Acute Heart Failure

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)

1. Definition 2. Classification of pulmonary hypertension



3. Epidemiology of PH due to LHD

4. Pathophysiology

5. Clinical issues and diagnosis

6. Therapeutic considerations



7 Cardiorenal syndrome (CRS)

1. Definition

2. Epidemiology and prognostic issues

3. Clinical issues and diagnosis

4. Pathophysiology

5. Management

a) Diuretics

b) Blood pressure /renal perfusion pressure

c) Further measures





Index

Abbreviations