Universitätsklinik für Kardiologie. Test. Thomas M. Suter Akute Herzinsuffizienz Diagnostik und Therapie 1

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1 Test Thomas M. Suter Akute Herzinsuffizienz Diagnostik und Therapie 1

2 Heart Failure - Definition European Heart Journal (2008) 29, Akute Herzinsuffizienz Diagnostik und Therapie 2

3 Classification Heart Failure Acute / Acute Decompensated / Chronic Heart Failure Right vs. Left Heart Failure Systolic vs. Diastolic Heart Failure Akute Herzinsuffizienz Diagnostik und Therapie 3

4 Acute / Acutely Decompensated / Chronic Heart Failure Acute HF Ischemic Hypertensive Pulm. Emboli Toxic Infectious Valvular Acutely Decompensated Heart Failure Non-Compliance Adverse Drug Reaction Ischemic Arrhythmia Hypertensive Crisis Infection Alcohol Thyroid Chronic HF Ischemic Hypertensive Valvular Cardiomyopathy Toxic Infectious Akute Herzinsuffizienz Diagnostik und Therapie 4

5 Circulation A Continuum Akute Herzinsuffizienz Diagnostik und Therapie 5

6 Systolic vs. Diastolic Heart Failure Akute Herzinsuffizienz Diagnostik und Therapie 6

7 Heart Failure DIAGNOSIS Akute Herzinsuffizienz Diagnostik und Therapie 7

8 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 Akute Herzinsuffizienz Diagnostik und Therapie 8

9 Heart Failure Suspected Dyspnea Fatigue Edema Clinical History Clinical Examination Coronary Artery Disease Hypertension Arrhythmia Weight Gain Jugular Vein Distention 3. Heart Sound Pulmonary Rales Peripheral Edema Cardiac Murmur Akute Herzinsuffizienz Diagnostik und Therapie 9

10 Assessment of Volume Status Akute Herzinsuffizienz Diagnostik und Therapie 10

11 Heart Failure: Clinical Profiles Low perfusion (COLD) No Yes Congestion at rest (WET) No - Systolic Heart Failure Yes Diastolic Heart Failure Systolic Heart Failure Congestion: Orthopnea JVD Edema Ascites Rales (rarely) Low perfusion: Cool extremities; Narrow pulse pressure Organ perfusion (Renal dysfunction, confusion) Lynne Warner-Stevenson Akute Herzinsuffizienz Diagnostik und Therapie 11

12 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 Akute Herzinsuffizienz Diagnostik und Therapie 12

13 Natriuretic Peptides + Cardiac Overload - Neutral Endopeptidase Cytokines ANP+BNP Urodilatin Clearance CNP + NPR-C NPR-A/NPR-B NPR-A Decreased Vascular Growth Decreased Blood Pressure Increased Na/H 2 0 Excretion Adapted from Wilkins MR. Redondo J. Brown LA. Lancet 1997;349: Akute Herzinsuffizienz Diagnostik und Therapie 13

14 Chest X-Ray Chest X-ray Atlas Akute Herzinsuffizienz Diagnostik und Therapie 14

15 ECG Old anteroseptal MI Left Ventricular Hypertrophy Alan E. Lindsay ECG Learning Center Akute Herzinsuffizienz Diagnostik und Therapie 15

16 Imaging Echocardiography MUGA Akute Herzinsuffizienz Diagnostik und Therapie 16

17 Akute Herzinsuffizienz Diagnostik und Therapie 17

18 Noncardiogenic Pulmonary Edema Cardiac PE Cardiac PE Normal Heart Volume Overload Hypert. Crisis Renal Disease Noncardiac PE ARDS ASA Pulm.Eboli High Altitude Neurogen Reperfusion Akute Herzinsuffizienz Diagnostik und Therapie 18

19 Heart Failure THERAPY Akute Herzinsuffizienz Diagnostik und Therapie 19

20 Therapy of Acute and Acutely Decompensated HF Acute HF Ischemic Hypertensive Pulm. Emboli Toxic Infectious Valvular Acutely Decompensated Heart Failure Non-Compliance Adverse Drug Reaction Ischemic Arrhythmia Hypertensive Crisis Infection Alcohol Thyroid Akute Herzinsuffizienz Diagnostik und Therapie 20

