chief round guideline treatement for acute heart failure ... · pdf file2008,esc hf guideline...

Chief Round Guideline Treatement

for Acute Heart FailureCase-Challenges

黃金隆醫師黃金隆醫師黃金隆醫師黃金隆醫師(Huang Jin-Long MD, Ph D)

Chief of Hear Failure Division Associate Professor

CVC of TCVGH National Yang-Ming University

Acute Decompensated Heart Failure (ADHF)

�Clinical features

�Clinical evaluation

�Clinical treatment

�Case approach

Acute heart failure (AHF) is defined as a rapid onset or change inthe signs and symptoms of HF, resulting in the need for urgent therapy.

Clinical Conditions

2008,ESC HF guideline

0.6 0.51.2 1.0

2.0 2.23.1

3.2

5.05.1

6.47.0

7.5

8.98.5

11.9

0.0 %

2.0 %

4.0 %

6.0 %

8.0 %

10.0 %

12.0 %

＜55 55-59 60-64 65-69 70-74 75-79 80-84 ≧85

年齡

心臟衰竭盛行率-依年齡別及性別

男性

女性

From National Health Insurance data (2006)

European Heart Failure Survey (EHFS)HF ⅡⅡⅡⅡ – Classification of Heart Failure

Classification of AHF %

All De novo AHF

ADCHF

Decompensated HF 65.4 52.4 73.0***

Pulmonary Oedema 16.2 26.0 10.4***

Cardiogenic Shock 3.9 6.8 2.2***

Hypertension HF 11.4 11.4 11.3

Right HF 3.2 3.4 3.0

Clinical Status at Time of Discharge

Evidence of incomplete Relief From Congestion

All Enrolled Discharges (n=150,745) October 2001 to December 2004

Improved

(but still symptomatic)

40%

No Mention

11%

Asymptomatic

44%

20% of ADHF patients

discharged with weight

gain or no charge in weight

No Change <1%

Not Applicable 4%

Worse <1%

Clinical Outcome ??

• Let’s look at some events rates:� In hospital mortality overall 4% but

easy to define patients with 20%+� Post discharge – 60 day readmit

rate 25%.� Post discharge – 60 day mortality

10% and 6 months mortality 25% (especially those requiring vasoactive therapy)

Source: F.L. Kalon, et al., “Survival After the Onset of Congestive Heart Failure in Framingham Heart Study Subjects,”

Circulation, July 1993; ACHPR CHF Clinical Practice Guidelines

85%

50%

1 Year 5 Years

Survival After DiagnosisSurvival After Diagnosis

90%-95%80%-90%

50%-70%

Class II Class III Class IV

OneOne--Year Survival by NYHA ClassYear Survival by NYHA Class

Heart Failure Survival Rates

High mortality !!

Traditional Presentation Profiles of ADHF

• Under-Appreciated aspects of acute HF

� 50% have systemic HTN (>140mmHg)

� 40% have preserved LVEF

� eGFG < 60 common (1/3rd)

� Patients really are old > 75 common

� Co-morbidities are frequent (40% diabetic,

30% A-Fib, 60% CAD)

Summary data on approximately 200,000 patients

Am Heart J. 2006; 149:209-216Eur Heart J. 2003; 24:442-453J Am Coll Cardiol. 2005; 45(suppl A):345A, Abstract 844-4

60% CAD, 50% HT, 40% DM, 30% Afi or CKD !!

Combined adjusted all-cause mortality risk: severe renal impairment

J Am Coll Cardiol 2006;47:1987–96

Clinical Features of AHF

• Poor Control !!

• Poor Prognosis !!

• Multiple co-morbidities !!

• Old patients !!

Clinical Evaluation

� Optimize volume & perfusion

� Identify precipitating factors

� Identify etiology

Clinical Evaluation in summary

�Vital sign : BP, PR, BT, SaO2.�Edema: Lung, legs, JVE, et al.�Tissue perfusion: organ functions: CNS,

limbs, liver and renal functions…..

