Pulmonary edema resident survival guide: Difference between revisions
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❑ Optimization of chronic home medications <br> | ❑ Optimization of chronic home medications <br> | ||
❑ Persistent [[hyponatremia|<span style="color:white;">hyponatremia</span>]] and risk of cognitive impairment: vasopressin antagonist for short term (hypervolemic) </div>}} | ❑ Persistent [[hyponatremia|<span style="color:white;">hyponatremia</span>]] and risk of cognitive impairment: vasopressin antagonist for short term (hypervolemic) </div>}} | ||
{{familytree/end}} | |||
==Complete Diagnostic Approach== | |||
A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention.<ref name="pmid23741057">{{cite journal| author=Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE, Drazner MH et al.| title=2013 ACCF/AHA guideline for the management of heart failure: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. | journal=Circulation | year= 2013 | volume= 128 | issue= 16 | pages= 1810-52 | pmid=23741057 | doi=10.1161/CIR.0b013e31829e8807 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23741057 }} </ref><ref name="pmid19358937">{{cite journal| author=Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG et al.| title=2009 Focused update incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Developed in Collaboration With the International Society for Heart and Lung Transplantation. | journal=J Am Coll Cardiol | year= 2009 | volume= 53 | issue= 15 | pages= e1-e90 | pmid=19358937 | doi=10.1016/j.jacc.2008.11.013 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19358937 }} </ref> | |||
<span style="font-size:85%">'''Abbreviations:''' | |||
'''ANA:''' [[Antinuclear antibody]]; | |||
'''ARDS:''' [[Acute respiratory distress syndrome]]; | |||
'''BNP:''' [[B-type natriuretic peptide]]; | |||
'''BUN:''' [[Blood urea nitrogen]]; | |||
'''CAD:''' [[Coronary artery disease]]; | |||
'''CBC:''' [[Complete blood count]]; | |||
'''CCB:''' [[Calcium channel blocker]]; | |||
'''CHF:''' [[Congestive heart failure]]; | |||
'''CT:''' [[Computed tomography]]; | |||
'''CXR:''' [[Chest X-ray]]; | |||
'''DM:''' [[Diabetes mellitus]]; | |||
'''ECG:''' [[Electrocardiogram]]; | |||
'''JVP:''' [[Jugular venous pressure]]; | |||
'''HF:''' [[Heart failure]]; | |||
'''HTN:''' [[Hypertension]]; | |||
'''LVEF:''' [[Left ventricular ejection fraction]]; | |||
'''LVH:''' [[Left ventricular hypertrophy]]; | |||
'''MI:''' [[Myocardial infarction]]; | |||
'''MRI:''' [[Magnetic resonance imaging]]; | |||
'''NT-pro BNP:''' [[N-terminal pro-brain natriuretic peptide]]; | |||
'''OCPs:''' [[Oral contraceptive pill]]s; | |||
'''PAWP:''' [[Pulmonary capillary wedge pressure|Pulmonary artery wedge pressure]]; | |||
'''SBP:''' [[Systolic blood pressure]]; | |||
'''S1:''' [[First heart sound]]; | |||
'''S3:''' [[Third heart sound]]; | |||
'''TSH:''' [[Thyroid stimulating hormone]] | |||
</span> | |||
<br> | |||
{{familytree/start}} | |||
{{familytree | | | | | | | | A01 | | |A01=<div style="float: left; text-align: left; width: 30em; padding:1em;"> '''Characterize the symptoms:'''<br> | |||
''Symptoms of left-sided fluid accumulation''<br> | |||
❑ [[Dyspnea]]<br> | |||
:❑ At rest<br> | |||
:❑ Exertional<br> | |||
❑ [[Paroxysmal nocturnal dyspnea]]<br> | |||
❑ [[Orthopnea]]<br> | |||
❑ [[Cough]]<br> | |||
''Symptoms of right-sided fluid accumulation''<br> | |||
