History of Present Illness
81F with HTN, hyperlidemia, p.Afib, h/o V Tach s/p
ICD in 2004, COPD
Increased SOB, exertional dyspnea for 3 days.
PND +
Orthopnea +
Pedal edema +
Denied CP/lightheadedness/palpitation
Denied fever/cough
Been compliant with her meds.
Past History
Medical
Surgical
HTN
Right hip replacement
Hyperlipidemia
Appendectomy
Paroxysmal A Fib
Partial hysterectomy
H/o Vtach s/p ICD
Cataract surgery
Chronic HF
COPD
Mild pulmonary HTN
Family / Social History
FH
No premature CAD
SH
Denied smoking / ETOH
Lives with husband
Sedentary lifestyle
Allergies/Meds
Meds
Amiodarone
ASA EC
81 mg daily
Toprol XL
100 mg daily
Cozaar
100 mg daily
Lasix
80 mg daily
Lipitor
20 mg daily
K-Dur
20 mEq daily
Fosamax, Inspira, Lexapro
Allergies
Sulfa
Allergies/Meds
Meds
ASA EC
325 mg daily
Toprol XL
100 mg daily
Monopril
20 mg bid
Norvasc
5 mg daily
Lasix
100 mg daily
Lipitor
10 mg daily
Clonidine
0.2 mg bid
Cardura
4 mg daily
Avodart
0.5 mg daily
Lantus
18 units daily
Humulog
SS
Synthroid
Sulfa
Allergies
Physical Examination
Vitals:
BT 37
RS:
BP 98/70
R 30
P 66, regular
SpO2 77% on RA
GA:
Decreased bs lung bases
Scattered crackles
CVS:
JVD + 7 cm,
AAOx3, tachypneic
Regular S1 S2, no S3/S4
Talks in broken sentences
SEM LPSB 2/6
HEENT:
Mildly pale, anicteric sclera
Dry oral mucosa.
No thyroid enlargement
Abd:
BS+, soft, non-tender
Ext: pedal edema 1+
Differential Diagnosis
Cardiogenic pulmonary
edema
Non-cardiogenic
pulmonary edema
COPD exacerbation
Pneumonia
Pulmonary embolism
MI
Investigation
BUN/Cr
CBC
32/1.6
WBC
15.7
Ca / Mg
Hb/Hct
12.1/35.5
LFT - NL except TB 1.7
Plt
227
CIP
CK /CKMB
Chemistry
9.2 / 1.9
124/3.3
Trop I
Na
138
K
4
ABG
Cl
98
7.47 I 34 I 107 I 24
BNP > 3900
HCO3
26
2.2
Investigation
Chest x-ray
Cardiomegaly and
pulmonary edema
EKG
SR with 1st deg AV
block 78 bpm
New non specific ST-T
changes in inferior
and lateral
leads
Echocardiogram
EF 30%
Pseudonormal pattern of
LV diastolic filling
Multiple segmental
abnormalities (akinetic
apex; hypokinetic mid
posterior, lateral, septum,
anterior, inferior segments.)
Mild TR
Mild pulm HTN
Mildly dilated left atrium
Diagnosis
Acute decompensation of chronic HF
Pulmary edema
NSTEMI
Definition
Clinical syndrome in which patients have:
Signs
breathlessness, fatique, ankle swelling, etc.
Symptoms
tachycardia, tachypnea, rales, edema, etc.
Objective evidence of structural / functional abn of heart
Cardiomegaly, murmur, abn echo, raised BNP
Acute Heart Failure
Rapid onset of s/s of HF, resulting in the need for urgent
therapy
Signs and Symptoms
Prior h/o heart failure or
myocardial injury
Dyspnea on exertion
Orthopnea
PND
Fatique
Increased edema /
weight / abd. girth
Elevated JVD
Rales / hypoxia /
tachypnea
Diffuse PMI
Tachycardia / arrhythmia
Ventricular filling / atrial
gallop (S3, S4)
Peripheral edema /
ascites
Decreased urine output
Clinical Classification
Diagnosis
EKG
CXR
Labs:
CBC
BMP
LFT
INR
CIP
BNP
ABG
Echo
Various Therapies
Oxygen
Class 1, evidence C
Keep sat >95% (or >90% in COPD pts)
Non-Invasive Ventilation
Class 2a, evidence B
NIV with PEEP improves LV fn by reducing LV
afterload.
Indication:
Acute cardiogenic pulmonary edema
Hypertensive AHF
Key points:
Meta-analyses showed it reduces intubation and
short term mortality.
Caution in cardiogenic shock and RV failure
How to use it?
FiO2 0.4; PEEP 5-7.5 titrate to clinical response up to
10.
Morphine
Evidence for AHF is limited.
Should be considered esp. in pts with
Restlessness, anxiety, CP
IV boluses of morphine 2.5-5 mg
Caution in
Hypotension
Bradycardia
Advanced AV block
CO2 retention
Loop Diuretics
Class 1, evidence B
Recommended in presence of symptoms
secondary to congestion and volume overload
Patients who are unlikely to respond to diuretics:
Hypotension SBP < 90
Severe hyponatremia
Severe acidosis
Vasodilators
Class 1, evidence B
Recommended at early stage in patients who do
not have:
Symptomatic hypotension
SBP < 90
Serious obstructive valvular ds.
Key points:
Decreases L,R heart filling pressure
Decreases SVR
Relieves pulm congestion without compromising SV
/ O2 demand
Vasopressors
Indicated only in Cardiogenic Shock after failure
of inotropes + fluid challenge
Vasopressor of choice : NOREPINEPHRINE (2b, C)
Inotropes
Use in pts with
(Class 2a, evidence B)
low output states
Signs of hypoperfusion
Congestion despite use of vasodilators and/or
diuretics
Key points
Withdraw asap (inc oxygen demand)
Increase incidence of arrhythmias
Dobutamine
Milrinone / enoximone
Dopamine
Levosimendan
2b, B
2b, B
2b, C
2a, B
Cardiac glycosides
Maybe useful to slow ventricular rate in AF.
Produces small increase in cardiac output and
reduction in filling pressure.
2b, C
C
Specific Treatment Strategies
Decompensated chronic HF:
Vasodilator + diuretics
Pulmonary Edema
MO + Vasodilators + Diuretics + Inotropes
Hypertensive HF
Vasodilator + diuretics
Cardiogenic Shock
Fluid challenge (250 cc in 10 min) + inotropes +
norepinephrine + IABP
Right HF
Avoid MV; Suspect PE / RV MI
Fluid challenge + inotropes
AHF and ACS
Early reperfusion
BB / ACEI / ARB
If already on ACEI/ARB -> continue
If not
-> start before discharge
BB maybe interrupted / reduced if
Unstable with low output
Severe AHF
Bradycardia, adv AV block, cardiogenic shock
Initiate BB before discharge, after pt stabilized on
ACEI / ARB.
Hospital Course
Started on:
Dobutamine drip
Lasix IV
Nitropaste
9/25 -> Clinically improved. Plan to:
Restart ARB
Restart BB
Cardiac cath
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