Treatment algorithm in AHF


Fluid, SaO2, Perfusion

AHF Treatment Strategy (LVEDP)


Case Report-(1)• CC: Progressive dyspnea on Sep. 8.

• 67 yr male patient with HCVD for 30 yrs.

• DM 20 yrs, Cr:1.2.

• Gout for 10 years

• Smoke: 1PPD for 10 years.

• PE: bil basal rales, CPK: 176, Troponin-I:0.34 ng/ml

• Vtial sign: BP:216/88mmHg, PR: 100/min

RR: 30/min, BT: 36.20 C.

ABG: PH: 7.33, CO2: 47, O2: 85, HCO3: 25

CXR (94-09-08)

Cardiac echo1.AORTIC ROOT DILATATION (4.3CM) WITH MODERATE AR

2.LV(6.6,4.3) CCHAMBER DILATATION

3.GENERALIZED LEFT VENTRICULAR HYPOKINESIS,ESP,

LV INFERIOR WALL SHOWED AKINETIC MOTION,THE LVEF:36%

4.MINIMAL TR WITH PEAK PRESSURE GRADIENT -- 18 MMHG

5.MITRAL ANNULAR CALCIFICATION WITH MILD MR

6.CONC LVH(1.3,1.3CM).

AHF Treatment Strategy (BP)


Medications

• ? Captopril 1 TAB PO TID

• ? Amlodipine tab 5mg 1 TAB PO QD

• ? Furosemide tab-40 40 MG PO QD

• ? Isordil tab 10mg 1 TAB PO TIDAC

• ? 500mg Glucophage 1 TAB PO BID

• ? Amaryl tab 2mg 1 TAB PO BIDAC

• ? Bokey cap 100mg 1 CAP PO QD

CXR (94-09-09)

Clinical Evaluation


HFSA 2010 Practice Guideline (12.3, Table 12.3)

Acute Decompensated Heart Failure (ADHF)—Treatment Goals for Hospitalized Patients

• Improve symptoms, especially congestion and low-output symptoms

• Optimize volume status

• Identify etiology

• Identify precipitating factors

• Optimize chronic oral therapy; minimize side effects

• Identify who might benefit from revascularization

• Education patients concerning medication and HF self-assessment

• Consider enrollment in a disease management program

Strength of Evidence = C

PCI for CAD

Case 2• A 35 yr male patient is a case of severe

MR s/p annuloplasty, AF, CHF Fc IV. BP:92/56 mmHg, PR=120/min. LVEF:21%

• He was admitted due to severe dyspnea

and incrase of BW from 80 kgs to 98 kgs

AF with rapid ventricular response

Lab data

How to treat his fluid overload !!

Recommendations for Acute Decompensated Heart Failure

A low sodium diet (2 g daily) is recommended for most hospitalized patients.

Fluid restriction (<2 L/day) is recommended in patients with moderate hyponatremia (serum sodium <130 mEq/L).

In patients with severe (serum sodium <125 mEq/L) or worsening hyponatremia, stricter fluid restriction may be considered

2010, HFSA Guideline for HF

Diuretics



It is recommended that patients admitted with ADHF and evidence of fluid overload be treated initially with loop diuretics - usually given intravenously rather than orally.

Ultrafiltration may be considered in lieu of diuretics.

It is recommended that diuretics be administered at doses needed to produce diuresis

� symptomatic hypotension

� worsening renal function

� Electrolytes imbalance, which may precipitate arrhythmias or muscle cramps.


