Acute Heart Failure

Department of Cardiology and Vascular Medicine

Faculty of Medicine Universitas Padjadjaran/Hasan Sadikin Hospital
Bandung
Why we need to KNOW ?
• ACUTE HEART FAILURE  public
health problem  MAJORITY of
UNPLANNED hospitalization
• Despite major treatment achievement
in HF  OUTCOME AHF remain
POOR 90 day re-hospitalizations and
1 year mortality  10-30%

Arrigo M, et al. Eur Heart J. (2016) .11-18

Classification & Trajectories of HF based on LVEF
2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure
Risk Assessment, Management, and Clinical Trajectory of Patients
Hospitalized With Heart Failure

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Hollenberg et al.JACC VOL. 74, NO. 15, 2019
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Hollenberg et al.JACC VOL. 74, NO. 15, 2019 6
Diagnosis and Treatment of
Acute Heart Failure

Definition AHF

Patho-mechanism and Classification of AHF

Diagnosis of AHF

Treatment of AHF
Definition of AHF
Acute Heart Failure  rapid onset or worsening of symptoms and/or signs of HF a
life-threatening medical condition requiring urgent evaluation and treatment

Acute Heart Failure

Presentations Acute
De Novo
Decompensated
AHF
HF

Ponikowski P, et al. Eur Heart J (2016) , 43-55

Diagnosis and Treatment of
Acute Heart Failure

Definition AHF

Patho-mechanism and Classification of AHF

Diagnosis of AHF

Treatment of AHF
Main Patho-Mechanisms Leading to AHF

Arrigo M, et al. Eur Heart J. (2016) .11-18

Clinical Profile and Pathophysiology of AHF:
‘Cardiac’ VS ‘Vascular’ Failure

Ponikowski P, et al. Eur Heart J (2016) , 43-55

Classification of AHF

High BP, +/- preserved LV systolic

function

Severe respiratory distress, ↑RR, orthopnea,

rales. O2 sats <90%

low output in absence of pulmonary congestion with

increased JVP, w/ or w/out HSM, and low LV filling
Hypotension + hypoperfusion and pressures
pulmonary congestion develop rapidly

Felker GM, et al. Braunwalds Heart Disease. (2015) .484-507

Classification of AHF
In practice the most useful
classifications 
based on clinical presentation at
admission

Hollenberg et al.JACC VOL. 74, NO. 15, 2019

Ponikowski P, et al. Eur Heart J (2016) , 43-55
CLINICAL PRESENTATION ACUTE HEART FAILURE
Diagnosis and Treatment of
Acute Heart Failure

Definition AHF

Patho-mechanism and Classification of AHF

Diagnosis of AHF

Treatment of AHF
AHF Diagnosis
• Initial diagnosis of AHF: should be based on
• a thorough history assessing symptoms
• prior cardiovascular history
• potential cardiac and non-cardiac precipitants

Ponikowski P, et al. Eur Heart J (2016) , 43-55

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AHF Diagnosis
• Further appropiate additional investigations

ECG

CXR

Lab: Biomarkers

Echocardiography

Ponikowski P, et al. Eur Heart J (2016) , 43-55

AHF Diagnosis
• Chest X Ray
• Most specific findings for AHF:
• Pulmonary venous congestion
• pleural effusion
• interstitial or alveolar oedema
• cardiomegaly
• also useful to identify alternative non-cardiac diseases
• pneumonia
• non-consolidative pulmonary infections
• ECG
• Rarely normal in AHF  high negative predictive value
• Identifying underlying cardiac disease and potential precipitants
• rapid AF
• acute myocardial ischaemia
Ponikowski P, et al. Eur Heart J (2016) , 43-55
AHF Diagnosis
Role of Echocardiography in AHF

Haemodynamic
instability
Immediate
echocardiography
Acute life-threatening
structural or functional
cardiac abnormalities

