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Heart Failure: Acute Inpatient Management

Aaron Mittel, MD

Assistant Professor of Anesthesiology

CUMC

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Objectives

  • Review definitions of heart failure and functional classification
  • Review subtypes, HFrEF vs. HFpEF, and understand broad medical therapy goals
  • Understand basic physiologic approach to CO optimization
  • Understand basics of mechanical circulatory support

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Heart Failure: Definition and Presentation

”Heart failure is a complex clinical syndrome that results from any structural or functional impairment of ventricular filling or ejection of blood”

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Dyspnea, fatigue, fluid retention, morbidity, death

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CLINICAL DEFINITION

Heart failure = inability to deliver adequate blood to meet end-organ demands

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Heart Failure: Important Risk Factors

  • HTN
  • Atherosclerotic disease
  • Diabetes
  • Metabolic syndrome
    • Any 3 of:
      • Abdominal adiposity
      • Hypertriglyceridemia
      • Low HDL
      • HTN
      • Fasting hyperglycemia

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Staging of Heart Failure

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Heart Failure: Classification

Reduced EF (HFrEF)

    • LVEF < 40%
    • “Systolic”

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Preserved EF (HFpEF)

    • LVEF > 50%
      • Borderline: 41-49%
      • Improved: Previously HFrEF, now > 40% EF

RCTs and efficacious therapies

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Principles of Pharmacologic Interventions

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Heart Failure Physiology

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Afterload modification

Beta-blockade

Preload modification

Contractility

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HFrEF: Treatment Algorithm

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HFpEF: Treatment Guidelines

“Systolic and diastolic blood pressure should be controlled according to published clinical practice guidelines”

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“Diuretics should be used for relief of symptoms due to volume overload”

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Hospitalized Heart Failure

Work Up

  • H&P
  • Imaging
    • CXR
    • Echocardiography
  • Biomarkers
    • BNP, troponin
  • Rule out Acute Coronary Syndrome (”ACS”)
    • EKG, troponin

Treatment

  • Optimize volume status
    • Loop diuretics
  • Optimize rhythm
    • Beta-blockade
  • Optimize pump and tone

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Advanced Inpatient Management

  • Stage D heart failure = small subset of patients
    • More likely to die of issues due to low flow

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    • Less severe stages = die of arrhythmia (sudden cardiac death), alternative comorbid complications, etc

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  • Optimization of flow is paramount!
    • Flow = cardiac output

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How do we measure cardiac output?

What do we do about it?

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Measurement of Cardiac Output

  • Physical exam
    • Capillary refill
    • Temperature
    • Cognitive function
  • Laboratory analysis
    • Lactate, SvO2
    • End-organ biomarkers
  • Imaging
    • Echocardiography
    • CMRI

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Measurement of Cardiac Output, cont’d

  • “Non”-invasive monitors
    • Electrical bioimpedance
    • Photoplethysmography
    • Tonometry
    • Thoracic bioreactance
    • Carbon dioxide rebreathing
    • Pulse contour analysis
  • Invasive monitors
    • Pulmonary artery thermodilution
    • Continuous cardiac output

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Measurement of Cardiac Output, cont’d

Physiologic Gold Standard

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Clinical ”Gold” Standard

Pulmonary artery catheter

  • Intra-cardiac pressure measurement (Ohm’s law)
  • Thermodilution

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Pharmacologic Augmentation of CO

Catecholamines

Agent

Receptor Agonized

Norepinephrine

a1, B1

Epinephrine

B1, B2, a1, a2

Dopamine

DA -> B1 -> a1 (increasing doses)

Dopexamine

B2, DA1-2

Dobutamine

B1 > B2

Isoproterenol

B1, B2

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Pharmacologic Augmentation of CO

Non-catecholamines

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Agent

Receptor Agonized

Milrinone

PDE-3 inhibitor

Levosimendan

Cardiac troponin-C, ATP-sensitive K channels

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Refractory Heart Failure

Inotropic support

Mechanical circulatory support

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Mechanical Circulatory Support

  • IABP
  • TandemHeart
  • Impella
  • VA ECMO
  • Short-term VAD
    • CentriMag
  • Durable VAD
    • HeartMate
  • Total Artificial Heart

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Intra-aortic Balloon Pump

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IABP Waveform Analysis

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Impella

Pulls blood from left ventricle inlet and expels into ascending aorta

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Impella RP: Right Ventricular Support

  • Percutaneous RVAD
  • Transfemoral access
  • Inflow: IVC
  • Outflow: PA
  • Flows 4LPM
  • No oxygenator

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ProtekDuo

  • Percutaneous RVAD
  • Transjugular access
  • Inflow: right atrium
  • Outflow: pulmonary artery
  • 3.5-4LPM
  • Oxygenator
  • Patient mobilization

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ECMO: extra-corporeal membrane oxygenation

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Ventricular Assist Device: HM II

Inflow: “inflow” to device, from LV apex

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Outflow: “outflow” relative to device, into ascending aorta

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HM II vs. HM III

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References

  • Jessup M. et al. 2013 ACCF/AHA Guidelines for the Management of Heart Failure. JACC 2013; 62 (16): 147-239.

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  • Yancy CM et al. 2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guidelines on the Management of Heart Failure. Circulation 2017; 1-129.

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  • JAMA Cardiol. 2017 Oct 1;2(10):1090-1099. doi: 10.1001/jamacardio.2017.2945

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