Diagnosis and Management of Acute Heart Failure

, James L. JanuzziJr.2 and James L. JanuzziJr.3



(1)
Harvard Medical School Advanced Heart Failure and Cardiac Transplantation, Cardiology Division, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA

(2)
Harvard Medical School, Boston, USA

(3)
Cardiac Intensive Care Unit, Cardiology Division, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA

 



Introduction

Epidemiology []

Pathophysiology

Classification

Initial Assessment

Presentation

Physical Examination

Diagnostic Evaluation (Table )

Indications for Hospitalization

Initial Management of Acute HF Syndromes

Goals

After Admission

Management of Congestion

Support of Hemodynamics

Maintenance Therapy for HF

References


Abstract

Heart failure (HF) is a complex disorder that consists of a clinical syndrome with symptoms associated with pulmonary or systemic congestion with or without poor cardiac output. Acute heart failure is defined as acute onset of signs and symptoms of HF requiring urgent or emergent intervention. Symptoms may be of new onset or recurrent. Acute HF can be associated with reduced LV systolic dysfunction (HFrEF or Systolic HF) or can occur in patients with preserved LV ejection fraction (LVEF) (HFpEF or diastolic HF); up to 50 % of patients hospitalized with acute HF have preserved LV systolic function. It is important to recognize that acute HF can present without signs and symptoms of congestion and patients may only have manifestations of low cardiac output and cardiogenic shock.


Abbreviations


ACC

American college of cardiology

ACE

Angiotensin converting enzyme

ACS

Acute coronary syndromes

ADHF

Acute decompensated heart failure

AHA

American heart association

AR

Aortic regurgitation

ARB

Angiotensin II receptor blocker

BNP

B-type natriuretic peptides

BUN

Blood urea nitrogen

Ca

Calcium

cAMP

Cyclic adenosine monophosphate

CBC

Complete blood count

Cr

Creatinine

CRT

Cardiac resynchronization therapy

CVA

Cerebrovascular accident

CXR

Chest X-ray

HF

Heart failure

HFpEF

Heart failure with preserved ejection fraction

HFrEF

Heart failure with reduced ejection fraction

HFSA

Heart Failure Society of America

ICD

Implantable cardioverter defibrillator

JVP

Jugular venous pressure

K

Potassium

LFT

Liver function tests

LV

Left ventricle

LVEF

Left ventricle ejection fraction

MCS

Mechanical circulatory support

Mg

Magnesium

Na

Sodium

NSAIDS

Nonsteroidal anti-inflammatory drugs

NT-proBNP

N-terminal proBNP

NYHA

New York Heart Association

PAD

Peripheral arterial disease

PCWP

Pulmonary capillary wedge pressure

PVC

Premature ventricular contractions

PVR

Pulmonary vascular resistance

RV

Right ventricular

SVR

Systemic vascular resistance

TIA

Transient ischemic attack

VAD

Ventricular Assist Devices

VT

Ventricular tachycardia



Introduction


Heart failure (HF) is a complex disorder that consists of a clinical syndrome with symptoms associated with pulmonary or systemic congestion with or without poor cardiac output. Acute heart failure is defined as acute onset of signs and symptoms of HF requiring urgent or emergent intervention. Symptoms may be of new onset or recurrent. Acute HF can be associated with reduced LV systolic dysfunction (HFrEF or Systolic HF) or can occur in patients with preserved LV ejection fraction (LVEF) (HFpEF or diastolic HF); up to 50 % of patients hospitalized with acute HF have preserved LV systolic function [1, 2]. It is important to recognize that acute HF can present without signs and symptoms of congestion and patients may only have manifestations of low cardiac output and cardiogenic shock.


Epidemiology [3]






  • 670,000 people are diagnosed with HF annually in the US; more than 290,000 deaths are associated with HF.


  • HF is the most common reason for hospitalization in people over age 65.


  • Over one million hospitalizations occur annually due to acute HF



    • More than 70 % of admissions are from worsening of chronic HF



      • In-hospital mortality is 4 %, and 1 year mortality is 20 % [4]


      • 30-day readmission rate is high



        • Readmission rates of 26.9 % for HF vs. 19.1 for all comers [5]


  • Based on acute HF registries (ADHERE [4], OPTIMIZE-HF [6], EHFS II [7]), most who are admitted with HF are over age 70, have a prior history of admission for HF and 40–52 % have preserved LVEF


Pathophysiology


Variety of mechanisms, consisting of an underlying substrate, triggering mechanism and perpetuating factors [8]

A.

Substrate: myocardial structure and function



  • Normal myocardial substrate that has suffered an acute injury



    • Ischemia/infarction


    • Inflammation (myocarditis, autoimmune)


    • Could be completely reversible, partially reversible or irreversible


  • Abnormal underlying substrate



    • American College of Cardiology (ACC)/American Heart Association (AHA) Stage B with first symptomatic event


    • Those with chronic compensated HF who present with an acute decompensation



      • Most common presentation

 

B.

