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Surgical Treatment - Myocardial revascularization surgery is indicated when the coronary anatomy is not favorable to the percutaneous intervention, in patients with multiarterial involvement initially treated with emergency angioplasty or in cases of mechanical complications of acute myocardial infarction. There is evidence suggesting that early myocardial revascularization within 6 hours , either by angioplasty or surgical revascularization, can reduce mortality in 6 months , Cardiovascular complications are the most common cause of death in patients who undergo surgical procedures , , in whom DHF and recent acute myocardial infarction are the two most important predictors of perioperative risk , DHF can occur during the perioperative period in two situations: patients with DHF who require emergency surgical procedures, and patients with chronic and stable HF who develop decompensation during or after the surgery.

Perioperative mortality in heart failure is related to the functional class and with the presence of pulmonary congestion , especially when a third heart sound occurs 2. The adverse events during the perioperative period are related to the condition of the patient at the time of surgery, more than to the intensity of cardiopathy 2. The best recommendation to patients with acute or decompensated chronic HF who are candidates to surgery is to postpone the procedure until the decompensation is resolved Only emergency surgeries must be performed in patients with DHF. For those patients whose surgery cannot be postponed, the perioperative evaluation must be fast, simple and effective, and it must be focused on vital signs, evaluation of the volemic and hemodynamic status, and the analysis of simple tests such as electrocardiogram and thoracic radiography.

Only essential interventions should be recommended before the emergency surgical procedure; the more detailed analyses should be performed in the postoperative period. Laboratory Evaluation: It is recommended that patients with DHF during or after noncardiac surgeries be evaluated for the levels of urea and creatinine, sodium and potassium abnormalities, levels of hemoglobin and hematocrit, CKMB and troponin when acute coronary syndrome is suspected. Electrocardiogram: There are no studies that have evaluated the lead electrocardiogram in the preoperative assessment of patients with DHF.

In asymptomatic patients, the finding o "q" waves was correlated with adverse events, in addition to being related to the left ventricular ejection fraction , The electrocardiogram is recommended because it is a simple, fast, and low cost exam. Special attention must be paid to the occurrence of ischemia, blocks, ventricular and supraventricular arrhythmias without a control of the ventricular response.

Nevertheless, there is no information that indicates the benefit of the routine exam of perioperative echocardiogram in patients with HF already documented. The transthoracic echocardiogram is recommended in patients without a previously known echocardiogram, when a mechanical cause is suspected as the precipitating or contributory factor in HF following acute myocardial infarction, cardiac tamponade, valvular insufficiency, pulmonary embolism , or in HF decompensation following noncardiac surgeries.

The echocardiogram can be useful to detect new areas of low contractility and valvular dysfunctions, and it is a comparative method of the left ventricular function, diagnostic in the cardiac tamponade and evaluator of the right ventricular function in suspected cases of pulmonary embolism. Few studies have assessed the usefulness of transoperative transesophageal echocardiography in noncardiac surgeries in patients with decompensated HF.

Some studies suggest that this procedure might be able to detect the presence of ischemia There is no evidence to recommend the use of transesophageal echocardiography in noncardiac surgeries. Invasive Hemodynamic Monitoring: Monitoring with pulmonary artery catheter PAC intends to obtain optimal adjustments in perfusion and tissue oxygenation, and it has been proposed for patients in different clinical settings with conflicting results The use of PAC was related to the high frequency of complications and high costs , and its interpretation has high variability among physicians Different prospective studies have evaluated the efficacy of invasive monitoring of the pulmonary artery in high risk surgical patients There were no differences among the patients who received therapy guided by parameters offered by the pulmonary artery catheter and the patients with a clinical follow-up.

A recent metanalysis studied trauma patients with high surgical risk who underwent elective surgery and presented septic shock, and it suggested some improvement in the mortality rate for patients who had hemodynamic optimization However, there are no prospective studies about the value of PAC in patients with DHF who underwent noncardiac surgeries. Considering the seriousness of these patients and until more precise information is available, it is recommended that their perioperative care be carried out in an intensive care unit with hemodynamic and tissue oxygenation adjustments guided by invasive hemodynamic monitoring.

