Evaluation and Monitoring of Patients with Acute Heart Failure Syndromes

doi:10.1016/j.amjcard.2005.07.019

The American Journal of Cardiology

Volume 96, Issue 6, Supplement, 19 September 2005, Pages 32-40

https://doi.org/10.1016/j.amjcard.2005.07.019 Get rights and content

Advanced heart failure (HF) is associated with frequent hospitalizations, poor quality of life, and increased mortality. Despite optimal medical management, readmission rates remain high and account for approximately two thirds of all costs related to HF management. Evaluation of patients with HF is critical for the appropriate selection and monitoring of therapy as well as for the prevention of recurrent hospitalizations. This evaluation can be complex and relies on integration of the bedside evaluation and information available from invasive and other noninvasive diagnostic techniques. The clinical examination remains the cornerstone of HF evaluation. Key features of the history and physical examination can be used to assign hemodynamic profiles based on the absence or presence of congestion and adequacy of perfusion. These hemodynamic profiles provide prognostic information and may be used to guide therapy. Direct measurement of hemodynamics may be helpful in patients in whom the physical examination is limited or discordant with symptoms. Although the pulmonary artery catheter (PAC) is not recommended during routine therapy of patients hospitalized with HF, it is reasonable to consider the use of PAC monitoring to adjust therapy in patients who demonstrate recurrent or refractory symptoms despite ongoing standard therapy adjusted according to clinical assessment. This is particularly relevant in centers with experience in hemodynamic monitoring for HF. B-type natriuretic peptide (BNP) testing has been shown to facilitate diagnosis of the etiology of dyspnea in the urgent setting for patients without a prior diagnosis of HF. Furthermore, BNP levels provide important prognostic information in patients with chronic HF, but serial BNP testing has not been validated as a guide to inpatient or outpatient management. Echocardiographic assessment can provide prognostic information about ventricular function and size as well as information about hemodynamic status. Development of validated and reproducible noninvasive techniques to monitor patients with acute HF will be an important step in maximizing interventions to improve outcomes in this patient population.

Section snippets

Symptoms

Many physicians rely on the symptom history to assess a change in clinical status. A primary objective of advanced HF treatment is to resolve symptoms and improve functional capacity; therefore, therapy should encompass attention to symptoms and symptom relief. Patients with AHFS usually present with symptoms of worsening fluid retention or decreasing exercise tolerance and fatigue. Symptoms of congestion may be related to increased left or right ventricular filling pressures. Dyspnea on

Invasive Pulmonary Artery Catheter Use in Acute Heart Failure Syndromes

Introduction of the pulmonary artery catheter (PAC) in the early 1970s allowed physicians to obtain detailed information not easily gained from physical or laboratory evaluations. The use of the invasive PAC remains a pivotal component of management for patients in cardiogenic shock or other life-threatening circulatory compromise. After demonstration of the efficacy of acute intravenous vasodilator therapy transitioning to oral vasodilator therapy, some centers used the PAC to manage more

Laboratory Assessment of Acute Heart Failure Syndromes

Recognition of the role of neurohormones in the pathophysiology of HF has led to several studies suggesting that increased neurohormonal levels—including plasma renin activity, norepinephrine, endothelin-1, and B-type natriuretic peptide (BNP)—correlate with the severity of HF symptoms¹⁶ and prognosis.¹⁷ Of these, only BNP is a significant, independent predictor of elevated left ventricular end-diastolic pressure in patients with HF.¹⁸ Given the limitations of the clinical evaluation, there has

Other Noninvasive Techniques in Acute Heart Failure Syndromes

Integral to the evaluation and monitoring of patients with AHFS is an understanding of the underlying physiologic state and hemodynamic balance. Currently, invasive hemodynamic monitoring (use of a PAC) is the “gold standard” in accomplishing this goal. Given the concerns and potential risks involved with PAC use, techniques to evaluate hemodynamics noninvasively continue to be investigated.