Triggering mechanisms



  • Acute coronary syndromes (ACS) /ischemia


  • Medication non-compliance, iatrogenic changes in medications, drug interactions.


  • Dietary non-compliance


  • Worsening renal dysfunction



    • Renal artery stenosis [9] “Pickering syndrome”


  • Arrhythmias (Atrial or ventricular)



    • Atrial fibrillation [10]


    • Premature ventricular contractions (PVC) [11]


    • Ventricular tachycardia (VT)


  • Pulmonary emboli


  • Infection


  • Severe hypertension


  • Volume administration (e.g. intravenous fluids or blood transfusions)


  • Cardiotoxic agents



    • Antineoplastic agents



      • Anthracyclines


      • Trastuzumab


      • Cyclophosphamide


      • Imatinib


      • Mitoxantrone


      • Sunitinib


    • Cocaine


    • ETOH


    • Ephedra


  • Medications



    • Nonsteroidal anti-inflammatory drugs (NSAIDS)


    • Corticosteroids


    • Negative inotropes (e.g. verapamil/diltiazem)


  • RV pacing [12]


  • Hyper/hypothyroidism


  • Inflammation


  • Sleep apnea

 

C.

Perpetuating factors lead to chronic HF (see Chap. 15 )

 


Classification


Two major classification systems have been described for patients with HF [13]

A.

New York Heart Association (NYHA) Functional Classification of Heart Failure Symptoms (Table 14-1)


Table 14-1
New York Heart Association (NYHA) functional classification of heart failure symptoms


















Class I
No symptoms with ordinary activity

Class II
Slight limitation of physical activity; comfortable at rest, but ordinary physical activity results in fatigue, dyspnea or angina

Class III
Marked limitation of physical activity; comfortable at rest, but less than ordinary physical activity results in fatigue, dyspnea or angina

Class IV
Unable to carry out any physical activity without symptoms. Symptoms may be present at rest

 

B.

ACC/AHA Staging System for HF (Table 14-2)


Table 14-2
American College of Cardiology/American Heart Association staging system for HF





































Stage A
High risk for developing HF
Hypertension

CAD

Diabetes Mellitus

Family history of cardiomyopathy

Stage B
Asymptomatic HF
Previous MI

LV Systolic dysfunction

Asymptomatic valvular disease

Stage C
Symptomatic HF
Known structural heart disease

Shortness of breath and fatigue

Reduced exercise tolerance

Stage D
Refractory end-stage HF
Marked symptoms at rest despite maximal medical therapy

 


Initial Assessment



Presentation






  • Dyspnea on exertion



    • most sensitive symptom


  • Paroxysmal nocturnal dyspnea



    • most specific symptom [14]


  • Peripheral edema



    • less common (66 %)


  • Fatigue


  • Cough, particularly nocturnal


  • Chest discomfort


Physical Examination


A rapid initial assessment should be performed to identify (Table 14-3):


Table 14-3
Estimation of hemodynamic profile based on exam findings







































Congestion
Low cardiac output

S3 and/or S4 gallop
Narrow pulse pressure (Usually less than 25)

Prominent P2
Cool extremities

Elevated JVP
Lethargy/ altered mentation

JVD  >  10 cm corresponds to PCWP  >  22 mmHg with 80 % accuracy

Hepatojugular reflux
Hypotension

Hepatomegaly
Sinus Tachycardia

Edema
Pulsus alternans

Pulsatile liver
  

Ascites
  

Rales or wheezes (cardiac asthma)
  




  • Evidence of congestion


  • Evidence of low output/ cardiogenic shock


  • Presence of co-morbidities and precipitating factors

    NOTE: Clinical evaluation is often inaccurate


Diagnostic Evaluation (Table 14-4)





Table 14-4
Possible etiologies of AHF





































































Cardiac causes
Progression of underlying cardiomyopathy

New onset/acute cardiomyopathy

Postpartum

Myocarditis

Tako-tsubo syndrome

Ischemia

Arrhythmias

Pericardial

Constriction

Tamponade

Valvular dysfunction

Stenosis

Regurgitation

Pressure overload
Severe hypertension

Volume overload
Renal dysfunction

Sodium/ volume load

Medication non-compliance (diuretics)

High output
Thyroid disease

Shunt

Intracardiac

Extracardiac (A-V fistula)

Anemia

Septicemia

Miscellaneous causes
Infection

Pulmonary embolism

New medications/substances

NSAIDs

Corticosteroids

Cardiotoxic agents



1.

