falls in blood pressure
hypotension is associated with higher mortality
Recommendation For
Vasodilator Drug

ESC. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic
heart failure. Eurheartj. 2016;
ESC. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic
heart failure. Eurheartj. 2016;
 Pharmacological Agents:
Inotropes
Acute Treatment
Reserved for severe CO reduction (Cardiogenic shock).
May cause sinus tachycardia,ischaemia and arrhythmias.
Long-standing concern that they may increase mortality.
Vasopressors
peripheral arterial vasoconstrictor
action e.g NE
Raise BP and Redistribute CO to
the vital organs
adverse effects similar to
inotropes
Restricted to patients with
persistent hypoperfusion despite
adequate cardiac filling pressures.
Recommendation For Inotropic and
Vasopressor Drug

ESC. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic
heart failure. Eurheartj. 2016;
 Pharmacological Agents:
Stabilized
ACEi/ARB
Should be started as soon as possible (esp rEF) BP and renal function
evaluation
up-titrated as far as possible before discharge, and a plan made to
complete dose up-titration after discharge
Aldosteron Reseptor Antagonis
Should be started as soon as possible (esp rEF) renal function and
Potassium evaluation
MRA dose for HF has minimal effect on BP start during admission
regardless of hypotension
up-titrated as far as possible before discharge, and a plan made to
complete dose up-titration after discharge
 Pharmacological Agents:
Stabilized
Beta-blocker

Started ASAP after stable (esp rEF) evaluate BP and HR

up-titrated as far as possible before discharge, and a plan made to
complete dose up-titration after discharge.

Digoxin
rEF, control the Ventricular Responsee in AF if impossible to up-
titrate the beta-blocker.
Provide symptom benefit and reduce the risk of HF hospitalization in
patients with severe systolic HF
 Non Pharmacological Therapy :
Fluid Restriction
Restrict sodium intake to <2 g/day and fluid intake to <1.5
2.0 L/day during the initial management of an acute
episode of HF
 Non Pharmacological Therapy:
Ventilation
A. Non Invasive

CPAP and NIPPV relieve dyspnoea and improve SaO2 in ALO

Adjunctive therapy to relieve symptoms in patients with ALO and
severe respiratory distress unresponse to pharmacological therapy.
Contraindications include hypotension, vomiting, possible
pneumothorax, and depressed consciousness.

B. Invasive

primary indication ET intubation is:

respiratory failure leading to hypoxaemia, hypercapnia, and
acidosis.
Physical exhaustion, diminished consciousness,
inability to maintain or protect the airway
 Non Pharmacological Therapy:
Mechanical Circulatory Support
A. Intra-Aortic Balloon Pump
indications for IABP :
Bridging to surgical
correction
Severe Acute Myocarditis
Acute MCI before, during,
after revasc
Bridge to Implant or VAD

B. Ventricular Assist Device

Ultrafiltration

ESC. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic
heart failure. Eurheartj. 2016;
AHF with Cardiogenic Syock

ESC. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic
heart failure. Eurheartj. 2016;
AHF with Acute Lung Oedema

ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012
AHF with ACS

ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012
AHF with Atrial Fibrilation

ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012
ESC. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic
heart failure. Eurheartj. 2016;
ESC. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic
heart failure. Eurheartj. 2016;
Case Illustration
 Identitas
Nama : Ny LPH
Jenis kelamin : wanita
Usia : 66 thn
Pendidikan :-
Alamat : Sambas, Kalimantan Barat
No RM : 2016-41-12-83
Tanggal Masuk : 31-08-2016
 Anamnesa
Dilakukan secara : Aloanamnesa
Keluhan Utama : Sesak Napas
 Riwayat Penyakit Sekarang
Pasien mengalami sesak napas yang semakin memberat sejak 1
bulan yang lalu. Pasien mengalami sesak napas yang bertambah
dengan aktivitas. Pasien tidur dengan beberapa bantal. Ada
riwayat terbangun pada malam hari karena sesak. Keluhan
demam dan nyeri dada disangkal.
Pasien dirujuk dari RS GK dengan diagnosis MR acute ec ruptur
chordae papilaris ec MCI posterior + lung oedem refrakter. Tiga
minggu yang lalu pasien dirawat di bandung dengan keluhan
batuk-batuk.
Dua minggu yang lalu os dinyatakan mengalami infeksi paru-
paru dan dirawat di RS GK, mengalami perburukan dan
dilakukan intubasi lalu dirujuk ke RSJHK.
 Riwayat Penyakit Dahulu

