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ACUTE DECOMPENSATED HEART FAILURE: 2010 HEART FAILURE SOCIETY OF AMERICA GUIDELINES
BART COX, M.D., FACC ASSOCIATE PROFESSOR OF MEDICINE UNIVERSITY OF NEW MEXICO SCHOOL OF MEDICINE DIRECTOR , ADVANCED HEART FAILURE PROGRAM
DISCLOSURES
NONE
ADHF: 2010 HFSA GUIDELINE DEFINITION
THE DIAGNOSIS OF ACUTE DECOMPENSATED HEART FAILURE (ADHF) SHOULD BE BASED PRIMARILY ON SIGNS AND SYMPTOMS
ADHF STATISTICS > 5.5 MILLION HF PATIENTS IN USA
>650,000 NEW HF CASES ANNUALLY
1 YEAR MORTALITY IS 20-30%
5 YEAR MORTALITY RATE OF 50-60%
ADHF STATISTICS
1 MILLION HOSPITAL ADHF ADMISSIONS ANNUALLY
ANOTHER 2 MILLION ANNUAL ADMISSIONS IN WHICH HF COMPLICATED THE PRIMARY DIAGNOSIS
30-50% OF PATIENTS DISCHARGED WITH ADHF WILL BE READMITTED WITHIN 3-6- MONTHS
ADHF STATISTICS 50% OF ADHF ADMISSIONS HAVE
LVEF>40% 50% OF ADHF ADMISSIONS HAVE LVEF <
40% AVERAGE PATIENT ADMITTED WITH
ADHF IS 75 YEARS OF AGE WITH SUBSTANTIAL COMORBIDITES
MOST COMMON CAUSE OF ADHF HOSPITALIZATION IS EXACERBATION OF CHRONIC HF
FIGURE 43-1
10 MINUTES OF BAD MEMORIES
FILLING PRESSURES LEFT VENTRICULAR FILLING PRESSURE: THE
PRESSURE IN THE LV CAVITY AT THE END OF DIASTOLE ◦ LV END DIASTOLIC PRESSURE (LVEDP) ◦ MEAN LA PRESSURE ◦ PCWP
RIGHT VENTRICULAR FILLING PRESURE: THE PRESSURE IN THE RV CAVITY AT THE END OF DIASTOLE ◦ RV END DIASTOLIC PRESSURE (RVEDP) ◦ MEAN RIGHT ATRIAL PRESSURE ◦ CVP
LEFT VENTRICULAR FILLING PRESSURE
CONGESTION AND FILLING PRESSURES SYMPTOMATIC CONGESTION IS DUE
TO INCREASED FILLING PRESSURES ◦ ELEVATED LEFT VENTRICULAR FILLNG
PRESSURES =SIGNS AND SX OF PULMONARY CONGESTION APPEAR ◦ ELEVATED RIGHT VENTRICULAR FILLING
PRESSURES = SIGNS AND SX OF SYSTEMIC CONGESTION APPEAR
TO RELIEVE CONGESTION, LOWER
FILLNG PRESSURES!!!