Perioperative Management: Beta-blockers reduce mortality in patients with risk for ischemic heart disease when administered during the preoperative period , No studies have evaluated the introduction of beta-blockers in patients with heart failure who underwent noncardiac surgeries. Beta-blockers must be introduced prior to elective surgeries in patients with DHF and maintained during all the perioperative period, especially in individuals with ischemic cardiomyopathy. Nevertheless, there is no data to justify the recommendation to start this medication in patients who were not previously using it and who have DHF before undergoing emergency surgeries.

The patients must also be maintained as close as possible to an euvolemic status since pulmonary congestion is associated with more frequent events. Pulmonary congestion is more commonly caused by excessive administration of fluids during surgery and, it generally occurs hours after the surgery, when the patient is weaned from mechanical ventilation with positive pressure and there is mobilization of accumulated fluids in the extravascular space.

The use of diuretics, however, must be cautious since the depletion of the intravascular volume may precipitate the occurrence of hypotension during anesthesia. Intravenous inotropic agents are recommended in the presence of tissue hypoperfusion oliguria, acidosis, increased lactate, reduced consciousness level or hypotension. Inotropic agents have been related with increased mortality in patients with heart failure, and therefore should not be used as a prophylactic treatment in the preoperative period.

The use of a contrapulsation intra-aortic balloon IAB has been suggested in patients following acute myocardial infarction undergoing emergency surgery , Nevertheless, there are no randomized studies that have evaluated its use in patients with DHF undergoing emergency surgery.

The use of IAB should be considered only in individuals who maintain hypotension or tissue hypoperfusion, in spite of the use of inotropic agents. Ventricular dysfunction, both left and right, is a risk factor for patients undergoing cardiac surgeries. Like noncardiac surgeries, the cardiac surgeries must be postponed in patients with DHF. In cases of emergency surgery, it is important to seek the best possible compensation still in the preoperative period. A recent retrospective study with 1, patients suggested a beneficial effect of beta-blockers in patients with normal ventricular function undergoing myocardial revascularization surgeries Another recent study suggested the administration of beta-blockers prior to cardiac surgeries in order to reduce the perioperative risk in patients with ventricular dysfunction due to ischemic or valvular cardiomyopathy.

Beta-blockers must be introduced before elective surgeries in patients with DHF already stabilized and must be maintained during all the perioperative period, especially in patients with ischemic cardiomyopathy. Nevertheless, there is no data that recommends starting these medications in patients who were not previously receiving them and who have DHF prior to an emergency surgery. Patients with DHF who will undergo heart surgery must be monitored with a pulmonary artery catheter , Some authors have suggested the routine use of transesophageal echocardiography in heart surgery ; nevertheless, there is no data recommending the routine use of intraoperative transesophageal echocardiography in patients with HF.

The use of inotropic agents is indicated in patients with hypotension or signs of tissue hypoperfusion. Different studies compared the effects of inotropic agents in patients who underwent heart surgeries , , but there is no evidence that corroborates with specific recommendations for any of them.

The use of phosphodiesterase inhibitors as well as nitroglycerin has been suggested for patients with pulmonary hypertension due to their pulmonary vasodilator effect. In patients with serious heart failure and signs of tissue hypoperfusion, in spite of the use of intravenous inotropic agents, mechanical circulatory support must be considered as a support therapy until myocardial recovery e.

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IAB has been recommended for patients with obstruction of left coronary branch in mitral insufficiency in a condition of postoperative low output In patients whose signs of left ventricular dysfunction and tissue hypoperfusion are intense since the beginning, or in where the IAB failed to restore tissue perfusion, the implant of artificial ventricular support must be considered , Stunned and Hibernating Myocardium Table In ischemic cardiomyopathy, the abnormalities of the myocardial contractility are due to both tissue fibrosis and viable cells dysfunction in variable combinations.

