Acute Heart Failure

• Acute Heart Failure (AHF) happens when the heart's blood-pumping capacity is acutely reduced.
• This leads to hypoperfusion, hypoxia, and blood circulation stagnation.
• AHF manifests as dyspnea, fatigue, and organ dysfunction.
• AHF is a life-threatening condition and a pathology that disturbs the heart's pumping function.

Classification of Acute Heart Failure

• Clinical presentation
• Measurement of the left ventricle ejection fraction

Clinical Presentation

• According to clinical manifestation, AHF has forms as classified by the European Society of Cardiology.
• Acute decompensated heart failure manifests clinically
• AHF with pulmonary edema is a clinical variant
• AHF with hypertension is a clinical variant.
• Cardiogenic shock can occur as a clinical presentation of AHF.
• Right heart failure can be a clinical manifestation.

Classification Based on Congestion and Perfusion

• "Wet-warm" patients show congestion with adequate peripheral perfusion and typically have normal or high blood pressure, diffuse edema, and pulmonary edema.
• "Wet-cold" patients show congestion, hypoperfusion, low blood pressure, cardiogenic shock, and low ejection fraction.
• "Dry-cold" patients are free of congestion but have hypoperfusion.

Ejection Fraction Measurement Classifications

• HF with preserved left ventricle ejection fraction means the ejection fraction (EF) is greater than 50%. HF with reduced left ventricle ejection fraction means the EF is less than 40%.
• HF with mid-range left ventricle ejection fraction means the EF is between 41-49%.

Causes and Risk Factors

• Acute coronary syndrome which includes myocardial infarction and ventricular septal rupture.
• Arrhythmias like atrial fibrillation, ventricular tachycardia and fibrillation.
• Myocarditis can cause AHF
• Acute valvular heart diseases like acute valvular regurgitation and stenotic valvular diseases.
• Cardiomyopathies (hypertrophic, dilated, restrictive and stress induced).
• Hypertension can increase the risk of heart failure.
• Pericardial diseases.

Pathogenetic Mechanism

• Systolic and/or diastolic dysfunction leads to a disturbance in the heart's pumping function.
• Results in hypoperfusion and hypoxia.
• Leads to systemic congestion-edema in organs and tissues.
• Ultimately ends in organ dysfunctions.
• The course of acute heart failure varies depending on the cause.
• It also depends on the clinical form, heart and body reserves, and treatment effectiveness.
• Regardless of the cause, AHF leads to organ failure and potentially death within days or hours if left untreated.
• Common complications of AHF include shock and organ failure.

Clinical Examination: Signs of Hypoperfusion

• Shortness of breath
• Drop in pulse pressure
• Orthostatic collapse
• Hypotension
• Cold extremities
• Mental disorders, drowsiness
• Decreased diuresis
• Severe exercise intolerance

Clinical Examination: Signs of Congestion

• Orthopnea
• Paroxysmal nocturnal dyspnea
• Pulmonary rales
• S3 gallop
• Pulmonary arterial hypertension
• Venous pressure in the saphenous vein
• Hepatojugular reflux
• Hepatomegaly
• Edema
• Ascites

Laboratory Examinations

• Natriuretic peptide (brain natriuretic peptide (BNP) and N-terminal pro b-type natriuretic peptide (NT-proBNP)) indicates heart failure.
• Lactate and pH indicate perfusion.

Imaging and Other Diagnostic Tools

• Echocardiography helps determine the cause and form (left ventricular ejection fraction preserved, reduced, etc.)
• It can also show complications of AHF.
• Lung X-ray detects pulmonary edema and cardiomegaly.
• Lung ultrasound (LUS) is used for the detection and management of pulmonary edema.
• Cardiac catheterization helps determine the cause and severity of AHF.

Suspicion of AHF

• Dyspnea
• Orthopnea
• Exercise intolerance
• Fatigue

Confirmation of Diagnosis: High probability of AHF

• High probability exists in patients with a history of heart failure and who also have shortness of breath, signs of congestion.

Confirmation of Diagnosis: Moderate Probability of AHF

• Moderate probability with shortness of breath.
• Moderate probability with no history of heart failure.
• Moderate probability includes signs of heart diseases.
• Moderate probability includes no congestion.
• Can be confirmed by natriuretic peptide test and echocardiography.

Confirmation of Diagnosis: Low Probability of AHF

• Can be present in patients with shortness of breath
• Low probability given no signs of heart diseases,
• A sign of other diseases
• Requires natriuretic peptide, ECG and echocardiography.

Differential Diagnosis

• Pulmonary embolism
• Pneumonia
• Asthma
• Noncardiogenic pulmonary edema
• Cardiac tamponade

Diagnostic Criteria

• Dyspnea or orthopnea at rest
• Signs of congestion and/or hypoperfusion
• Cardiac dysfunction with other causes of shortness of breath ruled out.
• No single criterion exists for ruling out AHF.

Determination of the Cause: Diagnostic Testing

• Clinical evaluation
• Laboratory tests
• Imaging
• Other relevant tests
• Severity of AHF and complications

Considerations for Wet-Warm Patients

• Signs of congestion are in the foreground.
• Presents in ~70% of cases, with a relatively good prognosis.
• May present as diffuse edema and pulmonary edema or pulmonary edema and hypertension.

Considerations for Wet-Cold Patients

• Hypoperfusion is in the foreground.
• Blood pressure is low.
• Cardiogenic shock and low ejection fractions are also present.
• Presents in ~20% of cases with poor prognosis.

Considerations for Dry-Cold and Dry-Warm Patients

• Forms occur in approximately 10% of cases.

Treatment Principles

• Stabilization: hemodynamic stabilization, oxygenation and ventilation support.
• Optimization of the volemic status.
• Symptomatic treatments
• Treating the underlying etiology.

Treatment Methods

• Drug treatment: Diuretics, vasodilators, inotropes, and antiarrhythmic drugs.
• Cardioversion
• Surgical treatment: Artificial heart devices and heart transplantation.

Indications for Surgery

• Acute mitral and aortic valve insufficiency
• Aortic dissection
• Mechanical complications of coronary syndromes
• Ineffectiveness of conservative treatments
• Causes that can be eliminated by conservative methods are a contraindication to surgery.

Treatment Approach

• Involves managing patients with high suspicion of acute heart failure.
• Includes urgent stage treatment after the first encounter.
• Determine whether the patient is experiencing cardiogenic shock/respiratory failure and provide inotropes and respiratory/mechanical circulatory support if needed.
• It is important to identify the underlying cause, distinguishing between acute coronary syndrome, hypertensive emergency, arrhythmias, and acute mechanical causes.
• Begin specific treatment promptly, particularly if an embolism is detected.
• Heart failure is a progressive disease.
• Patients hospitalized with acute heart failure (AHF) have a poor prognosis.
• In-hospital mortality of AHF ranges from 3-4% and increases to 10% within 90 days.
• Close monitoring and disease follow-up are crucial in preventing decompensation among patients.
• Heart patients should regularly go for cardiology check-ups.
• Schedule follow-up examinations 1-2 weeks after discharge.
• Schedule include clinical and laboratory tests and echocardiography assessments.

Rehabilitation options

• Medical care at home
• In-patient rehabilitation facilities
• Palliative care facilities