2 TYPES OF CONGESTION
PULMONARY CONGESTION ◦ DUE TO ELEVATED LEFT HEART FILLING
PRESSURES
SYSTEMIC CONGESION ◦ DUE TO ELEVATED RIGHT HEART FILLING
PRESSURES
SYMPOTMS OF PULMONARY CONGESTION
DYSPNEA
ORTHOPNEA
PND
SUPINE COUGH
SYMPTOMS OF SYSTEMIC CONGESTION
EDEMA
ABOMINAL OR HEPATIC SWELLING AND DISCOMFORT
ANOREXIA
EARLY SATIETY
SIGNS OF PULMONARY CONGESTION RALES WHEEZING PLEURAL EFFUSION HYPOXEMIA LEFT-SIDED S3 WORSENING MITRAL
REGURGITATION
SIGNS OF SYSTEMIC CONGESTION ELEVATED JVP HEPATOJUGULAR REFLUX RIGHT-SIDED S3 WORSENING TRICUSPID
REGURGITATION HEPATIC ENLARGEMENT/
TENDERNESS ASCITES EDEMA
PERFUSION= CARDIAC INDEX
NORMAL PERFUSION= NORMAL
CARDIAC INDEX
DIMINISHED PERFUSION = LOW CARDIAC INDEX
CARDIAC OUTPUT
CARDIAC OUPUT (CO) = HR X STROKE VOLUME ◦ 3 PARAMETERS OF STROKE VOLUME: PRELOAD (LVEDP OR RVEDP) CONTRACTILITY AFTERLOAD (THE ARTERIAL PRESSURE
AGAINST WHICH THE VENTRICLE MUST CONTRACT; SYSTEMIC VASC. RESISTANCE, AORTIC IMPEDENCE)
NORMAL VALUES
NORMAL CO=5 L/MIN
NORMAL CI=3 L/MIN/SQ. METERS
TO IMPROVE PERFUSION,INCREASE CARDIAC OUTPUT
1) OPTIMIZE HEART RATE AND RHYTHM
2) OPTIMIZE FILLING PRESSURE 3) INCREASE CONTRACTILITY 4) DECREASE AFTERLOAD
HFSA GUIDELINES: WHEN IS HOSPITALIZATION RECOMMENDED
EVIDENCE OF SEVERELY DECOMPENSATED HF ◦ ALTERED MENTAL STATUS, LOW BP,
WORSENING RENAL FUNCTION
DYSPNEA AT REST (02 SAT <90%) HEMODYNAMICALLY SIGNIFICANT
ARRHYTHMIA ACUTE CORONARY SYNDROMES
HFSA GUIDELINES: WHEN HOSPITALIZATION SHOULD BE CONSIDERED
MAJOR ELECTOLYTE DISTURBANCE ASSOCIATED COMORBID CONDITIONS REPEATED ICD FIRINGS NEWLY DIAGNOSED HF WITH
SIGNS / SX OF CONGESTION
TAKEHOME MESSAGE:HOSPITALIZATION FOR ADHF IS REQUIRED WHEN:
ADHF + SOMETHING ELSE NEW ONSET ADHF SIGNIFICANTLY WORSENING CONGESTION WHEN ADHF REQUIRES A PROCEDURE: ◦ SWAN / ULTRAFILTRATION ◦ CARDIOVERSION / PACEMEAKER ◦ CATHETERIZATION / PCI ◦ INTUBATE / OXYGENATE
WHAT ARE THE TREATMENT GOALS FOR ADHF ADMISSION?
HFSA GUIDELINES: TREATMENT GOALS FOR ADHF ADMISSION
SYMPTOMS ABATED (TX CONGESTIVE SYMPTOMS, FATIGUE)
DEHYDRATED (ACHIEVE EUVOLEMIA) OXYGENATED (RESTORE NORMAL 02
SATURATION) ANTICOAGULATED (IF INDICATED) MEDICATED (OPTIMIZE MEDS) EDUCATED (MEDS/ SELF-MANAGEMENT) OPERATED (REVASCULARIZE IF NEEDED)
TREATMENT GOALS FOR ADHF ADMISSION
DIAGNOSED (ETIOLOGY,
PRECIPITATING FACTORS)
DEVICED (ICD, CRT)
DISEASE MANAGED (IF AVAILABLE)
ETIOLOGY OF HF
PERICARDIAL DISEASE CORONARY DISEASE MYOCARDIAL DISEASE VALVULAR DISEASE ELECTRICAL DISEASE CONGENITAL DISEASE GREAT VESSEL DISEASE
COMMON PRECIPITATING FACTORS OF ADHF DIETARY AND MEDICATION RELATED
