Acute Decompensated Heart Failure

[Mr. Nine]

Acute decompensated heart failure represents a heterogeneous group of
disorders that typically present as dyspnea,
edema and fatigue. Despite the high prevalence of this condition and
its associated major morbidity and mortality, diagnosis can be
difficult, and optimal treatment remains poorly defined.
Identification of the acute triggers for the decompensation as well as
noninvasive characterization of cardiac filling pressures and output
is central to management. Diuretics, vasodilators, continuous positive
airway pressure andinotropes can be used to alleviate symptoms.

CMAJ 2007;176(6):797-805


Acute decompensated heart failure (ADHF) accounts for almost one
million hospitalizations per year, and rehospitalization within six
months is as high as 50%. The annual mortality rate in patients
frequently hospitalized with ADHF—those with New York Heart
Association class III or IV symptoms—approaches 50%. While ADHF was
traditionally viewed as a disorder associated with sodium and water
retention and left-ventricular dysfunction, it is now understood to
beassociated with neurohormonal activation.

Proposed causes of acute decompensated heart failure due to left
ventricular dysfunction
Primary cardiac
• Progressive cardiomyopathy with remodelling
• Acute cardiomyopathy (myocarditis, postpartum cardiomyopathy)
• Myocardial ischemia
• Arrhythmia (tachy- or bradyarrhythmia)
• Valvular dysfunction (stenosis or regurgitation)
• Pericardial syndrome (tamponade, constriction)
Pressure overload
• Hypertensive urgency or emergency
Volume overload
• Sodium or volume load
• Decreased compliance with diuretics
• Renal dysfunction
• Hepatic dysfunction
High output
• Shunt (intra- or extracardiac)
• Anemia
• Septicemia
• Thyroid disease
Other
• Inflammation or infection
• Major surgery
• Lack of compliance with heart failure medications
• New medications (excess β-blockade)
• Substance abuse (alcohol, stimulants)

ADHF: Signs and Symptoms

Fluid Overload
Weight gain
Dyspnea on exertion
Paroxysmal nocturnal dyspnea (PND)
Orthopnea
Rales
Peripheral edema
Jugular venous distension
Ascites
Hepato-/splenomegaly
Low Cardiac Output
Fatigue
Nausea and vomiting
Early satiety
Weight loss
Increased serum creatinine

Disgnosis

The rapid diagnosis of acute decompensated heart failure is necessary
to initiate appropriate treatment. Unfortunately, the signs and
symptoms of acute decompensated heart failure often overlap with those
of other common medical conditions, particularly chronic obstructive
pulmonary disease.
In addition, because of the heterogeneous nature of acute
decompensated heart failure, no single finding is perfect
for diagnosis.

Tests that may help in the diagnosis and treatment of acute
decompensated heart failure
• Chest radiography
• Electrocardiography
• Measurement of B-type natriuretic peptide and N-terminal B-type
natriuretic peptide levels
• Other laboratory tests (complete blood count, renal function tests,
measurement of electrolyte levels, glucose level, transaminase levels,
prothrombin time, troponin level, D-dimer level and arterial blood gas
pressure, thyroid function tests and urinalysis)
• Transthoracic echocardiography
• Central venous line or pulmonary artery catheter

Treatment

The last 2 decades have seen the successful development of a number of
therapies for chronic systolic dysfunction. Angiotensin- converting-
enzyme (ACE) inhibitors, angiotensin II receptor blockers, β-blockers,
aldosterone antagonists, implantable cardioverter defibrillators and
cardiac resynchronization therapy have all been shown in large,
prospective, randomized controlled trials to reduce morbidity and
mortality among patients with stable congestive heart failure and
reduced left ventricular ejection fraction. Unfortunately,the same
success has not been seen in the treatment of acute decompensated
heart failure.

[အာကာ လြင္]

Plse explain me if u free,
...why it is associated with neurohormonal activation ?
...what effect and mechanism of excess beta blocker on this disease ?
....why present as a heterogenous group disorder ? can present as a homogenous?

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[Mr. Nine]

Dear Doctor, Thank you for your discussion. Firstly, I would like to
apologize you for my late reply, because I was very very busy these
days.


(1) Neuro hormonal Hypothesis

[ ↓ LV function >> ↓ Cardiac output >> ↑ Neurohormone activation -
RAAS, SNS, AVP, BNP, ET-1, TNF-α, IL-6 >> ↑ Salt and water retention
>> ↑ Impedance >> again ↓ LV function ] >> ↑ Progressive heart failure
(HF)

RAAS = renin-angiotensin-aldosterone system;
SNS = sympathetic nervous system; AVP = arginine vasopressin; BNP = B-
type natriuretic peptide;
ET-1 = endothelin-1; TNF-α = tissue necrotizing factor α;
IL-6 = interleukin-6; LV = left ventricular


(2) Effect & mechanism of excess beta blocker on ADHF

B-blockers are stopped or decreased in people with a low BP. However
continuation of B-blockers if the blood pressure is adequate is
appropriate.
Long-term treatment with β-blockers in patients with HF decreases the
circulating levels of vasoconstrictors such as norepinephrine, renin,
endothelin, and proinflammatory cytokines and may upregulate
myocardial β-1-receptor density , which in turn may help restore the
inotropic and chronotropic responsiveness of the myocardium. β-Blocker
use also decreases mortality and rehospitalization rates. Excess of B-
blockers may lead to myocardial hyperresponsiveness which lead to
Acute Decompemsation on chronic heart failure.
But, beta-blockers improve the impaired cardiac autonomic regulation
during high sympathetic stress of decompensated heart failure. (Int J
Cardiol. 2001 Jun;79(1):31-9.)


(3) It can't present as homogenous disorder, because it is not a
particular disease, it is a complicaton of many diseases. So it
present as heterogenous group of disorders which present with symptom
complexes. And, due to the heterogeneous nature of acute decompensated
heart failure, no single finding is perfect for diagnosis, and
instead, a broad array of signs and symptoms are associated with the
condition.

regards,
feedback and comments are warmly welcome :)
yours sincerely