❑ [[Peripheral edema]]<br> | |||
❑ [[Right upper quadrant abdominal discomfort]]<br> | |||
❑ [[Bloating]]<br> | |||
❑ [[Satiety]]<br> | |||
''Symptoms of reduced cardiac output''<br> | |||
❑ [[Fatigue]]<br> | |||
❑ [[Exercise intolerance]]<br> | |||
❑ [[Oliguria]]<br> | |||
❑ [[Dizziness]]<br> | |||
❑ [[Syncope]]<br> | |||
❑ [[Altered mental status]]<br> | |||
❑ [[Cyanosis]]<br> | |||
❑ [[Anorexia]]<br> | |||
❑ [[Abdominal pain]] (suggestive of [[mesenteric ischemia]])<br> | |||
''Symptoms suggestive of precipitating events''<br> | |||
❑ [[Chest pain]] (suggestive of [[coronary heart disease|myocardial ischemia]])<br> | |||
❑ [[Palpitations]] (suggestive of [[arrhythmia]]s)<br> | |||
❑ [[Fever]] (suggestive of [[infection]])<br> | |||
''Nonspecific symptoms''<br> | |||
❑ [[Nausea]]<br> | |||
❑ [[Weight loss]]<br> | |||
---- | |||
'''Obtain a detailed history:'''<br> | |||
❑ '''Past medical history'''<br> | |||
:❑ [[Atrial fibrillation]]<br> | |||
:❑ [[Cardiomyopathy]]<br> | |||
:❑ [[Diabetes mellitus]]<br> | |||
:❑ [[Hypertension]]<br> | |||
:❑ [[Myocarditis]]<br> | |||
:❑ [[myocardial infarction|Previous myocardial infarction]]<br> | |||
:❑ [[Congestive heart failure|Prior heart failure]]<br> | |||
:❑ [[Sleep apnea]]<br> | |||
:❑ [[Thyroid disease]]<br> | |||
:❑ [[Valvular heart disease]]<br> | |||
❑ '''Medication history'''<br> | |||
:❑ Noncompliance with previously prescribed medications for [[heart failure]]<br> | |||
:❑ Intake of the following drugs:<br> | |||
::❑ [[Alcohol]]<br> | |||
::❑ [[Beta blockers]]<br> | |||
::❑ [[Calcium channel blockers]] like [[verapamil]] which can exacerbate CHF or [[diltiazem]] which can cause [[peripheral edema]]<br> | |||
::❑ [[Chemotherapy]] drugs - [[anthracyclines]]<br> | |||
::❑ [[NSAID]]s which should not be given in CHF<br> | |||
::❑ [[Thiazolidinedione]]<br> | |||
❑ '''Family history'''<br> | |||
:❑ History of [[dilated cardiomyopathy]]<br> | |||
:❑ [[Radiation]] to the chest | |||
---- | |||
'''Determine the [[Heart failure resident survival guide#Classification by Severity of Congestive Heart Failure|NYHA classification]] based on symptoms:''' <br> | |||
❑ Class I (no symptoms) <br> | |||
❑ Class II (symptoms with ordinary activities) <br> | |||
❑ Class III (symptoms upon minimal activity) <br> | |||
❑ Class IV (symptoms at rest) | |||
</div>}} | |||
{{familytree | | | | | | | | |!| | | | |}} | |||
{{familytree | | | | | | | | B01 | | | |B01=<div style="float: left; text-align: left; width: 25em; padding:1em;"> '''Examine the patient:'''<br> | |||
'''General appearance:'''<br> | |||
❑ Ill-looking<br> | |||
❑ In respiratory distress<br> | |||
❑ In upright sitting position<br> | |||
'''Vitals:'''<br> | |||
❑ [[Temperature]]<br> | |||
:❑ [[Fever]] (suggestive of underlying [[infection]])<br> | |||
❑ [[Pulse]]<br> | |||
:❑ [[Tachycardia]]<br> | |||
:❑ [[Pulse pressure#Narrowed Pulse Pressure causes|Narrow pulse pressure]] (<25% of SBP)<br> | |||
❑ [[Blood pressure]]<br> | |||
:❑ [[Hypotension]] (suggestive of circulatory collapse)<br> | |||
:❑ [[Hypertension]] <br> | |||
❑ [[Respiration]]<br> | |||
:❑ [[Tachypnea]] (most common symptom)<br> | |||
❑ [[Pulse oximetry]] (maintain oxygen sat ≥ 94% unless COPD)<br> | |||
'''Weight:'''<br> | |||
❑ Measure weight daily at the same time after the first void<br> | |||
❑ Subtract 'dry weight' from current weight to estimate extent of volume overload and [[edema]]<br> | |||