The viable myocardium presents potentially reversible mechanical dysfunction and it can be classified as stunned and hibernating. While the hypocontractility of the stunned myocardium remains in spite of the reperfusion already attained, in the hibernating myocardium it represents an adaptation to the chronic low flow. Several studies have demonstrated the potential improvement of function by means of myocardial revascularization in patients with preoperative identification of viable segments Thus, in patients with ischemic HF, the assessment of myocardial viability is important to verify the partial or total reversibility of ventricular dysfunction with surgical treatment.

It must be emphasized, however, that these studies were performed in stable patients. To this day, there are no data in the literature about the assessment of myocardial viability in patients with DHF. Viability tests must be performed after stabilization of the clinical status. Stress Echocardiography with dobutamine , The viable myocardium has its own preserved contractile reserve responsiveness to inotropic agents.

Scintigraphy with thalium , Positron emission tomography PET , The F FDG tracer is a glucose analogue absorbed by metabolically active cells. The presence of viability is demonstrated when there is disparity between flow and metabolism. Considered a gold standard in the assessment of myocardial viability, this method is limited by its high cost and restricted availability. Magnetic Resonance Imaging , It can be associated with stress echocardiography with dobutamine to assess the contractile reserve. It has a high spatial resolution, allowing for the discrimation between areas of transmural and non-transmural abnormalities.

The relationship between viability, increased contractility, improvements of the clinical condition and prognosis needs to be demonstrated in randomized prospective studies. Diastolic Dysfunction Table Diastolic heart failure is the one related to the increases in the diastolic filling in part of or in the whole heart. Different conditions can lead to diastolic dysfunction.

This current analysis focuses on the myocardial causes , Diagnosis: In spite of the lack of clinical and electrocardiographic criteria, the presentation of HF in a patient with preserved systolic function probably represents diastolic failure.

I Latin American Guidelines for the assessment and management of decompensated heart failure

The inclusion of the B-type natriuretic peptide measurement can increase the diagnostic accuracy It is crucial to pay close attention to some general principles in the treatment of diastolic failure: reduction of volume overload, control of the arterial blood pressure and relief of the myocardial ischemia. Drugs that block the renin-angiotensin-aldosterone system are particularly attractive based on pathophysiologic studies.

General Treatment : Drug therapy in general involves the use of diuretics and negative inotropic agents. Calcium channel blockers and beta-blockers have shown benefits to enhance physical capacity and, in small studies and subgroup analyses, to reduce mortality In the study conducted by the Digoxin Investigators Group , digoxin showed an impact on the reduction of hospitalization rates in patients with and without systolic dysfunction it is believed the mechanism involved is the control of ventricular rate.

For patients with atrial fibrillation, the restoration of sinus rhythm and organized atrial contraction may improve diastolic filling Clinical and experimental studies revealed that blockade of the renin-angiotensin-aldosterone system may improve the diastolic performance in view of the deleterious role of angiotensina II in the ventricular relaxation 14,, Short-term treatment with losartan seems to be associated with an improvement in exercise tolerance, which might be due to afterload reduction In addition to that, inducers of hypertrophy regression seem to be beneficial in cases where the left ventricular hypertrophy LVH is the main element of diastolic dysfunction.

It is possible that losartan has a beneficial action in the reduction of myocardial fibrosis and reduction of wall stiffness 24, Currently, various multicentric, randomized, placebo-controlled studies are being conducted, aiming at assessing the role of the angiotensin conversion inhibitors, antagonists of angiotensin receptor and beta-blockers in patients with diastolic heart failure 25, Candersartan may reduce hospitalization due to heart failure in patients with diastolic heart failure Treatment under investigation : Aldosterone seems to be important in the development of fibrosis, both in systolic HF remodeling and in the development of LVH.

In the study Randomized Aldactone spironolactone Evaluation Study for Congestive Heart Failure RALES , directed to systolic dysfunction, placebo group patients with the highest serum values of collagen degradation markers had the poorest performance, but they were the ones who best responded to spironolactone. It is unknown whether this benefit could be observed in patients with diastolic dysfunction.

