Acute Heart Failure

1
Acute Heart Failure

• Dilated
• Nonischemic/Familial dilated cardiomyopathy
• Myocardial ischemia
• Valvular disease
• Peripartum cardiomyopathy
• Toxin
• Non-dilated
• Myocarditis
• Myocardial ischemia
• Valvular disease
• Infiltrative cardiomyopathy
• Acute stress cardiomyopathy

2
Differential Diagnosis

• Ischemic heart disease
• Valvular heart disease
• Endocarditis
• Sepsis
• immunocompromised
• Unmasked cirrhotic cardiomyopathy
• Infiltrative cardiomyopathy

3
Clinical Assessment of Hemodynamic Status

• Congestion at Rest

Signs/Symptoms of Congestion Orthopnea / PND
Cough Dyspnea Elevated JVP Hepatomegaly
Edema Rales
NO
YES
A
B
NO
Low Perfusion at Rest
Warm Dry
Warm Wet
(Complex)
(Low Profile)
C
L
YES
Cold Dry
Cold Wet
Possible Evidence of Low
Perfusion Cool extremities/poor pulses
Hyponatremia Decreased mental status
Hypotension Narrow pulse pressure
Renal dysfunction
Nohria A et al., JAMA 2002
4
Hemodynamic Changes in Cirrhosis

• Increased cardiac output
• 9.0 3.0 l/min
• Decreased systemic vascular resistance
• 861 333 dynes-sec-cm-5
• Decreased mean arterial pressure
• 76 16 mmHg
• Normal wedge pressure
• 10 5

Dig Dis Sci 200954869
5
Cirrhotic Cardiomyopathy

• A form of chronic cardiac dysfunction in
  patients with cirrhosis, characterized by blunted
  contractile responsiveness to stress, and/or
  altered diastolic relaxation with
  electrophysiologic abnormalities in the absence
  of other known cardiac disease.

Gut 200857268
6
Differential Diagnosis

• Ischemic heart disease
• Valvular heart disease
• Sepsis
• Unmasked cirrhotic cardiomyopathy
• Infiltrative cardiomyopathy

7
Infiltrative Cardiomyopathy

• Amyloidosis
• Sarcoidosis
• Hemochromatosis

8
Iron Overload

• Hereditary Hemochromatosis
• C282Y homozygous
• C282Y/H63D compound heterozygote
• Secondary
• Anemia Transfusions
• Liver Disease
• Dietary iron overload

9
Porto-systemic Shunting

• Decrease in first-pass iron metabolism in the
  liver
• Increased duodenal iron absorption
• Although rare, case reports of shunts potentially
  leading to iron overload states including
  cardiomyopathy (1960s)

10
Diagnosis

• Progressive heart failure culminating in
  cardiogenic shock due to secondary
  hemochromatosis
• Potential contribution from cirrhotic
  cardiomyopathy