Heart failure: Wet and cold, hypotensive

Presentation of Heart failure
Wet and cold

Wet

• Systemic venous congestion
• Orthopnea
• Paroxysmal nocturnal dyspnoea
• Breathlessness
• Bi-basilar rales
• An abnormal blood pressure response to the Valsalva maneuver (left-sided)
• Symptoms of gut congestion
• Jugular venous distension
• Hepatojugular reflux
• Hepatomegaly
• Ascites
• Peripheral oedema (right-sided)
• Wet mucous membranes
• Inferior vena cava does not appear collapsed on imaging
• Improves with diuresis

Cold

• Poor cardiac output
• Inadequate peripheral perfusion
• Cold skin

 

Hypotensive

• Systolic blood pressure below 90 mmHg

 

Management

In critical care areas

• Arterial cannulation
• Direct measurement of mean arterial pressure
• Inotropic therapy
• Vasopressor therapy
• Mechanical circulatory support

If blood pressure climbs above 90 mmHg

• Follow algorithm here

 

References

1. Piotr Ponikowski, Adriaan A Voors, Stefan D Anker, Héctor Bueno, John G F Cleland, Andrew J S Coats, Volkmar Falk, José Ramón González-Juanatey, Veli-Pekka Harjola, Ewa A Jankowska, Mariell Jessup, Cecilia Linde, Petros Nihoyannopoulos, John T Parissis, Burkert Pieske, Jillian P Riley, Giuseppe M C Rosano, Luis M Ruilope, Frank Ruschitzka, Frans H Rutten, Peter van der Meer, ESC Scientific Document Group, 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC)
   Developed with the special contribution of the Heart Failure Association (HFA) of the ESC, European Heart Journal, Volume 37, Issue 27, 14 July 2016, Pages 2129–2200, https://doi.org/10.1093/eurheartj/ehw128

Heart failure: Wet and cold, normotensive

Presentation of Heart failure

Wet and cold

Wet

• Systemic venous congestion
• Orthopnea
• Paroxysmal nocturnal dyspnoea
• Breathlessness
• Bi-basilar rales
• An abnormal blood pressure response to the Valsalva maneuver (left-sided)
• Symptoms of gut congestion
• Jugular venous distension
• Hepatojugular reflux
• Hepatomegaly
• Ascites
• Peripheral oedema (right-sided)
• Wet mucous membranes
• Inferior vena cava does not appear collapsed on imaging
• Improves with diuresis

Cold

• Poor cardiac output
• Inadequate peripheral perfusion
• Cold skin

 

Normotensive

• Systolic blood pressure equal to 90 mmHg or above

 

Management

• Vasodilation therapy
• Diuretic therapy

In critical care areas

• Arterial cannulation
• Direct measurement of mean arterial pressure
• Inotropic therapy

If blood pressure falls below 90 mmHg

• Follow algorithm here

 

References

1. Piotr Ponikowski, Adriaan A Voors, Stefan D Anker, Héctor Bueno, John G F Cleland, Andrew J S Coats, Volkmar Falk, José Ramón González-Juanatey, Veli-Pekka Harjola, Ewa A Jankowska, Mariell Jessup, Cecilia Linde, Petros Nihoyannopoulos, John T Parissis, Burkert Pieske, Jillian P Riley, Giuseppe M C Rosano, Luis M Ruilope, Frank Ruschitzka, Frans H Rutten, Peter van der Meer, ESC Scientific Document Group, 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC)
   Developed with the special contribution of the Heart Failure Association (HFA) of the ESC, European Heart Journal, Volume 37, Issue 27, 14 July 2016, Pages 2129–2200, https://doi.org/10.1093/eurheartj/ehw128

Heart failure: Dry and cold

Presentation of Heart failure

Dry (5% of Acute Heart Failure patients)

• No systemic venous congestion
• No pulmonary oedema
• Lower probability of peripheral oedema
• Dry mucous membranes
• Normal jugular venous pulse
• Inferior vena cava appears collapsed on imaging
• Worsens with diuresis

Cold

• Inadequate peripheral perfusion
• Cold skin

 

Pathophysiology

• Hypoperfused
• Hypovolaemic

 

Management

• Fluid challenge
• Inotropic therapy

 

