40 MINUTES
2
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Are we missing the point?
Despite timely PPCI with STEMI
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mortality decreased to 7%
but heart failure increased to 22%
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(1 year after event)3
WHAT IS EXPECTED TO KNOW?
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? Definitions
? HEMODYNAMICS
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? Etiology? CLINICAL RECOGNITON &
? Types
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DIFFERENTIATION
? Symptoms
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? ASSESSING SEVERITY? Signs
? ORDERING TESTS
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? Medical Tx
? IMMEDIATE MANAGEMENT
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? Surgical Tx? LONG TERM MANAGAMENT
4
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WHAT HAPPENS IN HEART FAILURE?SVC 5
PV 10
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SVC 8
PV 25 PCWP 25
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RA 5LA 10
RA 8
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LA 25
RV 25/0-5
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LV 120/0-10RV 40/0-8 LV 100/0-25
PA 25/10
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AO 120/80
PA 40/25 AO 100/60
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NORMALAHF: LVEDP 25
LVEDP=mLAP=mPCWP CPP=DBP-LVEDP
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SVC 5
PV 12 PCWP 12
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SVC 5PV 20 PCWP 20
RA 5
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LA 12
RA 5
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LA 20RV 30/0-5
LV 10/0-12
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RV 40/0-5
LV 10/0-20
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PA 30/12AO 100/70
PA 40/20
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AO 80/60
COMPENSATED HF
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DECOMPENSATED HFLVEF reduced: Perfusion Low 5
CLINICAL RECOGNITION
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LEFT HEART FAILURE
RIGHT HEART FAILURE
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? DOE? SWELLING
? ORTHOPNEA (LAP>24)
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? ABDOMINAL PAIN
? BENDOPNEA*
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? JVP ELEVATED? PND (LAP>18)
? PINK FROTHY SPUTUM
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? HJR+ (PCWP> 18)
? RAPID THREADY PULSE
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? PEDAL EDEMA? SBP LOW
ALSO
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? CARDIOMEGALY
? S3 (LVEDP>18)
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? LOW URINE OUTPUT? BILATERAL BASAL CREPS
? CONFUSION
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? COLD EXTREMITIES
? FATIGUE
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6NYHA
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MODIFIED ROSS SCALELAP<12
LAP 12-18
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LAP 18-24
LAP>24
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Outdoor WorkSUCK REST SUCK
Household Choirs
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DIAPHORESIS
Personal Activities
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FEEDING DIFFICULTYPND
FTT
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Orhtopnea
7
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ACC/ AHA8
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FRAMINGHAM CRITERIA
2 MJ/ 1MJ+2MN
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FOR CHILDREN
NADAS CRITERIA
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1 MJ/ 2MN9
VOLUME STATUS
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PERFUSION STATUS
BENDOPNEA
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10HOW GOOD
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ARE THE CLINICAL SIGNS?11
12
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FORRESTER
n
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2>
2
.
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2L
/
mi
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CIn
2
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<2
.
2
L
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/mi
CI
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PCWP<18mmHgPCWP>18mmHg
13
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STEVENSON
14
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ELLIS
NYHA 2
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NYHA 3PND
NYHA 4
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Orthopnea
15
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TYPES!!? ACUTE/ CHRONIC
? COMPENSATED/
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DECOMPENSATED
? SYSTOLIC/ DIASTOLIC/ both
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? HFREF/ HFPEF/ both? LHF/ RHF/ CHF
? Mild/mod/severe
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? A/B/C/L
16
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GROSS, OKAY &
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SUBTLEBatwing?HF?
Cephalization
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Pulm Venous
Congestion
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Kerley BBatwing
Interstitial
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edema
Alveolar edema 17
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ARDS VS HF18
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ACUTE ONSET SOB
ASTHMA
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RONCHI+
Pneumothx
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PCO2Absent BS
high
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Pulmonary
Pneumonia
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EmbolismDKA
Metabolic
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acidosis
19
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ECG in HFGoldberger's triad
LBBB+ Wide QRS
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LAE
20
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VALSALVA IN HF
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21COPD VS HF
VENTILLATED:
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`'VALSALVA'
Pulse oxymetry
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Biomarkers:Diagnosis/ prognosis
22
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WHAT LIES BENEATH?
LOW SALT
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B1 blockers
LOW FLUID
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DIURETICSSNS
Ivabradine
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RAAS
NP
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ACEINEPRILYSIN
ARB
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INHIBITOR
MRA
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PNEUMOVAC(ARNI)
INFLUVAC
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23
ESC
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GUIDELINE24
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ARNI: SACUBITRIL VALSARTAN
25
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CARDIAC RESYNCHRONISATION THERAPY
NYHA II-IVa + LVEF< 35%
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NYHA I + LVEF <30%LBBB + QRS>150 ms (>120ms)
NSR (AF)
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Life expectancy> 1 yr
26
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Ionotrops & more
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27Treatment Summary
28
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MECHANICAL CIRCULATORY DEVICE
29
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MECHANICAL CIRCULATORY DEVICETANDEM HEART
IMPELLA
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HEARTMATE
ECMO
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30HEART TRANSPLANT
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31Stem cell therapy
32
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What causes Acute heart failure?? <5 years: CHD (PDA>VSD)
? 5-15 years: Rheumatic carditis (h/o joint pain)
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viral (h/o fever) (MC Coxsackie)
? 15-35 years: Myocarditis (h/o fever)
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arrythmias (palpitation) (SVT>VT)HTN
? >35 years: Ischemic (Chest pain ? ACS)
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arrhythmia (palpitation) (AF>VT>SVT)
myocarditis (fever)
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CKDALWAYS RULE OUT HTN CRISIS AND AF
33
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What causes Chronic heart failure?
? <5 years: CHD (PDA>VSD)
? 5-15 years: Rheumatic heart dis (h/o joint pain)
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viral (h/o fever) (MC Coxsackie)? 15-35 years: RHD
CHD
? >35 years: Ischemic
CMP (r/o alcohol CMP)
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ALWAYS RULE OUT ANAEMIA, hypoThy
34
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Treat the underlying cause!
? Myocarditis: supportive therapy only
? Arrhythmia: DC shock (SVT 50-100J, VT 200J)
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? ACS: PTCA+S? Anemia: keep Hb around 10
? DO NOT GIVE IV FLUID (NS) TO HF PATIENTS
? Old MI EF 35%: No role of PTCA w/o viability
? Rule out Cardiomyopathies by Echo/ Imaging
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35
ACUTE CHEST PAIN + SOB + NORMAL CAG
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50 yr old+ HTN + Obese Lady+ DOE
37
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10 year child CHF no murmer
38
? HEMODYNAMICS
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Increased LVEDP ? LAP - PCWP
? CLINICAL RECOGNITON & DIFFERENTIATION
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Volume status/ perfusion status/ HTN/ anemia/ AF? ASSESSING SEVERITY
AHA/ ACC, Killip, NYHA, CPK level
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So,
? ORDERING TESTS
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Pallor/ Hb (r/o Anemia)very little Murmer (r/o structural heart dis)
to learn ECG and trop I (r/o ACS)
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CXR (r/o pneumothx)
actual y.. CPK (confirming HF)
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ABG (r/o Asthma/ COPD)Echo (r/o CMP, structural heart dis)
? IMMEDIATE MANAGEMENT
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O2/ IV Diuretics/ NIV (BIPAP, CPAP)/ ionotrops
? LONG TERM MANAGAMENT
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Pharmacotherapy/ CRT/ low salt + fluid/ vaccines39
LVAD ? HTX ? Stem Cell therapy
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