Acute Heart Failure (eBook)

Dr.  Wolfgang Kruger is a physician trained and specialized in general internal medicine, cardiology and intensive care medicine, with international certification. He has worked as a consultant intensivist and cardiologist throughout Europe, with special interests in acute heart failure and circulatory disorders of critically ill patients. Currently he is working as senior consultant at the Medical University Department of the Cantonal Hospital in Aarau, Switzerland, where he holds teaching responsibilities. His attempt to incorporate the newest research into everyday evidence-based medicine led him to write a textbook on this topic.

Foreword   1         Cardiac physiology of acute heart failure syndromes     1.1 Cardiac performance     1.2 The fundamental equation of the circulation     1.3 Preload            a) Definition            b) Frank–Starling mechanism            c) Venous return and CVP in daily practice      1.4 Haemodynamic monitoring            a) Assessment and monitoring of fluid status            b) Prediction of fluid responsiveness                 i) Pressure measurements                 ii) Volumetric measurements                 iii) Dynamic parameters                 iv) Fluid challenge                 v) PiCCO-monitoring                 vi) Echocardiography            c) Arterial blood pressure                  i) BP and autoregulation                  ii) Assessment of tissue perfusion 1.5 Afterload            a) Definition            b) Vascular properties, effective arterial elastance, wall stress and the law of LaPlace            c) Afterload mismatch and acute heart failure syndromes 1.6 Contractility            a) Definition            b) Ventricular elastance and other measurements and indicators of contractility                    c) Inotropic medications 1.7 Heart rate and contractility   1.8 Diastolic ventricular interaction/interdependance (DVI)          a) Definition          b) Septum and trans-septal pressure          c) Pericardium          d) Pulmonary hypertension and the risk of DVI                         e) Acutely exacerbated chronic congestive (left-sided or biventricular) HF          f) Conclusions 1.9 Ventriculo-arterial coupling        a) Definition        b) Arterial elastance        c) Ventricular elastance        e) Deranged coupling 1.10 Myocardial and chamber stiffness 1.11 Evaluation and assessment of cardiac performance 1.12 Summary       a) Key physiology       b) Afterload       c) Systolic function       d) Volume status       e) Ventriculo-arterial coupling       f) Diastolic ventricular interaction       g) Myocardial and chamber stiffness       h) Cardiac power output / index       i) Echocardiography     2             Acute heart failure syndromes 2.1 Definition 2.2 Classification of acute heart failure syndromes (AHFS) 2.3 Etiology and epidemiology 2.4 Pathophysiology       a) General pathophysiological remarks       b) Special pathophysiological issues           i)   LVEDP and congestion           ii)  Neurohormonal systems, endothelial dysfunction and inflammation           iii) Vascular properties, AV-coupling, afterload mismatch and Cotter`s dual pathway concept           iv) Fluid redistribution, splanchnic veins and the venocentric input           v)  Fluid accumulation, venous congestion and the link between cardiac and vascular pathway           vi) (Self)-amplification and vicious cycles        c)  Summary 2.5 Diagnosis, symptoms, presentation, important clinical and prognostic data         a) Typical symptoms and diagnosis        b) Prognostic indicators         c) Initial clinical assessment, diagnostic measures and considerations            i)   Hemodynamic profiles on admission            ii)  Identification of precipitants             iii) Other diagnostic measures 2.6 Therapy      a) Therapeutic principles and goals      b) Initial therapeutic approach          i)  Treatment of underlying  diseases          ii)  Common basic measures          iii)  Typical and specific measures -          Diuretics and ultrafiltration -          Vasodilators -          Inotropic drugs           iv)  Essential, permanent medication in the acute phase           v)   Arrhythmias and heart failure           vi)  Continuous  positive airway pressure (CPAP) and other non-invasive positive pressure                    ventilatory support (NIPPV)              vii) Anticoagulation 2.7 Valvular heart disease presenting as heart failure        