'''Skin'''<br> | |||
❑ [[Cool extremities|Cool and clammy]] (suggestive of hypoperfusion)<br> | |||
❑ [[Cyanosis]] (suggestive of severe [[hypoxemia]])<br> | |||
❑ [[Anasarca]]<br> | |||
❑ [[Jaundice]] (suggestive of liver dysfunction secondary to right-sided fluid overload)<br> | |||
'''Neck examination:'''<br> | |||
❑ [[Jugular vein distention]] (suggestive of right-sided fluid overload)<br> | |||
❑ Positive [[hepatojugular reflux]] (suggestive of right-sided fluid overload)<br> | |||
'''Respiratory examination'''<br> | |||
❑ [[Tachypnea]]<br> | |||
❑ [[Wheeze]]<br> | |||
❑ Dullness at lung bases (suggestive of [[pleural effusion]], may be present in chronic HF secondary to lymphatic compensation)<br> | |||
❑ [[Crackles]]/[[crepitations]]/[[rales]] (suggestive of [[pleural effusion]])<br> | |||
❑ [[Cheyne-stokes respiration]]<br> | |||
'''Cardiovascular examination'''<br> | |||
❑ Displaced [[apex beat]] (suggestive of enlarged [[left ventricle]])<br> | |||
❑ [[Parasternal heave]] (suggestive of elevated right ventricular pressure)<br> | |||
❑ [[Heart sounds#Third heart sound S3|S3]] (typical) or [[Heart sounds#Fourth heart sound S4|S4]] or both<br> | |||
❑ Soft S1 <br> | |||
❑ Pulsus alternans <br> | |||
❑ [[S4]] (suggestive of [[diastolic]] dysfunction) <br> | |||
❑ New or changed [[murmur]] (suggestive of an underlying [[valvular heart disease]]s)<br> | |||
:❑ [[Mitral regurgitation]] - [[Systolic heart murmur#Holosystolic (pansystolic)|Holosystolic murmur]]<br> | |||
:❑ [[Aortic regurgitation]] - [[Diastolic heart murmur#Individual murmurs|Decrescendo diastolic murmur]]<br> | |||
:❑ [[Aortic stenosis]] - Crescendo-decrescendo systolic ejection murmur with ejection click<br> | |||
'''Abdominal examination'''<br> | |||
The following findings suggest volume overload and / or poor forward cardiac output:<br> | |||
❑ [[Hepatojugular reflux]]<br> | |||
❑ [[Hepatomegaly]]<br> | |||
❑ [[Ascites]]<br> | |||
'''Extremity examination'''<br> | |||
❑ [[Pedal edema]]<br> | |||
'''Neurological examination'''<br> | |||
❑ [[Altered mental status]]<br> | |||
❑ [[Syncope]] (suggestive of [[aortic stenosis]] or [[pulmonary embolism]]) | |||
----- | |||
'''Determine status of congestion and perfusion based on physical exam:'''<br> | |||
''Congestion at rest (dry vs. wet)'' <br> | |||
:"Wet" suggested by orthopnea, ↑JVP, positive hepatojugular reflux, abnormal valsalva response, rales, dullness upon percussion in bases, S3, peripheral edema, hepatomegaly, ascites, jaundice <br> | |||
''Low perfusion at rest (warm vs. cold)'' <br> | |||
:"Cold" suggested by narrow pulse pressure, cool extremities, hypotension, soft S1, pulsus alternans, decreased urinary output <br> | |||
The patient is: <br> | |||
❑ Warm and dry, OR <br> | |||
❑ Warm and wet, OR <br> | |||
❑ Cold and dry, OR <br> | |||
❑ Cold and wet | |||
</div>}} | |||
{{familytree | | | | | | | | |!| | | | | |}} | |||
{{familytree | | | | | | | | D01 | | | |D01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Order tests''': <br> | |||
'''Routine''' ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]])<br> | |||
:❑ [[Complete blood count|CBC]] (rule out [[anemia]]) <br> | |||
:❑ [[Troponin]] | |||
::❑ Elevated in [[myocardial ischemia]] and acute cardiogenic pulmonary edema, particularly if [[creatinine clearance|creatinine clearance (CrCl)]] is reduced<br> | |||
