1. Οξεια καρδιακη ανεπαρκεια με υποταση
Γεώργιος Μπακώσης
Τμήμα Καρδιακής Ανεπάρκειας, Β’ Παν/κή Καρδιολογική κλινική,
Π.Γ.Ν. “ΑΤΤΙΚΟΝ”

2. Disclosures
I have no actual or potential conflict of interest in relation to this presentation

3. What is the preferable IV therapy of Hypotensive AHF according to the ESC guidelines ?
1. iv diuretics
2. iv nitrates
3. iv inotropes
4. 1 and 2
5. 1 and 3

4. Patient profile Demographics and risk factors 65 year-old male
Admitted April 2017

5. Patient profile Cardiovascular history
First Heart Failure diagnosis in Acute anterior MI
PCI in LAD in 2015
Negative SPECT for ischemia one year after PCI
NYHA II, 2015
Mild renal failure
Creatinine 1.6 mg/dL (NR ) - eGFR 46 ml/min/1,73m2
Chronic anemia
Haemoglobin 10.7 g/dL (NR )
Hospitalized for decompensation in January 2017

6. Chronic medications prior to admission
With treatment, stable for 2 months
Low sodium diet; regular exercise; daily weight measurements
Medical therapy
Enalapril 10 mg
Furosemide 80 mg per os
Eplerenone 50 mg
Bisoprolol 2.5 mg
Acetylsalicylic acid 100 mg
Atorvastatin 20 mg
Warfarin (episodes of AF)

7. Clinical evaluation at outpatient clinic (referral)
Early April (10 wks after last hospitalisation)
Decreased exercise tolerance (NYHA III)
Increased furosemide 80  160 mg/day
Evaluated for ICD

8. ER evaluation - NYHA IV Next two weeks (mid April) Symptom worsening
Progressive dyspnoea
Weight gain 5 kg
ER admission
NYHA IV
23 April 2017

9. ER Physical exam results
General Dyspnoea at rest
Vital signs BP 90/60 mm Hg
HR 101 bpm
RR 24 ipm
Neck Jugular vein distension
Lungs Rales over the lung bases
Heart S2P > S2A; S3 at apex
Abdominal Liver enlarged 3 cm; mild ascites
Extremities Oedema of lower extremities
Cool extremities +

10. ECG

11. Admission echocardiogram
Left Atrium: 61 mm (NR, 20 – 40)
LVEDD: 76 mm (NR, 35 – 56)
LVESD: 66 mm (NR, 25 – 40)
LVEF, Simpson: 28% (NR > 55 %)
Long axis
Systole RV LV AV
Mitral insufficiency 2+/4
Aortic insufficiency 1+/4
Tricuspid insufficiency 2+/4 LA MV
Elevatet right heart pressures (estimated pulmonary pressure = 48 mmHg)

12. Admission laboratory tests
Haemoglobin 10.4 g/dL (NR= )
Urea mg/dL (NR= mg/dL)
Creatinine 2.3 mg/dL (NR= mg/dL)
Sodium 131 mEq/L (NR= mEq/L)
Potassium 3.54 mEq/L (NR= mEq/L)
NT-proBNP 6550 pg/ml (NR <300pg/ml)
INR (NR= )
Arterial blood gas
pH = 7.39 (NR = )
PO2 = 67 mm Hg (NR= mm Hg)
PCO2 = 39 mm Hg (NR=35-45 mmHg)
HCO3- = 25 mEq/L (NR=21-28 mEq/L)

13. Case summary History Presentation 65 year-old male
2-year known history of HF due to ischemic cardiomyopathy
Presentation
Worsening HF in the last 2 weeks  NYHA IV
SBP: 90 mmHg
Acutely aggravated renal dysfunction
Pulmonary and systemic congestion
Mild chronic anaemia

14. Eur Heart J 2016;37:

15. What is the preferable IV therapy of Hypotensive AHF according to the ESC guidelines ?
1. iv diuretics
2. iv nitrates
3. iv inotropes
4. 1 and 2
5. 1 and 3

16. Eur Heart J 2016;37:

17. Initial treatment Admission to the ward Bed rest, fluid restriction
Oxygen by nasal cannula
Correct potassium level
IV diuretics (furosemide 40 mg iv bolus initially, and continuous infusion at least equal dose of oral regimen)
ACE inhibitor discontinued
Bisoprolol discontinued

18. ACEi and b-blockers in AHF
ACEi should be stopped if:
Potasium rises to >5.5 mmol/L or
Creatinine >100% or >3.5 mg/dL (eGFR=20mg/min/1.73m2)
B-blockers
If increasing congestion, increase dose of diuretic or halve dose of beta-blocker (if increasing diuretic dose does not work)
Both should be stopped in hypotension
ESC Guidelines 2016

19. Evolution in ward NEXT STEP After 2 hours No significant improvement
Worsening dyspnoea (oxygen saturation 89%)
Rales over 2/3 of lungs
Blood pressure: 90/60 mm Hg
Decreased urine output
NEXT STEP

