Vancouver IM LMR

In this case we review a 78 year old man with HFrEF (EF 34%) from ischemic cardiomyopathy, CRT-D, and CKD who presents with shortness of breath. He is hypoxemic and hypertensive on exam. He has evidence of diffuse cardiogenic pulmonary edema on CXR and lung ultrasound but looks intravascularly hypovolemic on exam and POCUS and does not respond to diuretics.

Here are the didactic slides from our noon report.

Key points of the case:

1. Be aware there are different phenotypes of acute heart failure that may require different management strategies
   • The ESC (European Society of Cardiology) 2021 lists 4 different phenotypes:
     • Acute decompensated heart failure (ADHF)
     • ADHF with severe pulmonary edema*
     • Cardiogenic shock
     • Isolated right ventricular failure
   • These phenotypes can (and often) overlap with each other
2. *Hypertensive acute heart failure (also known as ADHF with severe pulmonary edema, SCAPE i.e. sympathetic crashing acute pulmonary edema, flash pulmonary edema) is one phenotype to know that is characterized by:
   • Sympathetic activation causing vaso/venoconstriction, increased afterload against an already diseased LV causing acute LV dysfunction, and ultimately redistribution of fluid into the lungs resulting in acute (or flash) pulmonary edema
   • In these cases, patients are hypertensive may be hypovolemic, euvolemic, or hypervolemic
   • Presentation and resolution are both hyperacute
   • Treatment is with:
     • Afterload reduction with vasodilatory agents (first line is nitroglycerin infusion)
     • NIPPV (non-invasive positive pressure ventilation) i.e. CPAP or BiPAP (any positive pressure ventilation decreases both left heart preload and afterload)
     • Diuresis can be used if patients examine hypervolemic but may not be necessary if they examine hypovolemic or euvolemic
3. In all cases of acute decompensated heart failure, consider if your patient would benefit from afterload reduction to optimize LV function

ND: This was my first noon report! Any feedback is welcome.