Chest X-ray (CXR)



  • Initial radiographs may not show evidence of pulmonary congestion [15]


  • >25 % of patients with acute decompensated heart failure (ADHF) present without CXR findings [16]


  • CXR findings include:



    • Dilated upper lobe vessels


    • Interstitial edema


    • Enlarged pulmonary arteries


    • Pleural effusion


    • Alveolar edema


    • Prominent superior vena cava


    • Kerley B lines

 

2.

Electrocardiogram



  • Assess for



    • Acute myocardial ischemia/infarction


    • LV hypertrophy


    • Arrhythmias



      • Atrial fibrillation



        • present in 31 % of patients presenting with acute HF


      • Heart block


      • PVC’s


    • Pacemaker malfunction, particularly in those patients with cardiac resynchronization therapy (CRT) devices; assess for adequate biventricular pacing.

 

3.

Laboratory tests



  • Electrolytes, including sodium (Na), calcium (Ca), potassium (K) and magnesium (Mg)


  • Renal function (blood urea nitrogen (BUN), Creatinine (Cr)) [17]


  • Liver function tests (LFT’s)


  • Thyroid function tests


  • Natriuretic Peptides



    • Two forms have been studied:



      • B-type natriuretic peptides (BNP), N-terminal proBNP (NT-proBNP)


    • Can be used when the diagnosis of acute HF is uncertain, for prognostication or to guide therapy [18]


    • Levels may be elevated in states other than acute HF, including chronic, compensated HF, acute myocardial infarction, valvular heart disease, and arrhythmias, while non-cardiac causes may include advancing age and renal failure.


    • complete blood count (CBC)

 

4.

Echocardiography



  • Assess LV and RV Function

    1.

    Preserved or reduced

     

    2.

    Ventricular structure

     

    3.

    Size

     

    4.

    Wall thickness

     


  • Other structural abnormalities

    5.

    Valvular

     

    6.

    Pericardial

     

    7.

    Right ventricle

     

    8.

    Atrial size

     

 


Indications for Hospitalization




A.

Per Heart Failure Society of America (HFSA) guidelines [19], hospitalization is recommended for patients with ADHF who present with the following clinical circumstances:



  • Hypotension


  • Worsening renal function


  • Altered mentation


  • Rest dyspnea


  • Tachypnea


  • Hypoxia


  • Hemodynamically significant arrhythmias


  • New onset rapid atrial fibrillation


  • ACS

 

B.

Consideration of hospitalization should be made if:



  • Evidence of worsening pulmonary or systemic congestion (even in the absence of dyspnea or weight gain)


  • Marked electrolyte disturbances


  • Multiple implantable cardioverter defibrillator (ICD) firings


  • Co-morbid conditions



    • Pneumonia


    • Diabetic ketoacidosis


    • Pulmonary embolus


    • Transient ischemic attack (TIA)/cerebrovascular accident (CVA)

 


Initial Management of Acute HF Syndromes



Goals






  • Rapidly relieve symptoms of congestion


  • Identify reversible causes, particularly ischemia


  • Restore hemodynamics


  • Ensure adequate oxygenation


  • Prevent end organ damage


  • Identify patients with low output states




  • Management should be based on hemodynamic profile



    • Rapid assessment and initiation of therapy can be made using the following 2  ×  2 diagram demonstrating the various hemodynamic profiles of patients presenting with acute HF (Fig. 14-1) [20]

      A306999_1_En_14_Fig1_HTML.jpg


      Figure 14-1
      2  ×  2 HF hemodynamic profiles. The above diagram demonstrates the hemodynamic profiles, signs and symptoms and treatment approach of patient’s presenting with heart failure. Quadrant A represents the patient who is not congested and has adequate perfusion. Quadrant B represents the patient who is congested but has adequate perfusion. Quadrant C represents the patient who is congested and has poor perfusion. Quadrant D represents the patient who has a normal to low volume status and poor perfusion. Treatment approaches overlap in the low output profiles, as those patients who are congested and also poorly perfused may need a separate treatment approaches to both conditions


After Admission


Practice guidelines recommend that the following parameters be monitored in patients hospitalized for acute HF [19]:



  • Daily weight


  • Daily measurement of fluid intake and output


  • Vital signs (more than once daily, as indicated)


  • Physical exams signs (at least daily)



    • Increased jugular venous pressure (JVP)


    • Hepatojugular reflux


    • Rales


    • Edema


    • Hepatomegaly


    • Liver tenderness


  • Labs (at least daily)



    • Electrolytes


    • Renal function


  • Symptoms (at least daily)



    • Fatigue


    • Dyspnea


    • Orthopnea


    • Paroxysmal nocturnal dyspnea or cough


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Jul 13, 2016 | Posted by in CARDIOLOGY | Comments Off on Diagnosis and Management of Acute Heart Failure

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