Swollen
Answer: B
This woman is suffering from heart failure – most likely from diastolic dysfunction – given her risk factors of gender, history of diabetes, and long-standing poorly controlled hypertension which has resulted in left ventricular hypertrophy and poor diastolic filling.
In the 2013 update on heart failure, the American Heart Association estimated that 23 million people worldwide have heart failure (5 million of whom live in the US). With an ageing population and focus on new therapies, presentations to the ED are expected to rise steadily. Currently more than one million hospitalizations occur annually in the US, and these patients are particularly fragile: the all-cause re-hospitalization rate at one month in heart failure patients is 25%. The total cost of care for these patients in the US alone was over $40 billion annually as of 2010.
Emergency physicians are charged with identifying patients at risk, those without a previous diagnosis, and those with worsening signs and symptoms of heart failure:
Evidence of volume overload
Orthopnea
Elevated jugular venous pressure
Increasing S3
Edema
Ascites
Rales
Abdominojugular reflux
Evidence of poor perfusion
Narrow pulse pressure
Pulsus alternans
Cool forearms and legs
Marked sleepiness or frank obtundation
Symptomatic hypotension
Declining serum sodium level
Worsening renal function
In general, there are four main presentations of heart failure, characterized by volume status and perfusion. A review of the acute phase of treatment for each:
Warm and Dry: these patients are euvolemic, have good perfusion, and have mild if any symptoms. The focus here is on long-term prevention of exacerbations, diet control, medication adherence, and follow up.
Warm and Wet: these patients are volume overloaded, but have good systemic perfusion. As they are hemodynamically stable, the focus is on steadily “drying them out” with diuretics. These patients often benefit initially from a vasodilator such as nitroglycerin (a study from the ADHERE registry suggests a decrease in mortality and hospital stay if nitrates are given with six hours of admission). Admission depends on a number of factors, included evidence of pulmonary edema, anasarca, poorly controlled comorbidities, and practicalities such as the social situation.
Cold and Wet: despite the volume overload, these patients have poor perfusion. To make any headway, it is necessary to “warm them up to dry them out”. Improvement of perfusion with vasodilators such as nitroglycerin and nitroprusside (and potentially ionotropes such as dobutamine and milrinone with or without vasopressor support) is initiated before diuretics are given. It is important to hold drugs such as β-blockers and ACE inhibitors
on these patients until their hemodynamic status is much improved.
Cold and Dry: this is a less common presentation – the patient with low cardiac output without evidence of elevated filling pressures. These patients are the most difficult to remedy acutely and often need inpatient monitoring and careful stabilization and adjustment and optimization of medications over days.
Squeeze problem or filling problem?
All of the myriad causes of heart failure boil down to whether the end-systolic ejection fraction is preserved or not.
Systolic dysfunction and heart failure (also called heart failure with reduced ejection fraction, HFrEF) is due to loss of myocardium and/or left ventricular enlargement (EF ≤35 to 40%). Although many risk factors exist, ischemic disease is the most prevalent. Many of the typical therapies for HFrEF have shown to decrease either morbidity, mortality, or both.
Diastolic dysfunction and heart failure (also called heart failure with preserved ejection fraction, HFpEF) is due to a hypertrophic or stiff left ventricle (EF is usually normal or may be slightly increased). Although there are many causes of a hypertrophic or stiff left ventricle causing poor filling, the most prevalent is poorly controlled hypertension. Unfortunately, many therapies that reduce morbidity or mortality in systolic failure have not been shown to do so in diastolic failure. Strict control of the underlying process (again, usually hypertension)
and treating symptoms are the goal.
Other acute therapies (less common, off-the-beaten-path, or under investigation) for heart failure
Ultrafiltration or dialysis – for volume overloaded patients refractory to diuretics. Small trials suggest greater fluid removal and less hospital readmissions at 90 days.
Vasopressin Receptor Antagonists – vasopressin can cause hyponatremia and fluid retention; there is a suggestion that use of antagonists may be beneficial by avoiding the neurohormonal effects which may be seen in some loop diuretics.
Relaxin – a naturally occurring peptide, it plays a role in the hemodynamic adaptive changes in pregnancy. Currently there are pilot studies addressing its potential in arterial compliance via nitric oxide release
Calcium Sensitizers – a new category of ionotrope with an affinity for troponin C, it increases contractility without
increasing epinephrine or norepinephrine levels. It has, however, shown lackluster performance in trials to date.