a) Mitral regurgitation        b) Mitral stenosis        c) Aortic regurgitation        d) Aortic stenosis 2.8 Summary   3         Cardiogenic shock 3.1 Definition 3.2 Epidemiology 3.3 Etiology 3.4 Pathophysiological aspects and special pathobiological features        a) Classical pathophysiology and new cardiogenic shock paradigm        b) The role and impact of hypotension in cardiogenic        c) Myocardial ischemia and LV- compliance        d) The right ventricle and cardiogenic shock        e) Other acute causes of a substantial impairment in contractility 3.5 Clinical features and diagnostic remarks        a) Hypoperfusion        b) Right ventricular infarction        c) The LVEDP in cardiogenic shock        d) Differential diagnosis of cardiogenic shock 3.6 Therapy        a) Main therapeutic strategies        b) Adjunctive treatment            i)    Re-establishing and maintaining appropriate coronary and systemic perfusion            ii)   Fluid administration            iii)   Vasopressor administration            iv)   Inotropic medication            v)   Intra-aortic balloon counter pulsation (IABP)              vi)  Renal function              vii) Compensation of acidosis              viii) Anticoagulation therapy    3.7 Summary   4      Acute right heart failure 4.1 Definitions 4.2 Epidemiology and etiology 4.3 Physiological and pathophysiological aspects       a) General physiology and pathophysiology       b) Special pathophysiological issues             i)     Diastolic ventricular interactions             ii)    The role of the pericardium in diastolic-ventricular interaction             iii)   Auto-aggravation              iv)   Series effect              v)  Pulmonary hypertension and ischemia             vi)  The interventricular septum and the apex             vii) The left ventricle             viii) Mechanical ventilation 4.4 Diagnostic aspects        a)  Clinical features        b)  Serum biomarkers        c)  Electrocardiography        d)  Echocardiography        e)  Invasive hemodynamic assessments 4.5 Therapy       a) Specific measures       b) Adjunctive therapy           i)   Fluid management and optimization of preload, diuretics           ii)   Vasopressors: Treatment and avoidance of ischemia           iii)  Critical RV-afterload reduction           iv)   Improvement of RV systolic function / contractility           v)    Intra-aortic balloon pump           vi)   Hypercapnia and acidosis           vii)  Oxygen therapy           viii)  AV sequential stimulation            ix)   Mechanical ventilation            x)    Anticoagulation            xi)   Digoxin      c) Therapeutic conclusions 4.6   Summary      a) Pathophysiological and clinical issues      b) Overview of treatment options, figure by Naeije and and Manes   5      Heart failure with normal left ventricular ejection fraction (HFNEF) 5.1 Definition and general remarks 5.2 Epidemiology and etiology 5.3 Etiopathogenesis and basic pathophysiological issues and considerations 5.4  Special pathophysiology          a)   The pressure-volume relation and the filling pressure (LVEDP) in HFpEF         b)   Pathomechanisms                  i)     Diastolic dysfunction                 ii)    Vascular stiffening and av-coupling     iii)   Systolic function and cardiac reserve       iv)   Pulmonary hypertension and RV dysfunction, DVI       v)    Ventricular dys-synchrony       vi)   Left atrial dysfunction       vii)  Peripheral factors      5.5   Diagnosis and clinical issues   a)       Symptoms and signs of heart failure   b)       Ejection fraction   c)       Diastolic dysfunction, structural changes and bio-markers   i)        Natriuretic peptides   ii)    Functional and structural alterations   iii)   E/e`ratio   iv)   Inconclusive E/e`ratio - surrogate markers   v)    Invasively derived parameters     vi)   Diastolic stress test   5.6     Therapy   6   Pulmonary hypertension (PH) in left heart disease (LHD - PH) 1.          Definition 2.          Classification of pulmonary hypertension 3.           Epidemiology of PH due to LHD 4.           Pathophysiology 5.           Clinical issues and diagnosis 6.           Therapeutic considerations   7   Cardiorenal syndrome  (CRS) 1.       Definition 2.       Epidemiology and prognostic issues 3.       Clinical issues and diagnosis 4.       Pathophysiology 5.       Management a)      Diuretics b)      Blood pressure /renal perfusion pressure c)       Further measures     Index Abbreviations