Edema polmonare acuto

Transcript

1 Emergenze in casa di riposo Sant Angelo Lodigiano (LO), ottobre 2005 Edema polmonare acuto Simone Franzoni Gruppo di Ricerca Geriatrica Centro Medico Richiedei - Palazzolo s/o

2 Arch Intern Med Feb 28;165(4): Integrating palliative care into heart failure care. Hauptman PJ, Havranek EP. Heart failure is a condition for which both palliative care and hospice care can be appropriate. The disease's increasing prevalence and predilection for elderly patients with significant comorbidity underscore the need to integrate these modes of care with the acute care approach that has dominated heart failure treatment. We propose integration of a palliative care approach early in the course of heart failure treatment and a tiered process for selecting patients for hospice care. A transition of the focus to palliative care rather than mortality reduction should occur over time, when clinical status deteriorates and advanced therapeutic options become inappropriate or ineffective. Failure to respond to the need for palliative care puts at risk the mandate to treat the patient with heart failure during the entire course of illness.

3 Caso clinico Edema polmonare acuto L.L.L., F, 82 anni, viene trasferita in Riabilitazione Geriatrica da un Reparto di Medicina, dove è stata ricoverata per: TIA: disartria, deficit di forza arto superiore sinistro, deviazione rima buccale. Richiesta di proseguimento delle cure in ambito riabilitativo è stata giustificata in base alla presenza di instabilità posturale. Familiari descrivono da qualche mese progressivo declino funzionale e cognitivo.

4 Anamnesi sociale: 17 anni di scolarità; ex ostetrica, nubile. Prima dell evento acuto viveva da sola con aiuto familiare (anche IADL intra-moenia). Anamnesi patologica remota: - ipertensione arteriosa sistemica e diabete mellito II tipo (in trattamento dagli anni 90) - ricovero per frattura femore sx da caduta (osteosintesi, complicata da piaga da decubito tallone, tromboflebite arto inferiore e delirium 95) - ascesso perianale fistolizzato (toilette chirurgica DH 97)

5 Anamnesi patologica remota: - ricovero per diabete scompensato (IO insulina), insufficienza renale cronica, cardiopatia ischemica cronica, dislipidemia, insufficienza venosa arti inferiori, deterioramento cognitivo (MMSE 24/30) ( 99) - diagnosi ambulatoriale: steatosi epatica, gastropatia microerosiva, osteoporosi ( 01) - ricovero per verosimile TIA, encefalopatia multinfartuale, aterosclerosi TSA (stenosi 40-50% ACI sx e 30% ACI e ACE dx 01).

6 Esami strumentali recenti: TC encefalo ( 01): Grossolane alterazioni corticosottocorticali sovra-sottotentoriali, più evidenti in sede temporo-parietale. Diffusa leucomalacia periventricolare con aumento volumetrico ex-vacuo cavità ventricolari. Strutture mediane in asse. Non espansi extracerebrali. ECOcardio ( 01): FE 53%. Terapia in atto: Acido Acetilsalicilico 1c Cardioaspirin Perindopril 1c Procaptan Atorvastatina 1c Totalip 20 Fenformina+glibenclamide 1/2+1+1c Suguan Ca carbonato+colecalciferolo 1c Ideos

7 Esame obiettivo (all ingresso in RG): - condizioni generali discrete, tono umore depresso, decubito indifferente (BMI 32) - stazione eretta possibile con appoggio, dismetria arti inferiori, deambula cautelata con evidente zoppia - varici e discromie arti inferiori, lieve linfedema - es.neurologico: indenni i nervi cranici, ipertono arti superiori bilaterale, ROT normali, lieve deficit forza emisoma sx, Babinski e riflesso palmomentoniero sx - incontinenza urinaria cronica da urgenza e stress. NO ipotensione ortostatica PA 105/65 mmhg ECG: tachicardia sinusale (FC 115 bpm). BAV I. Intervallo QT ai limiti superiori. Asse elettrico equilibrato. Onda Q in V1-2. Onde T appiattite in V4-6.

8 Diagnosi d'ingresso: - Disturbo dell equilibrio e della marcia a genesi mista: -encefalopatia multinfartuale. Recente TIA (emisindr.sx) -dismetria art inferiori (osteosintesi frattura femore sx 95) -poliartrosi (rachide e anche) - Deterioramento cognitivo moderato a genesi mista; pregresso delirium postchirurgico ( 95) - Ipertensione arteriosa sistemica, grado I, a rischio cardiovascolare molto elevato - Cardiopatia ischemica cronica; tachicardia ndd - Aterosclerosi TSA non emodinamica - Diabete mellito 2 tipo (IO; in fase di complicanze sistemiche: insuff.renale cronica, ascesso perianale 97) - Dislipidemia II tipo, steatosi epatica, obesità - Gastropatia microerosiva ( 01) - Insuff.venosa arti inferiori; tromboflebite sx ( 95).