Drugs to Avoid in Heart Failure
Non-steroidal anti-inflammatory drugs (NSAIDs): associated with an increased risk of renal dysfunction (sodium retention, inhibition of diuretic effect) and heart failure exacerbation (aspirin for ischemic disease has a better risk:benefit)
Thiazolidinedione (the diabetic glitazones): can cause fluid retention
Metformin: hold in exacerbations – increased risk of metabolic acidosis
Other Drug Issues in Heart Failure
Warfarin and digoxin can readily become supertherapeutic in heart failure.
Amiodarone may be a safer (less pro-arrythmogenic) than most agents for ventricular arrhythmias in heart failure.
Summary
Presentations:
Warm and Dry – optimize outpatient therapy, focus on maintenance of health and prevention of exacerbation (and congratulate them!)
Warm and Wet – diuretics, vasodilators
Cold and Wet – (“warm ‘em up before you dry ‘em out!) ionotropes, vasodilators, then when perfusing better,
diuretics
Cold and Dry – careful, titrated use of ionotropes, vasodilators
Classifications:
Systolic heart failure – more common in men, history of MI (loss of heart muscle and/or dilated cardiomyopathy, poor squeeze --> low ejection fraction)
Diastolic heart failure – more common in women, long-standing hypertension (hypertrophic/stiff ventricle, poor
diastolic filling --> normal or slightly higher ejection fraction)
References
Chatterjee K, Massie B. Systolic and Diastolic Heart Failure: Differences and Similarities. J Cardiac Fail.
2007;13:569e576.
Nohria A, Lewis E, Stevenson LW. Medical Management of Advanced Heart Failure. JAMA. 2002;287(5):628-640.
Pirracchio R, Cholley B, De Hert S, Sola AC, Mebazaa A. Diastolic heart failure in anaesthesia and critical care. Brit J Anaesth. 2007; 98(6):707–21.
Yancy CW, Jessup M, Bozkurt B, Masoudi FA, Butler J, McBride PE, Casey DE Jr, McMurray JJ, Drazner MH, Mitchell JE, Fonarow GC, Peterson PN, Geraci SA, Horwich T, Januzzi JL, Johnson MR, Kasper EK, Levy WC, Riegel B, Sam F, Stevenson LW, Tang WH, Tsai EJ, Wilkoff BL; ACCF/AHA Task Force Members. 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013
Jun 5. pii: S0735-1097(13)02114-1. doi: 10.1016/j.jacc.2013.05.019. [Epub ahead of print]
This woman is suffering from heart failure – most likely from diastolic dysfunction – given her risk factors of gender, history of diabetes, and long-standing poorly controlled hypertension which has resulted in left ventricular hypertrophy and poor diastolic filling.
In the 2013 update on heart failure, the American Heart Association estimated that 23 million people worldwide have heart failure (5 million of whom live in the US). With an ageing population and focus on new therapies, presentations to the ED are expected to rise steadily. Currently more than one million hospitalizations occur annually in the US, and these patients are particularly fragile: the all-cause re-hospitalization rate at one month in heart failure patients is 25%. The total cost of care for these patients in the US alone was over $40 billion annually as of 2010.
Emergency physicians are charged with identifying patients at risk, those without a previous diagnosis, and those with worsening signs and symptoms of heart failure:
Evidence of volume overload
Orthopnea
Elevated jugular venous pressure
Increasing S3
Edema
Ascites
Rales
Abdominojugular reflux
Evidence of poor perfusion
Narrow pulse pressure
Pulsus alternans
Cool forearms and legs
Marked sleepiness or frank obtundation
Symptomatic hypotension
Declining serum sodium level
Worsening renal function
In general, there are four main presentations of heart failure, characterized by volume status and perfusion. A review of the acute phase of treatment for each:
Warm and Dry: these patients are euvolemic, have good perfusion, and have mild if any symptoms. The focus here is on long-term prevention of exacerbations, diet control, medication adherence, and follow up.
Warm and Wet: these patients are volume overloaded, but have good systemic perfusion. As they are hemodynamically stable, the focus is on steadily “drying them out” with diuretics. These patients often benefit initially from a vasodilator such as nitroglycerin (a study from the ADHERE registry suggests a decrease in mortality and hospital stay if nitrates are given with six hours of admission). Admission depends on a number of factors, included evidence of pulmonary edema, anasarca, poorly controlled comorbidities, and practicalities such as the social situation.
Cold and Wet: despite the volume overload, these patients have poor perfusion. To make any headway, it is necessary to “warm them up to dry them out”. Improvement of perfusion with vasodilators such as nitroglycerin and nitroprusside (and potentially ionotropes such as dobutamine and milrinone with or without vasopressor support) is initiated before diuretics are given. It is important to hold drugs such as β-blockers and ACE inhibitors
on these patients until their hemodynamic status is much improved.
