Current Updates on Breathing Difficulty :

Current Management of Cardiogenic

Dyspnea
Focused on Acute Heart Failure
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Acute Dyspnea in Emergency

Kelly et.al., Academic Emergency Medicine 2016

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Acute Heart Failure

▪ Rapid onset or worsening of symptoms and/or
signs of HF.

▪ It is a life-threatening medical condition

requiring urgent evaluation and treatment,
typically leading to urgent hospital admission.

▪ De novo ; exacerbation of preexisting HF

(Acute Decompensated HF)

▪ Have precipitant/triggering factors

Ponikowski P., Voors A.A., et.al European Heart Journal

2016
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Acute Heart Failure : ESC 2016 Guideline

updated
▪ the concept of an early initiation of appropriate therapy going along with relevant
investigations in acute HF that follows the ‘time to therapy’ approach already well
established in acute coronary syndrome (ACS)

▪ a new diagnosis algorithm for combined diagnosis and treatment approach for AHF
based on presence /and absence of congestion

Ponikowski P., Voors A.A., et.al European Heart Journal

2016
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AHF in ED, what are the challenges ?

▪ Establishing diagnosis using limited data

▪ Risk stratification for major cardiac events

▪ Fast decision making 🡪 what therapy and intervention must be give to the patient
🡪 hemodynamic stabilization

Wientraub et.al., Circulation

2010
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AHF Diagnosis in ED

ECG
Phys exam
Chest X
Ray

Anamnesis Laboratorium

Five fingers BNP >100 pg/ml

diagnostic
tools NT-Pro BNP >300
pg/ml

Procalcitonin
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AHF Diagnosis in ED

▪
▪
Normal A Line and seashore sign B line : pulmonary edema
▪

Normal A line lung and seashore sign

Liechtenstein D.A., Meziere G.A., CHEST Journal

2008
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Risk Stratification of AHF

▪ Early detection of circulatory and
respiratory support.

▪ Find the triggering factor that most

likely can cause SCD (Sudden
Cardiac Death)

Ponikowski P., Voors A.A., et.al European Heart Journal

2016
A. Laki-laki 56 th sesak nafas tiba-tiba 3 jam SMRS, TD 190/100
HR 120 x/menit RR 30x/menit Sp.O2 94 %, rales (+) bilateral,
edema perifer (-), nadi kuat (+) akral hangat (+).

B. Wanita 70 th sesak memberat 3 hari, somnolent, TD 80/60 HR

110 x/menit, RR 28 x/menit Sp.O2 90%, rales +/+, edema perifer
(+), akral dingin

C. Laki-laki 65 th sesak memberat 1 minggu TD 130/70, HR 80

x/menit, RR 26 x/menit, SpO2 98% rales (-) edema perifer (-),
sebah (+)
D. Wanita 67 th sesak 1 hari, TD 70/50 mmHg HR 110 x/menit
RR 30 x/menit SpO2 89 % rales (-), edema (-) akral dingin (+)
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Initial Management of AHF in ED

▪ Concurrent diagnostic and management approach based on hemodinamic profiles

▪ Early detection of trigger factor with high probability SCD and apply spesific guideline.
Examples : ACS  revascularization, arrhythmia  electrical cardioversion,

Forrester classification in AHF

Ponikowski P., Voors A.A., et.al European Heart Journal 2016

Forrester JS.,Diamond GA,. Swan HJ., Am J Cardiol 1977

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Wet and Warm

▪ Fluid redistribution vs Fluid overload

▪ Fluid status assessment

▪ Vasodilator optimalisation in fluid redistribution

▪ Diuretic and ultrafiltration in fluid accumulation

Ponikowski P., Voors A.A., et.al European Heart Journal

2016
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Diuretic strategy in AHF : high dose vs low dose, bolus vs cont drip

Felker et al., NEJM 2011

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Diuretic strategy in AHF : high dose vs low dose, bolus vs cont drip

Felker et al., NEJM 2011

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Diuretic strategy in AHF

Ponikowski P., Voors A.A., et.al European Heart Journal 2016

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Vasodilator in AHF

Ponikowski P., Voors A.A., et.al European Heart Journal

2016
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Wet and Cold Dry and Cold

Ponikowski P., Voors A.A., et.al European Heart Journal 2016

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Cardiogenic Shock

Ponikowski P., Voors A.A., et.al European Heart Journal 2016

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Inotropic and Vasopressor

Ponikowski P., Voors A.A., et.al European Heart Journal 2016

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Inotropic and Vasopressor

▪ Have detrimental effects such as proarrhythmia,

vasocontriction 🡪 high afterload 🡪 decrease cardiac output
(in very severe heart failure)

▪ Must be used cautiously with target to resolved

hypoperfusion.

▪ Once hypoperfusion had achieved, inotropic and vasopressor

must be tappering off.
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Dry and Warm

Ponikowski P., Voors A.A., et.al European Heart Journal 2016

A. Laki-laki 56 th sesak nafas tiba-tiba 3 jam SMRS, TD 190/100
HR 120 x/menit RR 30x/menit Sp.O2 94 %, rales (+) bilateral,
edema perifer (-), nadi kuat (+) akral hangat (+).

B. Wanita 70 th sesak memberat 3 hari, somnolent, TD 80/60 HR

110 x/menit, RR 28 x/menit Sp.O2 90%, rales +/+, edema perifer
(+), akral dingin

C. Laki-laki 65 th sesak memberat 1 minggu TD 130/70, HR 80

x/menit, RR 26 x/menit, SpO2 98% rales (-) edema perifer (-),
sebah (+)
D. Wanita 67 th sesak 1 hari, TD 70/50 mmHg HR 110 x/menit
RR 30 x/menit SpO2 89 % rales (-), edema (-) akral dingin (+)
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