9 Obiettivi: - Riabilitazione all equilibrio e alla marcia - Valutazione decadimento cognitivo - Monitoraggio valori pressori e compenso cardiovascolare (tachicardia). Terapia instaurata all ingresso: Acido Acetilsalicilico 1c Cardioaspirin Fenformina+glibenclamide 1/2+1+1c Suguan Sinvastatina 1c Liponorm 20 Nitroglicerina 1cer Nitrodur 10 (sospeso antipitertensivo e calcio)

10 Diario clinico: 1-2 giornata: tranquilla, parzialmente orientata, cammina con aiuto, insight rischio caduta Normale frequenza cardiaca, PA 120/70 mmhg; sospeso monitoraggio ECG applicato al momento dell ingresso. Si richiede consulenza neuropsicologica, RX ginocchia. Assessment: MMSE 14/30 GDS 8/15 BADL 6/6 perse Barthel 30/100 IADL 7/8 perse Tinetti tot. 8/28 PPT 4/28 IPN 24.3

11 3-7 gg: iniziata FKT motoria, FC e PA nella norma. Edemi declivi (fasciatura compressiva elastica). 8 gg: da alcuni giorni astenia ingravescente e peggioramento resistenza all esercizio fisico. FC 108 bpm aritmico. PA 130/85 mmhg. Es.obiettivo sovrapponibile all ingresso. Durante la giornata più episodi di tachicardia (circa 130 bpm). Monitor per controllo PA, FC e saturazione O2 (Sat.O2: 88-90% in aria ambiente; 93-94% in O2 1,5 l/min. Non si applica O2; si richiede RX torace). ECG: wondering PM. FC 104 bpm. Non alterazioni significative ripolarizzazione ventricolare. 9 gg: persiste tachicardia, nulla di rilevante all es.obiettivo polmonare.

12 RX torace: focolaio di addensamento parenchimale, piuttosto esteso, nei segmenti basali lobo inferiore dx. Versamento pleurico consensuale lieve. Ampliamento vasi polmonari centrali, cuore con aumento diametro trasverso. Riduzione in altezza D11 tendente deformazione a cuneo. OD: pleuropolmonite basale destra. Lieve versamento pleurico bilaterale. Stasi piccolo circolo. Crollo osteoporotico D11. Richiesti es.ematochimici. Inizia ceftidoxima 2g/die. 11 gg: lieve stato soporoso, persiste astenia. No leucocitosi neutrofila, solo peggioramento anemia (Hb da 11.6 a 10.6 g/dl). Data l assenza di dispnea e di reperti obiettivi toracici significativi non eseguita terapia broncodilatatrice.

13 11 gg ore 23: dispnea acuta, con severo broncospasmo diffuso. PA 140/70 mmhg. FC 110 bpm. Sat.O2 aa: 84% (95% con O2 4l/min). Praticata ripetutamente terapia broncodilatatrice con beta stimolanti, cortisonici e anticolinergici. Dato aggravarsi broncospasmo eseguita aminofillina e cortisonico ev. ore 0.30: PA 140/90 mmhg, FC 130 bpm, Sat.O2: 94% (3 l/min). Ridotto broncospasmo, risolta la dispnea. Si mantiene monitoraggio.

14 12 gg ore 8.30: PA 130/80 mmhg FC 72 bpm; eupnoica, persiste lieve broncospasmo. Prosegue terapia broncodilatatrice e si aggiunge furosemide 25 mg/die. ore 16: intensa precordialgia. PA 90/60 mmhg. ECG: segni ischemia in V4-5-V6. Si somministra isosorbide dinitrato sbl. ore 16.30: persiste precordialgia, ECG invariato. Trasferita in UCC. ore 22: rientra in reparto.

15 Consulenza cardiologia: Paziente ipertesa, diabetica, affetta da demenza senile, insuff.renale cronica, recente TIA in trattamento riabilitativo, inviata per precordialgia. Non attendibile, riferisce dolore da 3 giorni, ma successivamente nega. Tranquilla, buon compenso emodinamico. PA 130/80 mmhg, ECG RS, BAV I con alterazioni aspecifiche ripolarizzazione V4-6, peraltro già evidenti (4/ 02). EO: torace MV ridotto basi. Non segni scompenso. Troponina nella norma. In considerazione lunga durata sintomatologia e negatività troponina, il dolore non sembra di origine cardiaca. Vista l anamnesi aggiungere diltiazem 60 ½ c x2. Ricontrollare troponina, domani. OD: dolore toracico non cardiaco

16 13-24 gg: Persiste grave astenia, non è più in grado di mantenere la stazione eretta autonomamente e riesce a deambulare solo con doppio aiuto umano. Obiettività respiratoria nella norma. Assente precordialgia. Non è possibile eseguire FKT. Prosegue con terapia antibiotica (fino in 14 gg); diltiazem 60 ½ c x 2. PA 95/60 mmhg. FC 100 bpm. Troponina negativa. Leucocitosi neutrofila, K 5.6 meq/l e peggioramento anemia (Hb 10.3 g/dl).

