Acute Decompensated HF
Acute Decompensated HF is defined as pts having new or worsening symptoms of ________, ___________, _____________ where additional medical care is indicated.
- Systemic volume overload
- Acute pulmonary edema
T/F: Acute Decompensated HF may have preserved or impaired LV fxn
What kind of meds could cause acute decompensated HF?
- Anthracyclines (chemo)
- NSAIDs, COX2i
- non-DHP CCB
List 10 etiology/precipitating factors of ADHF:
- Non-adherence to meds/diet
- Infection (pneumonia)
- HTN crisis
- Excessive alcohol/drug use
- Cardiac event
- Pulm. embolus
- Endocrine dz
- De novo HF
- Severe LV systolic dysfxn w progressive worsening of CO refractory to therapy
List examples of cardiac events that could cause ADHF:
- Recurrent MI
- Myocardial ischemia
- A fib
T/F: We assess ADHF with a complete hx, physical exam, and MRI to determine perfusion and volume status.
Aside from perfusion and volume status, what else is assessed for ADHF?
- Onset, duration, severity of sx
- Precipitating factors/comorbidities
- New onset exacerbation of chronic dz
- Preserved EF
- Chest radiographs, electrocardiogram, echocardiography
Symptoms of pulmonary congestion:
- Paroxysmal nocturnal dyspnea
Signs of pulmonary congestion:
- Pulmonary edema
- Pleural effusion
- 3rd heart sound (L sided) -S3 gallop
Symptoms of systemic congestion:
- Ab/hepatic pain/swelling
Signs of systemic congestion:
- Hepatojugular refluc
- Hepatic enlargement and tenderness
- 3rd heart sound (R sided) -S3 gallop
Symptoms of poor perfusion:
- Extreme fatigue and tiredness
- Poor appetite
- Early satiety
- Mental status changes
Signs of poor perfusion:
- ↓ BP
- ↓ CO
- Worsening renal fxn
- Cool extremeties
T/F: Someone presenting w/ ADHF will have JVD, ascites, and leg edema, while someone presenting w/ CHF will have neck muscle retraction, JVD, air hunger with wide eyes and cyanosis of lips
In the physical exam, what is being assessed?
- Heart sounds
- Pulmonary exam
Tools for diagnosing ADHF:
Which lab values are assessed for ADHF?
- Renal fxn
- Cardiac troponin
- BNP (higher = indicator for HF)
An invasive HD monitoring tool that can measure CO:
Normal CI value:
Cardiac index (CI) is indicative of _____________
In pts w/ HF, the pulmonary capillary wedge pressure (PCWP) range is:
If PCWP is < 18 in HF pt, how would we describe the pt?
If PCWP is > 18 in HF pt, how would we describe the pt?
If CI is > 2.2, how would we describe the pt?
If CI is < 2.2, how would we describe the pt?
T/F: Invasive hemodynamic monitoring is recommended for all HF pts because they are at high risk for sudden death
CI >2.2 and PCWP <18
I (warm and dry)
CI >2.2 and PCWP >18
II (warm and wet)
CI < 2.2 and PCWP <18
III (cold and dry)
CI < 2.2 and PCWP >18
IV (cold and wet)
Which subset is has the worst outcome?
IV (cold and wet)
T/F: Subset I has 2x increased risk in mortality than subset I, and subset IV has a 2.5x increased risk in mortality than subset I.
Goals of therapy for ADHF:
- Relieve congestive sx
- Treat sx of low CO
- Minimize risks of pharm therapy
- ID and treat underlying cause
- Optimize oral therapy prior to discharge
- Adequate pt education
Tx for subset I:
- Maximize oral therapy (especially w/ HFrEF)
T/F: Subset I has the highest mortality
Tx for subset II:
Need to ↓ pulmonary congestion and maintain CO:
- IV preload reducers: Loop diuretics, vasodilators (NTG, nitroprusside, nesiritide)
- Na restriction, supplemental O2 PRN, Fluid restriction
First line tx for subset II:
IV loop diuretics
If IV loop diuretics are inadequate to relieve congestion (diuretic resistance), what would be the next step?
- Higher dose of loop diuretic
- Addition of second diuretic (i.e. metolazone)
- Continuous infusion of loop diuretic
Last line therapy for subset II:
T/F: Vasodilators can be used alone or in combo with diuretics in pts with or without hypotension for treating volume overload in subset II
First line tx for subset III:
- How dry? If PCWP < 15: IV fluids
- If PCWP 15 -18: IV positive inotropes
Examples of IV positive inotropes:
Tx for subset IV:
Combo of IV positive inotropes, diuretics, and/or vasodilators
List examples of loop diuretics:
T/F: It is recommended to use oral loop diuretics first until volume status is optimized, and then switch to IV
Loop diuretics improve pulmonary congestion by decreasing _________ (fxnl venodilation, Na and H2O excretion)
Loop diuretic use must be used with caution to avoid:
- dropping volume too much:
- ↓ CO
- Symptomatic ↓ in BP
- ↓ in renal fxn
What is the minimum IV bolus dosing for furosemide?
