Acute HF

A clinical syndrome in which the heart fails to

maintain adequate circulation for metabolic needs

Acute decompensated heart failure (ADHF): a new or

worsened HF with
signs and symptoms that require medical therapy and/or
hospitalization
_ Acute Decompensated Heart Failure (ADHF) is a
rapidly progressive failure state (hrdays)
Common reason for presentation to the ED
Usually caused by a precipitating event in which
the heart does not have the reserve to
compensate for the added burden

Cardiogenic shock (CS): an extreme form of ADHF where

cardiac output is so
low that end-organ function is profoundly impaired
despite adequate intravascular
volume.
ETIOLOGY
Underlying causes and acute precipitants

Decreased
myocardial
contractility:
Myocardial
ischemia/infarction
Cardiomyopathy
(including, alcoholic
and
pregnancy-related)
Myocarditis
Dysrhythmias
Decreased
contractile efficiency:
Drug related
(negative inotropes)
Metabolic disorders
Pressure overload
states:
HTN
Valvular abnormalities
Arrhythmia
Congenital heart disease
Pulmonary embolism
Primary pulmonary hypertension, sleep apnea
syndromes (right heart failure)
Volume overload:
Dietary indiscretion (sodium overload)
Drugs leading to sodium retention
(glucocorticoids, NSAIDs)
Overload due to transfusion or IV fluid
High demand states:
Hyperthyroidism, thyrotoxicosis
Pregnancy
A-V fistula
Beriberi (thiamine deficiency)
Paget disease
Severe anemia
Aortic insufficiency

Pediatric etiologies: Volume/pressure overload

lesions vs. acquired HD:
1st 6 mo: VSD and PDA
Older children: Subvalvular aortic stenosis,
coarctation
Acquired dysfunction: Nonspecific age of onset,
including myocarditis, valvular disease, and
cardiomyopathies; cocaine/stimulant abuse in
adolescents

Pathophysiology

Cardiac dysfunction CO Filling Pr. CVP & Pul. Edema

Hypoxemia , Acidosis Further dysfunction
Co renal perfusion + neurohormonal system (NHS) and its downstream
mediators (renin-angiotensin-aldosterone-system
(RAAS), the sympathetic nervous system (SNS), and the endothelin system (ET-1).)
With a 25% impairment of systolic contraction, acute heart failure may occur;
at 40%, cardiogenic shock is imminent. With preexisting heart failure, even minor
cardiac ischemia can trigger CS.

Systolic Heart Failure versus Diastolic Heart Failure

Systolic heart failure results from diminished myocardial contractility, usually
with an ejection fraction less than 40%. When stressed, the cardiac function is
incapable of responding and intracardiac pressures rise, resulting in dyspnea,
fatigue, or pulmonary edema.
Diastolic heart failure (also called HF with preserved systolic function) is
the inability of the heart to relax. Cardiac compliance is decreased while enddiastolic
pressures are increased and systemic hypertension may be present.
Transmission of these pressures to the pulmonary and systemic vasculature
results in the congestive symptoms similarly seen with systolic dysfunction. The
ejection fraction is preserved in diastolic HF at or above 40%.