pd dr. med. thomas m. suter - kardiologie.insel.ch · akute herzinsuffizienz – diagnostik und...

Akute Herzinsuffizienz – Diagnostik und Therapie 1

Universitätsklinik für Kardiologie

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Test

Thomas M. Suter



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Heart Failure - Definition

European Heart Journal (2008) 29, 2388–2442



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Classification Heart Failure

• Acute / Acute Decompensated / Chronic Heart Failure

• Right vs. Left Heart Failure

• Systolic vs. Diastolic Heart Failure



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Acute / Acutely Decompensated / Chronic Heart Failure

Acute HF Chronic HF Acutely Decompensated

Heart Failure

Ischemic Hypertensive

Valvular Cardiomyopathy

Toxic Infectious

Ischemic Hypertensive Pulm. Emboli

Toxic Infectious Valvular

Non-Compliance Adverse Drug Reaction

Ischemic Arrhythmia

Hypertensive Crisis Infection Alcohol Thyroid



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Circulation – A Continuum



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Systolic vs. Diastolic Heart Failure



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DIAGNOSIS Heart Failure



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Heart Failure Suspected • Dyspnea • Fatigue • Edema

Clinical History Clinical Examination Specific Examination

• Coronary Artery Disease • Hypertension • Arrhythmia

• Weight Gain • Jugular Vein Distention • 3. Heart Sound • Pulmonary Rales • Peripheral Edema • Cardiac Murmur

• Laboratory • Electrocardiogram (ECG) • Chest X-Ray • Echocardiogram

Heart Failure Confirmed



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Clinical History Clinical Examination



Presenter

Presentation Notes

Klinische Diagnose einer Herzerkrankung Die Diagnose der «Herzinsuffizienz» beruht auf einer gründlichen Anamnese und der klinischen Untersuchung des Patienten. Die Symptome der Herzinsuffizienz werden im wesentlichen durch 2 Faktoren bestimmt: 1.Anstieg des diastolischen Füllungsdruckes, mit den Zeichen der Lungenstauung und 2.Reduktion des Herzminutenvolumens, mit den Zeichen der allgemeinen Leistungsintoleranz. Die häufigsten Symptome sind: 1.Dyspnoe, Orthopnoe, paroxysmale nächtliche Dyspnoe, Husten, Prälungenödem und Lungenödem; 2.Allgemeine Leistungsintoleranz mit Müdigkeit, Hypotonie und zerebraler Hypoperfusion; 3. Prätibiale Oedeme, gestaute Halsvenen, Hepatosplenomagalie und Aszites. Die klinische Diagnose wird aufgrund der Anamnese (Herzinfarkt, Angina pectoris, Hypertonie, etc.) und der klinischen Untersuchung mit den Zeichen des erhöhten Iugularvenendruckes, dem verlagerten Herzspitzenstoss und dem dritten Herzton gestellt. Häufig kann auch eine Mitralinsuffizienz (Anulusdilatation) auskultiert werden und über der Lunge sind feinblasige, feuchte Rasselgeräusche hörbar. Spezielle Untersuchungen sind das EKG und das Thoraxröntgenbild sowie die wichtigste Untersuchung heute das Echokardiogramm, welches wichtige Hinweise auf die Aetiologie der Herzerkrankung geben kann.



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Assessment of Volume Status



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Heart Failure: Clinical Profiles

Congestion at rest (WET) No Yes

Low

per

fusi

on (C

OLD

)

No

Yes

- Diastolic Heart Failure

Low perfusion: Cool extremities; Narrow pulse pressure Organ perfusion (Renal dysfunction, confusion)

Congestion: Orthopnea JVD Edema Ascites Rales (rarely)

Lynne Warner-Stevenson

Systolic Heart Failure

Systolic Heart Failure



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Clinical History Clinical Examination Specific Examination



• Laboratory • Electrocardiogram (ECG) • Chest X-Ray • Echocardiogram

Heart Failure Confirmed



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Adapted from Wilkins MR. Redondo J. Brown LA. Lancet 1997;349:1307-1310

Cardiac Overload

Urodilatin

NPR-A

Increased Na/H20 Excretion

ANP+BNP

NPR-A/NPR-B

Decreased Blood Pressure

Neutral Endopeptidase Cytokines

Clearance

NPR-C

Decreased Vascular Growth

CNP +

- +

Natriuretic Peptides

Presenter

Presentation Notes

Central to the NPS are ANP and BNP. Because their release kinetics are based on chamber stress, they are central regulators for natriuresis and reduced vascular pressure in congestive heart failure.



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Chest X-Ray

© Chest X-ray Atlas



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ECG

Old anteroseptal MI Left Ventricular Hypertrophy

Alan E. Lindsay ECG Learning Center



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MUGA

Echocardiography

Imaging



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Noncardiogenic Pulmonary Edema

Cardiac PE

Noncardiac PE

• ARDS • ASA

• Pulm.Eboli • High Altitude

• Neurogen • Reperfusion

Cardiac PE Normal Heart

• Volume Overload

• Hypert. Crisis • Renal Disease



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THERAPY Heart Failure



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Therapy of Acute and Acutely Decompensated HF

Acute HF Acutely Decompensated

Heart Failure

Ischemic Hypertensive Pulm. Emboli

Toxic Infectious Valvular

Non-Compliance Adverse Drug Reaction

Ischemic Arrhythmia

Hypertensive Crisis Infection Alcohol Thyroid



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Hospitalization for Acute Decompensated HF • Severely decompensated