17 ECG: persistono onde T negative in V5-6. Positivizzazione in V4. RX anche: osteopenia. A sx esiti frattura consolidata collo femore (vite dinamica). Coxartrosi senza rilevante compromissione interlinee articolari. RX ginocchia: gonartrosi bilaterale, calcificazioni arterie poplitee. RX torace (controllo): completa scomparsa addensamento parenchimale e versamenti pleurici. Si incrementa nitrato transdermico a 15 mg/die. Dato elevato rischio tromboembolico inizia eparina calcica s.c UI x 2.

18 25 gg:ore 1.30: dispnea acuta, rantoli a piccole bolle campi medio-basali bilateralmente. Edemi declivi. PA 120/70 mmhg. FC 110 bpm. ECG: non ischemia in atto. Somministrato metilprednisolone 40 mg e.v. e praticata aerosol terapia. Posizionato catetere vescicale. O2 terapia 2l/min. PA 120/70 mmhg, FC 140 bpm. Sat.O2 93%. ore 2.45: dopo 100 mg furosemide ev la dispnea si risolve. PA 100/85 mmhg. FC 108 bpm. Stabile Sat.O2. Diuresi 600cc. OD: edema polmonare acuto

19 26 gg: scarso compenso cv, incremento ponderale 6 Kg rispetto all ingresso. Diuresi 2300 cc/24h. Glicemia 500 mg/dl. Sostituito IO con insulina e nitrato TTS con isosorbide mononitrato 50 mg/die; prosegue furosemide 40 mg/die. Aggiunto ciprofloxacina 500 mg x 2. Richiesto ecocardio. OD: diabete mellito 2 tipo in fase di scompenso gg: miglioramento quadro emodinamico, calo 6 kg. Ecocardio: lieve dilatazione (ipertrofia eccentrica) e disfunzione sistolica Vsx (FE 40%); non aumentata pressione telediastolica. Insuff.mitralica moderata. Ipertensione polmonare (PAPs 40mmHg). Non aumentata PVC. OD: scompenso sistolico, insufficienza mitralica moderata, ipertensione polmonare

20 Sostituito diltiazem con carvedilolo 6,25 mg/die. Ancora labile compenso glicometabolico, incremento insulina. 31 gg: febbre (38.1 C). Sostituita ciprofloxacina con imipenem / cilastatina 500mg x 3. Richiesti es.ematochimici, marker neoplastici, Rx torace ed ecografia addominale (sindrome paraneoplastica?). 34 gg: RX torace: sostanzialmente sovrapponibile al precedente Ecografia addominale: colelitiasi Persiste leucocitosi neutrofila, grave anemia (Hb 7.1 g/dl) CA19/9 34.7(0-34 U/ml), CEA 4.8(0-3.4 ng/ml), TPA,CA15/3 e alfafeto V.N. Trasferimento in Geriatria per acuti.

21 39 gg: Diagnosi di trasferimento (dopo 5gg): - Sepsi da infezione vie urinarie - Anemia normo/cromica/citica di recente insorgenza (3 emotrasfusioni) - Gastrite atrofica diffusa, erosioni duodenali, ernia jatale - Scompenso cardiaco da prevalente disfunzione sistolica - Cardiopatia ischemica cronica - Ipertensione arteriosa sistemica - Recente polmonite basale destra - Diabete mellito tipo 2 (attuale terapia dietetica) - Encefalopatia vascolare (recente TIA); decadimento cognitivo moderato-severo secondario, delirium anamnestico - Poliartrosi (osteosintesi femorale per frattura 95) - Colelitiasi - Insufficienza venosa arti inferiori - Pregresso ascesso perianale fistolizzato ( 97)

22 Terapia consigliata: - Imipenem + cilastatina 500 x 4 Tenacid Isosorbide mononitrato 50 1 c Monocinque R 50 - Carvedilolo c Dilatrend Omeprazolo 20 1 c Antra 20 - Movicol 2 b - Atem + Pulmaxan 2cc + 1 f x 2 Dieta ipoglucidica.

23 40-47 gg: astenia, esegue a fatica i passaggi posturali. Deambula con doppio aiuto umano per brevi tragitti. Ematuria con contrazione diuresi e obiettività polmonare suggestiva di stasi; ripresa terapia diuretica (furosemide 25 mg) e rimosso catetere vescicale. Scarso controllo glicemia, riprende insulina. Apiressia, compenso emodinamico soddisfacente (PA 130/80 mmhg. FC 84 bpm).

