Nwalozie J.C. 17/03/2014

Question  A 50 year old man presents with sudden-onset breathlessness & feeling of impending doom.  Discuss 3 differential diagnoses & describe the management of Acute Left Ventricular Failure.

Answers  3 differential diagnoses: 1. Acute Severe asthma 2. Pulmonary Embolism 3.Acute exacerbation of COPD

MANAGEMENT OF ACUTE LEFT VENTRICULAR FAILURE

Outline  Introduction Precipitating factors Pathophysiology Clinical features Investigations  Management Treatment Prognosis & Monitoring Follow-up  Conclusion

Introduction  Inability of the left ventricle to effectively handle its pulmonary venous return with leakage of fluid from the pulmonary capillaries & venules into the alveolar space (secondary to increased hydrostatic pressure) leading to rapid onset of breathlessness.  It is a medical emergency.  It can arise de novo or on a background of chronic left ventricular failure.

PRECIPITATING FACTORS  Dietary indiscretion  Uncontrolled hypertension  Non adherence to drugs  Myocardial ischaemia or infarction  Arrhythmias  Thyrotoxicosis  Fluid overload  Anaemia  Pulmonary & other infections  Inappropriate medications- -ve inotropes, NSAIDS  Acute valvular insufficiency

PATHOPHYSIOLOGY ↓ CARDIAC OUTPUT INCREASED PCWP ACTIVATION OF RENIN ANGIOTENSIN SYSTEM ACTIVATION OF S/S SYSTEM INCREASED HEART RATE INCREASED SYSTEMIC VASCULAR RESISTANCE INCREASED PRELOAD CARDIAC ISCHAEMIA ↓ LEFT VENTRICULAR FUNCTION SYMPTOMATIC DECOMPENSATION

CLINICAL FEATURES  Extreme SOB with use of accessory muscles of respiration  Sensation of drowning, chest pain, palpitations  Cough(with pink, frothy sputum)  Previous history: Of cardiac disease  Restlessness, Profuse sweating

CLINICAL FEATURES Orthopnoea(patient noticed to be sitting up in bed) - sensitivity 5% - specificity 77%  PND  Pulse(Tachycardia, Pulsus Alternans)   BP  S3  Wheezing (Cardiac ‘asthma’) – sensitivity 22% - specificity 58%  Crepitations - sensitivity 6% - specificity 78%

 Other features: -Cyanosis -Cold skin -Features of underlying heart disease/precipitating factor -Features of right heart failure

INVESTIGATIONS  1.Pulse oximetry  2. Blood  3. Electrocardiography  4. Radiologic  5.Others- eg. Pulmonary arterial catheterisation

BLOOD INVESTIGATIONS  ABG  FBC – anaemia, infection  U & Es  CARDIAC MARKERS

CARDIAC MARKERS  CARDIAC ENZYMES  OTHER CARDIAC MARKERS

IMPORTANCE OF BNP IN HF  1. Useful in Diagnosis  2. Assessing Severity  3. Predicting short & long-term CVS mortality

WHAT LEVELS ?  NO HEART FAILURE -BNP < 100pg / dl -NT PRO-BNP < 300pg / dl  HEART FAILURE -BNP >500pg / dl -NT PRO-BNP > 1000pg / dl *80% Sensitivity for heart failure

ELECTROCARDIOGRAM  Ischaemia / infarction  Arrhythmia – A fib  LVH  Prolonged QRS

CHEST RADIOGRAPH  FINDINGS IN HEART FAILURE  Cardiomegaly – 74% sensitive, 78% specific  Vascular redistribution  Interstitial oedema  Alveolar oedema  Pleural effusions (right sided/bilateral)

Others  Echocardiography 1.Identify reversible cause eg MI, valvular insufficiency,tamponade 2.Distinguish between systolic and diastolic dysfunction Monitor urine output

Treatment  A medical emergency  Begin treatment before investigations  ABC of resuscitation, Patient to sit up  Treatment can be medical, radiological/surgical

TREATMENT  AIMS OF IMMEDIATE MANAGEMENT Overall aim- Redistribute fluid out of lungs! -Decrease Preload (right-sided filling) eg loop diuretics,morphine,tolvaptan -Increase left-sided emptying eg ACE- I,NTG,nitroprusside ↓ Afterload,  Cardiac output -± improve LV contractility – inotropes eg dopamine,dobutamine,milrinone,levosimendan

 Other measures-diet, fluid restriction, ultrafiltration, treat precipitating cause eg infection  Radiological-IABP,LV assist device, CRT  Surgical-Valve repairs, transplantation

Prognosis & monitoring  Poor prognostic factors include: -Underlying heart disease/precipitating factor -BNP>500 pg/dl -K <3mmol/l -Na < 133mmol/l -Frequent ventricular extrasystoles Monitoring for vital signs, other signs, symptoms,urine output,renal function,electrolytes.

 Follow Up

Conclusion  ALVF is a life-threatening medical emergency that is as a result of LV compromise leading to accumulation of fluid in the lungs with resultant acute onset of symptoms.  It is essential to make a diagnosis( ie differentiate it from similar conditions) so that necessary interventions can be instituted as soon as possible  Management is multidisciplinary and should be individualised according to how each patient presents.

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