Acute decompensated heart failure

1. Acute Decompensated Heart FailureAcute Decompensated Heart Failure
(ADHF)- Inpatient Management(ADHF)- Inpatient Management
Dr.Armaan Singh

2. ObjectivesObjectives
Learn to identify the signs and symptoms
of ADHF
Learn to interpret pertinent laboratory
data and imaging
Learn the inpatient management of
ADHF

3. Clinical VignetteClinical Vignette

4. Clinical VignetteClinical Vignette
 62 year old Caucasian male with PMH of ischemic
cardiomyopathy (EF 25%), CAD, HTN presents with two
week history of dyspnea
 Previously able to walk 2 miles, currently cannot walk more
than 10 feet before developing DOE
 PND 3 times per night
 4 pillow orthopnea
 Increasing lower extremity edema
 ROS: loss of energy, loss of appetite, 10# weight gain

5. Clinical VignetteClinical Vignette
PMH: ischemic cardiomyopathy (EF 25%,
based on echocardiogram 6 months prior),
CAD (s/p MI with PCI in 2002), HTN
Home medications: ASA 81mg daily,
Lisinopril 5mg daily, Lasix 40mg daily
Allergies: NKDA
ROS: denies CP, denies dizziness, denies
palpitations

6. Clinical VignetteClinical Vignette
VS: Temp 36.5, HR 90, BP 108/72, RR 20, SpaO2
91% on RA
Pertinent physical exam:
◦ General: appears uncomfortable, able to speak short
sentences
◦ HEENT: Jugular venous distension at 10cm
◦ CVS: PMI displaced laterally to mid-axillary line in the 6th
ICS, (-) heaves, thrills, RRR, (+) S3, (-)S4, (-) murmurs or
rubs
◦ Chest: loss of tactile fremitus at the base with dullness to
percussion, (+) rales throughout bottom half of lung fields
bilaterally
◦ Abdomen: distended, (+) mild fluid wave, (+)
hepatojugular reflux,
◦ Extremities: 2+ pitting edema up to knees bilaterally, cool
to touch, 2+ DP and PT pulses

7. Clinical VignetteClinical Vignette
Current presentation consistent with
acute decompensated heart failure
(ADHF)
What labs should we order to help
evaluate further?

8. Laboratory DataLaboratory Data
CBC
◦ Anemia, infection can precipitate ADHF
BMP
◦ Hyponatremia- poor prognostic sign
◦ Elevated creatinine- impaired renal perfusion
LFT
◦ May be elevated due to congestive hepatopathy
Troponin
◦ Ischemia can precipitate HF
◦ Troponin may be mildly elevated in HF as well from
demand ischemia

9. Laboratory DataLaboratory Data
BNP
◦ < 100 strongly suggestive against HF
◦ >400 suggestive of HF exacerbation
 However may be falsely elevated in:
 Renal disease, atrial fibrillation, pulmonary HTN
 May be falsely low in:
 Obese patients, HFPEF
Toxicology screen
◦ In select patients, as drug abuse can trigger
exacerbation
TSH
◦ Untreated thyroid disease can precipitate exacerbation

10. Clinical VignetteClinical Vignette
At this point, what imaging should be
obtained to further assist with
management?

11. Imaging: EKGImaging: EKG
Important to look for underlying
◦ Ischemia
◦ Arrhythmias

12. Imaging: Chest x-rayImaging: Chest x-ray
Enlarged cardiac silhouette
Pulmonary edema
Pulmonary congestion
◦ Cephalization
◦ Kerley B lines
◦ Peri-bronchial cuffing
Pleural effusions, typically bilateral

13. Clinical VignetteClinical Vignette
Should an echocardiogram be repeated?

14. Imaging: EchoImaging: Echo
Typically repeated no sooner than annually
Provides information regarding;
◦ Ejection fraction
◦ Diastolic dysfunction
◦ Wall motion abnormalities
◦ Chamber sizes
◦ Pulmonary HTN
◦ Ventricular dysynchrony

15. Clinical VignetteClinical Vignette
How should we begin our inpatient
management?

16. Non-pharmacologic ManagementNon-pharmacologic Management
Daily weight
Strict I’s and O’s
Low sodium diet (<2g daily)
Fluid restriction
◦ Typically only for patients with hyponatremia

17. Clinical VignetteClinical Vignette
What should we use to improve our
patient’s volume status?

18. Treatment: DiureticsTreatment: Diuretics
Recommend to give intravenously initially
Typically at least twice a day
Agents
◦ Furosemide
 Can give home dose as IV (2:1 po to IV ratio)
 Titrate up based on response (goal net negative
1.5-2L daily on average)
◦ Bumetanide
 Alternative to Furosemide in tolerant patients
 40 mg IV Lasix = 1 mg IV Bumetanide = 1mg po
Bumetanide

19. Clinical VignetteClinical Vignette
The patient is now receiving 40mg
Furosemide IV twice a day
What could be done next if the patient
did not respond to Furosemide?
How often should his electrolytes be
monitored?