Conclusion

Hospitalization for AHFS identifies a sick patient population with a poor prognosis. Early identification and treatment of decompensation may prevent subsequent hospitalization and improve outcomes in this patient population. Clinical history and physical examination, although limited, are the primary tools for evaluating and monitoring AHFS. The PAC can provide a useful adjunct for evaluating hemodynamics and guiding therapy in select patient populations who have not responded well to initial

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Citation Excerpt :
Based on hemodynamic profile and congestion status, ADHF patients can be classified into four categories [10] (Fig. 1). Subset I (Warm and dry) patients exhibit no hypoperfusion and no severe congestion; Subset II (Warm and wet) patients exhibit congestion without hypoperfusion; Subset III (Cold and dry) patients exhibit hypoperfusion without congestion; and Subset IV (Cold and wet) patients exhibit both congestion and hypoperfusion [10]. Each of these categories of ADHF requires differing specific therapy.
Heart failure (HF) affects over 26 million people world-wide. It is a syndrome triggered by loss of normal cardiac function due to many acute (eg myocardial infarction) and/or chronic (eg hypertension) causes and characterized by mixed beneficial and deleterious activation of a complex of multifaceted neurohormonal systems the net effect of which frequently is further adverse disruption of pressure-volume homeostasis. Unlike the situation in chronic heart failure, current strategies for treatment of acute heart failure are empirical and lack a strong evidence base. Management includes any of a combination of vasodilators, diuretics and ionotropic agents depending on the hemodynamic profile of the patient. Despite the improvement in the options available to improve outcomes in patients with chronic HF, for several decades little gain has been made in the treatment of the acute decompensated state. Morbidity and mortality rates remain high necessitating new therapeutic agents.
The cardiac natriuretic peptides (NPs) are key hormones in pressure–volume homoeostasis. There are three isoforms of mammalian NPs, namely ANP, BNP and CNP. These peptides bind to membrane-bound NP receptors (NPRs) on the heart, vasculature and kidney to lower blood pressure and circulating volume. Intravenous infusion of NPs in HF patients improves hemodynamic status but is associated with occasional severe hypotension. Apart from mammalian NPs, snake venom NPs are an excellent source of pharmacologically distinct ligands that offer the possibility of engineering NPs for therapeutic purposes. Venom NPs have long half-lives, differential NPR activation profiles and varied NPR specificity. The scaffolds of venom NPs encode the molecular information for designing NPs with longer half-lives and improved and differential vascular and renal functions. This review focuses on the structure-function paradigm of mammalian and venom NPs and the different peptide engineering strategies that have been utilized in the design of clinically relevant new NP-analogues.
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la insuficiencia cardiaca aguda es la principal causa de hospitalización en adultos mayores de 65 años. La duración de las hospitalizaciones es un determinante del incremento en los costos por la atención hospitalaria.
describir el perfil clínico de los pacientes hospitalizados por insuficiencia cardiaca aguda en un centro de referencia cardiovascular e identificar la duración de la estancia hospitalaria y los predictores de una hospitalización prolongada.
estudio observacional analítico, cohorte, prospectivo.
