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- Evidence-based review of the pathophysiology, diagnosis, and therapy of acute heart failure syndromes
- Designed for easy use in everyday clinical practice, an introduction into the topic
- Designed to satisfy the need of Acute Medicine/the Heart Team concept
- Contains extensive references, allowing the reader to easily refer to the original experimental studies
Acute heart failure is a potentially life threatening situation where correct, rapid therapy can save lives. Information from the latest research and studies has been used to update this text to bring the latest understanding of the pathophysiology together with a practical guide to diagnosis and management using an evidenced based approach. Since the first edition of Acute Heart Failure, this research has brought to light three important issues to be integrated into a second edition. First, the so-called “vascular heart failure” has been identified as a common and decisive mechanism provoking acute heart failure due to the coupling and interaction between the heart (right and left heart) and the large vessel systems (aorta and pulmonary artery). Second, the interaction and cross-talk between heart and kidneys, the so-called ‘cardiorenal syndrome’ has been identified as another feature of acute heart failure syndromes. Third, we have new knowledge and updated points of views about the development of pulmonary hypertension in patients suffering from heart failure, the group 2 of the classification system of pulmonary hypertension. These are all covered in this second edition. This revision to a seminal text is a valuable addition to any practitioner who treats patients with acute heart failure and wants a deeper understanding of the condition. Table of Contents1. Cardiac physiology of acute heart failure syndromes - 1.1 Cardiac performance
- 1.2 The fundamental equation of the circulation
- 1.3 Preload
- a) Definition
- b) Frank–Starling mechanism
- c) Venous return and CVP in daily practice
- 1.4 Haemodynamic monitoring
- a) Assessment and monitoring of fluid status
- b) Prediction of fluid responsiveness i) Pressure measurements ii) Volumetric measurements iii) Dynamic parameters iv) Fluid challenge v) PiCCO-monitoring vi) Echocardiography
- c) Arterial blood pressure i) BP and autoregulation ii) Assessment of tissue perfusion
- 1.5 Afterload
- a) Definition
- b) Vascular properties, effective arterial elastance, wall stress and the law of LaPlace
- c) Afterload mismatch and acute heart failure syndromes
- 1.6 Contractility
- a) Definition
- b) Ventricular elastance and other measurements and indicators of contractility
- c) Inotropic medications
- 1.7 Heart rate and contractility
- 1.8 Diastolic ventricular interaction/interdependance (DVI)
- a) Definition
- b) Septum and trans-septal pressure
- c) Pericardium
- d) Pulmonary hypertension and the risk of DVI
- e) Acutely exacerbated chronic congestive (left-sided or biventricular) HF
- f) Conclusions
- 1.9 Ventriculo-arterial coupling
- a) Definition
- b) Arterial elastance
- c) Ventricular elastance
- e) Deranged coupling
- 1.10 Myocardial and chamber stiffness
- 1.11 Evaluation and assessment of cardiac performance
- 1.12 Summary
- a) Key physiology
- b) Afterload
- c) Systolic function
- d) Volume status
- e) Ventriculo-arterial coupling
- f) Diastolic ventricular interaction
- g) Myocardial and chamber stiffness
- h) Cardiac power output / index i) Echocardiography
2 Acute heart failure syndromes- 2.1 Definition
- 2.2 Classification of acute heart failure syndromes (AHFS)
- 2.3 Etiology and epidemiology
- 2.4 Pathophysiology
- a) General pathophysiological remarks
- b) Special pathophysiological issues i)LVEDP and congestion ii) Neurohormonal systems, endothelial dysfunction and inflammation iii) Vascular properties, AV-coupling, afterload mismatch and Cotter`s dual pathway concept iv) Fluid redistribution, splanchnic veins and the venocentric input v) Fluid accumulation, venous congestion and the link between cardiac and vascular pathway vi) (Self)-amplification and vicious cycles
- c) Summary
- 2.5 Diagnosis, symptoms, presentation, important clinical and prognostic data
- a) Typical symptoms and diagnosis
- b) Prognostic indicators
- c) Initial clinical assessment, diagnostic measures and considerations i) Hemodynamic profiles on admission ii) Identification of precipitants iii) Other diagnostic measures