24 48 gg: Sospeso imipenem/cilastatina (dopo 21 gg) gg: ridotta astenia, dispnea assente, apiressia, peso corporeo stazionario. Esegue a fatica i passaggi posturali; deambula con singolo aiuto umano per brevi tragitti. Sostituita terapia insulinica con IO. Sospesa eparina. Ridotta furosemide a 12,5 mg/die. Inizia FKT motoria.

25 58 gg: ore 2.30: dispnea acuta, rantoli a piccole bolle campi medio-basali bilateralmente. Edemi declivi. PA 100/60 mmhg. FC 120 bpm. ECG: non ischemia in atto. Somministrato furosemide 125 mg ev, nitroglicerina ev, O2 terapia 3l/min. ore 3.00: dispnea risolta. PA 90/55 mmhg. FC 102 bpm. Stabile Sat.O2 in aa. Diuresi 800cc. OD: edema polmonare acuto

26 59-66 gg: lieve astenia, dispnea assente (a riposo), apiressia, peso corporeo 2 Kg rispetto all ingresso. Non sufficiente controllo glicemia, si ritorna a insulina. Stato funzionale invariato. Hb 11.4 g/dl, azotemia 68 mg/dl, creatininemia 1.7 mg/dl. Assessment di dimissione: MMSE 11/30 GDS 6/15 Val.neuropsicologica indicativa per severo deterioramento varie funzioni cognitive di tipo prevalentemente degenerativo. Tinetti tot. 10/28 PPT 9/28

27 Diagnosi di dimissione: - Scompenso cardiaco sistolico (NYHA III; intercorrenti episodi di edema polmonare acuto), insuff.mitralica moderata, ipertensione polmonare - Cardiopatia ischemica cronica - Ipertensione arteriosa sistemica, grado I, a rischio cv molto elevato - Pleuropolmonite basale dx intercorrente con versamento pleurico bilater. - Sepsi da infezione vie urinarie intercorrente - Anemia acuta ndd intercorrente (emotrasfusa); pregressa anemia da disordine cronico - Diabete mellito 2 tipo in trattamento con insulina e in fase di complicanze sistemiche: insufficienza renale cronica, ascesso perianale ( 97) - Dislipidemia II tipo, obesità - Gastrite atrofica diffusa, erosioni duodenali, ernia jatale, colelitiasi - Insufficienza venosa arti inferiori; pregressa tromboflebite sx ( 95). - Poliartrosi (rachide, anche, ginocchia); crollo osteoporotico D11; dismetria arti inferiori (esiti osteosintesi per frattura femore sx da caduta 95) - Demenza mista associata a disturbo depressivo; delirium postchirurgico ( 95); encefalopatia multiinfartuale; recente TIA (emisindrome sx) - Disturbo equilibrio e marcia a genesi mista con elevato rischio di caduta - Incontinenza urinaria cronica mista. IDS 26/64 GIC IV

28 Terapia consigliata: - Isosorbide mononitrato 50 1 c Monocinque R 50 - Carvedilolo c Dilatrend Omeprazolo 20 1 c Antra 20 - Ticlopidina 1+1c Opteron - Humulin R 4+4U e 30/70 14U Dieta per diabetici 1400 KCal/die, calze elastiche

29 Dopo 6 mesi: Ricovero in ospedale per acuti per edema polmonare acuto Incremento ponderale + 8 Kg Trasferimento in RSA; aggiunta furosemide 25 mg/die Dopo altri 12 mesi: Non più episodi di scompenso cardiaco acuto. Peso non valutabile

30 Spunti di discussione: DD: polmonite, broncospasmo, edema polmonare acuto Ecocardiogramma? Approccio farmacologico corretto? Catetere vescicale, sempre? Erano prevenibili gli ultimi 2 episodi di edema polmonare? Monitoraggio dispnea nel paziente demente (FR?) Trasferimento in ospedale per acuti? CPAP in RSA?

31 Prognostic Judgments and Triage Decisions for Patients With Acute Congestive Heart Failure Wally R. Smith, MD; Roy M. Poses, MD; Donna K. McClish, PhD; Elizabeth C. Huber, MD; F. Lynne W. Clemo, MD; Donna Alexander, PhD; and Brian P. Schmitt, MD (CHEST 2002;121:1610 7) Study objectives: To determine how well triage physicians judge the probability of death or severe complications that require treatment only available in an ICU to maintain life for patients with acute congestive heart failure (CHF). Patients or participants: Patients were those visiting the emergency department (ED) with acute CHF, excluding those who already required a treatment only available in an ICU to maintain life, and those with possible or definite myocardial infarction. Physician participants were those caring for the patients in the ED.

