Acute Heart Failure/Acute pulmonary oedema

Clinical assessment

1. a sudden onset of dyspnoea at rest
2. Orthopnoea
3. Sweating*
4. Agitated,
5. Pale and clammy*

On Examination:

6. The peripheries are cool
7. Tachycardia
8. The BP is usually high (because of sympathetic nervous system activation) but may be normal or low if the patient is incardiogenic shock.

9. The jugular venous pressure (JVP) is usually elevated* particularly when  associated with fluid overload or right heartfailure.
10. A ‘gallop’ rhythm (a third heart sound) may be heard.
11. Crepitations at the lung bases (pulmonary oedema) or throughout the lungs if pulmonary oedema is severe.
12. Expiratory wheeze often found (which confuses with asthma)

* = key discriminatory point with the Differentials. 

D/D

• Acute Exacerbation of COPD
• Acute Brochial Asthma
• Pulmonary Embolism 

Investigations for Acute Heart failure (AHF)

Initial investigations performed in the emergency room should include the following- 

                A. A 12-lead ECG to look for

1. acute coronary syndromes,
2. left ventricular hypertrophy,
3. atrial fibrillation,
4. valvular heart disease,
5. Left bundle branch block

               

Heart Failure Chest X-ray

               B. Chest X-ray. Look for

1. Cardiomegaly,
2. Pulmonary congestion with upper lobe diversion,
3. Pulmonary oedema
4. Pleural effusion 

               C. Blood tests

1. Full blood count CBC (To look for ↓Hb% )
2. Liver biochemistry(↑ALT)
3. Urea and electrolytes, ( to identify renal dysfunction )
4. Blood Glucose

Also (when conditions permit and or available)- 

5. Plasma BNP or NTproBNP (BNP >100 pg/mL or NTproBNP>300 pg/mL) indicates heart failure.
6. Cardiac enzymes (Troponin I/CKMB) to identify Acute MI

               D.Echocardiography

• *Systolic and diastolic function,
• *Regional wall motion (indicates IHD)

also-

• Cardiac chamber dimension,
• Valvular heart disease,
• Cardiomyopathies. 

Management

AHF has a poor prognosis with a 60-day mortality rate of nearly 10%.

So, This is  an  acute  medical  emergency: 

Patient should be treated inhigh-care area^Pwith continuous monitoring of cardiac rhythm, BP and pulse oximetry.

1. Bed rest in propped up position (to reduce  pulmonary   congestion).
2. High-flow oxygen- Non-invasive positive  pressure  ventilation(NIPPV)  or (continuous positive airways pressure (CPAP) may be needed
3. Loop diuretic, such as Frusemide(50–100 mg IV)
4. IV GTN (glyceryltrinitrate) (10–200 mcg/min)

        Or

Buccal GTN 2–5 mg, titrated upwards every 10 minutes)

Until clinical improvement occurs or systolic BP falls to less than 110 mmHg.

If these measures prove ineffective-

5. Inotropic agents – particularly in hypotensive patients.
• ^p2–20 μg/kg per min (usually starts with 5mcg/min, may need highdose in patients on betablockers)
• and noradrenaline^P

If facilities available-

6. Insertion of an intra-aortic balloon pump (may be beneficial in patients with acute cardiogenic pulmonary oedema and shock) 

Further management (may be considered)-

7. Low-molecular-weight heparin^P - enoxaparin 1 mg/kg s.c. twice daily if Acute Coronary Syndrome supervenes or 40 mg s.c. daily as a prophylaxis. 

When Good Response achieved- 

8. Angiotensin-converting enzyme inhibitor

 Courtesy : PDM