Heart Failure management in ICU

By Dr. Ahmad Y. AlansiAlthawra Modern General Hospital

Cardiac surgery department Anesthesia & ICU unite

introduction Definitions Which heart failure patient should be

admitted in ICU? Monitoring Classification and plan Medical treatment Mechanical support The future Summary

Definition of Advanced HFA subset of patients with chronic HF will

continue to progress and develop persistently severe symptoms despite maximum therapy .Various terminologies have been used to describe this group of patients who are classified with ACCF/AHA stage D HF, including “advanced HF,” “end-stage HF,” and “refractory HF.

Definition

Definition

Definition

Definition

But are those only

patients should go

to ICU ???!!

Which heart failure patient should be admitted in ICU?

Decompensated chronic heart failure (advanced heart failure)

Acute heart failureACSSepsisPost CPRToxic

VO2 Oxygen uptake from tissuesMRO2 Metabolic requirement for oxygen

●Nonadherence with medication regimen, sodium and/or fluid restriction

●Acute myocardial ischemia

●Uncorrected high blood pressure

●AF and other arrhythmias

●Recent addition of negative inotropic drugs (e.g., verapamil, nifedipine, diltiazem, beta blockers)

●Pulmonary embolus

●Initiation of drugs that increase salt retention (e.g., steroids, thiazolidinediones, NSAIDs)

●Excessive alcohol or illicit drug use

●Endocrine abnormalities (e.g., diabetes mellitus, hyperthyroidism, hypothyroidism)

●Concurrent infections (e.g., pneumonia, viral illnesses)

●Additional acute cardiovascular disorders (e.g., valve disease endocarditis, myopericarditis, aortic dissection

Common Factors That Precipitate Acute Decompensated HF

Physiological parameters

Hypotension systolic BP < 90 mmHgSpO2 < 90%

PH < 7.35Lactate > 2.0Oliguria, BUN > 30Worsening renal function

VsO2 < 50%

So the following patients should be admitted to ICU :

All pateints with NYHA class III-IV. Suspected or diagnoseed ACS . Potential life threatening arrhythmia (VF, VT, high

grade a- v block, persistent symptomatic tachy or brady).

Requiring or at risk of requiring invasive ventilatory support .

Cardiogenic shock or otherwise requiring chemical or mechanical circulatory support (dopmamine , dobutamine,….IABP,LVAD….etc)

Multisystem Failure .

Non invasive monitoringi.e. temperature, respiratory rate, arterial pressure, continuous ECG, pulse oximetry, daily I/O chart and body weight are required in all patients

Monitoring

Invasive monitoring:

1 -Arterial pressure monitoring: continues BP monitoring

repetitive blood gas analysis

. 2 - Central venous catheter:

Monitoring right-sided filling pressure Delivering vasoactive medication

Rapid volume replacement

Monitoring

3 -Pulmonary artery catheterization (PAC)

Indicated in patients with left ventricular dysfunction

.In patients requiring inotropic or vasoconstrictor drugs.

For monitoring Cardiac output

Estimation of systemic vascular resistance Mixed venous oxygen saturation

Lost popularity because of Invasiveness and no different in mortality rate

Monitoring

4 -Transoesophageal Echocardiography Recently gained popularity as a haemodynamic monitoring tool for ventilated intensive care patients .

It provides valuable information about morphology and haemodynamic state,

but interpretation of data requires considerable training and experience.

So Transthoracic Echo Is more performed and remain the main tool.

Monitoring

Classification and plane

Low Output Failure in which there is decreased contractility of heart leading to decreased cardiac output

High Output Failure in which demands of body are high, which are not met even with increased cardiac output like in case of severe Anemia , Thyrotoxicosis and Thiamine deficiency

Classification and plan

Classification and plan

Which side of heart is affected – Left (more common) – Right (right-sided MI, pulmonary HTN)

Which heart function is affected– Systolic (↓ contraction and EF, dilated

LV)– Diastolic (↓ relaxation,)

Failure of LV filling Contractile function and EF usually normal

Pharmacological management

The management of heart failure described here is meant for patients with advanced or decompensated heart failure. The approach here is specifically designed for ICU patients: it is based on invasive hemodynamic measurements rather than symptoms and uses only drugs that are given by continuous intravenous infusion

Left-Sided (Systolic) Heart Failure : 1- High Blood Pressure 2- Normal Blood Pressure 3- Low Blood Pressure

Pharmacological management

Left-Sided (Systolic) Heart Failure :

1- High Blood Pressure (e.g. early period after cardiopulmonary bypass surgery )

Profile: High PCWP/Low CO/High BP

Treatment: Vasodilator therapy with nitroprusside or nitroglycerin. If the PCWP remains above 20 mm Hg, add diuretic therapy with furosemide.

Pharmacological management

Left-Sided (Systolic) Heart Failure :

2- Normal Blood Pressure: e.g. ischemic heart disease, acute myocarditis, and the advanced stages of chronic cardiomyopathy.

Profile: High PCWP/Low CO/Normal BP

Treatment: Inodilator therapy with dobutamine or milrinone, or vasodilator therapy with nitroglycerin. If the PCWP does not decrease to <20 mm Hg, add diuretic therapy with furosemide.

Pharmacological management

Left-Sided (Systolic) Heart Failure :

3- Low Blood Pressure is the sine qua non of cardiogenic shock. e.g. associated with cardiopulmonary bypass surgery, acute myocardial infarction, viral myocarditis, and pulmonary embolus.

Profile: High PCWP/Low CO/Low BP

Treatment: Dopamine in vasoconstrictor doses or combination with Dubtamin.Mechanical assist devices can be used as a temporary measure in selected cases.

