S1E10: Acute Heart Failure - Cardiology
This month we’re getting right to the heart of things…
Orla is joined by Karl and Saf for a great case and a very informative discussion, with Dr. Brendan McCann keeping a close eye on their work.
For our second segment, we’re delighted to welcome back the one and only Dr. Cian McDermott for a fascinating chat about POCUS in cardiac arrest.
And to round things off, Dr. Mustafa Mehmood dropped by to take us through a great approach to syncope.
Alright, let’s get to it!
Acute Heart Failure - It’s All About the Blood Pressure
Acute Heart Failure is either new onset heart failure (HF) or acute decompensation of chronic heart failure. It is a common cause of hospitalization in those aged > 65 years and associated with a high risk of mortality and rehospitalization. Those who present with AHF need a thorough assessment, treatment of acute organ dysfunction and identification of underlying cause. These patients can often present in either cardiogenic shock or respiratory failure. The ESC 2016 guideline uses a mnemonic CHAMP for the underlying ACUTE cause.
Acute Coronary Syndrome
Hypertension Emergency
Arrhythmia
Acute Mechanical Cause
Pulmonary Embolism
Acute mechanical causes refers to myocardial rupture complicating acute coronary syndrome (free wall rupture, ventricular septal defect, acute mitral regurgitation), chest trauma or cardiac intervention, acute native or prosthetic valve incompetence secondary to endocarditis, aortic dissection or thrombosis.
In most cases, patients with AHF present with either preserved (90–140mmHg) or elevated (>140mmHg; hypertensive AHF) systolic blood pressure. Only 5–8% of all patients present with an SBP <90mmHg), which is associated with poor prognosis, particularly when hypoperfusion is also present.
There are multiple classification systems, but as an EM physician clinical classification following bedside assessment is very useful in deciding what treatment patients need!
Depending on the signs and symptoms they are either
Warm and wet - well perfused and congested
Warm and dry - compensated well perfused with no congestion
Cold and wet - hypoperfused and congested
Cold and dry - hypoperfused with no congestion
Have a look at the diagram below and remember hypoperfusion is not synonymous with hypotension but often hypoperfusion is accompanied by hypotension!
For a treatment order of importance, remember to think P.O.N.D.:
Positive pressure (NIV)
Oxygen
Nitrates
Diuresis
Treatment of ADHF is not “one size fits all’’, it has to be tailor made for each patient.
Guidelines
2016 European Society of Cardiology Clinical Practice Guidelines on Acute and Chronic Heart Failure
https://www.escardio.org/Guidelines/Clinical-Practice-Guidelines/Acute-and-Chronic-Heart-Failure
2014 NICE Clinical Guideline on Acute Heart Failure: Diagnosis and Management
Syncope in the Emergency Department
History is everything - be methodical and meticulous with the events preceding, during, and after the ‘event’.
Every patient should get an ECG and lying - standing blood pressure (measured at 1 AND 3 minutes - see references for a how to guide)
Beware the presentation of ‘dizziness’ and distinguish from ‘lightheadedness’. They are distinct and different symptoms, and require a precise definition, as each presentation requires different investigations and management.
IAEM Syncope Clinical Guidelines
http://www.iaem.ie/wp-content/uploads/2019/07/IAEM-syncope.pdf
2018 European Society of Cardiology Clinical Practice Guidelines on the Diagnosis and Management of Syncope
Emed Patient information on Postural Hypotension
http://emed.ie/Patient-Info/Info_Postural_Hypotension.php
RCP London Guide to Lying Standing Blood Pressure Measurement
https://www.rcplondon.ac.uk/projects/outputs/measurement-lying-and-standing-blood-pressure-brief-guide-clinical-staff
Cardiac Arrest - Can We Do It Better with Ultrasound?
Why should I use US at a code?
Is there a problem that I can treat immediately?
Signs of RV strain, cardiac tamponade, occult VF
If there is no cardiac activity, should I terminate the resuscitation?
Can I perform US guided CPR to improve the chances of successful resuscitation? Could I re-position CPR to compress the LV
What is cardiac activity?
This definition has been difficult to standardise - I use the REASON trial definition
visible movement of the myocardium
excluding any valvaular or blood pool motion
What’s the evidence?
Romolo Gaspari trial (Gaspari et al. 2016)
Prospective observational study 2011 to 2014
20 centres in North America, 793 patients included
ED cardiac arrests - asystole, PEA included
Scan at start & end of the code (arrest)
Key findings
If no cardiac activity present, less than 1% patients survived to hospital discharge
‘Asystole’ had cardiac activity in 10% cases
‘PEA’ had cardiac activity in 54% cases
Does US prolong the duration of the ‘pulse check’? (Huis In ’t Veld et al. 2017)
Group that used US - duration of pulse check was 21s
Group that did not use US - duration of pulse check was 13s
Answer is maybe it does...
Possible solution is to protocolise use of US at the pulse check - listen to this appraisal of CASA study by Nagdev et al https://www.ultrasoundgel.org/posts/apsU8sD08C5PgvO2AKL3-Q
Key take home messages
Use US at cardiac arrests
not for shockable arrhythmia, only PEA or asytole
for the ‘pulse check’ or for more information use it continuously during the arrest (intra-arrest)
Think about ergonomics
separate operator, dedicated machine that is battery-operated & fits at the bedside away from other critical interventions
have a go-to view eg subcostal but also have another one that are comfortable using eg modified PLAX
Think about prognostication
is there cardiac activity?
If not, should I consider stopping?
Is the LV compressed and allowed to recoil during CPR?
If not, should I move the mechanical compression device/ hand position to achieve this?