CAUSES PROGRESSIVE CARDIAC
DYSFUNCTION CARDIAC CAUSES NOT PRIMARILY
MYOCARDIAL IN ORIGIN NON-CARDIAC CAUSES ADVERSE CARDOVASCULAR EFFECTS
OF MEDICATIONS
COMMON PRECIPITATING FACTORS ARRHYTHMIAS (AF, A FLUTTER, SVT, VT) EXACERBATION OF HYPERTENSION MYOCARDIAL ISCHEMIA/INFARCTION ANEMIA THYROID DISEASE SIGNIFICANT DRUG INTERACTION RIGHT VENTRICULAR PACING PULMONARY DISEASE
THE 4 HEMODYNAMIC PROFILES
INITIAL CLINCIAL ASSESSMENT
FIRST HOSPITALIZATION PRIORITY: ASSESS LEVEL OF HEMODYNAMIC COMPROMISE ◦ PERFUSION (CARDIAC INDEX) ◦ CONGESTION (PCWP AND RA
PRESSURE)
RECOGNIZING THE FOUR HEMODYNAMIC PROFILES
CONGESTION = WET NO CONGESTION=DRY
NORMAL PERFUSION= WARM
DIMINISHED PERFUSION=COLD
PROFILES AND HEMODYNAMICS
DRY= PCWP <18 AND RA < 8
WET = PCWP >18 OR RA > 8
WARM= CI > 2.2
COLD= CI < 2.2
RECOGNIZING THE 4 HEMODYNAMIC PROFILES
2 HEMODYNAMIC COMPONENTS OF DECOMPENSATED HEART FAILURE: ◦ ELEVATED FILLING PRESSURES ◦ REDUCED CARDIAC OUTPUT (RARE)
THESE 2 COMPONENTS MAY NOT OCCUR TOGETHER
RECOGNIZING THE 4 HEMODYNAMIC PROFILES
IN THE MAJORITY OF PATIENTS,
FILLING PRESSURES HAVE BEEN INCREASING FOR AT LEAST 2 WEEKS
IT’S FAR EASIER TO ACCURATELY JUDGE FILLING PRESSURE THAN PERFUSION
2 MINUTE ASSESSMENT AND 4 HEMODYNAMIC PROFILES
PRINCIPLES OF THERAPY: FOCUS ON CONGESTION / FILLING PRESSURES IN WET PATIENTS
RELIEVE CONGESTION BY REDUCING FILLING PRESSURES
ABSENT CRITICAL ORGAN/RENAL/SYSTEMIC HYPOPERFUSION THAT LIMITS FILLING PRESSURE REDUCTION, IMPROVING CARDIAC OUTPUT DOES NOT WORK!!!
PRINCIPLES OF THERAPY: THE OPTIMAL FILLING PRESSURE
WITH LOW EF, OPTIMAL PCWP < 15-16 ◦ LOWERING FILLING PRESSURES -> IMPROVED
STROKE VOLUME ELEVATED FILLING PRESSURES: ◦ RESPONSIBLE FOR SX OF CONGESTION ◦ ACTIVATE NEUROHORMONES (RAS, SNS) ◦ INCREASE VALVULAR REGURGITATION ◦ RESPONSIBLE FOR PULMONARY HYPERTENSION ◦ CAUSE RIGHT VENTRICULAR DYSFUNCTION ◦ CAUSE ABNORMAL LV FILLING PATTERNS
FILLING PRESSURES AND STROKE VOLUME
STROKE VOLUME IMPROVED BY DECREASING MR
PROFILE A: WARM AND DRY
PROFILE B: WARM AND WET
PROFILE B: WET AND WARM MOST PATIENTS PRESENTING WITH ADHF
ARE PROFILE B GOAL OF TX: SX IMPROVEMENT BY
REDUCTION IN FILLING PRESSURES ◦ ELEVATED FILLING PRESSURES ARE DUE TO: INCREASED INTRAVASCULAR VOLUME INCREASED SVR BOTH
FOR MAJORITY, IV DIURETIC TX IS THE MAIN INTERVENTION ◦ MAY REQUIRE ADDITION OF METOLAZONE OR
IV CHLORTHIAZIDE
PROFILE B: ROLE FOR ADJUNCTIVE AGENTS USE OF ADJUNCTIVE THERAPIES BEYOND
DIURETICS HAS NOT BEEN DEMONSTRATED TO IMPROVE OUTCOMES IN HOSPITALIZED ADFH PATIENTS IN PROFILE B ◦ INOTROPES: ISCHEMIA, ARRHYTHMIAS, POSSIBLY