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Erymycin cap

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1 2 1

Tazocin

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2.25gm

Exacin inj 200mg

1 1 2 3 4 5 6 7

Piperacillin inj 2g

1 2

Tapimycin inj 2.25g

1 2 3

排便 0 0 0 0 0 0 0 3 0 0 0 6 0 0 2

輸

入量

飲食量 90 740 854 995 1162 600 1375 1210 1131 1085 1260 1250 947 1418 1011 1060 1428

注射量 107 393 484 591 489 465 746 877 691 402 254 232 50 220 52 70 71

輸

出量

尿量 610 1150 910 3650 3860 2360 1170 3670 10700 2560 1120 1360 1040 660 2020 3750 3220

失血量 145

IV bolus lasix 20 to 40 mg bid + ACEI+ aldactone+ Dopamine + digoxin

lasix 240 mg iv drip + ACEI +Dopamine + aldactone

CCU + Endo + SWAN-GANZ

2012-5-30 2012-6-2

2012-6-8

Strategies

� Continuous infusion (Chest 1992): After 48 h, total urine output:↑↑↑↑ 12 to 26 %, Total Na: ↑↑↑↑ 11 to 33 %. IV furosemide (J Intern Med 1994): dramatically increase the urine output and decrease of body weight.

� Combined therapy (Br Heart J 1994): Different kinds of diuretics work synergically.

� Combined with inotropic agents : Dobutamine or dopamine.

� Combined with vasodilator : Nipride or nitrate.

� Ultra filtration or Hemdialysis.

Case 3

• 78 y/o male: dyspnea after 10-min walking.

• Past history:1.old extensive ant.MI with acute on CKD (Cr:1.7); 2. CAD-TVD. 3. Af with RVR; 4. HTN for 25 yrs; 5. T2DM for 20 yrs. LVEF:19%

• Dehydration was suspected.

• BP: 96/60 mmHg, PR=120/min

齊00(18天) 001538494I

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1 gm

Cefazo

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Inj 1.2g Augmentin

1 2 3 4 5 6 7 8

排便 2 5 4 0 0 0 0 3 1 1 0 3 0 0

輸

入量

飲食量 330 1905 890 790 310 330 555 1008 808 926 364 1142 1150 1456 918 1310 1312 1160

注射量 450 1754 1770 879 733 314 150 130 140 647 0

輸

出量

尿量 920 1190 320 940 1760 3000 2600 1100 1480 710 1100 580 630 860 700 410 530 685

嘔吐量 130

ICU + VF

LVEF:17%

101-5-21 101-5-24

101-5-27


The routine use of invasive hemodynamic monitoring in patients with ADHF is not recommended.

Invasive hemodynamic monitoring should be considered in a patient:

� refractory to initial therapy

� volume status and cardiac filling pressures are unclear

� significant hypotension (typically SBP <80 mm Hg), or worsening renal function

� Be considered for cardiac transplant and needs assessment of degree and reversibility of pulmonary hypertension

� In whom documentation of an adequate hemodynamic response to the inotropic agent is necessary when chronic outpatient infusion is being considered.


Inotropic agents

When needed, inotropic agents should be administere d as earlyas possible and withdrawn as soon as adequate organ perfusion is restored and/or congestion reduced.

Vasodilator in AHF

Vasodilators are recommended at an early stage for AHF patients without symptomatic hypotension, SBP ,90 m mHg or serious obstructive valvular disease.

HFSA 2010 Practice Guideline (12.5-12.20)

Overview of Treatment Options for Patients with Acute Decompensated HF

� Fluid and sodium restriction

� Diuretics, especially loop diuretics

� Ultrafiltration/renal replacement therapy (in selected patients only)

� Parenteral vasodilators *(nitroglycerin, nitroprusside, nesiritide)

� Inotropes * (milrinone or dobutamine)*See recommendations for stipulations and restrictions.

What’s strategy for this patient ??

101-5-23 transfer to ICU

101-5-24 in ICU

101-5-25 in ICU

SDL:1.37 ng/ml

PCI for his CAD

Medication after discharge

DM in HF of ESC 2008

One week later !!

Q & A

• Invasive hemodynamic monitoring

• Bi-PAP.