32 Measurements and results: We performed chart reviews to ascertain whether each patient died or had severe complications develop by 4 days. A calibration curve that stratified these judgments by decile demonstrated that physicians consistently overestimated this probability (p < 0.01). Physicians judgments were only moderately good at discriminating which patients would have the outcome (receiver operating characteristic curve area, 0.715). Conclusions: Physicians drastically overestimated the probability of a severe complication that would require critical care for patients with acute CHF who were candidates for ICU admission. Their judgments of this probability were associated with their triage decisions, as they should be according to several guidelines for ICU triage. Overestimation of the probability of severe complications may have lead to overutilization of scarce critical care resources. Current critical care triage guidelines should be revised to take this difficulty into account, and better predictive models for patients potentially requiring critical care should be developed. (CHEST 2002; 121: )

33 Treatment of acute pulmonary oedema: diuresis or vasodilatation? Michael Gammage THE LANCET Vol 351 February 7, 1998 Intravenous loop diuretics have formed the mainstay of treatment for acute cardiogenic pulmonary oedema since the 1960s but in recent years increasing use has been made of intravenous nitrates as adjunctive therapy for acute and chronic pulmonary oedema. In 1983 Nelson and colleagues reported a randomised, prospective study of isosorbide dinitrate infusion versus furosemide infusion that showed similar falls in pulmonary-artery occluded pressure (equivalent to leftatrial pressure) and suggested that isosorbide dinitrate resulted in haemodynamically better changes with regard to myocardial oxygen consumption and peripheral perfusion. Despite studies such as these, the use of nitrates instead of (rather than as well as) loop diuretics in the management of acute pulmonary oedema has not become standard practice. This might relate to the inconvenience of infusion therapy but, until recently, there had been no randomised, prospective comparison of the two therapies when given as bolus injection as opposed to infusion.

34 When given intravenously, furosemide causes rapid venodilation, which results in a decrease in left and right ventricular end-diastolic pressures; there is, however, still some disagreement about the extent of this fall in filling pressures in the absence of the diuresis, which usually starts within 30 min. Transient rises in blood pressure have been shown to occur with furosemide, probably because of activation of the sympathetic and reninangiotensin systems, which leads to increased peripheral vascular resistance and afterload; this effect has the potential to decrease cardiac output and increase cardiac work, with the possibility of worsening myocardial and other tissue ischaemia. Since many patients with acute cardiogenic pulmonary oedema have underlying myocardial ischaemia or infarction, the initial symptomatic benefit may be followed by detrimental effects on myocardial perfusion with extension or completion of myocardial necrosis. Many patients with acute pulmonary oedema are not fluid overloaded before the event, so redistribution rather than reduction of circulating volume might be a more appropriate approach.

35 Theoretically, therefore, nitrates offer many of the advantages but not the disadvantages associated with intravenous loop diuretics. But can they be as effective and are they as convenient in an emergency? In the prethrombolysis era, management of the patient with myocardial infarction and acute pulmonary oedema was (relatively) simple; sit the patient up in bed, give oxygen, administer intravenous opioids and furosemide, monitor, and leave for 30 to 60 min. As the management has become more active, the concept of greater physician involvement has evolved, but will a bolus injection of isosorbide dinitrate, repeated every 5 min, be a practical proposition for the busy junior doctor? The idea of bolus administration of intravenous nitrates is not new but, until recently, most commercially available preparations were thought suitable for use only by continuous infusion.the demonstration that isosorbide dinitrate can be given safely as small boluses, repeated every 5 min as necessary, has the potential to change that perception. In their randomised, prospective study of 104 patients, Cotter and colleagues have shown, as secondary

36 Intravenous isosorbide dinitrate has a rapid onset of action, with peak vasodilatation at 5 min,10 12 but the short elimination half-life (0 6 h) requires frequent repeat dosing when given by bolus. Isosorbide-5-mononitrate shares the pharmacological actions of the dinitrate and is the main active metabolite formed after administration of isosorbide dinitrate,13 but it has a much longer half-life (5 1 h). The mononitrate therefore seems to represent a better long-acting nitrate for intravenous bolus use in acute pulmonary oedema. For intravenous nitrate therapy to displace furosemide for the management of acute pulmonary oedema, it needs to be effective in a single bolus injection in most cases, must be safe to use in the presence of moderate hypotension, and must be effective in patients on chronic long-acting nitrate or diuretic therapy. Bolus isosorbide dinitrate has not yet been shown to fulfil these criteria; bolus isosorbide mononitrate might, but a large, randomised prospective comparison with furosemide or a furosemide/isosorbide dinitrate combination is required.

