Rapid clinical assessment of hemodynamic profiles and targeted treatment of patient with acutely decompensated heart failure

Abstract

Acutely decompensated heart failure (ADHF) is characterized by hemodynamic abnormalities and neurohormonal activation that contribute to heart failure (HF) symptoms, end‐organ dysfunction, arrhythmias, and progressive cardiac failure. The management of ADHF in the emergency department (ED) can be simplified and improved by a 2‐min bedside assessment that identifies any of four possible hemodynamic profiles on the basis of clinical signs and symptoms. The profiles are based on whether congestion is present or absent (wet or dry) and perfusion is adequate or limited (warm or cold). A wet‐warm profile is seen more frequently in the ED than any of the other three profiles (wet‐cold, dry‐warm, and dry‐cold). The four clinically determined profiles have been shown to predict clinical outcomes and may be used to guide initial HF therapy. The goals of treating ADHF are to stabilize the patient, reverse acute hemodynamic abnormalities, rapidly reverse dyspnea and/or hypoxemia caused by pulmonary congestion, and initiate treatments that will decrease disease progression and improve survival. An ideal agent for the wet‐warm profile would rapidly reduce pulmonary congestion, produce balanced arterial and venous dilation, promote natriuresis, lack direct positive inotropic effects, and not cause reflex neuroendocrine activation. Intravenous nesiritide in conjunction with loop diuretics has been found safe and effective as initial treatment for patients with the wet‐warm profile. For the wet‐cold profile, more intensive therapy and invasive hemodynamic monitoring may prove useful. This review will discuss the rapid clinical determination of hemodynamic profiles in patients presenting to the ED with ADHF and the options for their initial medical management. Case studies representing the wet‐warm, wet‐cold, dry‐warm, and dry‐cold profiles will be presented and discussed.

Erforderliches Monitoring auf der Intensivstation

“…zentralvenösen Sauerstoffsättigung (ScvO 2 ) reflektiert zwar global den Sauerstoffmetabolismus des gesamten Organismus, erlaubt aber keine Aussage über die regionalen Verhältnisse auf Organebene und den realen Sauerstoffbedarf [41]. [18]. Ihr Vorteil ist darin zu sehen, dass eine abrupte Änderung der Werte im zeitlichen Verlauf im Sinne eines "Frühwarnsystem" auf unerwartete Komplikationen hinweisen kann; die Kosten für diese Kathetersysteme sind aber nicht unerheblich [41].…”

“…Die kontinuierliche Messung der SvO 2 durch fiberoptische Katheter ist einer Reihe von potentiellen Störungen unterworfen. Hämodynamische Zeichen der Hypoperfusion: Herzzeitindex (CI) ≤ 2,2 l/min/m 2 [18]. [18].…”

Management of Acute Decompensated Heart Failure in Patients With Cancer

“…Mills and Hobbs (2001) defi ned decompensated heart failure as a decrease of at least one New York Heart Association functional classifi cation (see Table 1). Decompensated heart failure is characterized by hemodynamic abnormalities and neurohormonal activation that contribute to heart failure symptoms, end-organ dysfunction, arrhythmias, and progressive cardiac failure (Fonarow & Weber, 2004). Acute decompensated heart failure (ADHF) is characterized by increases in symptoms such as dyspnea, fatigue, and fl uid retention.…”

Pathway for the Management of Acute Heart Failure

“…1 Acute heart failure accounts for over 1,000,000 hospitalizations in the United States with an inhospital morality rate of 4.1% and a mean length of stay of 6.5 days. Whether the result of inadequate inhospital treatment, refractory disease, noncompliance with diet or medications, or comorbidities, there is a hospital readmission rate of 20% within 30 days and 50% during the next 6-to 12-month interval.…”