Acute Heart Failure.ppt

1、Acute Heart Failure,Dilated Nonischemic/Familial dilated cardiomyopathy Myocardial ischemia Valvular disease Peripartum cardiomyopathy ToxinNon-dilated Myocarditis Myocardial ischemia Valvular disease Infiltrative cardiomyopathy Acute stress cardiomyopathy,Differential Diagnosis,Ischemic heart disea

2、se Valvular heart disease Endocarditis Sepsis immunocompromised Unmasked cirrhotic cardiomyopathy Infiltrative cardiomyopathy,Clinical Assessment of Hemodynamic Status,Congestion at Rest,Signs/Symptoms of Congestion:Orthopnea / PNDCoughDyspneaElevated JVPHepatomegalyEdemaRales,Low Perfusion at Rest,

3、C,NO,NO,YES,YES,L,A,B,Warm & Dry,Warm & Wet,Cold & Wet,Cold & Dry,(Complex),(Low Profile),Possible Evidence of Low Perfusion:Cool extremities/poor pulses HyponatremiaDecreased mental status HypotensionNarrow pulse pressure Renal dysfunction,Nohria A et al., JAMA 2002,Hemodynamic Changes in Cirrhosis

4、,Increased cardiac output9.0 3.0 l/min Decreased systemic vascular resistance861 333 dynes-sec-cm-5 Decreased mean arterial pressure76 16 mmHg Normal wedge pressure10 5,Dig Dis Sci 2009;54:869,Cirrhotic Cardiomyopathy,“A form of chronic cardiac dysfunction in patients with cirrhosis, characterized b

5、y blunted contractile responsiveness to stress, and/or altered diastolic relaxation with electrophysiologic abnormalities in the absence of other known cardiac disease.”,Gut 2008;57:268,Differential Diagnosis,Ischemic heart disease Valvular heart disease Sepsis Unmasked cirrhotic cardiomyopathy Infi

6、ltrative cardiomyopathy,Infiltrative Cardiomyopathy,Amyloidosis Sarcoidosis Hemochromatosis,Iron Overload,Hereditary Hemochromatosis C282Y homozygous C282Y/H63D compound heterozygoteSecondary Anemia Transfusions Liver Disease Dietary iron overload,Porto-systemic Shunting,Decrease in first-pass iron

7、metabolism in the liver Increased duodenal iron absorption Although rare, case reports of shunts potentially leading to iron overload states including cardiomyopathy (1960s),Diagnosis,Progressive heart failure culminating in cardiogenic shock due to secondary hemochromatosisPotential contribution from “cirrhotic cardiomyopathy”,