Riwayat DM (+)
Hipertensi (+)
Dislipidemi (+)
 Riwayat Terapi Sebelumnya
Noradrenalin 0,09 mcg/Kg BB/ jam
Dobutamine 5 mcg/Kg BB/jam
Furosemide 20 mg/jam
Meropenem 3 x 1 gr
Cravit 1x 750 mg/hari
Gastrofer 2x1 iv
Ondansetron 2 x 8 mg iv
Vectrin 3x1
Atorvastatin 1x1
Sukralfat 3x10cc
Ramipril 3x2,5mg
 Pemeriksaan Fisik
Kesadaran : Somnolen, terintubasi
Tanda vital :
TD : 95/65 dengan support
HR : 110x/menit
RR : 30x/menit, Sat O2 : 100% on intubasi
Cor : S1, S2 reguler, pansistolik murmur 2/6 di apex,
gallop tidak ada
Pulmo : vesikuler, ronkhi basah halus kedua lapang paru,
wheezing -/-
abdomen : supel , BU normal, Liver tak teraba membesar
Ekstrimitas : oedem -/-, akral hangat
EKG
EKG (cont)
EKG (cont)
 Penunjang
Ro Thorax (RS GK) : Kardiomegali, oedem paru bilateral
terutama kanan
DPL (RS Graha) : Hb 11,4; L 15.200; Tr 319.000; Ur 52; Cr 0,9;
GDS 138 gr/dl
AGD : pH 7,26; pO2 163; pCO2 54; saO2 99%; BE -2,6
Elektrolit : Na 141; K 4,7; Cl 98
PCR TB (-)
Analisis Cairan Effusi : Cairan jernih , mengandung lekosit, sel
ganas (-)
Rontgen

2 September 2016
 Echocardiography
Dilakukan tanggal 1 September 2016
Pemeriksaan on norepinephine 0.05 mcg/kgBB/min dan
dobutamin 5 mcg/kgBB/min
Hasil:
EDP = 67 / ESD = 56 / EF 39% / TAPSE 1,7
Hipoketik berat inferior, inferolateral
MR severe ec. Prolaps & flail PML
Ruptur kordae (+) peak E 2,0, PV sistolik Rev (+)
IVC = 22/16 ; LVOT VTI = 21 cm ; LVOT diameter = 1,8 ; SV
= 53,4 ; CO = 5,4 liter / menit ; SVR = 745 dyne
Kesan: Volum cukup, SV dan CO normal, SVR menurun
 Diagnosa Kerja
Acute MR severe ec. MVP, rupture cordae

Respiratory failure ec. ALO on ventilator

Efusi pleura bilateral post tapping pleura kiri (28/08/16)

CAP on antibiotik dd/ TB paru

 Terapi
Noradrenalin 0,03 mcg/Kg BB/ jam IV drip
Dobutamine 5 mcg/Kg BB/jam IV drip
Furosemide 20 mg/jam IV drip
Meropenem 3 x 1 gr IV
Levofloxacin 1x 750 mg/hari IV
Theragram M 1x1 amp IV
Sprironolactone 1x50 mg PO
Trizedone MR 2x1 tab PO
Atorvastatin 1x20 mg PO
Ramipril 2x2,5mg PO
Vectrin 3x1 tab PO
Terima Kasih