::❑ [[Troponin|Troponin T]] ≥ 0.1 ng/mL (associated with poor survival)<ref name="Perna-2002">{{Cite journal | last1 = Perna | first1 = ER. | last2 = Macín | first2 = SM. | last3 = Parras | first3 = JI. | last4 = Pantich | first4 = R. | last5 = Farías | first5 = EF. | last6 = Badaracco | first6 = JR. | last7 = Jantus | first7 = E. | last8 = Medina | first8 = F. | last9 = Brizuela | first9 = M. | title = Cardiac troponin T levels are associated with poor short- and long-term prognosis in patients with acute cardiogenic pulmonary edema. | journal = Am Heart J | volume = 143 | issue = 5 | pages = 814-20 | month = May | year = 2002 | doi = | PMID = 12040342 }}</ref> | |||
:❑ [[Electrolytes]]<br> | |||
::❑ [[Sodium]]: hyponatermia may occur due to fluid overlaod | |||
:❑ [[calcium|Serum calcium]]<br> | |||
:❑ [[Magnesium|Serum magnesium]] can be lowered by [[diuresis]]<br> | |||
:❑ [[Serum bicarbonate]]: to monitor [[contraction alkalosis]] with [[diuresis]] | |||
:❑ [[BUN]], [[creatinine]]: may be elevated due to poor renal perfusion<br> | |||
:❑ [[Urinalysis]] <br> | |||
:❑ [[Blood sugar|Fasting blood sugar]]<br> | |||
:❑ [[Lipid profile|Fasting lipid profile]]<br> | |||
:❑ [[Liver function tests]]: can be elevated secondary to peripheral hypoperfusion<br> | |||
:❑ [[Thyroid-stimulating hormone|TSH]]<br> | |||
❑ [[B-type natriuretic peptide|BNP]] or NT-pro BNP (if diagnosis is uncertain)<br> | |||
Heart failure is unlikely if:<ref name="pmid22611136">{{cite journal| author=McMurray JJ, Adamopoulos S, Anker SD, Auricchio A, Böhm M, Dickstein K et al.| title=ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. | journal=Eur Heart J | year= 2012 | volume= 33 | issue= 14 | pages= 1787-847 | pmid=22611136 | doi=10.1093/eurheartj/ehs104 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22611136 }} </ref><ref name="pmid16638247">{{cite journal| author=Fuat A, Murphy JJ, Hungin AP, Curry J, Mehrzad AA, Hetherington A et al.| title=The diagnostic accuracy and utility of a B-type natriuretic peptide test in a community population of patients with suspected heart failure. | journal=Br J Gen Pract | year= 2006 | volume= 56 | issue= 526 | pages= 327-33 | pmid=16638247 | doi= | pmc=PMC1837840 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16638247 }} </ref> <br> | |||
:❑ [[B-type natriuretic peptide|BNP]] ≤ 100 pg/mL, or<br> | |||
:❑ [[NT-pro BNP]] ≤ 300 pg/mL <br> | |||
❑ [[Chest X-ray]] ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]])<br> | |||
:❑ [[Cardiomegaly]] ([[cardiothoracic ratio]] >50%)<br> | |||
:❑ Cardiogenic [[pulmonary edema]]<br> | |||
:❑ [[Kerley B lines]]<br> | |||
:❑ [[Peribronchial cuffing]]<br> | |||
:❑ [[Congestive heart failure chest x ray#Cephalization|Cephalization]] | |||
[[Image:Pulmonary edema.gif|center|200px|thumb|Chest X-ray findings in a patient with acute heart failure ]]<br> | |||
❑ [[ECG]] (to help identify the cause of heart failure)<br> | |||
:❑ [[Low QRS voltage]] (suggestive of infiltrative or dilated cardiomyoapthy)<br> | |||
:❑ [[Arrhythmia]] ([[atrial fibrillation]] carries a poor prognosis and requires slowing of the heart rate to improve filling & [[cardiac output]])<br> | |||
:❑ [[Poor R wave progression]] (suggestive of a prior [[MI]])<br> | |||
:❑ [[Left ventricular hypertrophy]] (consistent with a history of [[hypertension]])<br> | |||
