Should we use NIV or HFNC for acute hypoxaemic respiratory failure?

Acute Decompensated HF with congestion - ESC Guideline Approach

Learning objectives:

Current guidelines regarding diuretic use in HF patients

Different mechanism of action of different diuretic agents

Using diuretics in real clinical practice

When to switch to mechanical fluid removal

Define future needs for new diuretic agents

Key points are actually interesting

1) measuring UNa+ @ 2 hours if no UOP >100 cc/hr. UNa+ has to be > 50 mEq/ L to make sure you actually achieve "natriuresis" ( poor fellow running around all night checking Una + levels !)
2) A rise in creatinine is to be expected in many cases and should not lead to backing off from diuresis. I think we see as soon as creatinine goes up MDs back off on diuresis , which is the exact wrong thing to if congestive symptoms are still present
3) Inotropes are discouraged , unless the patient has "true" low output symptoms...and dopamine is not on this list, milrinone is preferred. Any inotrope in the acute setting is associated with increased mortality and purely provides symptomatic relief.

Arrhythmia-Induced Cardiomyopathy

You are probably getting extremely tired seeing one cardiologyarticle  after an other . However ,this  JACC State-of-the-Art Review on Arrhythmia -Induced Cardiomyopathy, I thought was very important as it is a diagnosis seen not just in the CCU but also the MICU. The concept of a cardiomyopathy causing ventricular arrhythmia is nothing new. The reverse pathophysiology is actually very interesting. If you see a patient with atrial fibrillation with chronically uncontrolled rate mostly due to noncompliance or a patient with very frequent ventricular extrasystole, you have to think HFrEF. Below you will find the Central Figure,  Abstract and links to the MP3 summary and actual article.   

• • Tachycardias, AF, and PVCs are known to trigger a reversible dilated CM.
• • AiCM should be highly suspected in patients without an obvious etiology.
• • Ambulatory ECG monitors are key to screen and properly diagnose AiCM.
• • Reversal of CM by elimination of arrhythmia not only confirms the diagnosis but may significantly improve outcomes.

Podcast 📌

This a good review article from  Circulation 

Diagnosis of HFpEF

Most people we see with acute decompensated heart failure with congestion are secondary to HFpEF ( 50% vs HFrEF)
Unfortunately, 90% of the echoes are read wrong in either direction .
I posted this clip to show some of the measurements that go into it . Even when the parameters are obtained  a correct diagnosis is  still a challenge .
A pearl here is that patients with a normal size LA by CT scan or ECHO rarely have acute decompensated CHF unless acute MR from flail leaflet for  example  ( myxomatous valve) , or  ischemic MR  as two examples . There are others off course .
If their LA is very large they probably do have elevated LA pressure and the diagnosis of ADHF with congestion.
For example grade III DD is impossible with a  nomal size LA . I rarely believe DD with elevated LAP unless I can look at CT and ECHO myself or the clinical scenario is compatible with this diagnosis.

You see from the slide show no busy cardiologist will look at this and the the tech has to set wall and gain filters just perfect .