Definition The situation when the heart is incapable of maintaining a cardiac output adequate accommodate metabolic requirements and the venous return” ---- E. Braunward

Determinants of Ventricular Function

Etiology Hypertension Coronary artery disease Cardiomyopathy / myocarditis Valvular heart disease Pericardial disorders Anemia, hyperthyroidism

Classification Left heart failure ---- Right heart failure Systolic ---- diastolic heart failure High output heart failure

Stage -- NYHA Functional Class Class I symptoms of HF only at activity levels that would limit normal individuals Class II symptoms of HF with ordinary exertion Class III symptoms of HF with less than ordinary exertion Class IV symptoms of HF at rest

Precipitating Factors (table 53-4) Non-compliance Salt/fluid overload Drug non-compliance Cardiac cause New Arrhythmia Rapid Af ACS or AMI Uncontrolled HTN Iatrogenic CCB, beta-blockers, NSAID Inapproate therapy reduction Antiarrhythmic agents in 48 hrs Volume overload Renal failure Pregnancy Pul. embolism Infection Anemia Hyperthyroidism

Clinical Manifestations Right heart failure ankle edema elevated CVP hepatomegaly ascites anorexia Left heart failure pulmonary edema orthopnea PND; night cough cold limbs dizziness; malaise

Diagnosis Heart failure is a clinical diagnosis

Modified Framingham Criteria for Heart Failure Minor Criteria Bil. leg edema Night cough Dyspnea on exertion Hepatomegaly Pleural effusion Tachycardia (>120BPM) Weight loss > 4.5 kgs in 5 days Major criteria PND Orthopnea Elevated jugular vein pressure Pul. Rales S3 Cardiomegaly (Xray) Pulmonary edema (X-ray) Weight loss > 4.5 kgs in 5 days in response to Tx 診斷需 2 major or 1 major +2 minor criteria cannot be attributed to another medical condition. From Senni, M, Tribouilloy, CM, Rodeheffer, RJ, et al, Circulation 1998; 98:2282; ada pted from McKee, PA, Castelli, WP, McNamara, PM, Kannel, WB. N Engl J Med 1971; 85:1441.

Lab and exam EKG Chest films Lab Echocardiography SMA, CBC, U/A, etc.. BNP (cutoff level 100 pg/mL) Se: 90~94%, Sp: 76~94%, PPV 79~90%, NPV: 89~96% Echocardiography

Treatment – General considerations Reduce Preload Reduce Afterload Increase Contractility Maintain adequate heart rate/rhythm Eliminate aggravating factors

Treatment for decompensate CHFor APE L: Lasix 40mg IV stat M: Morphine 2~5 mg IV N: NTG 0.6 mg SL (may shift to IV form) O: O2 If BP unstable  as ACLS guideline Contraindications to vasodilatation: RV failure AS Volume depletion HCM hypotension

Protocol

Morphine Venodilator effect (↓preload, ↓afterload) Sedative effect( improve anxiety) Improve chest pain Dosage: 2-5mg iv, repeat if needed Caution: hypotension; respiratory inhibition

Loop Diuretics -- Furosemide More potent Initial vasodilator effect (↓preload) Dose: 0.5 – 1.0 mg/kgs, iv stat; repeat 2-4 hours later if needed Side effect: hypotension, hypokalemia; ototoxicity, nephrotoxicity; allergy

Nitrates Venodilator effect (↓preload, ↓afterload) Coronary arterial dilatation Rapid onset 0.6mg 1# sl, followed by IV infusion( esp. in patients with CAD) Caution: hypotension; constrictive pericarditis; hypertrophic cardiomyopathy; acute RV infarction

Nitroprosside Potent arteriodilators (if NTG無法有效降血壓) Rapid onset Easy to titrate Dosage: 0.3~10 ug/kg/min, titrate to effect Caution: need A-line monitor, hypotension, thiocyanate intoxication

ACE inhibitors Reduce mortality in chronic HF Efficacy on ADHF (12~24hrs) no evidence 已經在使用的  小心使用 Newly use  started after patient stable Arterial and venous dilator effect Improve neurohormonal status Effect on LV remodeling

Started with low dose, titrate to effect ACE inhibitors Contraindication: Bilateral renal artery stenosis Renal insufficiency ( Cr > 2.0) Hyperkalemia (> 5.0) Hypotension Pregnancy Started with low dose, titrate to effect

ACEI alternative: still reduce mortality ARBs( Angiotensin II receptor Blockers) Less dry cough than ACEI Less angiodema than ACEI Reserve for patients intolerance to ACEI Hydralazine + isosorbide

Spironolactone Decrease mortality in NYHA Class III~IV (chronic HF) Generally, not started in ED

Beta-blocker Reduce mortality in Chronic HF Inhibit cardiotoxicity of catecholamines Reduce neurohormonal activation Antihypertensive and antiaginal Antiarrhythmic Unlikely to started in acute setting, except for rate control Contraindication: HR< 60, high degree AVB, SBP<100 mmHg, severe HF<30% in acute stage, COPD or asthma

Increase Contractility Dopamine Dobutamine Digoxin

Dopamine/Dobutamine Reverse for patients with Caution: Hypotension low cardiac output refractory to conventional treatments Caution: Increase heart O2 consumption Arrhythmogenic skin necrosis( extravasation)

Digoxin 非一線用藥, Not improved mortality Improve symptoms Reduce heart rate( rapid Af) 當其他藥物都用了仍無效才考慮 Caution in patients impaired renal function dehydrated hypokalemia

Drugs Aaoided in HF CCB NSAID antiarrhythmics

Disposition APE: Decompensate HF Often need ICU Ordinary ward if patient response to initial therapy Decompensate HF admission to ordinary ward

Reference Marx: Rosen's Emergency Medicine: Concepts and Clinical Practice, 6th ed., 2006 Mosby. Tintinalli et al: Emergency Medicine: A Comprehensive Study Guide. 6th ed. 2004 Schaider et al: Rosen & Barkin's 5-Minute Emergency Medicine Consult. 3rd ed. 2007. Lippincott Williams & Wilkins. Acute Congestive Heart Failure in the Emergency Department, Robert L. Cariology Clinics 24(2006) 115-113 Using the Emergency Department Clinical Decision Unit for Acute Decompensated Heart Failure. W. Frank; Cardiology Clinics 23(2005) 569-588 Acute Decompensated Heart Failure (cardiogenic pulmonary edema); UpToDate, version 14.3, 2006 Guidelines 2005 for Resuscitation and Emergency Cardiovascular Care Science; Circulation 2005; 112

Practice 70 y/o M Sudden onset of SOB since 1 hours ago Vital sign: BP: 84/60, HR: 120, RR: 28/min, BT: 37.0 C PH: Congestive heart failure, CAD, DM Please evaluate this patient

EKG