:❑ [[Left bundle branch block]] ([[LBBB]]) due to prior [[MI]], may result in dysynchrony)<br> | |||
:❑ [[Left atrial enlargement]] (due to [[valvular disease]] or [[hypertension]])<br> | |||
:❑ Non-specific [[ST segment]] and [[T wave]] changes may suggest [[ischemia]]<br> | |||
❑ 2-D [[echocardiography]] with Doppler <br> ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]]) | |||
:❑ Assess chambers size, wall thickness, wall motion, and valve function<br> | |||
:❑ Assess [[ejection fraction]] | |||
❑ [[Cardiac radionuclide imaging|Radionuclide ventriculography]] or [[MRI]]<br> | |||
:❑ To assess [[LVEF]] and volume when [[echocardiography]] is inadequate<br> | |||
:❑ To assess myocardial infiltrative processes or scar burden ([[MRI]])<br> | |||
❑ [[Coronary angiography]] looking for CAD<br> | |||
❑ Comprehensive metabolic panel if no evidence of CAD on coronary angiography <br> | |||
❑ Consider [[Right heart catheterization|pulmonary artery catheterization]] in case of failure to respond to medical therapy, [[respiratory distress]], [[shock]], uncertainty regarding volume status, or increase in creatinine; assess the following parameters:<br> | |||
:❑ [[PCWP]] | |||
:❑ [[Cardiac output]] | |||
:❑ [[Systemic vascular resistance]] | |||
---- | |||
'''Order additional tests to rule out other etiologies:'''<br> | |||
❑ [[Antinuclear antibodies|ANA]] and [[rheumatoid factor]] (for rheumatologic diseases)<br> | |||
❑ Diagnostic tests for [[hemochromatosis]] and [[pheochromocytoma]]<br> | |||
❑ [[Endomyocardial biopsy]] (when [[myocarditis]] is suspected) | |||
</div>}} | |||
{{familytree | | | | | | | | |!| |}} | |||
{{familytree | | | | | | | | W01 | |W01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Consider alternative diagnoses:'''<br> | |||
---- | |||
<table class="wikitable"> | |||
<tr class="v-firstrow"><th>Alternative diagnoses</th><th>Features</th></tr> | |||
<tr><td> [[Asthma|Acute asthma]]</td><td>❑ [[Wheeze]]<br>❑ Reversal of symptoms following<br> administration of [[bronchodilator]]s</td></tr> | |||
<tr><td> [[COPD]]</td><td>❑ Increased [[cough]]<br>❑ Increased [[dyspnea]]<br>❑ Increased [[sputum]] production </td></tr> | |||
<tr><td> [[Acute respiratory distress syndrome|ARDS]]</td><td>❑ Severe [[hypoxia]]<br>❑ Bilateral opacities on [[chest X-ray]]<br>❑ [[Pulmonary capillary wedge pressure|PCWP]] < 15 mmHg</td></tr> | |||
<tr><td> [[Pneumonia]]</td><td>❑ [[Fever]], [[cough]], [[sputum]]<br>❑ [[Pneumonia chest x ray|Consolidation]] on [[chest X-ray]]</td></tr> | |||
<tr><td> [[Pulmonary embolism]]</td><td>❑ [[Pleurisy|Pleuritic chest pain]], [[cough]], [[Heart sounds#Fourth heart sound S4|S4]]<br>❑ Risk factors: trauma, immobilization, smoking, OCPs <br>❑ Clot in pulmonary artery on [[Pulmonary embolism CT pulmonary angiography|CT pulmonary angiography]] </td></tr> | |||
</table></div>}} | |||
{{familytree | | | | | | | | |!| | |}} | |||
{{familytree | | | | | | | | Z01 | | |Z01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Assess the stage of heart failure using the [[Acute heart failure resident survival guide#Classification|ACCF/AHA staging system]] to guide chronic therapy''' | |||
</div>}} | |||
{{familytree | | | | | | |,|-|^|-|.| | | | | |}} | |||
{{familytree | | | | | | X01 | | X02 | | | |X01=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''[[Acute heart failure resident survival guide#Prevention of Heart Failure|Stage C]]''' <br> <br> | |||
