Acute heart failure.

Heart failure is condition when heart is unable to pump enough blood to meet body demand
that’s mean heart can’t produce adequate cardiac output to meet the perfusion and oxygenation
requirements of the body’s tissues. Patient become shortness of breath, edema, fatigue, tachycardia,
and confused. Heart rate and respiratory rate will increase and patient becomes tachypnea and hypoxic
resulting from decrease blood supply to the body. Initial treatments to improved oxygenation are by
prop up the patient in a semi or high Fowler’s position then applying hi-flow mask oxygen. Aim of
achieving oxygen saturation of more than 95% in order to maximize tissue oxygenation and prevent end
organ dysfunction or multi organ failure. Elective ventilation using Noninvasive positive pressure
ventilator (Continuous Positive Airway Pressure [CPAP] or Bi-level Positive Airway Pressure [BIPAP])
should be consider early if necessary. It provides positive end expiratory pressure that means amount of
pressure above atmospheric pressure in the airway at the end of respiratory cycle. Advantage of NIV is it
will improve gas exchange, improve vital sign by decrease blood pressure, decrease pulse, increase spo2
and improve respiratory effort by decrease respiratory rate. This will reduce need for intubation. Then
endotracheal intubation and mechanical ventilation is necessary while oxygen saturation inadequate or
the patient develop respiratory muscle fatigue.

Overall, heart failure causes a decrease in cardiac output. Implement to improve cardiac output
is by reduce cardiac workload. Cardiac workload can be reduced by decrease preload and afterload.
Preload is volume of blood filled in the ventricle by the end of diastole. Too much preload will lead to
pulmonary edema and systemic venous congestion overload because heart can’t handle the excess
volume. Drug that affect preload include vasodilators and diuretics. Diuretics therapy (furosemide) will
reduced sodium and water retention and subsequently reduce cardiac workload. Nitroglycerin (NTG)
help to dilates the venous system, which causes more blood to remain in the peripheral circulation. This
will reduce preload, cardiac workload and blood pressure.

Afterload is the pressure to contraction of the cardiac muscle fiber to eject blood into systemic
circulation. Increase afterload will be inducing pain and anxiety, also increase blood pressure. ACE
inhibitors (captopril) will reduce vascular resistance and subsequently decrease cardiac workload. Beta
Blocker will help to control blood pressure.

Positive inotropic agents (digoxin, dopamine, dobutamine) will improve myocardial contractility
and increase cardiac output. Patient with improved cardiac output would be reflected by an
improvement in clinical condition, decrease in heart rate and improvement in his oxygen saturation.
Capillary refill time less than 3 second, absent giddiness, warm skin, blood pressure and pulse rate
return in normal range and good urine output.

If no improvement further management would depend upon blood pressure and tissue
perfusion. In presence of adequate blood pressure, frusemide and inotropes combination is more
effective. Vasodilators (sodium nitroprusside) would be useful in patient not responsive to nitrates.
Correction the acidosis and consider ventilation. Invasive hemodynamic monitoring include arterial
pressure line, central venous pressure and pulmonary artery catheter. This is more accurate assessment
of fluid status and allow better titration of medication. Intra-Aortic Balloon counterpulsation (IABP).
ventricular Assist Devices (VAD) useful in patient who recovery from AHF is expected or for whom heart
transplantation is an option.

Risk factor leading to heart failure is coronary artery disease (CAD) where the major blood vessel
supplies the heart muscle with blood and oxygen become narrow or disease leading to damage heart
muscle. Myocardial infarction or heart attack which the death heart muscle to the ischemic event.
Cigarette smoking, hypertension witch list to let ventricular hypertrophy witch made the harder to
oxygenate the heart muscle and leading ischemic damage to the heart muscle. Obesity and diabetes
which can be both to CAD. Heart valve disease (e.g. Aortic stenosis) let ventricular hypertrophy and
ischemic changes similar to hypertension. Cardiomyopathy or other name is heart muscle disease, for
example dilated cardiomyopathy leading heart ability to pump blood is decrease because heart main
pumping chamber the left ventricle is large associated with alcohol and environment infection.
Hypertrophic cardiomyopathy witch is associated with thickening of the heart muscle most commonly at
the septum between left and right ventricle. Restrictive cardiomyopathy with the condition is the wall of
the heart are abnormally rigid and lack flexibility to expand and ventricle fill with blood, associated with
amyloidosis, sarcoidosis, fibrosis.