Pharmacological management

Diastolic Heart Failure :

Incidence of purely diastolic HF in nature is not known.

no general agreement about the optimal treatment but two recommendations seems to be valid : 1- positive inotropic agents have no role in the treatment of diastolic heart failure. 2- diuretic therapy can be counterproductive, vasodilator agents, such as nitroglycerin and milrinone, Calcium channel blockers like verapamil are effective.

Pharmacological management

Right Heart Failure The strategies below pertain only to primary right heart failure (e.g., following acute myocardial infarction) and not to right heart failure secondary to chronic obstructive lung disease: 1- If PCWP is below 15 mm Hg, infuse volume until the PCWP or CVP increases by 5 mm Hg or either one reaches 20 mm Hg . 2- If the RVEDV is less than 140 mL/m2, infuse volume until the RVEDV reaches 140 mL/m2 . 3- If PCWP is above 15 mm Hg or the RVEDV is 140 mL/m2 or higher, infuse dobutamine, beginning at a rate of 5 mg/kg/minute .In the presence of AV dissociation or complete heart block, institute sequential A-V pacing and avoid ventricular pacing .

Pharmacological management

Diuretics in Hospitalized Patients: Recommendations

Class I1. Patients with HF admitted with evidence of significant fluid overload should be promptly treated with intravenous loop diuretics to reduce morbidity (Level of Evidence: B)

2. If patients are already receiving loop diuretic therapy, the initial intravenous dose should equal or exceed their chronic oral daily dose and should be given as either intermittent boluses or continuous infusion. Urine output and signs and symptoms of congestion should be serially assessed, and the diuretic dose should be adjusted accordingly to relieve symptoms, reduce volume excess, and avoid hypotension (Level of Evidence: B)

3. The effect of HF treatment should be monitored with careful measurement of fluid intake and output, vital signs, body weight that is determined at the same time each day, and clinical signs and symptoms of systemic perfusion and congestion. Daily serum electrolytes, urea nitrogen, and creatinine concentrations should be measured during the use of intravenous diuretics or active titration of HF medications. (Level of Evidence: C)

Pharmacological management

Diuretics in Hospitalized Patients: Recommendations

Class IIa1. When diuresis is inadequate to relieve symptoms, it is reasonable to intensify the diuretic regimen using either: a. higher doses of intravenous loop diuretics (Level of Evidence: B); b. addition of a second (e.g., thiazide) diuretic (Level of Evidence: B).

Class IIb

Low-dose dopamine infusion may be considered in addition to loop diuretic 1 therapy to improve diuresis and better preserve renal function and renal blood flow (Level of Evidence: B)

Pharmacological management

Mechanical Circulatory support

Short term therapeutic options (Nondurable )Bridge to recovery

Long term therapeutic options Bridge to transplantation ( durable)

Destination therapy (permanent)

Percutaneous devicesIABPImpellaECMO and centrifugeal pump devices

Implantable devices (cardiotomy)LVAD, RVAD, BiVAD, total artificial heart (different models, different indications)

Class IIa

MCS is beneficial in carefully selected* patients with stage D HFrEF in whom definitive management (e.g., cardiac transplantation) or cardiac recovery is anticipated or planned . (Level of Evidence: B)

Nondurable MCS, including the use of percutaneous and extracorporeal ventricular assist devices (VADs), is reasonable as a “bridge to recovery” or “bridge to decision” for carefully selected* patients with HFrEF with acute, profound hemodynamic compromise . (Level of Evidence: B) Durable MCS is reasonable to prolong survival for carefully selected* patients with stage D HFrEF (672-675). (Level of Evidence: B)

Mechanical Circulatory Support: Recommendations

selected* patients are those with LVEF <25% and NYHA class III-IV functional

status despite GDMT, when CRT indicated , with either high predicted 1- to 2-y mortality or dependence on continuous parenteral inotropic support.

Mechanical Circulatory Support: Recommendations

Intra-Aortic Balloon CounterpulsationIntra-aortic balloon counterpulsation was introduced in 1968 as a method of promoting coronary blood flow .It is available in various lengths to match body height.

Hemodynamic Effects Inflation begins at the onset of diastole, just after the aortic valve closes that cause Increase in diastolic pressure which should also augment coronary blood flow, because the bulk of coronary flow occurs during diastole.Deflation at the onset of ventricular systole, just before the aortic valve opens so Deflation of the balloon reduces the end-diastolic pressure, This decreases ventricular afterload and promotes ventricular stroke output.

Mechanical Circulatory Support:

IABP Indication:when cardiac pump failure is life-threatening and either pump function is expected to improve spontaneously, or a corrective procedure is planned.

Cardiogenic shock following CPB Acute MI . Unstable angina, Acute mitral insufficiency, Planned cardiac transplantation. Support PCI & reduce size of Infarction ??!!! controversy

Mechanical Circulatory Support:

Mechanical Circulatory Support:IABP

The future Yemeni futureGet to international standards of treatment (new drugs, assist devices programs)Transplantation

International futureGeneticsStem cell cultures and implantationTruly viable total artificial heart

The approach to advanced or decompensated heart failure in the ICU is best guided by invasive hemodynamic measurements and by the type of heart failure involved (systolic, diastolic, left-sided, or right-sided failure).

The management of acute, decompensated heart failure should augment cardiac output and reduce ventricular filling pressures while producing little or no increase in myocardial O2 consumption.

Patients with HF admitted with evidence of significant fluid overload should be promptly treated with intravenous loop diuretics to reduce morbidity .

Diuretic therapy should not play a major role in the management of acute heart failure, particularly if the failure is due to diastolic dysfunction.

Low-dose dopamine infusion may be considered in addition to loop diuretic 1 therapy to improve diuresis and better preserve renal function and renal blood flow .

If cardiogenic shock is identified, mechanical cardiac support should be initiated as soon as possible, if indicated.

Summry