Proper Fluid Therapy ,
Vasopressors, and
inotropic in
Acute Heart Failure
VIDYA GILANG REJEKI, MD
Importance of Acute Heart Failure (AHF)
In-hospital mortality ranges from 4% to 10%.
Post-discharge 1-year mortality can be 25-30% with up to more than
45% deaths or readmission rates.
Definition of Heart Failure
Clinical syndrome consisting of cardinal symptoms (e.g.
breathlessness, ankle swelling, and fatigue) that may be
accompanied by signs (e.g. elevated jugular venous
pressure, pulmonary crackles, and peripheral oedema).
It is due to a structural and/or functional abnormality of
the heart that results in elevated intracardiac pressures
and/or inadequate cardiac output at rest and/or during
exercise.
McDonagh et al. European Heart Journal (2021)
Bozkurt et al. Universal Definition of Heart Failure. 2021
Pathophysiology HF
Lily L. Pathophysiology of Heart Disease. 5th ed. Baltimore: Lippincott Williams and Wilkins; 2011. 216 p.
Pathophysiology of congestion.
The two main pathogenetic pathways of fluid redistribution and retention are interrelated
Dikutip dari ESC Guidelines for the
diagnosis and treatment of acute
and chronic heart failure: The
Task Force for the diagnosis and
treatment of acute and chronic
heart failure of the European
Society of Cardiology (ESC)
Developed with the special
contribution of the Heart Failure
Association (HFA) of the ESC
2015, 467
Definition
AHF refers to rapid onset or worsening of symptoms and/or signs of heart
failure
• Life-threatening medical condition requiring urgent evaluation and treatment, leading to
urgent hospital admission
AHF may present as:
A first occurrence (de novo)
A consequences of acute decompensated of chronic HF
Classification
CAD, old MI, FH,
HT,DM, CKD
McDonagh, et al. The 2021 ESC
Guidelines for the diagnosis and
treatment of acute and chronic heart
failure. Eur Heart J 2021
• Assessment of Congestion: Clinical
and Technical Evaluation
• Early symptoms of congestion
typically occur without significant
weight gain, suggesting fluid
redistribution rather than
hypervolemia
1. Mullens W, et al. The use of diuretics in HF with congestion. Eur J Heart
Failure 2019
2. Mentz RJ, et al. Decongestion in acute HF. Eur J Heart Failure 2014
Chest X-Ray
Lung Ultrasound
B-lines are defined as discrete laser-like vertical
The B lines hyperechoic reverberation artifacts that arise from the
pleural line, extend to the bottom of the screen without
fading, and move synchronously with lung sliding
sum of the B-lines found on each scanning site
yields a score denoting the extent of the
pulmonary interstitial syndrome
Lung rockets are defined as three or more B-lines
in a view between two ribs
Clinical presentations of acute heart failure
Acute Decompensated Heart Acute Pulmonary Edema Isolated right ventricular Cardiogenic Shock
Failure (ADHF) failure
Main LV dysfunction Increased afterload and/or RV dysfunction and/or Severe cardiac
Mechanism Water and Sodium Retention predominant pulmonary hypertension dysfunction
LV diastolic dysfunction
Valvular Heart Disease
Main Cause of Fluid accumulation, increase Fluid redistribution to the Increased central venous Systemic hypoperfusion
Symptoms intraventricular pressure lungs and acute respiratory pressure and often systemic
failure hypoperfusion
Onset Gradual (days) Rapid (hours) Gradual or rapid Gradual or rapid
Main Increase LVEDP and PCWP Increased LVEDP and PCWP Increased RVEDP Increased LVEDP and
hemodynamic Low or normal cardiac output Normal cardiac output Low cardiac output PCWP
Abnormalities Normal to low SBP Normal to high SBP Low SBP Low CO, Low SBP
Main Clinical “Wet and warm” or “Wet and warm” “Wet and cold” “Wet and cold”
Presentation “Wet and cold”
Main Diuretics, Inotropes or Diuretics, Vasodilators Diuretics, Inotropes or Inotropes or
treatment vasopressors (if hypotension vasopressors (if hypotension vasopressors, short term
or hypoperfusion), short term or hypoperfusion), short MCS or RRT if needed
MCS or RRT if needed term MCS or RRT if needed
McDonagh, et al. The 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J 2021
Acute Heart Failure Management
14.2% 26.3%
Rehospitalization
29.4%
16.7%
Chioncel O, et al. European Journal of Heart Failure (2019) 21, 1338–1352
Ponikowski P, et al. European Heart Journal (2016)
Key areas in optimizing patient management in
Acute Heart Failure
Differential Choice & Assessment of Consideration for
diagnosis & risk implementation of adequacy of discharge/transition
stratification initial therapy therapy of care
The Role of Emergency Physician Attending Cardiologist
McDonagh, et al. The 2021 ESC Guidelines for the diagnosis and treatment of acute and
chronic heart failure. Eur Heart J 2021