20. Treatment: DiureticsTreatment: Diuretics
If not responding to initial diuretic dose:
◦ Can titrate dose up further
◦ Older patients, underlying renal dysfunction may
require higher doses
Can consider adding Metolazone for additional
effect
◦ Thiazide diuretic
Monitoring of electrolytes closely
◦ Check potassium and magnesium at least daily
◦ If aggressive diuresis, check at least twice daily

21. Clinical VignetteClinical Vignette
The patient did not come in on a beta
blocker, but this has been shown to
improve long-term mortality in heart
failure
Should we begin a beta blocker at this
time?
Which beta blocker (if any) should we
choose?

22. Treatment: Beta blockersTreatment: Beta blockers
Typically not initiated during acute exacerbation
Continue if already on
◦ Stopping can worsen RAAS activation
◦ If SYMPTOMATIC hypotension, can decrease the
dose
Options
◦ Carvedilol: lowest dose 3.125mg BID
◦ Metoprolol XL: lowest dose 25mg daily
◦ Titrate to goal HR of 60 bpm
 Or as much as BP can tolerate

23. Caveat: Blood pressureCaveat: Blood pressure
Patients with heart failure frequently have a
lower BP than the general population
◦ Due to reduced cardiac output
Not unusual to see patient’s with reduced
EF to have a SBP in the 80s-100s
Use of medications which can lower BP is
not contraindicated in these populations
◦ However, need to ensure patient does not have
lightheadedness, orthostatic hypotension

24. Clinical VignetteClinical Vignette
The patient has been having an appropriate
diuresis
Clinically, patient reports improvement in
shortness of breath and now able to walk
without DOE
PE: resolution of rales, peripheral edema
How should the diuretic dose be adjusted?
What medications should be added to his
regimen prior to discharge?

25. Medication AdjustmentMedication Adjustment
Diuretic
◦ Patient should be transitioned to po regimen
◦ Can base the po on the dose of the IV dose
 E.g. Furosemide 40mg IV BID  40mg po BID
◦ Should monitor for at least 24 hours on po to
ensure proper response

26. Chronic medical managementChronic medical management
 ACEI/ARB
◦ Shown to improve mortality
◦ Already on Lisinopril, can titrate up further as tolerated
◦ Consider decreasing dose or discontinuing if: SYMPTOMATIC
hypotension, AKI, hyperkalemia
 Spironolactone
◦ Shown to improve mortality (RALES trial)
◦ Indications: EF <30% and NYHA Class II OR EF <35% and NYHA Class
III/IV
◦ Benefits: enhances diuresis, minimizes K wasting
◦ Dosing: lowest: 12.5mg, titrate up as tolerated
 Digoxin
◦ Reduces rate of hospital admissions
◦ No significant effect on mortality  no longer used as frequently now

27. Clinical VignetteClinical Vignette
Which patients benefit from combination
therapy with Isosorbide
dinitrate/Hydralazine?

28. Treatment:Treatment:
Isosorbide dinitrate/HydralazineIsosorbide dinitrate/Hydralazine
◦ Added to standard therapy for heart failure
◦ Efficacious and increases survival among black
patients with heart failure
◦ Dosing:
Isosorbide dinitrate/Hydralazine
20mg/37.5mg TID

29. Transition to OutpatientTransition to Outpatient

30. Our patient’s discharge medsOur patient’s discharge meds
Furosemide 40mg BID
Lisinopril 5mg daily
Carvedilol 3.125mg BID
Spironolactone 12.5mg daily
ASA 81mg daily

31. SummarySummary
Identify clinical signs and symptoms of ADHF
Pertinent labs
◦ Sodium, creatinine, troponin, BNP
Relevant imaging
◦ EKG, CXR, echocardiography
Treatment
◦ Diuresis, BB, ACEI/ARB, Spironolactone, Digoxin,
Isosorbide dinitrate/Hydralazine
Transition to outpatient
◦ Strict instructions, close-follow-up