DEATH ◦ NTG: NEUTRAL OUTCOMES ◦ NESIRITIDE: EXPENSIVE PLACEBO ◦ ENDOTHELIN ANTAGONIST: NO IMPROVEMENT ◦ VASOPRESSIN ANTAGONISTS: NEGATIVE FLUID
BALANCE NOT SUSTAINED LONG-TERM
PROFILE B: VERY HIGH OR VERY LOW SYSTEMIC VASCULAR RESISTANCE(SVR)
VERY HIGH SVR > 2000 dyne/sec/cm-5 HOW TO RECOGNIZE ◦ HIGH BP ◦ VERY NARROW PULSE PRESSURE ◦ PA CATHETER MEASUREMENT
VERY LOW SVR (WITHOUT MEDS): LOW BP + REASONABLE PULSE PRESSURE + WARM EXTREMITIES
PROFILE C: COLD AND WET
PROFILE C: WET AND COLD
<3% OF PATIENTS PRESENT WITH CARDIOGENIC SHOCK
WET=CONGESTION COLD=INADEQUATE PERFUSION TX: MAY NEED TO WARM THEM UP
BEFORE DRYING THEM OUT ◦ DIURESIS WILL IMPROVE CARDIAC OUTPUT ◦ IN MANY CASES, DIURESIS IS NOT POSSIBLE
IF RENAL PERFUSION SEVERLY COMPROMISED
PROFILE C: IV VASODILATORS OR INOTROPES? CHOICE OF THERAPY DEPENDS ON
SYSTEMIC VASCULAR RESISTANCE ◦ IF SVR SIGNIFICANTLY ELEVATED:
VASODILATOR ◦ IF SVR NORMAL-LOW: INOTROPE
IF INOTROPES USED, KEEP THE DOSE
AS LOW AS POSSIBLE
PROFILE L:COLD AND DRY
PROFILE L: DRY AND COLD EXTEMELY RARE PRESENTATION REQUIRE PA CATHETER PLACEMENT TO
EVALUATE FILLING PRESSURES ◦ IF PCWP<12 OR RA PRESSURE <8: PO FLUID
REPLACEMENT OFF DIURETICS ◦ IF PCWP>16: PROFILE C ◦ IF PCWP 12-16 + NORMAL RA PRESSURE:
LIMITED OPTIONS INOTROPES AND VASODILATORS ONLY
TEMPORARY FIX; VAD/ TRANSPLANT BETA BLOCKERS MAY LEAD TO LATER
IMPROVEMENT IN LV FUNCTION
ADHF EVALUATION
HISTORY PHYSICAL EXAMINATION EKG PA AND LATERAL CHEST XRAY ECHOCARDIOGRAM LABS ISCHEMIA EVALUATION AS
APPROPRIATE
ADHF: THE HISTORY
CLASSIC SYMPTOMS DOE OR AT REST REDUCTION IN EXERCISE CAPACITY ORTHOPNEA PND OR NOCTURNAL COUGH EDEMA ASCITES OR SCROTAL EDEMA
ADHF: THE HISTORY
LESS SPECIFIC PRESENATION OF HF ◦ EARLY SATIETY, N&V, ABDOMINAL
DISCOMFORT ◦ WHEEZING OR COUGH ◦ UNEXPLAINED FATIGUE ◦ CONFUSION / DELERIUM ◦ DEPRESSION / WEAKNESS
ADHF HISTORY: WHAT TO INCLUDE ANGINA SX SUGGESTING AN EMBOLIC EVENT SX SUGGESTIVE OF SLEEP DISORDERED
BREATHING SX OF ARRHYTHMIA (PALPITATIONS) SX OF CEREBRAL HYPOPERFUSION
(SYNCOPE, PRESYNCOPE, LIGHTHEADEDNESS)
NYHA FUNCTIONAL CLASSIFICATION IN HF
CLASS I: NO FATIGUE, PALPITATIONS, OR DYSPNEA (FPD) WITH ORDINARY ACTIVITY
CLASS II: FPD WITH ORDINARY ACTIVITY CLASS IIIA:FPD WITH LESS THAN
ORDINARY ACTIVITY CLASS IIIB: FPD WITH MINIMAL ACTIVITY CLASS IV: FPD AT REST
SENSITIVITY OF EXAM FOR ELEVATED LEFT-SIDED FILLING PRESSURES IN LOW EF
RIGHT –SIDED FINDINGS ◦ JVP > 12 65% ◦ EDEMA >2+ 41% ◦ HJR 83% ◦ HEPATOMEGALY > 4 FB 15%
SENSITIVITY OF EXAM FOR ELEVATED LEFT-SIDED FILLING PRESSURES IN LOW LVEF
