ESC Guidelines for the ESC Guidelines for the Diagnosis and Treatment of Diagnosis and Treatment of Acute Heart Failure Acute Heart Failure Eur Heart J 2005;26:384-416 2005 1 ESC Guidelines on the Diagnosis and Treatment of Acute Heart Failure ESC Guidelines on the Diagnosis and Treatment of Acute Heart Failure
Task Force Members Task Force Members Markku S. Nieminen (Finland), MD, PhD, FESC Markku S. Nieminen (Finland), MD, PhD, FESC Chairperson Chairperson Kenneth Dickstein (Norway), MD, PhD, FESC Kenneth Dickstein (Norway), MD, PhD, FESC Co-author Co-author Michael Böhm, Germany José Lopez-Sendon, Spain José Lopez-Sendon, Spain Martin Cowie, UK Alexandre Mebazaa, France Alexandre Mebazaa, France Helmut Drexler, Germany Marco Metra, Italy Marco Metra, Italy Gerasimos S. Filippatos, Greece Andrew Rhodes, UK Andrew Rhodes, UK Guillaume Jondeau, France Karl Swedberg, Sweden, Karl Swedberg, Sweden, Yonathan Hasin, Israel 2 ESC Guidelines on the Diagnosis and Treatment of Acute Heart Failure ESC Guidelines on the Diagnosis and Treatment of Acute Heart Failure
3 ESC Guidelines on the Diagnosis and Treatment of Acute Heart Failure ESC Guidelines on the Diagnosis and Treatment of Acute Heart Failure
Contents Introduction Introduction Definition, aetiology and mechanisms Definition, aetiology and mechanisms Classifications Classifications Diagnostic algorithm Diagnostic algorithm Laboratory tests Laboratory tests Treatment goals Treatment goals Initial management Initial management Invasive monitoring Invasive monitoring Specific pharmacological treatments Specific pharmacological treatments • Diuretics • Diuretics • Vasodilators • Vasodilators • Inotropic agents • Inotropic agents Treatment of rhythm disturbances Treatment of rhythm disturbances Conditions requiring surgical management Conditions requiring surgical management 4 ESC Guidelines on the Diagnosis and Treatment of Acute Heart Failure ESC Guidelines on the Diagnosis and Treatment of Acute Heart Failure
Introduction AHF Guidelines: • provide an approach to diagnosis and treatment • describe the rationale for therapeutic decisions The recommendations prepared by the Acute Heart Failure Task Force were approved by the Committee for Practice Guidelines (CPG) of the ESC and the European Society of Intensive Care Medicine (ESICM). 5 ESC Guidelines on the Diagnosis and Treatment of Acute Heart Failure ESC Guidelines on the Diagnosis and Treatment of Acute Heart Failure
Classes of Recommendations Condition for which there is evidence and/or general agreement I that a given procedure or treatment is useful and effective Condition for which there is conflicting evidence and /or a divergence II of opinion about the usefulness / efficacy of a procedure or treatment IIa Weight of evidence /opinion is in favour of usefulness / efficacy IIb Usefulness/efficacy is less well established by evidence / opinion Evidence or general agreement that the treatment is not useful/effective III and in some cases may be harmful Levels of Evidence A Data derived from multiple randomised clinical trials or meta-analyses Data derived from a single randomised trial or large non-randomised B studies Consensus of opinion of experts and/or small studies, retrospective C studies , registries 6 ESC Guidelines on the Diagnosis and Treatment of Acute Heart Failure ESC Guidelines on the Diagnosis and Treatment of Acute Heart Failure
Definitions and Aetiology Definitions and Aetiology • AHF is defined as the rapid onset of • AHF is defined as the rapid onset of symptoms and signs, secondary to symptoms and signs, secondary to abnormal cardiac function abnormal cardiac function • Cardiac dysfunction can be related to • Cardiac dysfunction can be related to systolic or diastolic dysfunction, to systolic or diastolic dysfunction, to abnormalities in cardiac rhythm or to abnormalities in cardiac rhythm or to preload and afterload mismatch preload and afterload mismatch • It is often life threatening and • It is often life threatening and requires urgent treatment requires urgent treatment 7 ESC Guidelines on the Diagnosis and Treatment of Acute Heart Failure ESC Guidelines on the Diagnosis and Treatment of Acute Heart Failure