37 Does Continuous Positive Airway Pressure by Face Mask Improve Patients With Acute Cardiogenic Pulmonary Edema Due to Left Ventricular Diastolic Dysfunction? Karim Bendjelid, MD, MS; Nicolas Schu tz, MD; Peter M. Suter, MD, FCCP; Gerard Fournier, MD; Didier Jacques, MD; Samir Fareh, MD; and Jacques-A Romand, MD CHEST MARCH, 2005 Objective: Continuous positive airway pressure (CPAP) by face mask is an effective method of treating severe cardiogenic pulmonary edema (CPE). However, to our knowledge, no study has provided a precise evaluation of the effects of CPAP on cardiac function in patients presenting with CPE and preserved left ventricular (LV) function. Setting: A 14-bed, medical ICU at a university hospital. Patients: 9 consecutive patients presenting with hypoxemic acute CPE.

38 Interventions: All patients were selected for 30 min of CPAP with 10 cm H2O by mask with fraction of inspired oxygen adjusted for a cutaneous saturation > 90%. Measurements and results: in patients with preserved LV systolic function, mean arterial pressure and LV enddiastolic volume were decreased significantly by CPAP (p < 0.04). In patients with LV systolic dysfunction, CPAP improved LV ejection fraction (p < 0.05) and decreased LV end-diastolic volume (p 0.001) significantly. Conclusion: CPAP improves oxygenation and ventilatory parameters in all kinds of CPE. In patients with preserved LV contractility, the hemodynamic benefit of CPAP results from a decrease in LV end-diastolic volume (preload).

39 Guidelines on the diagnosis and treatment of Acute Heart Failure (AHF) The task force on AHF of the European Society of Cardiology March 2005

40 Patients with AHF have a poor prognosis. Mortality: Particularly high in patients with AMI (30% at 12 mo) Max: 40% at 12 mo Predictors: elevated pulmonary capillary pressure, low serum sodium, increased left ventricular dimension. Hospitalization: 45% rehospitalized at least once within 12 mo

41 Definition AHF As a rapid onset of symptoms and signs secondary to abnormal cardiac function. I. AHF decompensated (de novo or decompensation CHF) symptoms and signs mild and do not fulfil criteria for cardiogenic shock, pulmonary oedema, hypertensive crisis II. Hypertensive AHF symptoms and signs are accompanied by high blood pressure and relatively preserved left ventricular function with a chest radiograph compatible with acute pulmonary oedema

42 III. Pulmonary oedema verified by chest X-ray, accompanied by severe respiratory distress, with crackles over the lung and orthopnea, O2 saturation <90% IV. Cardiogenic shock evidence of tissue hypoperfusion induced by HF after correction of preload. Systolic blood pressure < 90mmHg and/or low urine output (<0.5 ml/kg/h), with a pulse rate > 60/min with or without evidence of organ congestion

43 V. High output failure (arrhythmias, anemia) high heart rate, warm peripheries, pulmonary congestion, low blood pressure (sepsi) VI. Right heart failure low output syndrome with increased jugular venous pressure, increased liver size and hypotension.

44 Diagnosis of AHF is clinical and supported by Clinical evaluation blood pressure, heart rate, external jugular veins, wet rales in lung fields, peripheral temperature ECG rate, rhythm, acute coronary syndrome, atrial-ventricular strain Chest X-ray assess pulmonary congestion, infectious lung disease Laboratory tests arterial blood gas analysis, pulse oximetry? B-type natriuretic peptide? Echocardiography ventricular function, pulmonary artery pressure

45 Causes and precipitating factors in AHF 1) Decompensation of pre-existing CHF (cardiomyopathy) 2) Acute coronary syndromes (a) myocardic infarction / unstable angina with large extent of ischaemic dysfunction (b) mechanical complication of acute myocardical infarction (c) right ventricular infarction 3) Hypertensive crisis 4) Acute arrhythmia (ventricular tachycardia and fibrillation, atrial fibrillation or flutter, other supraventicular tachycardia) 5) Valvular regurgitation / endocarditis / rupture of chordae tendinae, worsening of pre-existing valvular regurgitation 6) Severe aortic valve stenosis 7) Acute severe myocarditis 8) Cardiac tamponade 9) Aortic dissection

46 Causes and precipitating factors in AHF 11) Non-cardiovascolar precipitating factors (a) lack of compliance with medical treatment (b) volume overload (c) infections, particularly pneumonia or septicaemia (d) severe brain insult (e) after major surgery (f) reduction in renal function (g) asthma 12) High output syndromes (a) septicaemia (b) thyrotoxicosis (c) anaemia (d) shunt syndromes

47 Goals of treatment of the patient with AHF Clinical symptoms (dyspnoea and / or fatigue), clinical signs, body weight diuresis, oxygenation Laboratory Serum electrolyte and blood glucose normalisation BUN and/or nomalisation, S-bilirubin, plasma BNP Haemodynamic pulmonary capillary wedge pressure to<18 mmhg cardiac output and/or stroke volume Outcome lengh of stay in the intensive care unit, duration of hospitalisation, mortality time to hospital re-admission Tolerability Low rate of withdrawal from therapeutic measures Low incidence of adverse effects BUN= blood urea nitrogen

