Acute Heart Failure Syndromes

Acute Heart Failure Syndromes from Sun YaiCheng

Acute Heart Failure Syndromes: 
Emergency Department Presentation, Treatment, and Disposition:
Current Approaches and Future Aims
Circulation. Nov 9, 2010;122:1975-1996


Current Diagnostics

• The evaluation of possible AHFS in the ED includes history, physical examination, CXR, 12-lead ECG,cardiac troponin I or T, electrolytes, and CBC.
• The BNP and NT-proBNP have demonstrated diagnostic utility when clinical uncertainty remains after initial history, physical examination, and CXR.
• Either BNP or NT-proBNP should be measured in patients in whom there is clinical uncertainty concerning the diagnosis of AHFS.

Optimal NT-proBNP cut-points for the diagnosis or exclusion of AHFS

• BNP and NT-proBNP single cut point of 300 pg/mL to rule out AHFS
• 2 cut points to rule in AHFS depending on age:

<50 years old ( >450 pg/mL)
>50 years old ( >900pg/mL)

Am J Cardiol. 2005;95:948–954.

• Age-independent cutoff of 900 pg/mL
• Age-stratified approach of 450/900/1800 for patients aged <50/50 to 75/>75 years

Category	Optimal cut-point	Sensitivity  (%)	Specificity (%)	PPV (%)	NPV (%)	Accuracy (%)
Confirmatory (‘rule in’) cut-points
<50 years (n=184)	450 pg/mL	97	93	76	99	94
50–75 years (n=537)	900 pg/mL	90	82	83	88	85
>75 years (n=535)	1800 pg/mL	85	73	92	55	83
Rule in, overall		90	84	88	66	85
Exclusionary (‘rule out’) cut-point
All patients (n=1256)	300 pg/mL	99	60	77	98	83

Eur Heart J. 2006;27:330–337
Am J Cardiol. 2008;101:29–38

Current Therapy: Heterogeneous Presentations Met With Homogeneous Therapy

• Regardless of the baseline cardiac pathophysiology, critical presenting features such as hemodynamic status, presence of myocardial ischemia, and renal dysfunction, the current goals of ED therapy are to relieve congestion, balance hemodynamics, achieve euvolemia.
• Initial stabilization focuses on determining whether the patient requires ventilatory support.
• Diuretics and vasodilators are frequently used in the treatment of AHFS with congestion and normal or elevated blood pressure.
• Hypertension may appear to be the most acutely ill, but aggressive blood pressure management often results in rapid resolution of symptoms. 

ED Disposition

• 80% of patients who present to the ED with AHFS are hospitalized.

Predictors of Adverse Events

• Elevated BUN or creatinine 
• Hyponatremia 
• Ischemic ECG changes 
• Elevated BNP levels 
• Elevated troponins 
• Low systolic blood pressure 

Morbidity and Mortality in Hospitalized Patients with AHFS

• The average risk of death during hospital admission for AHFS is apprximately 4%. 
• Patients requiring the use of inotropic agents had a mortality rate of 12% to 13%. 
• Traditional HF medical therapy including ACE inhibitors, ARB, β-blockers, and selective aldosterone receptor antagonists. Early initiation of this therapy, before hospital discharge, with appropriate titration, improves symptoms, reduces hospitalizations, and saves lives. 

Patient Characterization
The European Society of Cardiology classification:

1. Worsening or decompensated chronic HF 
2. Cardiogenic pulmonary edema 
3. Hypertensive AHFS 
4. Cardiogenic shock 
5. Isolated right HF 
6. AHFS with ACS

• Nitrates might be used in higher relative doses to diuretics in the hypertensive profile Ultrafiltration could be usedin the diuretic-resistant patient 
• Inotropic agents should be considered in the rarer cases of advanced/low-output HF 
• Hypotension and tachycardia should be avoided, especially in patients with coronary artery disease 

ACC/AHA Stages of Heart Failure

• A: At high risk for HF but without structural heart disease or symptoms of HF 
• B: Structural heart disease but without signs or symptoms of HF 
• C: Structural heart disease with prior or current symptoms of HF 
• D: Refractory HF requiring specialized interventions

Risk Stratification: Low-Risk, Not High-Risk Markers Are Necessary

• Hypotension, hyponatremia, renal dysfunction, increased troponin levels, and elevated BNP all portend a poor prognosis. 
• The absence of high-risk markers does not define a low-risk patient.
• Data suggest that EP would be comfortable discharging a patient if there was a combined overall risk of in-hospital events or 30-day mortality of <2%. 

第4張 slide 更正：

• BNP and NT-proBNP can be elevated in sepsis, pulmonary hypertension, older age, renal insufficiency, atrial fibrillation, pulmonary embolism and obesity. 

• Obesity is associated with disproportionately low BNP levels.