1. Acute Heart Failure Dilated –Nonischemic/Familial dilated cardiomyopathy –Myocardial ischemia –Valvular disease –Peripartum cardiomyopathy –Toxin Non-dilated –Myocarditis –Myocardial ischemia –Valvular disease –Infiltrative cardiomyopathy –Acute stress cardiomyopathy

2. Differential Diagnosis Ischemic heart disease Valvular heart disease –Endocarditis Sepsis –immunocompromised Unmasked cirrhotic cardiomyopathy Infiltrative cardiomyopathy

3. Clinical Assessment of Hemodynamic Status Congestion at Rest Signs/Symptoms of Congestion:: Orthopnea / PND Cough Dyspnea Elevated JVP Hepatomegaly Edema Rales Low Perfusion at Rest C NONO NOYES YESYES L AB Warm & Dry Warm & Wet Cold & Wet Cold & Dry (Complex)(Low Profile) Possible Evidence of Low Perfusion: Cool extremities/poor pulses Hyponatremia Decreased mental status Hypotension Narrow pulse pressure Renal dysfunction Nohria A et al., JAMA 2002

4. Hemodynamic Changes in Cirrhosis Increased cardiac output 9.0 ± 3.0 l/min Decreased systemic vascular resistance 861 ± 333 dynes-sec-cm-5 Decreased mean arterial pressure 76 ± 16 mmHg Normal wedge pressure 10 ± 5 Dig Dis Sci 2009;54:869

5. Cirrhotic Cardiomyopathy “A form of chronic cardiac dysfunction in patients with cirrhosis, characterized by blunted contractile responsiveness to stress, and/or altered diastolic relaxation with electrophysiologic abnormalities in the absence of other known cardiac disease.” Gut 2008;57:268

6. Differential Diagnosis Ischemic heart disease Valvular heart disease Sepsis Unmasked cirrhotic cardiomyopathy Infiltrative cardiomyopathy

7. Infiltrative Cardiomyopathy Amyloidosis Sarcoidosis Hemochromatosis

8. Iron Overload Hereditary Hemochromatosis –C282Y homozygous –C282Y/H63D compound heterozygote Secondary –Anemia ± Transfusions –Liver Disease –Dietary iron overload

9. Porto-systemic Shunting Decrease in first-pass iron metabolism in the liver Increased duodenal iron absorption Although rare, case reports of shunts potentially leading to iron overload states including cardiomyopathy (1960s)

10. Diagnosis Progressive heart failure culminating in cardiogenic shock due to secondary hemochromatosis Potential contribution from “cirrhotic cardiomyopathy”