21 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 Akute Herzinsuffizienz Diagnostik und Therapie 21

22 Corbis Universitätsklinik für Kardiologie Akute Herzinsuffizienz Diagnostik und Therapie 22

23 Acute Heart Failure Initial Therapy Oxygen Assisted Ventilation Diuresis Vasodilator Morphine Akute Herzinsuffizienz Diagnostik und Therapie 23

24 Diuretics - Pharmacokinetics Renal Failure Effective/ Target Range Modified Brater C, NEJM 1998; 339: 387 Akute Herzinsuffizienz Diagnostik und Therapie 24

25 Diuretica - Pharmacokinetics Bioavail. % Normal subject Elimination Half-life (hrs) Renal insuff Cirrhosis CHF Loop Furosemid Torasemid Thiazide HCTZ ?.? Indapamide ??? Distal Spirnonlactone? ? Modified Brater C, NEJM 1998; 339: 387 Akute Herzinsuffizienz Diagnostik und Therapie 25

26 Diuretics Akute Herzinsuffizienz Diagnostik und Therapie 26

27 Akute Herzinsuffizienz Diagnostik und Therapie 27

28 Akute Herzinsuffizienz Diagnostik und Therapie 28

29 no Heart failure suspected SWISS CARDIOVASCULAR CENTER BNP > 100 ng/ml Heart Failure Algorithm 2011 yes Swiss Cardiovascular Center, Bern Heart failure unlikely Systolic Dysfunction Echocardiography / LVEF < 40 % LVEF 40 % Diastolic Dysfunction Most important: coronary artery disease, HTN 1. Work up for etiology Most important: arterial hypertension 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 Diuretics (preferable loop diuretics) if needed [Class I / Level B] Baseline Thearpy: 1a) ACE inhibitor or ARB [Class I/Level A] 1b) β-blockers [I/A] 1c) Aldosterone antagonists [I/A] Baseline Therapy: 1) ARB or ACE inhibitor 2) β-blockers or verapamil or diltiazem (to lower heart rate; goal rest) 2) (if symptomatic on 1a 1c) Digoxin, add ARB, TX PAHT 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) Add on: Nitrates Maintenance of SR Cardiology, Inselspital Bern 2011

30 Acute Heart Failure Initial Therapy Vasodilator Akute Herzinsuffizienz Diagnostik und Therapie 30

31 Heart Failure: Clinical Profiles Low perfusion (COLD) No Yes Congestion at rest (WET) No Inotrops Yes - Diuretics Warm up first, then dry out Vasodilatation Diuretics Congestion: Orthopnea JVD Edema Ascites Rales (rarely) Low perfusion: Cool extremities; Narrow pulse pressure Organ perfusion (Renal dysfunction, confusion) Lynne Warner-Stevenson Akute Herzinsuffizienz Diagnostik und Therapie 31

32 Vasodilator Acute Chronic NTG Nitroprussid Nesiritide ACE-Inh ACE-Inh ARB Akute Herzinsuffizienz Diagnostik und Therapie 32

33 Heart Failure THERAPY TRANSITION TO CHRONIC Akute Herzinsuffizienz Diagnostik und Therapie 33

34 no Heart failure suspected SWISS CARDIOVASCULAR CENTER BNP > 100 ng/ml Heart Failure Algorithm 2011 yes Swiss Cardiovascular Center, Bern Heart failure unlikely Systolic Dysfunction Echocardiography / LVEF < 40 % LVEF 40 % Diastolic Dysfunction Most important: coronary artery disease, HTN 1. Work up for etiology Most important: arterial hypertension 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 Diuretics (preferable loop diuretics) if needed [Class I / Level B] Baseline Thearpy: 1a) ACE inhibitor or ARB [Class I/Level A] 1b) β-blockers [I/A] 1c) Aldosterone antagonists [I/A] Baseline Therapy: 1) ARB or ACE inhibitor 2) β-blockers or verapamil or diltiazem (to lower heart rate; goal rest) 2) (if symptomatic on 1a 1c) Digoxin, add ARB, TX PAHT 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) Add on: Nitrates Maintenance of SR Cardiology, Inselspital Bern 2011

35 Acute Heart Failure acute dyspnea ischemic, hypertension, iatrogenic O2, diuretics, vasodilators, MO Akute Herzinsuffizienz Diagnostik und Therapie 35

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