Acute Pulmonary Edema SpO2 target: 94–98%
• (Respiratory distress) –
Sat O2 < 90%
• Congestion (rales)
• respiratory failure
(hypoxaemia-
hypercapnia),
tachypnoea, >25
breaths/min, and
increased work of
breathing
McDonagh, et al. The 2021 ESC Guidelines for the diagnosis and treatment of
acute and chronic heart failure. Eur Heart J 2021
McDonagh, et al. The 2021 ESC Guidelines for the diagnosis and treatment of acute and
chronic heart failure. Eur Heart J 2021
McDonagh, et al. The 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J 2021
McDonagh, et al. The 2021 ESC
Guidelines for the diagnosis and
treatment of acute and chronic heart
failure. Eur Heart J 2021
Main pathogenic mechanisms leading to AHF. Examples of causes or
precipitating factor are provided for each mechanism
Dikutip dari ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart
failure of the European Society of Cardiology (ESC) Developed with the special contribution of the Heart Failure Association (HFA) of the ESC 2015, 467
Management based on
Hemodynamic Profile
PCWP > 15 mmHg
Dry Wet Diuretic
Congestion absent Vasodilator
Warm Congestion present:
Good Perfusion A B Pulmonary rales, elevated JVP,
orthopnea, ascites, edema
Cardiax Index
2.2 L/min/m2
Cold
Poor Perfusion:
- MAP <65 mmHg
C D
- Cold extremities
- Altered mental status Fluid Challenge
Inotropic drugs
- Oliguria
Acute Heart Failure
• Nitrates (IV) • Furosemide
Vasodilator Diuretics
Vaso-
Inotropics
presors
• Dobutamine
• Norepinephrine
• Dopamine
• Adrenaline
• Milrinone
Inotropes and Vasopressors
HEMODYNAMIC
PROFILE
Takagi K, et al. Int J Heart Fail. 2020
ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J 2016
Vasodilator in AHF
Mebazza. Intensive Care Med 2015
Diuretics
McDonagh, et al. The 2021 ESC
Guidelines for the diagnosis and
treatment of acute and chronic heart
failure. Eur Heart J 2021
How to do Fluid Challenge ?
- 2 – 4 cc/kgbb/10 min → evaluate
Steps CVP (cmH2O) Fluid Infusion Rate
Observe CVP for 10 min <8 200 mL x 10 min
before challenge
<14 100 mL x 10 min
≥14 50 mL x 10 min
During infusion (0-9 min) >5 Stop
Immediately following 10 ≤2 Continue infusion
min infusion
2-5 Wait 10 min
After 10 min >2 Stop
≤2 Repeat fluid challenge
Makabali C, et al. Cardiovasc. Rev. Rep. 3:899, 1982.
FRANK STARLING CURVE
Preload
Ventricular
Function
Hemodynamic
Resuscitation
Goals
Fluid Challenge
Take Home Messages
Always assess hemodynamic profile in patient with AHF
Assess any respiratory compromised and any hypoperfusion
Whether Vascular type vs Cardiac type predominates is
important to decide further management therapy
Diuretic response, especially at early phase is crucial to notes for
optimal decongestion therapy
Fluid challenge should be initiated with close monitoring
Search for CHAMPIT
Quiz 1 - What is your diagnosis ?
Male 75 yo, Severe shotness of breath A. HT emergency
History of DOE (+), HT (+), DM (+)
BP : 80/50 mmHg B. Cardiogenic shock
HR : 110x/min
SatO2 : 88% C. Acute Lung Edema
Rales ½
D. Acute RV failure
Acute Decompensated Heart Acute Pulmonary Edema Isolated right ventricular Cardiogenic Shock
Failure (ADHF) failure
Main LV dysfunction Increased afterload and/or RV dysfunction and/or Severe cardiac
Mechanism Water and Sodium Retention predominant pulmonary hypertension dysfunction
LV diastolic dysfunction
Valvular Heart Disease
Main Cause of Fluid accumulation, increase Fluid redistribution to the Increased central venous Systemic hypoperfusion
Symptoms intraventricular pressure lungs and acute respiratory pressure and often systemic
failure hypoperfusion
Onset Gradual (days) Rapid (hours) Gradual or rapid Gradual or rapid
Main Increase LVEDP and PCWP Increased LVEDP and PCWP Increased RVEDP Increased LVEDP and
hemodynamic Low or normal cardiac output Normal cardiac output Low cardiac output PCWP
Abnormalities Normal to low SBP Normal to high SBP Low SBP Low CO, Low SBP
Main Clinical “Wet and warm” or “Wet and warm” “Wet and cold” “Wet and cold”
Presentation “Wet and cold”
Main Diuretics, Inotropes or Diuretics, Vasodilators Diuretics, Inotropes or Inotropes or
treatment vasopressors (if hypotension vasopressors (if hypotension vasopressors, short term
or hypoperfusion), short term or hypoperfusion), short MCS or RRT if needed
MCS or RRT if needed term MCS or RRT if needed
Quiz 2
What is the hemodynamic A. Wet and warm
profile ? B. wet and cold
C. dry and warm
D. dry and cold
B. wet and cold
Quiz 3
What is your initial treatment ? A. Oxygen and Vasodilator
B. Oxygen and diuretic
C. Oxygen and Inotropic
D. Oxygen and Vasoconstrictor
Management AHF in early phase
Int J Heart Fail. 2020 Apr
Management AHF in early phase
Int J Heart Fail. 2020 Apr
Thank You