❑ '''Patients with structural heart disease'''<br> | |||
This refers to patients with the following:<br> | |||
:❑ Previous [[MI]]<br> | |||
:❑ LV remodeling* (including [[ LVH]] + low [[EF]])<br> | |||
:❑ Asymptomatic [[valvular disease]]<br><br>'''AND'''<br> | |||
❑ '''Signs or symptoms of heart failure'''<br><br> | |||
''LV remodeling refers to the changes in size, shape and function of the heart resulting from cardiac load or injury''</div> | |||
|X02=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''[[Acute heart failure resident survival guide#Prevention of Heart Failure|Stage D]]''' <br> <br> | |||
❑ '''Refractory heart failure'''<br> | |||
:❑ Marked symptoms at rest<br> | |||
:❑ Recurrent hospitalizations</div>}} | |||
{{familytree/end}} | {{familytree/end}} |
Revision as of 20:29, 8 March 2018
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief:
Overview
This section provides a short and straight to the point overview of the disease or symptom. The first sentence of the overview must contain the name of the disease.
Causes
Life Threatening Causes
Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.
Common Causes
Diagnosis
Shown below is an algorithm summarizing the diagnosis of [[disease name]] according the the [...] guidelines.
Treatment
Shown below is an algorithm summarizing the treatment of [[disease name]] according the the [...] guidelines.
FIRE: Focused Initial Rapid Evaluation
A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients of pulmonary edema in need of immediate intervention.[1]
Boxes in red signify that an urgent management is needed.
Abbreviations:
BU: Blood urea nitrogen;
COPD: Chronic obstructive pulmonary disease;
D5W: 5% dextrose solution in water ;
HF: Heart failure;
IV: Intravenous;
MAP: Mean arterial pressure;
Na: Sodium;
NSAID: Non steroidal anti-inflammatory drug;
SBP: Systolic blood pressure;
S3: Third heart sound;
Identify cardinal findings that increase the pretest probability of acute decompensated heart failure ❑ Dyspnea | |||||||||||||||||
Does the patient have any of the following findings that require hospitalization and urgent management? ❑ Severe decompendated HF:
❑ Dyspnea at rest manifested by tachypnea or oxygen saturation <90% | |||||||||||||||||
Yes | No | ||||||||||||||||
Admit to to a level of care that allows for constant ECG monitoring given the risk of arrhythmia | |||||||||||||||||
Initial stabilization: Assess congestion and perfusion: Identify precipitating factor and treat accordingly:
❑ COPD Treat congestion and optimize volume status:
❑ Low sodium diet (<2 g daily)
❑ Consider low dose dopamine infusion for improved diuresis and renal blood flow (IIb-B) Venodilators
Treat low perfusion:
Invasive hemodynamic monitoring: VTE prevention: Chronic medical therapy:
❑ DO NOT INITIATE ACE INHIBITORS during an acute decompensation Monitor laboratory tests: Management of hyponatremia:
❑ Optimization of chronic home medications | |||||||||||||||||
Complete Diagnostic Approach
A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention.[1][2]
Abbreviations:
ANA: Antinuclear antibody;
ARDS: Acute respiratory distress syndrome;
BNP: B-type natriuretic peptide;
BUN: Blood urea nitrogen;
CAD: Coronary artery disease;
CBC: Complete blood count;
CCB: Calcium channel blocker;
CHF: Congestive heart failure;
CT: Computed tomography;
CXR: Chest X-ray;
DM: Diabetes mellitus;
