![]() ![]() diuretic nonadherence, iatrogenic fluid administration)? Weight gain or loss? gastroenteritis, over-diuresis) or volume gain (e.g. ![]() Clinical history can be very useful here: is there a history of volume loss (e.g.Alternatively, patients with marked peripheral edema and systemic congestion often have some degree of right ventricular dysfunction (often combined with left ventricular dysfunction). Note that it's possible for patients to have an elevated pulmonary capillary wedge pressure without total body volume overload (e.g., euvolemia plus an acutely deteriorating left ventricle).Total body volume status (systemic congestion).Ultrasonography is more sensitive than chest X-ray or exam to detect mild cardiogenic pulmonary edema. Bilateral diffuse B-lines imply elevated wedge pressure, whereas bilateral A-lines suggest a low or normal wedge pressure. The best test to determine wedge pressure is lung ultrasonography.High wedge pressure is suggested by pulmonary edema (dyspnea, edema on chest X-ray, and B-lines on lung ultrasound).Pulmonary capillary wedge pressure (pulmonary congestion).However, shock index may be insensitive in the presence of negative chronotropic medications (e.g., beta-blockers) or conduction system disease. Elevated shock index (heart rate divided by systolic blood pressure) above ~0.8 is concerning for impending or present shock.For example, some patients in occult cardiogenic shock may have normal mentation despite malperfusion of other organs (e.g. Normal mentation doesn't prove that perfusion is adequate, as some patients with cardiogenic shock may have preserved mentation until very late in the disease process.Some comments on various findings are included below. Noninvasive hemodynamic assessment is essential for the initial diagnosis and management of cardiogenic shock (table above).Hemodynamic evaluation & risk stratification Less common types of heart failure with unique physiology (e.g., acute valvular regurgitation, hypertrophic cardiomyopathy, dynamic LV outflow tract obstruction □).□ However, many patients with LV failure also have some RV failure as well (i.e., biventricular failure) – such patients are included in this chapter. Isolated right ventricular failure (cor pulmonale) – this requires a unique approach.However, the chapter on SCAPE will be more clinically applicable to that scenario. □ The basic principles in this chapter will apply to SCAPE. SCAPE (Sympathetic Crashing Acute Pulmonary Edema), a distinct form of rapid-onset heart failure which is associated with hypertension.Patients with severe heart failure may go in and out of cardiogenic shock, depending on their management.Cardiogenic shock isn't necessarily a discrete entity, but rather may be conceptualized as the most severe form of heart failure.LV failure spans a spectrum of severity which ranges from mild heart failure decompensation to frank cardiogenic shock.Any beta-blocker or calcium-channel blocker (e.g., diltiazem) in a patient with cardiogenic shock.Initiation of beta-blocker in decompensated heart failure.Nephrotoxins (e.g., NSAIDs, ACE-inhibitors, angiotensin receptor blockers).Consider for persistent organ failure – device of choice is patient/institution specific.Ischemic cardiomyopathy: Revascularization, treatment for acute MI if present.Bradycardia or inappropriately slow heart rate: treat.New-onset tachyarrhythmia causing heart failure: cardioversion, antiarrhythmics.Note: Digoxin may be considered as a weak inotropic agent in patients with chronic AF, HFrEF, and refractory heart failure.(b) Refractory cardiogenic pulmonary edema in hypotensive patient.(a) Normotensive patient with organ hypoperfusion.Diuresis if: significant systemic/pulmonary congestion, assessment suggests total body volume overload.Ĥ) consider dobutamine in HFrEF if either: □.Fluid challenge if: hypoperfusion, no pulmonary congestion (no B-lines on ultrasound), assessment suggests total body hypovolemia.(Epinephrine is another option in HFrEF with hypoperfusion). Hypotension (severe or w/ organ dysfunction) ➡️ Norepinephrine.HTN/normotension ➡️ Afterload reduction (Nitroglycerine infusion, or hydralazine 37.5 mg & isosorbide dinitrate 20 mg q6hr).Consider inhaled epoprostenol for intubated patient with right ventricular failure or pulmonary hypertension.Large effusion(s) may be drained if causing acute distress.Consider BiPAP (vs intubation) in cardiogenic pulmonary edema.TSH and/or digoxin level depending on context.Troponin, Lactate, liver function tests if shock is suspected.Rapid reference: severe heart failure & cardiogenic shock ![]()
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