Ponikowski P, et al. Eur Heart J (2016) , 43-55

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AHF Diagnosis
Natriuretic peptides  help
differentiation of AHF from non-cardiac
BNP
causes of acute dyspnoea  ROLE • < 100 pg/mL
OUT
• high sensitivity NT-proBNP
• normal levels  diagnosis of AHF unlikely • <300 pg/mL

• Elevated levels of NPs : do not automatically

confirm the diagnosis of AHF
MR-proANP
• wide variety of cardiac and non-cardiac • <120 pg/mL
causes

Ponikowski P, et al. Eur Heart J (2016) , 43-55

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Paul A. HeidenreichCirculation,Volume 145, Issue 18, 3 May 2022
Diagnosis and Treatment of
Acute Heart Failure

Definition AHF

Patho-mechanism and Classification of AHF

Diagnosis of AHF

Treatment of AHF
• The vast majority of acute heart failure episodes are characterized by increasing symptoms and signs of congestion with
volume overload
• The goal of therapy in those patients is the relief of congestion through achieving a state of euvolaemia, mainly through the
use of diuretic therapy
• The appropriate use of diuretics however remains challenging, especially when worsening renal function, diuretic resistance
and electrolyte disturbances occur
• When patients with heart failure with reduced (HFrEF) or preserved ejection fraction (HFpEF) decompensate, they often
can present with a similar profile of congestion

The goals of therapy in patients presenting with congestion and volume overload consists of

(i) Achieving thorough decongestion without residual volume overload (the optimal stopping
point of decongestive therapy is often dif cult to determine)
(ii) Ensuring adequate perfusion pressures to guarantee organ perfusion

(iii) Maintaining guideline-directed medical therapies as these medications may also increase
diuretic response and improve long-term survival
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fi
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Mullens, European Journal of Heart Failure (2019)
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AHF Management
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Parenteral Vasodilation Therapy in Patients Hospitalized With HF

Paul A. HeidenreichCirculation,Volume 145, Issue 18, 3 May 2022

Management of Cardiogenic Shock

Paul A. HeidenreichCirculation,Volume 145, Issue 18, 3 May 2022

 Maintenance or Optimization of GDMT During Hospitalization

• Withholding or reducing beta-blocker therapy should be considered in patients with marked volume overload or marginal
low cardiac output
• True contraindications are rare, such as advanced degree atrioventricular block for beta blockers in the absence of
pacemakers; cardiogenic shock that may preclude use of certain medications until resolution of shock state; or angioedema
for ACEi or ARNi
Paul A. HeidenreichCirculation,Volume 145, Issue 18, 3 May 2022 33
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Hollenberg et al.JACC VOL. 74, NO. 15, 2019
Pathway Optimization HF Treatment

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2017ACC Expert consensus decision pathway to OMT. J Am Coll Cardiol.2017;23:1-26.
MODERN CONCEPT IN HF MANAGEMENT 
CONTINUE & COMPREHENSIVE TREATMENT
APPROACH

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Mesquita AT et al.Int J Cardiovasc Sci. 2017;30(1):81-90
Take Home Messages
• AHF  the most common cause of hospital admission
• The main contributor to the huge health care costs of heart failure
• An initial step in the diagnostic workup of AHF is to rule out alternative
causes for the patient’s symptoms and signs
• In paralel evaluation circulatory and respiratory status, coexisting life-
threatening clinical conditions and/or precipitants that require urgent
treatment/correction
QUESTION

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AHF Diagnosis
• Physical exam should assess:

signs/symptoms of congestion
• Orthopnea
• >> JVP
• Edema
• Ascites
Signs/symptoms
• Rales of hypoperfusion
•
• Narrow pulse
Abd-Jugular pressure
reflux
• Cold extrimities
• Agitation, << consciousness
• Worsening renal function Ponikowski P, et al. Eur Heart J (2016) , 43-55
In-Hospital Mortality, According to Precipitating
Factors in the OPTIMIZE-HF Registry