If the pt is on furosemide at home, what one time IV bolus would the recieve?
Total home daily dose (max 200 mg)
If the pt is not on furosemide at home, what one time IV bolus would the recieve?
- If SCr <2: 40 mg
- If SCr >2: 80 mg
After the initial IV bolus of furosemide is given, when should urine output be checked?
Goal urine output in first 2 hrs if SCr ≤ 2.5
≥ 500 ml
Goal urine output in first 2 hrs if SCr > 2.5
≥ 250 ml
If pt is not at goal urine output after first 2 hrs, what dose of furosemide should be given?
Double initial dose (given w/in 2-4h of last dose)
List reasons for diuretic resistance:
- ↓ rate of absorption = ↓ peak concentrations = ↓ responsiveness
- High [Na] reaching distal tubule
- Low CO, ↓ renal perfusion = ↓ delivery of drug to kidney
List second diuretics to add in the case of diuretic resistance:
- Chlorthalidone (IV once daily)
Non-pharm therapy for diuretic resistance:
- Restrict Na and fluid intake
Monitoring for diuretics:
- Fluid in/out
- S/sx of congestion
- Renal fxn (BUN/SCr)
- Electrolytes (K, Mg, Na)
- Hemodynamics (BP, HR, PCWP, CI)
In the absence of symptomtatic HoTN, _____________ can be added to diuretic therapy for relief of dyspnea in pts w/ acutely decompensated HF
T/F: Arterial vasodilators ↓ afterload = ↑ CO, while venodilators ↓ preload = ↓ sx of pulmonary congestion.
Vasodilators should be avoided in SBP < _____ mmHg
T/F: Vasodilators do not need to be protected from light
What kind of vasodilator is nitroprusside?
Mixed arterial and venous vasodilator
Effects of mixed arterial and venous vasodilators on the body:
- ↓ SVR
- ↓ BP
- ↑ CO
Which drug should be considered in pts w/ significantly ↑ SVR?
T/F: Nitroprusside has a long half life and can be stopped quickly if needed
- ↓BP, HA, ↑ ICP
- Thiocyanate toxicity - concern w/ renal impairment
- Cyanide toxicity - concern w/ liver impairment
NTG is what kind of vasodilator?
Mild arterial vasodilator
How does NTG affect preload and PCWP?
AE of NTG:
- ↓ BP, ↑ HR
- Excessive ↓ PCWP
- ↓ BP
- Use of PDE-5i
- allergy to corn or corn products
T/F: Tolerance may develop to NTG
____________ is an IV vasodilator that is no longer available in the US
_______________ are recommended in pts w/ severe systolic fxn who present w/ signs of hypoperfusion - to maintain systemic perfusion and preserve end-organ performance
MOA of positive inotropes:
Enhance contractility by increasing cAMP
Examples of positive inotropes:
- β-agonists (dobutamine, dopamine)
- PDEi (milrinone)
Which class of drug activates adenylate cyclase which catalyzes adenosine triphosphate to increase cAMP?
Which class of drug inhibits the breakdown of cAMP?
T/F: Digoxin is used in the acute management of ADHF
- Arrhythmia risk (ECG)
This drug has potent inotropic effects (β1) with vasodilating effects as well (β2) and has minimal change on MAP
Why does dobutamine have minimal effects on MAP?
↑ CI and ↓ arteriolar resistance
This drug has positive inotropic and arterial and venous vasodilating effects (inodilator). Can either have no change in or decrease MAP and reflex ↑ HR
T/F: Milrinone can cause a greater drop in BP than dobutamine
T/F: Milrinone dose should be reduced in renal impairment (CrCl <50)
This drug is reserved for marked HoTN or cardiogenic shock
- May ↑ myocardial O2 demand and ↓ myocardial blood flow
- ↑ HR
List other meds that can be used for ADHF:
- VTE prophylaxis
- Vasopressin antagonists
When should VTE prophylaxis be used?
pts hospitalized for HF
Examples of vasopressin antagonists:
- Conivaptan (Vaprisol)
- Tolvaptan (Samsca)
When should vasopressin antagonists be used?
pts hospitalized for HF w/ volume overload and persistent severe hyponatremia
Monitoring response to therapy should be done how often?
If a pt is on GDMT therapy prior to admission, what should be done?
Continue GDMT in the absence of hemodynamic instability or contraindications
If a pt is not on GDMT therapy prior to admission, what should be done?
- Initiate GDMT prior to hospital discharge
- Initiate BB after optimization of volume status and successful DC of IV diuretics, vasodilators, and inotropic agents
Examples of GDMT:
ARNI, ACEi/ARBs, BB, sprionolactone
Discharge counseling for ADHF pts:
- Discharge meds
- Daily weight monitoring
- Activity level
- FU appts
- What to do if sx worsen
- FU clinic visit scheduled usually 7-14 d