48 Organization of the treatment of AHF Requires a treatment plan in the hospital system. Best results are achieved if patients are treated promptly by expert staff in areas reserved for HF patients. Should be followed by a subsequent HF clinic programme. Non-invasive monitoring Blood pressure (every 5 min. until the dosage of vasodilators, diuretics, or inotropes has been stabilized), heart rate, respiratory rate, temperature, Pulse oximeter (every hour if receiving oxygen therapy), ECG

49 General therapeutic approach in AHF by findings on invasive haemodynamic monitoring Haemodynamic Characteristic Suggested therapeutic approach Cardiac Index Decreased Decreased Decreased Decreased Maintained Pulmonary Capillary Wedge Pressure Low High or Normal High High High Systolic Blood Pressure >85 <85 >85 Outline of therapy Fluid loading Vasodilator (nitroprusside NTG, fluid Loading may become Necessary) Consider inotropic agents (dobutamine, dopamine) and i.v. Diuretics Vasodilators (nitroprusside, NTG) and i.v. diuretics and consider inotrope (dobutamine) i.v. diuretics if SBP is low, vasocontrictive Inotropes

50 Treatment of AHF - Oxygen and ventilatory assistance Outcome: adequate levels of oxygenation at the cellular in order to prevent end-organ dysfunction and the onset of multiple organ failure. Maintenance of a patient airway is imperative. Sat.O2: 95-98% No evidence that giving increasing doses of oxygen results in an improved outcome. The use of increased concentrations of oxygen to patients without evidence of hypoxaemia may cause harm. RCT suggest that non-invasive ventilation (CPAP, NIPPV) in acute cardiogenic pulmonary oedema is associated with a significant reduction of tracheal intubation and mechanical ventilation. Insufficient data to demonstrate a significant reduction in mortality.

51 Treatment of AHF Morphine and its analogues Severe AHF with restlessness and dyspnoea. Induces venodilatation, mild arterial dilatation, and reduce heart rate. 3 mg iv (repeated if required) Anticoagulant Heparin showed no clinical improvement, but reduce venous thrombosis.

52 Treatment of AHF Vasodilators First line therapy, if hypoperfusion is associated with an adequate blood pressure and signs of congestion with low diuresis (to open peripheral circulation and to lower preload). Nitrates Low dose venodilatation High doses venodilatation + arteries dilatation (coronary). Balanced doses reduce left ventricular preload and afterload, without impairing tissue perfusion. U-shaped curve effect; low dose: limited effect in preventing AHF recurrences; high dose: less effectiveness. Nitrates iv have rapid development of tolerance: h. Initially N. may be given orally but i.v.n. are also well tolerated in AMI. N. i.v. dose tritation to the highest haemodynamically tolerable + low dose furosemide is superior than high dose of diuretic treatment alone. Tritating the dose against blood pressure decrease. The dose should be reduced if systolic blood pressure < mmhg.

53 Indications and dosing of vasodilators in AHF Vasolidator Indication Dosing Main side effects Other 5-monotritate AHF when blood pressure is adeguate Start 20µg/min, increase up to 200 µg/min Hypotension, headache Tolerance on continuous use Isosorbide Dinitrate AHF when blood pressure is adeguate Start 1mg/h increase up to 10 mg/h Hypotension, headache Tolerance on continuous use Nitroprusside Hypertensive crisis, mitral regurgitation, cardiogenic shock combined with inotropes µg/kg/min Hypotension, isocyanate toxicity Drug is light sensitive

54 Treatment of AHF Calcium antagonist should be considered contraindicated. ACE-inhibitors are not indicated in the early stabilisation of patients with AHF. B-Blocking agents should be used cautiously in patients with overt AHF and more than basal pulmonary rales. Among such patients where ongoing ischaemia and tachycardia are present, iv metoprololo ca be considered.

55 Treatment of AHF - Diuretics Decrease in plasma and extracellular fluid volume, total body water and sodium, reduction in right and left ventricular filling pressures and a decrease in peripheral congestion and pulmonary oedema. IV loop D. exerts a vasodilating effect (5-30 min) with decrease of right atrial and pulmonary wedge pressure as well as pulmonary resistances. With high bolus doses (> 1 mg/kg) there is a risk of reflex vasoconstriction. In acute coronary syndromes D should be used in low doses and preference given to vasodilator therapy. Dose should be tritated according to the diuretic response and relief of congestive symptoms. Administration of a loading dose followed by continued infusion of furosemide or torasemide is more effective than bolus alone. Combinations with thiazides and spironolattone or with dobutamine, dopamine, and nitrates are more effective than increasing doses of D.