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Comorbidities : Arterial hypertension is the largest risk factor for the development of CHF. Therefore, strict control of arterial blood pressure is essential in these patients. Occasionally, diastolic heart failure may require a complete investigation for coronary ischemia. Ischemic episodes can lead to diastolic dysfunction through changes in the ventricular relaxation, which can result in pulmonary congestion. Drug therapy and myocardial revascularization percutaneous or surgical reduce the symptoms and can prolong the survival of patients with CHD, who must be treated according to the current guidelines Acute Pulmonary Edema Table Patients with acute pulmonary edema APE tend to be older, have higher blood pressure and preserved left ventricular ejection fraction 24,28,17, This group is generally poorly represented in clinical assays, which leads to a limited applicability of the information contained in them.

Improvement in oxygenation can usually be attained with the patient sitting, and with the administration of oxygen through high flow masks. It has been recently proposed that the use of noninvasive ventilation NIV with positive pressure can improve the oxygen exchange Two prospective, randomized studies were performed with this purpose.

In the first one , NIV was compared with the use of high doses of nitrates. The study was interrupted early because of the excessive number of adverse events and reduced efficacy in the NIV arm.


On the other hand, a better control of pulmonary edema has been demonstrated with NIV, when compared with conservative treatment. Therefore, its use must be considered as an alternative strategy reserved for patients who did not respond to the conventional supply of oxygen and drug treatment.

Furosemide and morphine have long been considered as the standard treatment of APE. A recent study randomized patients to receive low doses of nitrates and a bolus of 80 mg furosemide or 40 mg furosemide and high doses of nitrate administered in repeated intravenous IV boluses of 3 mg isosorbide dinitrate.

The study showed that high doses of intravenous IV nitrate are clearly superior to furosemide in the treatment of APE. This represents a decrease of systemic vascular resistance, which confirms the importance of rapid arterial dilation as a primary objective in the treatment of APE. However, in patients with acute heart failure with reduced myocardial reserve, the inappropriate vasodilation may cause an important drop in arterial blood pressure, which can result in hemodynamic instability, ischemia, renal failure and shock.

Therefore, it is essential to pay close attention to arterial blood pressure monitoring. Medication doses should be reduced if systolic pressure is lower than mm Hg and they must be discontinued if there is a new drop in arterial blood pressure. In the first 24 hours, the vasodilator dose must be progressively reduced in order to prevent recurrent episodes of inappropriate vasoconstriction.

The drug selected for use to prevent new episodes of decompensation, after initial stabilization in patients hospitalized because of acute heart failure is not well defined yet. Nitrates have never been assessed in prospective, randomized studies. Two classes of vasodilators were recently developed for the treatment of acute heart failure; fast-acting endothelin antagonists are in phase II investigation. Larger studies are necessary to verify its exact role in acute heart failure. The second class of vasodilators is composed of natriuretic peptides. The first drug investigated in a clinical trial was niseritide The drug was effective to improve the subjective score of dyspnea, as well as to induce significant vasodilation, having been recently approved by the FDA for the treatment of acute HF.

Another group of drugs used in the first days after the initial stabilization is composed of diuretics. Although with a proven benefit in clinical practice, its excessive use can be harmful , A recent study compared low doses of dopamine with high doses of intravenous furosemide in patients with an episode of refractory decompensation The study was discontinued due to significant adverse events in the furosemide arm. Therefore, the dose of furosemide administered to patients with DHF must be titrated with the purpose of reducing the symptoms and congestion, without triggering adverse effects.

Peripartum Cardiomyopathy Table It occurs in women without any previous cardiomyopathy, from the last quarter of gestation until 6 months after delivery. Risk factors include multiparity, twin pregnancy, advanced age, preeclampsia, gestational hypertension and black ethnicity. Its diagnosis requires the exclusion of other causes of cardiomyopathy and it is confirmed by echocardiogram showing signs of systolic ventricular dysfunction.

Endomyocardial biopsy may be indicated if the patient is refractory to treatment, and it may show myocarditis. Myocarditis is defined as an inflammation in the cardiac muscle, frequently caused by an infectious agent which usually affects the myocytes, interstitium, vascular elements and the pericardium.

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Myocardial aggression basically occurs through three mechanisms: 1 immune-mediated lesion, which is probably the main mechanism ; 2 direct action on the myocardium; 3 production of a myocardial toxin e.