LEFT- SIDED FINDINGS ◦ ORTHOPNEA 86% ◦ RALES > “FEW @ BASES” 15% ◦ S3 63%
ADHF EVALUATION: ECHOCARDIOGRAM
SIZE, THICKNESS, AND FUNCTION OF BOTH VENTRICLES
FILLING PATTERN OF LV ATRIAL SIZE VALVULAR STRUCTURE AND FUNCTION PERICARDIUM GREAT VESSELS RVSP THROMBUS OR MASS
ADHF EVALUATION: EKG
ASSESS RHYTHM AND CONDUCTION ASSESS ELECTRICAL DYSSYNCHRONY,
ESPECIALLY IF LVEF < 35% (QRS DURATION)
ASSESS QTc INTERVAL DETECT MI OR ISCHEMIA DETECT LVH OR OTHER CHAMBER
ENLARGEMENT
ADHF EVALUATION: PA AND LATERAL CHEST XRAY
HEART SIZE PULMONARY CONGESTION PULMONARY PARENCHYMAL DISEASE PERICARDIAL OR VALVULAR
CALCIFICATION PLACEMENT OF IMPLANTED
CARDIAC DEVICE
ADHF: LABORATORY STUDIES CBC ELECTROLYTES, BUN, CREATININE,
GLUCOSE CALCIUM, MAGNESIUM URINALYSIS LIVER FUNCTION AND ALBUMIN THYROID FUNCTION URIC ACID FASTING LIPID PANEL BNP OR NT BNP
WHEN TO PLACE A SWAN
What I’m doing isn’t working…
it’s not going well….
I don’t know if they are wet or dry…
And I don’t want to make a mistake…
WHEN TO CONSIDER INVASIVE HEMODYNAMIC MONITORING:
HFSA GUIDELINES
THE ROUTINE USE OF INVASIVE HEMODYNAMIC MONITORING IN
PATIENTS WITH ADHF IS NOT RECOMMENDED
WHEN TO CONSIDER INVASIVE HEMODYNAMIC MONITORING:HFSA GUIDELINES
REFRACTORY TO INITIAL THERAPY AND
WHOSE VOLUME STATUS AND CARDIAC FILLING PRESSURES ARE UNCLEAR AND
HAS CLINICALLY SIGNIFICANT HYPOTENSION (TYPICALLY SBP <80-90 mm Hg
OR
WHEN TO CONSIDER INVASIVE HEMODYNAMIC MONITORING: HFSA GUIDELINES PATIENT IS BEING CONSIDERED FOR CARDIAC TRANSPLANT AND NEEDS ASSESSMENT OF DEGREE AND REVERSIBILITY OF PULMONARY HTN
OR WHEN DOCUMENTATION OF AN ADEQUATE HEMODYNAMIC RESONSE TO THE INOTROPIC AGENT IS NECESSARY WHEN CHRONIC OUTPATIENT INFUSION IS BEING CONSIDERED
GUIDELINE-ACCEPTED INDICATIONS FOR PA CATHETER PLACEMENT IN AN ADHF PATIENT
THERAPY ISN’T WORKING + VOLUME STATUS UNKNOWN + SBP <90
PRE-HEART TRANSPLANT WORKUP DOCUMENTING BENEFIT OF INOTROPE
BEFORE DISCHARGING ON CHRONIC INFUSION
DIURETICS
HFSA GUIDELINE:HOW TO DIURESE
DIURESES WITH IV LOOP DIURETIC ULTRAFILTRATION MAY BE USED IN
LIEU OF IV DIURETICS DIURESE UNTIL DRY DIURESE AT THE CORRECT RATE
HFSA GUIDELINES: WHAT TO MONITOR DURING DIURESIS MONITORING OF DAILY WEIGHTS,
INTAKE, AND OUTPUT IS RECOMMENDED TO ASSESS CLINICAL EFFICACY OF DIURETIC THERAPY.
ROUTINE USE OF A FOLEY CATHETER IS NOT RECOMMENDED FOR MONITORING VOLUME STATUS.
HFSA GUIDELINES: DIURETIC SIDE EFFECTS
OBSERVE FOR DEVELOPMENT OF DIURETIC-INDUCED SIDE EFFECTS
CHECK SERUM MAGNESIUM AND POTASSIUM LEVELS AT LEAST DAILY
OVERLY RAPID DIURESIS MAY BE ASSOCIATED WITH MUSCLE CRAMPS.