ECG: Electrocardiogram;
JVP: Jugular venous pressure;
HF: Heart failure;
HTN: Hypertension;
LVEF: Left ventricular ejection fraction;
LVH: Left ventricular hypertrophy;
MI: Myocardial infarction;
MRI: Magnetic resonance imaging;
NT-pro BNP: N-terminal pro-brain natriuretic peptide;
OCPs: Oral contraceptive pills;
PAWP: Pulmonary artery wedge pressure;
SBP: Systolic blood pressure;
S1: First heart sound;
S3: Third heart sound;
TSH: Thyroid stimulating hormone
Characterize the symptoms: Symptoms of left-sided fluid accumulation
❑ Paroxysmal nocturnal dyspnea Obtain a detailed history:
❑ Medication history
❑ Family history
Determine the NYHA classification based on symptoms: | |||||||||||||||||||||||||||||||||
Examine the patient: General appearance: Vitals: ❑ Pulse
❑ Pulse oximetry (maintain oxygen sat ≥ 94% unless COPD) Weight: Skin Neck examination: Respiratory examination Cardiovascular examination
Abdominal examination Extremity examination Neurological examination Determine status of congestion and perfusion based on physical exam:
Low perfusion at rest (warm vs. cold)
The patient is: | |||||||||||||||||||||||||||||||||
Order tests: Routine (Class I, level of evidence C)
❑ BNP or NT-pro BNP (if diagnosis is uncertain)
❑ Chest X-ray (Class I, level of evidence C)
❑ ECG (to help identify the cause of heart failure)
❑ 2-D echocardiography with Doppler
❑ Radionuclide ventriculography or MRI
❑ Coronary angiography looking for CAD Order additional tests to rule out other etiologies: | |||||||||||||||||||||||||||||||||
Consider alternative diagnoses:
| |||||||||||||||||||||||||||||||||
Assess the stage of heart failure using the ACCF/AHA staging system to guide chronic therapy
| |||||||||||||||||||||||||||||||||
Stage C ❑ Patients with structural heart disease
❑ Signs or symptoms of heart failure | |||||||||||||||||||||||||||||||||
- ↑ 1.0 1.1 Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE, Drazner MH; et al. (2013). "2013 ACCF/AHA guideline for the management of heart failure: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines". Circulation. 128 (16): 1810–52. doi:10.1161/CIR.0b013e31829e8807. PMID 23741057.
- ↑ Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG; et al. (2009). "2009 Focused update incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Developed in Collaboration With the International Society for Heart and Lung Transplantation". J Am Coll Cardiol. 53 (15): e1–e90. doi:10.1016/j.jacc.2008.11.013. PMID 19358937.
- ↑ Perna, ER.; Macín, SM.; Parras, JI.; Pantich, R.; Farías, EF.; Badaracco, JR.; Jantus, E.; Medina, F.; Brizuela, M. (2002). "Cardiac troponin T levels are associated with poor short- and long-term prognosis in patients with acute cardiogenic pulmonary edema". Am Heart J. 143 (5): 814–20. PMID 12040342. Unknown parameter
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ignored (help) - ↑ McMurray JJ, Adamopoulos S, Anker SD, Auricchio A, Böhm M, Dickstein K; et al. (2012). "ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC". Eur Heart J. 33 (14): 1787–847. doi:10.1093/eurheartj/ehs104. PMID 22611136.
- ↑ Fuat A, Murphy JJ, Hungin AP, Curry J, Mehrzad AA, Hetherington A; et al. (2006). "The diagnostic accuracy and utility of a B-type natriuretic peptide test in a community population of patients with suspected heart failure". Br J Gen Pract. 56 (526): 327–33. PMC 1837840. PMID 16638247.