Acute Heart Failure (2^nd Ed., 2nd ed. 2017) Putting the Puzzle of Pathophysiology and Evidence Together in Daily Practice

Acute heart failure is a potentially life threatening situation where correct, rapid therapy can save lives. Information from the latest research and studies has been used to update this text to bring the latest understanding of the pathophysiology together with a practical guide to diagnosis and management using an evidenced based approach.

Since the first edition of Acute Heart Failure, this research has brought to light three important issues to be integrated into a second edition. First, the so-called ?vascular heart failure? has been identified as a common and decisive mechanism provoking acute heart failure due to the coupling and interaction between the heart (right and left heart) and the large vessel systems (aorta and pulmonary artery). Second, the interaction and cross-talk between heart and kidneys, the so-called ?cardiorenal syndrome? has been identified as another feature of acute heart failure syndromes. Third, we have new knowledge and updated points of views about the development of pulmonary hypertension in patients suffering from heart failure, the group 2 of the classification system of pulmonary hypertension. These are all covered in this second edition.

This revision to a seminal text is a valuable addition to any practitioner who treats patients with acute heart failure and wants a deeper understanding of the condition.

1         Cardiac physiology of acute heart failure syndromes

    1.1 Cardiac performance

    1.2 The fundamental equation of the circulation

    1.3 Preload

           a) Definition

           b) Frank–Starling mechanism

           c) Venous return and CVP in daily practice

     1.4 Haemodynamic monitoring

           a) Assessment and monitoring of fluid status

           b) Prediction of fluid responsiveness

                i) Pressure measurements

                ii) Volumetric measurements

                iii) Dynamic parameters

                iv) Fluid challenge

                v) PiCCO-monitoring

                vi) Echocardiography

           c) Arterial blood pressure

                 i) BP and autoregulation

                 ii) Assessment of tissue perfusion

           a) Definition

           b) Vascular properties, effective arterial elastance, wall stress and the law of LaPlace

           c) Afterload mismatch and acute heart failure syndromes

1.6 Contractility

           a) Definition

           c) Inotropic medications

1.7 Heart rate and contractility  

1.8 Diastolic ventricular interaction/interdependance (DVI)  

       a) Definition  

       b) Septum and trans-septal pressure  

       c) Pericardium  

       d) Pulmonary hypertension and the risk of DVI                 

       e) Acutely exacerbated chronic congestive (left-sided or biventricular) HF  

       f) Conclusions

1.9 Ventriculo-arterial coupling

       a) Definition

       b) Arterial elastance

       c) Ventricular elastance

       e) Deranged coupling

1.10 Myocardial and chamber stiffness

1.11 Evaluation and assessment of cardiac performance

1.12 Summary

      a) Key physiology

      b) Afterload

      c) Systolic function

      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

       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

         i)  Treatment of underlying  diseases

         ii)  Common basic measures

         iii)  Typical and specific measures

-          Diuretics and ultrafiltration

-          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

    iv)   Pulmonary hypertension and RV dysfunction, DVI

    v)    Ventricular dys-synchrony

    vi)   Left atrial dysfunction

    vii)  Peripheral factors   

a)       Symptoms and signs of heart failure

c)       Diastolic dysfunction, structural changes and bio-markers

ii)    Functional and structural alterations

iii)   E/e`ratio

iv)   Inconclusive E/e`ratio - surrogate markers

v)    Invasively derived parameters  

5.6     Therapy

6   Pulmonary hypertension (PH) in left heart disease (LHD - PH)

1.          Definition

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 

Evidence-based review of the pathophysiology, diagnosis, and therapy of acute heart failure syndromes

Designed for easy use in everyday clinical practice, an introduction into the topic

Designed to satisfy the need of Acute Medicine/the Heart Team concept

Contains extensive references, allowing the reader to easily refer to the original experimental studies