– hypotension, renal failure, altered mental status

• Dyspnea at rest – resting tachypnea

• Hemodynamically significant arrhythmia

– atrial fibrillation, atrial flutter



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© Corbis



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Acute Heart Failure – Initial Therapy

Diuresis

Oxygen Assisted Ventilation

Morphine

Vasodilator



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Diuretics - Pharmacokinetics

Effective/ Target Range

Renal Failure

Modified Brater C, NEJM 1998; 339: 387



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Diuretica - Pharmacokinetics

Bioavail. Elimination Half-life (hrs) % Normal

subject Renal insuff

Cirrhosis CHF

Loop Furosemid

10-100

1.5-2

2.8

2.5

2.7

Torasemid 80-100 3-4 4-5 8 6

Thiazide HCTZ

65-75

2.5

↑

?

.?

Indapamide 93 15-25 ? ? ?

Distal Spirnonlactone

?

1.5

1.5

1.5

?

Modified Brater C, NEJM 1998; 339: 387



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Diuretics



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SWISS CARDIOVASCULAR CENTER

Heart Failure Algorithm 2011 Heart failure suspected

BNP > 100 ng/ml no yes

Heart failure unlikely Echocardiography /

Systolic Dysfunction Diastolic Dysfunction

2. Therapy of reversible causes a. Non-compliance (salt restriction, medication); b. Adverse drug effects (NSAID, verapamil, diltiazem, BB) c. Myocardial ischemia; d. Infection (viral, bacterial); e. Hypertension (not controlled); f. Alcohol abuse

g. Arrhythmia (atrial fibrillation, bradycardia) h. Thyroid dysfunction

Most important: coronary artery disease, HTN Most important: arterial hypertension

Baseline Therapy: 1) ARB or ACE inhibitor 2) β-Blockers or verapamil or diltiazem (to lower heart rate; goal 60-70/‘ @ rest)

Cardiology, Inselspital Bern 2011

Swiss Cardiovascular Center, Bern

LVEF < 40 %

1. Work up for etiology

Add on: Nitrates Maintenance of SR

Add on: CRT (NYHA III/IV;EF≤35;QRS≥120; I/A) (NYHA II; EF≤35; QRS≥150; I/A) ICD (SCD; ischemic I/A; non-isch I/B)

Baseline Thearpy: 1a) ACE inhibitor or ARB [Class I/Level A] 1b) β-Blockers [I/A] 1c) Aldosterone antagonists [I/A]

2) (if symptomatic on 1a – 1c) Digoxin, add ARB, TX PAHT

Diuretics (preferable loop diuretics) if needed [Class I / Level B]

LVEF ≥ 40 %



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Acute Heart Failure – Initial Therapy

Vasodilator



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Heart Failure: Clinical Profiles

Congestion at rest (WET) No Yes

Low

per

fusi

on (C

OLD

)

No

Yes

- Diuretics

Inotrops

Warm up first, then dry out Vasodilatation Diuretics

Low perfusion: Cool extremities; Narrow pulse pressure Organ perfusion (Renal dysfunction, confusion)

Congestion: Orthopnea JVD Edema Ascites Rales (rarely)

Lynne Warner-Stevenson



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ACE-Inh

Vasodilator

ACE-Inh Nitroprussid

NTG

ARB Nesiritide

Acute Chronic



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THERAPY TRANSITION TO CHRONIC

Heart Failure

SWISS CARDIOVASCULAR CENTER

Heart Failure Algorithm 2011 Heart failure suspected

BNP > 100 ng/ml no yes

Heart failure unlikely Echocardiography /

Systolic Dysfunction Diastolic Dysfunction

2. Therapy of reversible causes a. Non-compliance (salt restriction, medication); b. Adverse drug effects (NSAID, verapamil, diltiazem, BB) c. Myocardial ischemia; d. Infection (viral, bacterial); e. Hypertension (not controlled); f. Alcohol abuse

g. Arrhythmia (atrial fibrillation, bradycardia) h. Thyroid dysfunction

Most important: coronary artery disease, HTN Most important: arterial hypertension

Baseline Therapy: 1) ARB or ACE inhibitor 2) β-Blockers or verapamil or diltiazem (to lower heart rate; goal 60-70/‘ @ rest)

Cardiology, Inselspital Bern 2011

Swiss Cardiovascular Center, Bern

LVEF < 40 %

1. Work up for etiology

Add on: Nitrates Maintenance of SR

Add on: CRT (NYHA III/IV;EF≤35;QRS≥120; I/A) (NYHA II; EF≤35; QRS≥150; I/A) ICD (SCD; ischemic I/A; non-isch I/B)

Baseline Thearpy: 1a) ACE inhibitor or ARB [Class I/Level A] 1b) β-Blockers [I/A] 1c) Aldosterone antagonists [I/A]

2) (if symptomatic on 1a – 1c) Digoxin, add ARB, TX PAHT

Diuretics (preferable loop diuretics) if needed [Class I / Level B]

LVEF ≥ 40 %



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Acute Heart Failure • acute dyspnea

• ischemic, hypertension, iatrogenic • O2, diuretics, vasodilators, MO

pd dr. med. thomas m. suter - kardiologie.insel.ch · akute herzinsuffizienz – diagnostik und...

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