References

1. Piotr Ponikowski, Adriaan A Voors, Stefan D Anker, Héctor Bueno, John G F Cleland, Andrew J S Coats, Volkmar Falk, José Ramón González-Juanatey, Veli-Pekka Harjola, Ewa A Jankowska, Mariell Jessup, Cecilia Linde, Petros Nihoyannopoulos, John T Parissis, Burkert Pieske, Jillian P Riley, Giuseppe M C Rosano, Luis M Ruilope, Frank Ruschitzka, Frans H Rutten, Peter van der Meer, ESC Scientific Document Group, 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC)
   Developed with the special contribution of the Heart Failure Association (HFA) of the ESC, European Heart Journal, Volume 37, Issue 27, 14 July 2016, Pages 2129–2200, https://doi.org/10.1093/eurheartj/ehw128

Heart failure: Dry and warm

Presentation of Heart failure

Dry (5% of Acute Heart Failure patients)

• No systemic venous congestion
• No pulmonary oedema
• Lower probability of peripheral oedema
• Dry mucous membranes
• Normal jugular venous pulse
• Inferior vena cava appears collapsed on imaging
• Worsens with diuresis

 

Warm

• Adequate peripheral perfusion
• Warm skin

 

Pathophysiology

• If adequately perfused, this can be considered compensated heart failure.

 

Management

• Adjust oral therapy

 

References

1. Piotr Ponikowski, Adriaan A Voors, Stefan D Anker, Héctor Bueno, John G F Cleland, Andrew J S Coats, Volkmar Falk, José Ramón González-Juanatey, Veli-Pekka Harjola, Ewa A Jankowska, Mariell Jessup, Cecilia Linde, Petros Nihoyannopoulos, John T Parissis, Burkert Pieske, Jillian P Riley, Giuseppe M C Rosano, Luis M Ruilope, Frank Ruschitzka, Frans H Rutten, Peter van der Meer, ESC Scientific Document Group, 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC)
   Developed with the special contribution of the Heart Failure Association (HFA) of the ESC, European Heart Journal, Volume 37, Issue 27, 14 July 2016, Pages 2129–2200, https://doi.org/10.1093/eurheartj/ehw128

Heart failure: Wet and cold

Presentation of Heart failure

Wet (95% of Acute Heart Failure patients)

• Systemic venous congestion
• Orthopnea
• Paroxysmal nocturnal dyspnoea
• Breathlessness
• Bi-basilar rales
• An abnormal blood pressure response to the Valsalva maneuver (left-sided)
• Symptoms of gut congestion
• Jugular venous distension
• Hepatojugular reflux
• Hepatomegaly
• Ascites
• Peripheral oedema (right-sided)
• Wet mucous membranes
• Inferior vena cava does not appear collapsed on imaging
• Improves with diuresis

Cold

• Inadequate peripheral perfusion
• Cold skin

 

Blood pressure

If systolic blood pressure falls below 90 mmHg: 

See here

 

If systolic blood pressure remains at 90 mmHg or above:

See here

 

References

1. Piotr Ponikowski, Adriaan A Voors, Stefan D Anker, Héctor Bueno, John G F Cleland, Andrew J S Coats, Volkmar Falk, José Ramón González-Juanatey, Veli-Pekka Harjola, Ewa A Jankowska, Mariell Jessup, Cecilia Linde, Petros Nihoyannopoulos, John T Parissis, Burkert Pieske, Jillian P Riley, Giuseppe M C Rosano, Luis M Ruilope, Frank Ruschitzka, Frans H Rutten, Peter van der Meer, ESC Scientific Document Group, 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC)
   Developed with the special contribution of the Heart Failure Association (HFA) of the ESC, European Heart Journal, Volume 37, Issue 27, 14 July 2016, Pages 2129–2200, https://doi.org/10.1093/eurheartj/ehw128

Heart failure: Wet and warm

Presentation of Heart failure

 

Wet (95% of Acute Heart Failure patients)

• Systemic venous congestion
• Orthopnea
• Paroxysmal nocturnal dyspnoea
• Breathlessness
• Bi-basilar rales
• An abnormal blood pressure response to the Valsalva maneuver (left-sided)
• Symptoms of gut congestion
• Jugular venous distension
• Hepatojugular reflux
• Hepatomegaly
• Ascites
• Peripheral oedema (right-sided)
• Wet mucous membranes
• Inferior vena cava does not appear collapsed on imaging
• Improves with diuresis

 

Warm

• Adequate peripheral perfusion
• Warm skin

 

