“TIME IS LIFE !

”
Effective Strategy to Manage
Acute Heart Failure
Andrianto
Kandita Arjani
 Acute Dyspnea – In-Hospital Mortality

• A large proportion
of patients (7.4%)
presents to the ED
with acute
dyspnea.

• Patients presenting
with acute dyspnea
dysplay a high in
hospital mortality.

Mockel et al. Eur J Emerg Med 2013, 20:103–108

Acute dyspnea : difficult diagnosis
 Acute Heart Failure Management 2012:
Optimization leading to in-hospital mortality improvement

AHS – outcome data

In-hospital all-cause mortality by clinical profile at entry
50.0%

39.5% EHFS II (2005)

40.0%
EURObservational Programme
(2009/2010)
30.0%
22.0%
20.0%

9.1% 8.0%
10.0% 6.7% 6.1% 5.0%
3.8% 5.6%
1.5% 1.2% 3.2%
0.0%
Total CS PE HHF RV failure Decomp. HF

Nieminen M et al., Eur Heart J 2006 & Courtesy of A. Maggioni

CS=Cardiogenic shock; PE=Pulmonary edema

 ACUTE HEART FAILURE SYNDROME

Rapid change in heart failure signs and symptoms in

patients with chronic or de novo HF, who require urgent or
emergent therapy

Need therapy
as soon as posible
“TIME IS LIFE!”
In ACS when the coronary is occluded we say
‘time is muscle’ which means that the
quicker the vessel is dilated, the more heart
muscle is saved.
The same principle is true for AHF.”
Time Dependency :
Understanding The Concept

The first hour of hospitalization for AHF are marked by high risk
complication, including death “GOLDEN MOMENT” for intervention

High number of AHF patients die in the emergency department

(ED) before ICU/cardiac care unit (CCU) admission

Earlier diagnosis, triage, and initiation of specific treatment for AHF are
associated with reduced mortality as well as shorter lengths of hospital
stay
Treat Early or Die ?

Pulmonary
Edema

Cardiogenic
Organ Injury
Shock

Respiratory
Failure
Suspected AHF - Diagnostic work up
Same as ACS, AHF patients should receive appropriate therapy as early as
possible

Rapid transfer to the nearest hospital, preferably to a site with cardiology

department and/or CCU/ICU

On arrival, initial clinical examination, investigation and treatment should be

started immediately
Mebazaa A, Yilmaz MB, Levy P, et al. Recommendations on pre-hospital & early hospital management of acute heart failure: a consensus paper from the Heart
Failure Association of the European Society of Cardiology, the European Society of Emergency Medicine and the Society of Academic Emergency Medicine.
European Journal of Heart Failure. 2015;17: 544-558
Pre-hospital management
Initial management of AHF

DOI: https:
//doi.
org/1
0.100
7/s00
134-
015-
Evaluation
4041-
should be less
5
than 2 hours
Non Invasive Ventilation (NIV)

Non Invasive ventilation (NIV) should be considered as

soon as possible in case:
• Respiratory distress
• Pulmonary edema
• SpO2<90%

In symptoms of congestion, we should start diuretics to

relieve symptoms
The earlier ,
the better .....
Early vs Late CPAP

Plaisance et al, Eur Heart J, 2007 : 28 : 2895

 Early vs Late CPAP

Plaisance et al, Eur Heart J, 2007 : 28 : 2895

Early CPAP vs Late CPAP

Plaisance et al, Eur Heart J, 2007 : 28 : 2895

Door–to-Diuretic Time & In-Hospital Mortality

Matsue, Y et al. J Am Coll Cardio.2017;69(25);3042-51

Time-to-Furosemide Treatment
& In-Hospital Mortality

Matsue Y et al. J Am Coll Cardio.2017;69(25);3042-51

Time-to-Furosemide Treatment
& In-Hospital Mortality

Matsue Y et al. J Am Coll Cardio.2017;69(25);3042-51

Impact of The T-to-T Concept
on the outcome of AHF

• Impact

Trevisan et al, Arch Cardiovasc Dis. 2018

Impact of The T-to-T Concept
on the outcome of AHF

Trevisan et al, Arch Cardiovasc Dis. 2018

Take Home Messages

Earlier diagnosis, triage, and initiation of specific treatment for AHF

are associated with reduced mortality as well as shorter lengths of
hospital stay.

Time is Life & Time to Treatment Concept is very important for AHF
management .

Recommended that Time to Treat Strategy of < 60 minutes in AHF

associated with a better prognosis .