56 Diuretic dosing administration Severity of fluid retention Diuretic Dose (mg) Comments Moderate Furosemide, or Torameside, or Oral or iv according to symptoms Tritate dose according to clinical response Monitor Na+, K+, creatinine, blood pressure Severe Furosemide, or Furosemide infusion mg/h i.v. Better then very high bolus doses Torameside Orally Refractory to loop Diuretics Add HCTZ, or Metolazone, or Spironolactone twice daily once daily once daily Combination with loop diuretic better than very high dose of loop diuretics alone. Metolazone more potent if creatinine clearance <30mL/min Spironolactone best choice if patient not in renal failure and normal or low serum K+ In case of alkalosis Refractory to loop diuretic and thiazides Acetazolamide Add dopamine for renal vasodilatation, or dobutamine as an inotropic agent i.v. Consider ultrafiltration or haemodialysis if co-existing renal failure

57 Treatment of AHF Diuretic resistance Causes: - intravascular volume depletion, - renal failure (NSAIDs), - decreased renal perfusion (low output), - impaired gut absorption of an oral diuretic, - neurohormonal activation (angiotensin - aldosterone system, sympathetic nervous system). Associated with poor prognosis. More frequent in patient with severe, chronic HF on long-term diuretic therapy.

58 Treatment of AHF - Inotropic agents Indicated in the presence of peripheral hypoperfusion (hypotension, decreased renal function) with or without congestion or pulmonary oedema refractory to volume replacement diuretics and vasodilators at optimal doses. Their use is potentially harmful as they increase oxygen demand. NO BOLUS If no response is seen, the therapy should be terminated. Dopamine in AHF with hypotension and low urine output: < 2 ug/kg/min i.v. (dopaminergic) improved renal blood flow and diuresis and lowers peripheral resistance. 2-3 ug/kg/min i.v. (B-adrenergic) increase myocardial contractility and cardiac output. 5 ug/kg/min i.v. (A-adrenergic) increase peripheral resistance (useful only in patients with hypotension).

59 Treatment of AHF Dobutamine is used to increase the cardiac output. 2-3 ug/kg/min i.v. increased to 20 ug/kg/min because haemodinamic actions are proportional to its dosage. The elimination is rapid after cessation of infusion. Prolonged infusion (>24-48 h) is associated with tolerance and partial loss of haemodinamic effects. Risk of arrhythmia. Weaning may be difficult because of recurrence of hypotension, congestion, or renal insufficiency. Progressive decrease in dosage by step of 2-3 ug/kg/min/day.

60 Treatment of AHF Cardiac glycosides produces a small increase in cardiac output and a reduction of filling pressures. Indication: tachycardia-induced AHF (atrial fibrillation) No in AHF after myocardial infarction, bradycardia, AV block, SSS, hypok, hyperca. Efficacious in reducing the re-occurrence of AHF; predictors: - 3 heart sound - extensive LV dilatation - distended jugular veins.

61 Treatment of AHF - Underlying diseases and comorbidities Coronary artery disease (ICU) Most frequent cause. History an typical ECG signs. Inotropic agents may be deleterious. AHF and hypertension (no ICU) Flash pulmonary oedema because of its rapid onset. Systolic function is often preserved, while diastolic abnormalities is often present. Treatment should be started immediately (systolic o diastolic pressure < 30 mmhg in 2 min; after progressive decrease to the values measured before the hypertensive crisis in several hours): - oxygen therapy, CPAP, NIPPV - furosemide i.v. (if CHF and fluid overload) - nitroglicerina i.v. (to decrease venous preload and arterial afterload and increase coronary blood flow) - nicardipina (diastolic disfunction with an increased afterload; but may cause adrenergic activation tachycardia, intrapulmonary shunt - hypoxaemia) - NO B-blocker.

62 Treatment of AHF Renal failure Concomitant renal failure requires the treatment of alectrolyte abnormalities, metabolic acidosis. Serum Cr > mg/dl is necessary increase the dose of loop diuretics an add a diuretic with different mechanism of action (metolazone). Pulmonary diseases and bronchoconstriction When bronchoconstriction due to astma, chronic obstructive bronchitis, lung infection) is present bronchodilators should be used. They may improve cardiac function, but should not be used instead of relevant AHF treatment. Salbutamol nebulization over 20 min., repeated hourly during the first few hours. Arrhythmias (Atrial Fibrillation - AF) Verapamil and diltiazem should be avoided in acute AF as they may worsen HF and cause a III AV block. Amiodarone and B-blocking agents have been successfully used in AF for rate control and prevention of recurrrence. Rapid digitalization should be considered especially when AF is secondary to AHF.

63 Treatment of AHF Infections: in elderly patients with CHF, infections as pneumonia may be a cause for worsening HF and dyspnoea. An increase in CRP and a decrease in general condition may be the only signs of infection. Diabetes: AHF is associated with impaired metabolic control; hypoglycemic drugs should be stopped and shift to insulin. Catabolic state Renal failure: Both may cause, aggravate, and influence, the outcome of the other.