Acute heart failure

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Sections available in full article Introduction, Acute presentation, Age predisposition, Breed predisposition, Cost considerations, Special risks (e.g. anesthetic), Pathogenesis, Etiology, Pathophysiology, Timecourse (incubation, duration), Diagnosis, Client history, Clinical signs, Diagnostic investigation, Gross autopsy findings, Histopathology findings, Differential diagnosis, Treatment, Initial symptomatic treatment, Monitoring, Subsequent management, Sequelae, Prognosis, Expected response to treatment, Reasons for treatment failure, Sources, Publications, Vetstream contributor(s),
Contributors Dr Barret Bulmer DVM MS DACVIM-Cardiology
Ms Josephine Dandrieux BVM&S MRCVS
Dr Mark Oyama DVM DACVIM-Cardiology
Synonyms Decompensated heart failure, acute decompensation

Introduction

  • Although many patients suffering from cardiovascular disease are identified during routine examination or present with mild clinical signs, a subset will present on an emergency basis with severe, life-threatening congestive heart failure.
  • These patients often require aggressive therapy and intensive monitoring to achieve a successful outcome.
  • Despite their critical status at presentation many will survive for prolonged periods if the acute episode is successfully managed.

Diagnosis

Clinical signs

  • Tachypnea and/or dyspnea.
  • Orthopnea.
  • Weakness and lethargy.
  • Tachycardia.
  • Prolonged capillary refill time.
  • Adventitious lung sounds in cases of fulminant pulmonary edema.
  • Cardiac auscultation.
    • Murmurs  Cardiac sounds: overview  :
      • Systolic, parasternal murmur common in cases of hypertrophic obstructive cardiomyopathy or right ventricular tract outflow obstruction.
    • Arrhythmias  Heart: dysrhythmia  :
      • Sinus tachycardia.
      • Supraventricular premature complexes  ECG: supraventricular premature complexes 01   ECG: supraventricular premature complexes 02  .
      • Ventricular arrhythmias.
      • Atrial fibrillation (rare as compared to dogs with advanced heart disease).
    • Gallops:
      • S4 gallop may be ausculted.
  • May have decreased femoral pulse quality.
  • May display jugular distension if right-sided heart failure is present (positive hepato-jugular reflex).
  • May have decreased lung sounds or an auscultable fluid line in cases of significant pleural effusion.
  • Ascites is relatively uncommon as compared to dogs with advanced heart disease.

Diagnosis

Differential diagnosis

  • Respiratory distress:
    • Pneumonia   Pneumonia  .
    • Pulmonary thromboembolism   Thromboembolism: aorta  .
    • Pneumothorax   Pneumothorax  .
    • Non-cardiogenic pleural effusion or alveolar infiltration, eg hemothorax, chylothorax   Chylothorax  .
    • Diaphragmatic hernia  Peritoneal-pericardial diaphragmatic hernia (PPDH)  .
    • Neoplasia   Pericardium: neoplasia - heartbase tumor  .
    • Coagulopathies   Disseminated intravascular coagulation  .

Sequelae

Prognosis

  • Guarded at time of acute presentation but long-term prognosis depends on response to therapy. Aggressive therapy has potential to save cats that were only minutes from dying.
  • Cats already intensively managed with numerous cardiovascular drugs that remain decompensated have a worse prognosis.

Expected response to treatment

  • As heart failure resolves patients often progress from orthopneic    →     resting sternally    →    sleeping.
  • Respiratory rate and effort improve quickly in response to oxygen supplementation and resolution of edema.
  • Thoracocentesis dramatically and immediately resolves respiratory distress if pleural effusion accounts for the respiratory impairment.
  • If no improvement in 24 hours, therapy should become more aggressive.

Reasons for treatment failure

  • Underlying cardiovascular disease was end stage.
  • Therapy was not aggressive enough.
  • Concurrent medical condition (ie renal failure).
  • Respiratory distress was unrelated to cardiovascular disease.

Sources

Publications

Refereed papers

  • Recent references fromPubMed.
  • Ferasin L (2009)Feline myocardial disease.1: Classification, pathophysiology and clinical presentation.J Feline Med Surg11, 3-13.
  • Schober K E, Maerz I (2006) Assessment of left atrial appendage flow velocity and its relation to spontaneous echocardiographic contrast in 89 cats with myocardial disease.J Vet Intern Med20(1), 120-130.
  • Cesta M F, Baty C J, Keene B Wet al(2005) Pathology of end-stage remodeling in a family of cats with hypertrophic cardiomyopathy.Vet Pathol42(4), 458-467PubMed.
  • Cote E, Manning A M, Emerson Det al(2004)Assessment of the prevalence of heart murmurs in overtly healthy cats.JAVMA225(3), 384-388PubMed.
  • Pion P D (2004) Traditional and nontraditional effective and noneffective therapies for cardiac disease in dogs and cats.Vet Clin North Am Small Anim Pract34(1), 187-216PubMed.
  • Baty C J (2004) Feline hypertrophic cardiomyopathy: an update.Vet Clin North Am Small Anim Pract34(5), 1227-1234PubMed.
  • Rush J E, Freeman L M, Fenollosa N K, Brown D J (2002) Population and survival characteristics of cats with hypertrophic cardiomyopathy: 260 cases (1990-1999).JAVMA220(2), 202-207PubMed.

Other sources of information

  • Bryn TennantSmall Animal Formulary(2002) 4th edn. BSAVA. pp 211-212.
  • Kittleson M (2000)Therapy of heart failure.In:Textbook of Veterinary Internal Medicine.5th edn. Ed S J F E Ettinger. Philadelphia: WB Saunders Company. pp 713-737.
  • Sisson D & Kittleson M (1999)Management of Heart Failure: Principles of Treatment, Therapeutic Strategies, and Pharmacology.In:Textbook of Canine and Feline Cardiology: Principles and Clinical Practice. 2nd edn. Eds P R Fox, D Sisson and N S Moise. Philadelphia: WB Saunders. pp 216-250.

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