Predominant feature

• Hypertension: Vascular
• Congestion: Cardiac

 

References

1. Piotr Ponikowski, Adriaan A Voors, Stefan D Anker, Héctor Bueno, John G F Cleland, Andrew J S Coats, Volkmar Falk, José Ramón González-Juanatey, Veli-Pekka Harjola, Ewa A Jankowska, Mariell Jessup, Cecilia Linde, Petros Nihoyannopoulos, John T Parissis, Burkert Pieske, Jillian P Riley, Giuseppe M C Rosano, Luis M Ruilope, Frank Ruschitzka, Frans H Rutten, Peter van der Meer, ESC Scientific Document Group, 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC)
   Developed with the special contribution of the Heart Failure Association (HFA) of the ESC, European Heart Journal, Volume 37, Issue 27, 14 July 2016, Pages 2129–2200, https://doi.org/10.1093/eurheartj/ehw128

Heart failure: Wet and warm, cardiac type

Presentation of Heart failure

Wet and warm

Wet (95% of Acute Heart Failure patients)

• Systemic venous congestion
• Orthopnea
• Paroxysmal nocturnal dyspnoea
• Breathlessness
• Bi-basilar rales
• An abnormal blood pressure response to the Valsalva maneuver (left-sided)
• Symptoms of gut congestion
• Jugular venous distension
• Hepatojugular reflux
• Hepatomegaly
• Ascites
• Peripheral oedema (right-sided)
• Wet mucous membranes
• Inferior vena cava does not appear collapsed on imaging
• Improves with diuresis

 

Warm

• Adequate peripheral perfusion
• Warm skin

 

Predominant cause: cardiac

• Fluid accumulation
• Congestion predominates

 

Management

• Diuretic therapy
• Vasodilator therapy
• Ultrafiltration (consider if diuretic resistant)

 

References

1. Piotr Ponikowski, Adriaan A Voors, Stefan D Anker, Héctor Bueno, John G F Cleland, Andrew J S Coats, Volkmar Falk, José Ramón González-Juanatey, Veli-Pekka Harjola, Ewa A Jankowska, Mariell Jessup, Cecilia Linde, Petros Nihoyannopoulos, John T Parissis, Burkert Pieske, Jillian P Riley, Giuseppe M C Rosano, Luis M Ruilope, Frank Ruschitzka, Frans H Rutten, Peter van der Meer, ESC Scientific Document Group, 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC)
   Developed with the special contribution of the Heart Failure Association (HFA) of the ESC, European Heart Journal, Volume 37, Issue 27, 14 July 2016, Pages 2129–2200, https://doi.org/10.1093/eurheartj/ehw128

Heart failure: Wet and warm, vascular type

Presentation of Heart failure
Wet and warm

Wet (95% of Acute Heart Failure patients)

• Systemic venous congestion
• Orthopnea
• Paroxysmal nocturnal dyspnoea
• Breathlessness
• Bi-basilar rales
• An abnormal blood pressure response to the Valsalva maneuver (left-sided)
• Symptoms of gut congestion
• Jugular venous distension
• Hepatojugular reflux
• Hepatomegaly
• Ascites
• Peripheral oedema (right-sided)
• Wet mucous membranes
• Inferior vena cava does not appear collapsed on imaging
• Improves with diuresis

 

Warm

• Adequate peripheral perfusion
• Warm skin

 

Predominant cause: vasculature

• Fluid redistribution
• Hypertension predominates

 

Management

• Vasodilator therapy
• Diuretic therapy

 

References

1. Piotr Ponikowski, Adriaan A Voors, Stefan D Anker, Héctor Bueno, John G F Cleland, Andrew J S Coats, Volkmar Falk, José Ramón González-Juanatey, Veli-Pekka Harjola, Ewa A Jankowska, Mariell Jessup, Cecilia Linde, Petros Nihoyannopoulos, John T Parissis, Burkert Pieske, Jillian P Riley, Giuseppe M C Rosano, Luis M Ruilope, Frank Ruschitzka, Frans H Rutten, Peter van der Meer, ESC Scientific Document Group, 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC)
   Developed with the special contribution of the Heart Failure Association (HFA) of the ESC, European Heart Journal, Volume 37, Issue 27, 14 July 2016, Pages 2129–2200, https://doi.org/10.1093/eurheartj/ehw128