durante siete meses se incluyeron 251 pacientes con diagnóstico de insuficiencia cardiaca aguda. La mediana de edad fue de 71 años, fracción de eyección del ventrículo izquierdo de 25%, clasificación Nohria–Stevenson: húmedo–caliente 78,9%; húmedo–frío 15,1%; seco–caliente 2,8% y seco–frío 2,8%. El 15,9% de los pacientes requirieron inotrópicos y 1,2% vasopresores. Las complicaciones más frecuentes fueron el desarrollo de enfermedad renal aguda 33,1% y fibrilación auricular de novo 5,2%. La mediana de estancia hospitalaria fue de 5 días y el 65,7% presentó estancia prolongada (≥ 7 días). El análisis bivariado mostró predictores de estancia prolongada como requerimiento inotrópico (RR 2,41; IC 95% 1,77-3,27 p 0,000), clasificación Nohria–Stevenson seco-frío y húmedo-frío (RR 1,86; I 95%. 1,33-2,61 p 0,001), clasificación NYHA III-IV (RR 1,85; IC 95% 1,06-3,24 p 0,017), enfermedad renal aguda (RR 1,82; IC 95% 1,31-2,55 p 0,000) y diabetes mellitus (RR 1,47; IC 95% 1,05-2,06 p 0,026).
en una población con predominio de función cardíaca reducida y múltiples comorbilidades, la mediana de hospitalización por insuficiencia cardiaca aguda fue de 5 días. Se identificaron como predictores de estancia prolongada el soporte inotrópico, la clasificación Nohria–Stevenson seco–frío y húmedo–frío, NYHA III-IV, la enfermedad renal aguda y la diabetes mellitus.
Acute heart failure is the main cause of hospital admission in adults over 65 years-old. The length of the hospital stay is a determining factor in the increase in the costs of hospital care.
To describe the clinical profile of patients admitted to hospital Cardiovascular Reference Centre due to acute heart failure and to determine the duration of the hospital stay and the predictors of prolonged admission.
A prospective, analytical, observational, cohort study.
A total of 251 patients with a diagnosis of acute heart failure were admitted during a six-month period. The median age was 75 years, with a mean left ventricle ejection fraction of 25%, and a Nohria–Stevenson classification: wet-hot 78.9%; wet-cold 15.1%; dry-hot 2.8%, and dry-cold 2.8%. Inotropes were required by 15.9% of patients and vasopressors by 1.2%. The most frequent complications were development of acute kidney disease in 33.1%, and de novo atrial fibrillation in 5.2%. The median hospital stay was 5 days, and 65.7% had a prolonged stay (≥ 7 days). The bivariate analysis showed prolonged stay predictors such as inotrope requirement (RR 2.41; 95% CI; 1.77-3.27, P = .000), a Nohria–Stevenson classification of dry-cold and wet-cold (RR 1.86; 95% CI; 1.33-2.61, P = .001), NYHA classification of III-IV (RR 1.85; 95% CI; 1.06-3.24, P = .017), acute kidney disease (RR 1.82; 95% CI; 1.31-2.55, P = .000), and diabetes mellitus (RR 1.47; 95% CI; 1.05-2.06, P = .026).
In a population with a predominance of reduced cardiac function and multiple comorbidities, the median hospital stay due to acute heart failure was 5 days. Predictors of a prolonged stay were identified as inotrope support, a Nohria–Stevenson classification of dry-cold and wet-cold, NYHA III-IV, acute kidney disease, and diabetes mellitus.
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Evaluation and Monitoring of Patients with Acute Heart Failure Syndromes

Section snippets

Symptoms

Invasive Pulmonary Artery Catheter Use in Acute Heart Failure Syndromes

Laboratory Assessment of Acute Heart Failure Syndromes

Other Noninvasive Techniques in Acute Heart Failure Syndromes

Conclusion

J Am Coll Cardiol

Am J Cardiol

Am J Med

Am Heart J

J Card Fail

J Am Coll Cardiol

Am Heart J

Chest

J Vasc Surg

Am Heart J

Am Heart J

J Am Coll Cardiol

J Card Fail

Chest

J Am Soc Echocardiogr

Am J Cardiol

J Am Coll Cardiol

The limited reliability of physical signs for estimating hemodynamics in chronic heart failure

JAMA

The abdominojugular testtechnique and hemodynamic correlates

Ann Intern Med

A randomized, controlled trial of the use of pulmonary-artery catheters in high-risk surgical patients

N Engl J Med

Preoperative optimization of cardiovascular hemodynamics improves outcome in peripheral vascular surgerya prospective, randomized clinical trial

Ann Surg

Short-term intravenous milrinone for acute exacerbation of chronic heart failurea randomized controlled trial

JAMA