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

3. Determinants of Ventricular Function

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

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

6. 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

7. 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

8. 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

9. Diagnosis
Heart failure is a clinical diagnosis

10. 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.

11. 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

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

13. 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

14. Protocol

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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

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

23. 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

24. Increase Contractility
Dopamine
Dobutamine
Digoxin

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

27. 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

28. Drugs Aaoided in HF
CCB
NSAID
antiarrhythmics

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

30. 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 Lippincott Williams & Wilkins.
Acute Congestive Heart Failure in the Emergency Department, Robert L. Cariology Clinics 24(2006)
Using the Emergency Department Clinical Decision Unit for Acute Decompensated Heart Failure. W. Frank; Cardiology Clinics 23(2005)
Acute Decompensated Heart Failure (cardiogenic pulmonary edema); UpToDate, version 14.3, 2006
Guidelines 2005 for Resuscitation and Emergency Cardiovascular Care Science; Circulation 2005; 112

31. 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

32. EKG