Cold and Dry: this is a less common presentation – the patient with low cardiac output without evidence of elevated filling pressures. These patients are the most difficult to remedy acutely and often need inpatient monitoring and careful stabilization and adjustment and optimization of medications over days.
Squeeze problem or filling problem?
All of the myriad causes of heart failure boil down to whether the end-systolic ejection fraction is preserved or not.
Systolic dysfunction and heart failure (also called heart failure with reduced ejection fraction, HFrEF) is due to loss of myocardium and/or left ventricular enlargement (EF ≤35 to 40%). Although many risk factors exist, ischemic disease is the most prevalent. Many of the typical therapies for HFrEF have shown to decrease either morbidity, mortality, or both.
Diastolic dysfunction and heart failure (also called heart failure with preserved ejection fraction, HFpEF) is due to a hypertrophic or stiff left ventricle (EF is usually normal or may be slightly increased). Although there are many causes of a hypertrophic or stiff left ventricle causing poor filling, the most prevalent is poorly controlled hypertension. Unfortunately, many therapies that reduce morbidity or mortality in systolic failure have not been shown to do so in diastolic failure. Strict control of the underlying process (again, usually hypertension)
and treating symptoms are the goal.
Other acute therapies (less common, off-the-beaten-path, or under investigation) for heart failure
Ultrafiltration or dialysis – for volume overloaded patients refractory to diuretics. Small trials suggest greater fluid removal and less hospital readmissions at 90 days.
Vasopressin Receptor Antagonists – vasopressin can cause hyponatremia and fluid retention; there is a suggestion that use of antagonists may be beneficial by avoiding the neurohormonal effects which may be seen in some loop diuretics.
Relaxin – a naturally occurring peptide, it plays a role in the hemodynamic adaptive changes in pregnancy. Currently there are pilot studies addressing its potential in arterial compliance via nitric oxide release
Calcium Sensitizers – a new category of ionotrope with an affinity for troponin C, it increases contractility without
increasing epinephrine or norepinephrine levels. It has, however, shown lackluster performance in trials to date.
Drugs to Avoid in Heart Failure
Non-steroidal anti-inflammatory drugs (NSAIDs): associated with an increased risk of renal dysfunction (sodium retention, inhibition of diuretic effect) and heart failure exacerbation (aspirin for ischemic disease has a better risk:benefit)
Thiazolidinedione (the diabetic glitazones): can cause fluid retention
Metformin: hold in exacerbations – increased risk of metabolic acidosis
Other Drug Issues in Heart Failure
Warfarin and digoxin can readily become supertherapeutic in heart failure.
Amiodarone may be a safer (less pro-arrythmogenic) than most agents for ventricular arrhythmias in heart failure.
Summary
Presentations:
Warm and Dry – optimize outpatient therapy, focus on maintenance of health and prevention of exacerbation (and congratulate them!)
Warm and Wet – diuretics, vasodilators
Cold and Wet – (“warm ‘em up before you dry ‘em out!) ionotropes, vasodilators, then when perfusing better,
diuretics
Cold and Dry – careful, titrated use of ionotropes, vasodilators
Classifications:
Systolic heart failure – more common in men, history of MI (loss of heart muscle and/or dilated cardiomyopathy, poor squeeze --> low ejection fraction)
Diastolic heart failure – more common in women, long-standing hypertension (hypertrophic/stiff ventricle, poor
diastolic filling --> normal or slightly higher ejection fraction)
References
Chatterjee K, Massie B. Systolic and Diastolic Heart Failure: Differences and Similarities. J Cardiac Fail.
2007;13:569e576.
Nohria A, Lewis E, Stevenson LW. Medical Management of Advanced Heart Failure. JAMA. 2002;287(5):628-640.
Pirracchio R, Cholley B, De Hert S, Sola AC, Mebazaa A. Diastolic heart failure in anaesthesia and critical care. Brit J Anaesth. 2007; 98(6):707–21.
Yancy CW, Jessup M, Bozkurt B, Masoudi FA, Butler J, McBride PE, Casey DE Jr, McMurray JJ, Drazner MH, Mitchell JE, Fonarow GC, Peterson PN, Geraci SA, Horwich T, Januzzi JL, Johnson MR, Kasper EK, Levy WC, Riegel B, Sam F, Stevenson LW, Tang WH, Tsai EJ, Wilkoff BL; ACCF/AHA Task Force Members. 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013
Jun 5. pii: S0735-1097(13)02114-1. doi: 10.1016/j.jacc.2013.05.019. [Epub ahead of print]