- 2.6 Therapy
- a) Therapeutic principles and goals
- b) Initial therapeutic approach i) Treatment of underlying diseases ii) Common basic measures iii) Typical and specific measures - Diuretics and ultrafiltration - Vasodilators - Inotropic drugs iv) Essential, permanent medication in the acute phase v) Arrhythmias and heart failure vi) Continuous positive airway pressure (CPAP) and other non-invasive positive pressure ventilatory support (NIPPV) vii) Anticoagulation
- 2.7 Valvular heart disease presenting as heart failure
- a) Mitral regurgitation
- b) Mitral stenosis
- c) Aortic regurgitation
- d) Aortic stenosis
- 2.8 Summary
3 Cardiogenic shock- 3.1 Definition
- 3.2 Epidemiology
- 3.3 Etiology
- 3.4 Pathophysiological aspects and special pathobiological features
- a) Classical pathophysiology and new cardiogenic shock paradigm
- b) The role and impact of hypotension in cardiogenic
- c) Myocardial ischemia and LV- compliance
- d) The right ventricle and cardiogenic shock
- e) Other acute causes of a substantial impairment in contractility
- 3.5 Clinical features and diagnostic remarks
- a) Hypoperfusion
- b) Right ventricular infarction
- c) The LVEDP in cardiogenic shock
- d) Differential diagnosis of cardiogenic shock
- 3.6 Therapy
- a) Main therapeutic strategies
- b) Adjunctive treatment i) Re-establishing and maintaining appropriate coronary and systemic perfusion ii)Fluid administration iii)Vasopressor administration iv) Inotropic medication v) Intra-aortic balloon counter pulsation (IABP) vi) Renal function vii) Compensation of acidosis viii) Anticoagulation therapy
- 3.7 Summary
4 Acute right heart failure- 4.1 Definitions
- 4.2 Epidemiology and etiology
- 4.3 Physiological and pathophysiological aspects
- a) General physiology and pathophysiology
- b) Special pathophysiological issues i) Diastolic ventricular interactions ii) The role of the pericardium in diastolic-ventricular interaction iii) Auto-aggravation iv) Series effect v) Pulmonary hypertension and ischemia vi) The interventricular septum and the apex vii) The left ventricle viii) Mechanical ventilation
4.4 Diagnostic aspects- a) Clinical features
- b) Serum biomarkers
- c) Electrocardiography
- d) Echocardiography
- e) Invasive hemodynamic assessments
4.5 Therapy- a) Specific measures
- b) Adjunctive therapy i) Fluid management and optimization of preload, diuretics ii) Vasopressors: Treatment and avoidance of ischemia iii) Critical RV-afterload reduction iv) Improvement of RV systolic function / contractility v) Intra-aortic balloon pump vi) Hypercapnia and acidosis vii) Oxygen therapy viii) AV sequential stimulation ix) Mechanical ventilation x) Anticoagulation xi) Digoxin
- c) Therapeutic conclusions
4.6 Summary- a) Pathophysiological and clinical issues
- b) Overview of treatment options, figure by Naeije and and Manes
5 Heart failure with normal left ventricular ejection fraction (HFNEF)- 5.1 Definition and general remarks
- 5.2 Epidemiology and etiology
- 5.3 Etiopathogenesis and basic pathophysiological issues and considerations
- 5.4 Special pathophysiology
- a) The pressure-volume relation and the filling pressure (LVEDP) in HFpEF
- b) Pathomechanisms i) Diastolic dysfunction ii) Vascular stiffening and av-coupling iii) Systolic function and cardiac reserve iv) Pulmonary hypertension and RV dysfunction, DVI v) Ventricular dys-synchrony vi) Left atrial dysfunction vii) Peripheral factors
- 5.5 Diagnosis and clinical issues
- a) Symptoms and signs of heart failure
- b) Ejection fraction
- c) Diastolic dysfunction, structural changes and bio-markers i) Natriuretic peptides ii) Functional and structural alterations iii) E/e`ratio iv) Inconclusive E/e`ratio - surrogate markers v) Invasively derived parameters vi) Diastolic stress test
- 5.6 Therapy
6 Pulmonary hypertension (PH) in left heart disease (LHD - PH)- 6.1 Definition
- 6.2 Classification of pulmonary hypertension
- 6.3 Epidemiology of PH due to LHD
- 6.4 Pathophysiology
- 6.5 Clinical issues and diagnosis
- 6.6 Therapeutic considerations
7 Cardiorenal syndrome (CRS)- 7.1 Definition
- 7.2 Epidemiology and prognostic issues
- 7.3 Clinical issues and diagnosis
- 7.4 Pathophysiology
- 7.5 Management
- a) Diuretics
- b) Blood pressure /renal perfusion pressure
- c) Further measures
Index
Abbreviations
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