• Combined therapy (dopamine+ dobutamine + vasodilator)

• Other inotropic agents

• VF


Routine administration of supplemental oxygenin the presence of hypoxia is recommended. Routine administration of supplemental oxygen in the absence of hypoxia is not recommended.

Use of non-invasive positive pressure ventilation may be considered for severely dyspneic patients with clinical evidence of pulmonary edema.



In the absence of symptomatic hypotension, intravenous nitroglycerin, nitroprusside or nesiritidemay be considered as an addition to diuretic therapy for rapid improvement of congestive symptoms in patients admitted with ADHF.

Intravenous inotropes (milrinone or dobutamine or levosimendan) may be considered to relieve symptoms and improve end-organ function in patients with advanced HF characterized by LV dilation, reduced LVEF, and diminished peripheral perfusion or end-organ dysfunction (low output syndrome)


Combined effects of dopamine + dobutamine +

vasodilator !!

Inotropic and VasopressorCirculation. 2008;118:1047-1056

Combined hemodynamic effects of dopamine and dobutamine in

cardiogenic shockCirculation. 1983;67:620-626

MAP, Maintained PCWP, Hypoxia.

Beneficial effects of dopamine combined with intravenous NTG

Circulation. 1983;68:813-820

Milrinone and dobutamine in severe HFCirc 1986: 73:III175-83.

• Dobutamine and milrinone were administered IV up to maximum doses.

• ↓↓↓↓ in left and right heart filling pressures and mean arterial pressure.

• Milrinone caused a greater reduction in systemic vascular resistance than did dobutamine.

Acute effects of intravenous milrinone in heart failure (IIB)

Eur Heart J (1989) 10 (suppl C): 39-43

• Positive inotropic and dose-dependent vasodilatory effects.

• Bolus doses of 12·5–75 μg kg−1 markedly increase CO and cause a substantial reduction in cardiac filling pressure and in systemic and pulmonary vascular resistance.

• Minimal effects on HR or systemic blood pressure, except at very high doses.

Levosimendan (IIB)

�Levosimendan is a calcium sensitizer.

� Increases CO and SV and reduces pulmonary wedge pressure, systemic vascular resistance, and pulmonary vascular resistance.

�Maintained over several days.

Others in AHF (ESC 2008)

2008, ACC/AHA guideline

Conclusions

�Clinical evaluation of fluid-overload and tissue perfusion.

� Intensive diuresis with continous or combined therapy.

� Inotrope use to stabilize the patients

�Management of underlying diseases.

THANK YOU FOR YOUR ATTENTION !!

Q & A !!

CHADS2 -> CHA2DS2VASc

CHADS2 -> CHA2DS2VAScCHA2DS2-VASc Risk

Score

CHF or LVEF <40%

1

Hypertension 1

Age > 75 2

Diabetes 1

Stroke/TIA/ Thromboembolism

2

Vascular Disease

1

Age 65 - 74 1

Female 1

CHADS2 Risk Score

CHF 1

Hypertension 1

Age > 75 1

Diabetes 1

Stroke or TIA 2

From ESC AF Guidelines

http://www.escardio.org/guidelines-surveys/esc-guidelines/GuidelinesDocuments/guidelines-afib-FT.pdf

CHADS2 -> CHA2DS2VASc

CHADS2 score

Patients(n = 1733)

Adjusted stroke

rate %/year

0 120 1.9

1 463 2.8

2 523 4.0

3 337 5.9

4 220 8.5

5 65 12.5

6 5 18.2

CHA2DS2-VAScscore

Patients ( n = 7329)

Adjusted stroke

rate (%/year)

0 1 0

1 422 1.3

2 1230 2.2

3 1730 3.2

4 1718 4.0

5 1159 6.7

6 679 9.8

7 294 9.6

8 82 6.7

9 14 15.2

From ESC AF Guidelines: http://www.escardio.org/guidelines-surveys/esc-guidelines/GuidelinesDocuments/guidelines-afib-FT.pdf