DIURETIC SIDE EFFECTS HYPOKALEMIA HYPOMAGNESEMIA HYPONATREMIA HYPOTENSION NEUROHORMONAL ACTIVATION GOUT EXACERBATON HEARING LOSS INCREASED INCIDENCE OF DIG
TOXICITY
HFSA GUIDELINES: VOLUME OVERLOAD, RENAL DYSFUNCTION, AND DIURETIC USE
DURING DIURESIS, CAREFUL MONITORING FOR RENAL INSUFFICIENCY IS RECOMMENDED.
PATIENTS WITH MODERTE TO SEVERE RENAL DYSFUNCTION AND EVIDENCE OF FLUID RETENTION SHOULD CONTINUE TO BE TREATED WITH DIURETICS
Copyright ©2009 American College of Cardiology Foundation. Restrictions may apply.
Gheorghiade, M. et al. J Am Coll Cardiol 2009;53:557-573
The Cardio-Renal Syndrome
HFSA GUIDELINES: DESTROYING DIURETIC RESISTANCE
DIAGNOSE IT: ARE THEY TRULY WET? DECREASE THE Na AND FLUID INTAKE DOSE IT: INCREASE THE DOSE OF DIURETIC DRIP IT: SWITCH TO A CONTINUOUS INFUSION DOUBLE THE DIURETIC: ADD CHLORTIHIAZIDE DEVICE IT: CONSIDER ULTRAFILTRATION
DAILY CARE OF THE ADHF PATIENT
HFSA GUIDELINES:MONITORING RECOMMENDATIONS FOR HOSPITALIZED ADHF PATIENTS
WEIGHT (DAILY) FLUID I&O (AT LEAST DAILY) VITAL SIGNS: ORTHOSTATIC AND O2 SAT LABS: LYTES, BUN, Mg, CREATINNE (>DAILY) CONGESTIVE SIGNS (AT LEAST DAILY) CONGESTIVE SYMPTOMS (AT LEAST DAILY)
HFSA GUIDELINE: FLUID RESTRICTION RESTRICTING FLUID INTAKE TO 2
L/DAY IS USUALLY ADEQUATE FOR MOST HOSPITALIZED PATIENTS
FLUID RESTRICTION < 2 L/DAY IS RECOMMENDED IN PATIENTS WITH Na <130 mEq/L AND SHOULD BE CONSIDERED TO ASSIST IN TREATMENT OF FLUID OVERLOAD IN OTHER PATIENTS.
HFSA GUIDELINE: THE LOW SODIUM DIET
A 2 GRAM/DAY SODIUM DIET IS RECOMMENDED FOR MOST HOSPITALIZED PATIENTS
HFSA GUIDELINE: USE OF SUPPLEMENTAL OXYGEN IN ADHF ROUTINE ADMINISTRATION OF
SUPPLEMENTAL OXYGEN IN THE PRESENCE OF HYPOXIA IS RECOMMENDED
ROUTINE ADMINISTRATION OF SUPPLEMENTAL OXYGEN IN THE ABSENCE OF HYPOXIA IS NOT RECOMMENDED
HFSA GUIDELINE: USING NON-INVASIVE VENTILATION (NIV)
USE OF NON-INVASIVE POSITIVE PRESSURE VENTILATION MAY BE CONSIDERED FOR SEVERLY DYSPNIC PATIENTS WITH CLINICAL EVIDENCE OF PULMONARY EDEMA ◦ NIV IMPROVES DYSPNEA ◦ NIV LIKELY HAS NO IMPACT ON
INTUABION RATES OR MORTALITY
HFSA GUIDELINE: DVT PROPHYLAXIS IN THE ADHF PATIENT VENOUS THROMBOEMBOLSIM PROPHYLAXIS
WITH LOW DOSE UFH, LMWH, OR FONDAPARINUX TO PREVENT DEEP VENOUS THROMBOSIS(DVT) AND PULMONARY EMBOILISM IS RECOMMENDED FOR ADHF PATIENTS:
◦ WHO ARE NOT ALREADY ANTICOAGULATED
AND ◦ WHO HAVE NO CONTRAINDICATION TO
ANTICOAGULATION
HFSA GUIDELINE: DVT PROPHYLAXIS IN THE ADHF PATIENT VENOUS THROMBOLISM PROPHYLAXIS WITH A
MECHANICAL DEVICE (INTERMITTENT PNEUMATIC COMPRESSION DEVICES OR GRADED COMPRESSION STOCKINGS) TO PREVENT DVT AND PE SHOULD BE CONSIDERED FOR PATIENTS WHO AE ADMITTED TO THE HOSPITAL WITH ADHF AND ◦ WHO ARE NOT ALAREADY ANTICOAGULATED
AND ◦ WHO HAVE A CONTRAINDICATION TO
ANTICOAGULATION
VASODILATORS
IV VASODILATORS USED IN ADHF
NITROGLYCERIN
NITROPRUSSIDE
ASCEND-HF
No significant ↑ in major improvement in shortness of breath with nesiritide compared with placebo at 6 (15.0% vs. 13.4%) and 24 hours (30.4% vs. 27.5%)
At 30 days, death or CHF hospitalization: 9.4% vs. 10.1%; all-cause mortality: 3.6% vs. 4.0%, (p > 0.05)
Worsening renal failure: 31.4% vs. 29.5%, p = 0.11; symptomatic hypotension: 7.1% vs. 4.0%, p < 0.001
Trial design: Patients presenting with acute decompensated CHF and requiring intravenous treatment were randomized to receive intravenous infusion of nesiritide or placebo, in addition to standard therapy. Patients were followed for 30 days.