Definitions and Aetiology Definitions and Aetiology (1) Decompensation of chronic heart failure (2) Acute coronary syndromes (a) AMI / UAP / ischaemic dysfunction, (b) mechanical complications of AMI (c) right ventricular infarction (3) Hypertensive crisis (4) Acute arrhythmia (VT, VF, AF, SVT) 8 ESC Guidelines on the Diagnosis and Treatment of Acute Heart Failure ESC Guidelines on the Diagnosis and Treatment of Acute Heart Failure
Definitions and Aetiology Definitions and Aetiology (5) Cardiomyopathy and myocarditis (5) Cardiomyopathy and myocarditis (6) Valvular regurgitation (6) Valvular regurgitation (7) Aortic stenosis (7) Aortic stenosis (8) Acute myocarditis (8) Acute myocarditis (9) Cardiac tamponade (9) Cardiac tamponade (10) Aortic dissection (10) Aortic dissection (11) Post-partum cardiomyopathy (11) Post-partum cardiomyopathy 9 ESC Guidelines on the Diagnosis and Treatment of Acute Heart Failure ESC Guidelines on the Diagnosis and Treatment of Acute Heart Failure
Definitions and Aetiology Definitions and Aetiology (11) Non cardiovascular precipitating factors (11) Non cardiovascular precipitating factors (a) poor compliance for medical treatment (a) poor compliance for medical treatment (b) volume overload (b) volume overload (c) infections, especially pneumonia, septicaemia (c) infections, especially pneumonia, septicaemia (d) severe brain injury (d) severe brain injury (e) major surgery (e) major surgery (f) reduced renal function (f) reduced renal function (g) asthma (g) asthma (h) drug abuse (h) drug abuse (i) alcohol abuse (i) alcohol abuse (12) High output syndromes (12) High output syndromes (a) septicaemia (a) septicaemia (b) thyrotoxicosis (b) thyrotoxicosis (c) anaemia (c) anaemia (d) shunt syndromes (d) shunt syndromes 10 ESC Guidelines on the Diagnosis and Treatment of Acute Heart Failure ESC Guidelines on the Diagnosis and Treatment of Acute Heart Failure
Classification Classification Patients with AHF present Patients with AHF present with six distinct clinical with six distinct clinical conditions conditions 11 ESC Guidelines on the Diagnosis and Treatment of Acute Heart Failure ESC Guidelines on the Diagnosis and Treatment of Acute Heart Failure
Clinical Conditions Clinical Conditions Acute Acute AHF with pulmonary AHF with pulmonary decompensation of decompensation of oedema: severe oedema: severe CHF: Signs and CHF: Signs and respiratory distress with respiratory distress with symptoms are mild symptoms are mild rales over the lungs rales over the lungs • Heart rate +/- • Heart rate +/- • Heart rate + • Heart rate + • SBP +/- • SBP +/- • SBP +/- • SBP +/- • CI +/- • CI +/- • CI - • CI - • PCWP + • PCWP + • PCWP ++ • PCWP ++ • Diuresis + • Diuresis + • Diuresis + • Diuresis + • Hypoperfusion +/- • Hypoperfusion +/- • Hypoperfusion +/- • Hypoperfusion +/- 12 ESC Guidelines on the Diagnosis and Treatment of Acute Heart Failure ESC Guidelines on the Diagnosis and Treatment of Acute Heart Failure
Clinical Conditions Clinical Conditions Cardiogenic shock Cardiogenic shock Low output syndrome: Low output syndrome: Severe Cardiogenic Severe Cardiogenic reduced BP, low urine reduced BP, low urine shock: low BP, organ shock: low BP, organ output, tissue output, tissue hypoperfusion, anuria hypoperfusion, anuria hypoperfusion hypoperfusion • Heart rate ++ • Heart rate ++ • Heart rate + • Heart rate + • SBP -- • SBP -- • SBP - • SBP - • CI -- • CI -- • CI - • CI - • PCWP ++ • PCWP ++ • PCWP + • PCWP + • Diuresis -- • Diuresis -- • Diuresis - • Diuresis - • Hypoperfusion ++ • Hypoperfusion ++ • Hypoperfusion + • Hypoperfusion + 13 ESC Guidelines on the Diagnosis and Treatment of Acute Heart Failure ESC Guidelines on the Diagnosis and Treatment of Acute Heart Failure
Clinical Conditions Clinical Conditions Hypertensive AHF: Signs Hypertensive AHF: Signs and symptoms of AHF with and symptoms of AHF with high BP and preserved high BP and preserved LVEF LVEF • Heart rate + • Heart rate + • SBP ++ • SBP ++ • CI +/- • CI +/- • PCWP + • PCWP + • Diuresis +/- • Diuresis +/- • Hypoperfusion +/- • Hypoperfusion +/- 14 ESC Guidelines on the Diagnosis and Treatment of Acute Heart Failure ESC Guidelines on the Diagnosis and Treatment of Acute Heart Failure
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