1. Case - 84 year old woman Main symptoms – Acute dyspnea since 2 weeks, some coughing, yellow sputum Past medical history – Chronic obstructive lung disease (GOLD III) – Pulmonary embolism 3months before presentatoin – Peripheral arterial disease with aorto-bifemoral Y-prothesis 10 years ago – Smoking (several pack years) Current medication: – Fluticason/Salmeterol 250/50 inhaler 1-0-1 – Tiotropium 18 inhaler 1-0-0 – Methyl-prednisolone 20mg 1-0-0 (reducing) – Phenprocoumon daily (INR 2-3) Vitals – Respiratory rate 24/min, heart rate 72/min, BP 105/85mmHg, O2- saturation 89%, awake, cooperative (GCS 15)

2. Case - 84 year old woman Physical examination – Cooperative, orientated, lean person, „reduced general health state“ – Heart: heart sound very low-voiced, 2/6 holosystolic murmur, jugular vein not increased – Lung: very faint, symmetric, exspiratory rales – Abdomen: no pathologic findings – Others: Mild symmetric limb edema, palpable pulse on both sides Laboratory results: – Leuco9.3/nLHb14.6g/dLThrombo 214/nL – Na140mmol/LK3.7mmol/LKrea 0.66mg/dL – HN27mg/dLCRP 1.0mg/dL

3. 84 years old – 12-lead ECG Heart rate 95/min; paper speed: 25mm/sec

4. Woman, 84yr – chest X-ray Pulmonary infiltrates. Peribronchial accentuation, „dirty chest“ suggestive of COPD No clear signs for AHF

5. Echocardiographic Imaging Normal LV-dimensions (LVEDD) LV Ejection fraction about 55% LV wall thickness (IVSd 12mm, LVPWd 12mm) Longitudinal motion borderline (MAPSE 13mm) Mild mitral regurgitation (degenerative changes of mitral valve) Normal RV-dimensions Mild tricuspid regurgitation with delta p-max 40mmHg

6. Has this patient AHF? Cardiac markers: – proBNP 8171 pg/mL – hs-cTnT 0.026 ng/mL Working hypothesis – Acute heart failure – Community acquired pneumonia – Chronic obstructive pulmonary disease What doing next with this patient?

8. Admit to the hospital? 1.Yes 2.No

9. CCU or ICU? 1.Yes 2.No

10. Diuretics? 1.Yes 2.No

11. Vasodilators (e.g. nitro) 1.Yes 2.No

12. Stop vasodilator after blood pressure drop? 1.Yes 2.No

13. Antibiotics? 1.Yes 2.No

14. Non invasive ventilation? 1.Yes 2.No

15. Cath Lab? 1.Yes 2.No

16. Right heart catheterization? 1.Yes 2.No

17. What doing next with this patient? DimensionYour decision? Admit to the hospital? CCU? Diuretics? Vasodilators (e.g. nitro) Stop vasodilator after blood pressure drop? Antibiotics? Non invasive ventilation? Cath Lab? Right heart catheterization? Current state Yes No Yes No n.a. Yes No

18. Acute dyspnea – Nuremberg hospital Nuremberg hospital, June 2013 In-hospital mortality [%] n=91 AHF: n=54/91 (59%) Proportion [%]

19. AHF - Effect of treatment Severity assessment of dyspnea in patients: „How severe was your dyspnea at …“ (Numerical rating scale: 0 no dyspnea, 10 most severe dyspnea) numerical rating scale No AHF (n=48) Arrival EMS In the ED After 24h After 48h After 72h

20. Treatment of AHF in the EMS Dep. of Emergency and Critical Care Medicine, 2013 VariableAcurte dyspnea (n=120) AHF (n=68) No AHF (n=48) p= (%) Fluids69,267,672,90,579 Diuretics19,232,40< 0,001 Nitroglycerin2020,620,80,961 Steroids12,511,810,40,861 Beta-mimetics108,88,30,962 Anticholinergic agents0,81,500,410 Antihypertensives1520,68,30,090 Theophyline4,25,92,10,335 Non-invasive ventilation2,51,52,1 Mechanical ventilation2,51,52,1 n=120 patients with acute dyspnea

21. Some additional thoughts Definition of „acute heart failure“ for clinical purposes is not well known by pracitioners in Germany Many patients with acute heart failure are undertreated in EMS/ED/usual care wards AHF patients at increased risk are not identified in the primary care setting (no clinical use of risk stratification tools) Old patients and patients with HFPEF with AHF are not identified, treatment strategies not well defined

22. Army Surgeon. Philadelphia, PA: 1894 Sir William Osler: …. the value of experience is not in seeing much, but in seeing wisely.