20. What is the next step ? 1. iv nitrates 2. iv dobutamine
3. iv levosimendan
4. iv norepinephrine

21. INOTROPIC SUPPORT Dobutamine started
Continuous IV infusion at 3-5 μcg/kg/min for the next 48 hours
ECG monitoring

22. Improving status: urine output

23. In-hospital improvement
After 48 hours
Clinical improvement
Blood pressure 90/55 mmHg
HR: 96/min
Hypotensive episode during the initiation of bisoprolol
Ivabradine initiated at 2,5 mg x 2 and uptitrated to 5 mg x 2 in the next 3 days

24. Elevated HR at discharge is a predictor of one year mortality in HF patients (OFICA)
Importance of controlling HR early in the post-discharge management of HF patients
Logeart et al. Eur Heart J 2012

25. Pre-discharge and discharge management
At 7th day
Hospital discharge, NYHA II
HR: 72 bpm
NT-proBNP reduction >30%
On oral medication >24h
Follow-up in 2 weeks
Evaluataion for comorbidities
Scheduled for ICD
Future evaluation for LVAD
Oral medications at discharge
Ivabradine 5 mg x 2
Furosemide 80 mg
Eplerenone 50 mg
Warfarin
Atorvastatin 20mg

26. TAKE HOME MESSAGES
Central hemodynamics, SBP, HR and volume status guide the optimal early phase management of AHF.
Close monitoring and re-evaluation of therapy may be needed, especially if congestion/hypoperfusion persists
Chronic life saving medications in appropriate combinations should be initiated and up-titrated after clinical stabilization.
A detailed post-discharge plan with an early follow-up visit (2 weeks in high risk patients) along with evaluation for specific HF therapies (eg. ICD, CRT, VAD), management of comorbid conditions and patient education is mandatory.

29. Criteria for ICU/CCU admission
Need for intubation
Signs/symptoms of hypoperfusion
SaO2 <90% (despite supplemental O2)
RR > 25/min, use of accessory muscles
SBP <90 mmHg, 40 > HR > 130 bpm

30. IV loop diuretics: Bolus vs. continuous infusion
Metanalysis: Continuous Infusion Superior to Bolus Injection:
Total Urine output
P = 0.003
Increase in s. Creatinine
P <
Length of Hospitalization
All Cause Mortality
P =
Salvador DRK et al. The Cochrane Database of Systematic Reviews 2005

31. IV loop diuretics in AHF DOSE trial
No difference in death, rehospitalization or RF visits at 60d
Felker et al, N Engl J Med 2011

32. MRAs in AHF MRA should be stopped if: Potasium rises >6.0 mmol/L or
Creatinine >3.5 mg/dL
Hypotension
ESC Guidelines 2016

33. B-blockers in AHF: B-CONVINCED
Similar patient improvement
(Green: keep BB – Red: stop BB)
Similar outcome
Higher use of BB at 3 months
Jondeau et al. Eur Heart J 2009

34. Parissis & Mebazaa. Curr Opin Crit Care 2010

35. Levosimendan improves renal function in ADHF: Comparison with Dobutamine
Yilmaz et al. Cardiovasc Drugs Ther 2007

36. Impact of Discharge Use of Beta Blocker on Early Clinical Outcomes in Heart Failure
30 day Survival
P<0.01
1.00
P=0.0003
0.95
0.90
Survival Probability
0.85
0.80
0.75
Beta-Blocker
No Beta-Blocker
0.70 10 20 30 40 50 60 70 80 90
100
110
120
130
Patients at Risk
Beta-blocker
1,946
1,855
1,649
333 68
No Beta-blocker
362
337
304 60 7
Days After Hospital Discharge
*Only subset of patients with 60- to 90-day follow-up are included. Patients with beta-blocker contraindications are excluded. 27
Fonarow et al. J Am Coll Cardiol. 2008;52: 36

37. Implantable device diagnostics on day of discharge identify heart failure patients at increased risk for early readmission for heart failure
Four diagnostic criteria were evaluated on the discharge day:
(i) intrathoracic impedance >8 Ω below reference impedance
(ii) AF burden >6 h
(iii) CRT pacing <90% and
(iv) heart rate >80 b.p.m.
Patients were considered to have higher risk for HFR if ≥2 criteria were met, average risk if 1 criterion was met, and lower risk if no criteria were met.
Small et al, Eur J Heart Fail 2014

39. Effect of early treatment with ivabradine combined with beta-blockers versus beta-blockers alone in patients hospitalised with heart failure and reduced LVEF (ETHIC-AHF): A randomised study
The early co-administration of ivabradine and beta-blockers during hospital admission for acute HFrEF is feasible and safe, and it produces a significant decrease in HR at 28 days and at four months after hospital discharge. It also seemed to improve systolic function and functional and clinical parameters of HF patients at short-term. Hidalgo et al, Int J Cardiol 2016

40. Int J Cardiol 2015;201: