Acute CHF ICU Essay

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Postgraduate Education Corner

Acute Left Ventricular Dysfunction in the Critically Ill
Anand Chockalingam, MD; Ankit Mehra, MD; Smrita Dorairajan, MD; and Kevin C. Dellsperger, MD, PhD

Acute left ventricular (LV) dysfunction is common in the critical care setting and more frequently affects the elderly and patients with comorbidities. Because of increased mortality and the potential for significant improvement with early revascularization, the practitioner must first consider acute coronary syndrome. However, variants of stress (takotsubo) cardiomyopathy may be more prevalent in ICU settings than previously recognized. Early diagnosis is important to direct treatment of complications of stress cardiomyopathy, such as dynamic LV outflow tract obstruction, heart failure, and arrhythmias. Global LV dysfunction occurs in the critically ill because of the cardio-depressant effect of inflammatory mediators and endotoxins in septic shock as well as direct catecholamine toxicity. Tachycardia, hypertension, and severe metabolic abnormalities can independently cause global LV dysfunction, which typically improves with addressing the precipitating factor. Routine troponin testing may help early detection of cardiac injury and biomarkers could have prognostic value independent of prior cardiac disease. Echocardiography is ideally suited to quantify LV dysfunction and determine its most likely cause. LV dysfunction suggests a worse prognosis, but with appropriate therapy outcomes can be optimized. CHEST 2010; 138(1):198–207
Abbreviations: ACS 5 acute cardiac syndrome; BNP 5 brain natriuretic peptide; LV 5 left ventricular; NT-proBNP 5 N-terminalpro-B-type natriuretic peptide; RWMA 5 regional wall motion abnormalities

left ventricular (LV) dysfunction occurs
in about one-third of critically ill hospitalized

patients.1-4 The increasing incidence of LV dysfunction in ICUs is likely related to both changing patient characteristics (advancing age, increased comorbidities) and practice patterns (widespread troponin, creatine kinase-MB, and brain natriuretic peptide [BNP] testing, as well as more frequent performance of bedside echocardiography).3,5-8 A determination as
Manuscript received August 22, 2009; revision accepted December
7, 2009.
Affiliations: From the Division of Cardiovascular Medicine,
Department of Internal Medicine (Drs Chockalingam, Mehra,
Dorairajan, and Dellsperger), University of Missouri School of
Medicine; and the Cardiology Section (Dr Chockalingam), Harry
S. Truman VA Medical Center, Columbia, MO.
FundingրSupport: This study was funded by Veterans Administration Research award [VISN 15] to Dr Chockalingam.
Correspondence to: Anand Chockalingam, MD, Division of
Cardiology, University of Missouri–Columbia, 5 Hospital Dr,
CE306, Columbia, MO 65212; e-mail: chockalingama@health. © 2010 American College of Chest Physicians. Reproduction of this article is prohibited without written permission from the
American College of Chest Physicians (www.chestpubs.orgր siteրmiscրreprints.xhtml). DOI: 10.1378/chest.09-1996


to whether the LV dysfunction is the cause, effect, or a coincidental finding has to be made and revisited periodically. Acute medical or surgical plans, ongoing management targets, outcome expectations, and prognosis must be reconciled. Recognizing that all the individual causes and complexities cannot be captured here, we will summarize the most important causes of LV dysfunction in the critically ill (Table 1) and present a unified management approach from the cardiac standpoint.
Diagnosis of LV Dysfunction
Angina, dyspnea, pulmonary crackles, murmurs, tachyarrhythmias, biomarker elevations, or ischemic
ECG changes suggest cardiac pathology in hospitalized patients. Because of variability in patient characteristics and study design, predictive