Results
Conclusions
Presented by Dr. Adrian Hernandez at AHA 2010
(p = 0.31)
Nesiritide (n = 3,564)
Death or CHF hospitalization
• Nesiritide was associated with none to minimal improvements in dyspnea at 6 and 24 hours; clinical outcomes including death and repeat hospitalizations similar; no increase in renal failure with nesiritide
• Largest trial with this medication; no signal of harm as noted by earlier smaller trials; clinical utility is likely minimal
0
50
100
%
9.4 10.1
(p > 0.05)
3.6 4.0
5
All-cause mortality
Placebo (n = 3,577)
0
10
%
HFSA GUIDELINE: TREATING ADHF PATIENTS WITH ACUTE PULMONARY EDEMA OR SEVERE HYPERTENSON
INTRAVENOUS VASODILATORS (NITROGLYCERIN OR NITROPRUSSIDE) ARE RECOMMENDED FOR RAPID SYMPTOM RELIEF IN PATIENTS WITH ACUTE PULMONARY EDEMA OR SEVERE HYPERTENSION
HFSA GUIDELINES: USING IV VASODIALTORS IN ADHF IN THE ABSENCE OF SYMPTOMATIC
HYPOTENSION, IV NITROGLYCERIN OR NITROPRUSSIDE MAY BE CONSIDERED AS AN ADDITION TO DIURETIC THERAPY FOR RAPID IMPROVEMENT OF CONGESTIVE SYMPOTMS IN PATIENTS ADMITTED WITH ADHF.
HFSA GUIDELINES: OTHER USES OF IV VASODILATORS
INTRAVENOUS VASODILATORS (NITROPRUSSIDE OR NITROGLYCERIN) MAY BE CONSIDERED IN PATIENTS WITH ADHF WHO HAVE PERSISTENT SEVERE HF DESPITE AGGRESSIVE TREATMENT WITH DIURETICS AND STANDARD ORAL THERAPIES
INOTROPES: BEATING A DEAD HORSE
WHEN TO USE IV INOTROPES
IV INOTROPES (MILRINONE OR DOBUTAMINE) MAY BE CONSIDERED TO RELIEVE SYMPTOMS AND IMPROVE END-ORGAN FUNCTION IN PATIENTS WITH ADVANCED HF +LOW OUTPUT SYNDROME + UNRESPONSIVE TO/INTOLERANT OF DIURETICS AND VASODILATORS
ADVANCED HEART FAILURE REQUIRING INOTROPES
LV DILATION
REDUCED LVEF
DEFINITION OF LOW OUTPUT SYNDROME IN AN ADVANCED HF PATIENT DIMINISHED PERIPHERAL PERFUSION OR
END-ORGAN DYSFUNCTION +
MARGINAL SBP (<90 mm Hg) / SYMPTOMATIC HYPOTENSION DESPITE ADEQUATE FILLING PRESSURES
HFSA GUIDELINES: INOTROPE USE
IV INOTROPES MAY BE CONSIDERED IN THE SETTING OF: ◦ ADVANCED HF
+ ◦ LOW OUTPUT SYNDROME
+ ◦ INTOLERANT TO VASODILATORS
OR ◦ POOR RESPONSE TO IV DIURETICS
OR ◦ WORSENING RENAL FUNCTION
2 THINGS YOU MUST KNOW BEFORE STARTING AN INOTROPE: INTRAVENOUS INOTROPES (MILRINONE
OR DOBUTAMINE) ARE NOT RECOMMENDED UNLESS THE PA CATHETER READINGS OR CLEAR CLINICAL SIGNS DEMONSTRATE: ◦ LEFT HEART FILLING PRESSURES ARE
ELEVATED ◦ CARDIAC INDEX IS SEVERELYIMPAIRED
HFSA GUIDELINES: WHAT TO MONITOR WHEN ADMINISTERING AN INOTROPE
FREQUENT BLOOD PRESSURE MONITORING
CONTINUOUS MONITORING OF CARDIAC RHYTHM
IF VASODILATORS CAN BE TOLERATED, DO I USE
INOTROPES OR VASODIALTORS?
HFSA GUIDELINES: IV VASODILATORS VS. INOTROPES
WHEN ADJUNCTIVE THERAPY IS NEEDED FOR ADHF PATIENTS WITHOUT LOW OUTPUT SYNDROME, ADMINISTRATION OF VASODIALTORS SHOULD BE CONSIDERED INSTEAD OF IV INOTROPES
HFSA GUIDELINES:EVALUATING THE COMMON PRECIPITATING FACTORS OF ADHF
IT IS RECOMMENDED THAT PATIENTS ADMITTED WITH ADHF UNDERGO EVALUATION FOR THE FOLLOWING PRECIPITATING FACTORS: ◦ ATRIAL FIBILLATION OR OTHER ARRHYTHMIA ◦ EXACERBATION OF HYPERTENSION ◦ MYOCARDIAL ISCHEMIA OR INFARCTION ◦ ANEMIA ◦ THYROID DISEASE ◦ SIGNIFICANT DRUG INTERACTION
WHEN TO DISCHARGE
PLANNING FOR HOSPTIAL DISCHARGE 30- 50% OF PATIENTS DISCHARGED
WITH DX OF ADHF ARE REHOSPITALIZED WITHIN THE NEXT 3-6 MONTHS
FAILURE TO MEET DISCHARGE CRITERIA CONTRIBUTES TO REHOSPITALIZATION RATE
IT IS COST EFFECTIVE TO REMAIN IN HOSPITAL
HOSPTIAL DISCHARGE: DESIGNING THE ORAL REGIMEN
HOW WILL THIS TIME BE DIFFERENT? START SPIRONOLACTONE SEVERAL DAYS
BEFORE DISCHARGE ADD NITRATES/HYDRALAZINE TO AFRICAN
AMERICANS APPROPRIATELY STOP BETA BLOCKERS IN COLD PATIENTS,
CONTINUE IN OTHERS DON’T INITATE BETA BLOCKERS IF
RECENTLY COLD
HOSPITAL DISCHARGE: PATIENT EDUCATION INITATED AND CONTINUED
THROUGHOUT HOSPITALIZATION PARTICIPATE IN DAILY RITUAL OF
WEIGHT AND I&O DON’T CONCENTRATE ON WHAT
THEY CAN’T DO WHAT CAN THEY DO? KEEP DRY,
KEEP ACTIVE, KEEP GOALS WHEN TO CALL AND WHO TO CALL
DISCHARGE CIRTERIA FOR PATIENTS ADMITTED WITH ADHF EXACERBATING FACTORS ADDRESSES EUVOLEMIC STATE ACHIEVED TRANSITION FROM IV TO ORAL
DIURETIC SUCCESSFULLY COMPLETED PATIENT AND FAMILY EDUCATION
COMPLETED, INCLUDING CLEAR DISCHARGE INSTRUCTIONS
DISCHARGE CRITERIA FOR PATIENTS ADMITTED WITH ADHF LVEF DOCUMENTED SMOKING CESSATION COUNSELING
INITIATED NEAR OPTIMAL PHARMACOLOGIC THERAPY
ACHIEVED, INCLUIDING ACE INHIBITOR AND BETA BLOCKER (FOR PATIENTS WITH REDUCED LVEF), OR INTOLERANCE DOUCMENTED
FOLLOW-UP CLINIC VISIT SCHEDULED, USUALLY FOR 7-10 DAYS