ACUTE DECOMPENSATE

D HEART FAILURE 2014

BART COX, M.D., FACCDIRECTOR, ADVANCED HEART FAILURE PROGRAM

ASSOCIATE PROFESSOR OF MEDICINEUNIVERSITY OF NEW MEXICO SCHOOL OF MEDICINE

DISCLOSURESNONE

DEFINITIONS HEART FAILURE: a complex

clinical syndrome resulting from any structural or functional impairment of ventricular ejection of filling.

ASYMPTOMATIC LEFT VENTRICULAR DYSFUNCTION: LVEF < 50% + NO history (ever) of HF signs and symptoms

DEFINITIONS ACUTE DECOMPENSATED HEART

FAILURE: HF with a relatively rapid onset of signs and symptoms, resulting in hospitalization or an unplanned clinic or ED visit.

ACUTE HEART FAILURE SYNDROME: new-onset or gradual or rapidly worsening HF requiring urgent therapy

DEFINITIONS HEART FAILURE WITH REDUCED EJECTION

FRACTION (HFrEF): signs/sx of HF + LVEF <40%

HEART FAILURE WITH PRESERVED EJECTION FRACTION (HFpEF): signs/sx of HF + LVEF >50%

HEART FAILURE WITH PRESERVED EJECTION FRACTION, BORDERLINE (HFpEF, borderline): signs/sx of HF + LVEF 41-49%

HEART FAILURE WITH PRESERVED EJECTION FRACTION, IMPROVED (HFpEF, improved): signs/sx of HF +LVEF was < 40% now is > 40%

EPIDEMIOLOGY PREVALENCE: 5.1 million in US INCIDENCE: 650,000 new cases/year HOSPITALIZATION: 1 million/year

Rehospitalization Rate 30 days: 25%Rehospitalization Rate 6 month: 50%

MORTALITY: In hospital mortality: 4%1 year mortality: nearly 30% 5 year mortality: 50%

COST: $37-39 billion/year in US

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 PRESSURESELEVATED 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 CONGESTIONDUE TO ELEVATED RIGHT HEART FILLING PRESSURES

SYMPTOMS OF PULMONARY CONGESTION

DYSPNEA

ORTHOPNEA

PND

SUPINE COUGH

SYMPTOMS OF SYSTEMIC CONGESTION

EDEMA

ABOMINAL OR HEPATIC SWELLINGAND 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 ABDOMINOJUGULAR 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 VOLUME3 PARAMETERS OF STROKE VOLUME: PRELOAD (LVEDP OR RVEDP)CONTRACTILITYAFTERLOAD (The arterial pressure against which the ventricle must contract; systemic vascular resistance, aortic impedance)

NORMAL VALUES

NORMAL CO=5 L/MIN

NORMAL CI=3 L/MIN/SQ. METERS

TO IMPROVE PERFUSION,INCREASE CARDIAC OUTPUT

1) OPTIMIZE HEART RATE /RHYTHM2) OPTIMIZE FILLING PRESSURE3) INCREASE CONTRACTILITY4) DECREASE AFTERLOAD

THE 4 HEMODYNAMIC PROFILES

INITIAL CLINCIAL ASSESSMENT

FIRST HOSPITALIZATION PRIORITY: ASSESS LEVEL OF HEMODYNAMIC COMPROMISEPERFUSION (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 PRESSURESREDUCED 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 DECREASED VENTRICULAR COMPLIANCE

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-5RECOGNITION OF HIGH SVR:

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 OUTDIURESIS 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 + DC DIURETICS IF PCWP>16: PROFILE C IF PCWP 12-16 + NORMAL RA PRESSURE:

LIMITED OPTIONS INOTROPES AND VASODILATORS ONLY

TEMPORARY FIX; MCS/ TRANSPLANT BETA BLOCKERS MAY LEAD TO LATER

IMPROVEMENT IN LV FUNCTION

2013 ACCF/AHA HF GUIDELINES (CLASS I) : PRECIPITATING FACTORS

ACS precipitating acute HF decompensation should be promptly identified by ECG and serum biomarkers, including cardiac troponin testing, and treated optimally as appropriate to the overall condition and prognosis of the patient.

Common precipitating factors for acute HF should be considered during initial evaluation, as recognition of these conditions is critical to guide appropriate therapy.

PRECIPITANTS OF ADHF Myocardial Ischemia or Infarction Hypertension, Hypoxia, High Output HF Endocrine (DM, hypo-or- hyperthyroidism) Arrhythmia (especially a fib), Anemia Reduction in therapy, Renal disease Too much Na+ and fluid, Too little

medication Second Heart Disease: (e.g., aortic

dissection, endocarditis, acute MI)

PRECIPITANTS OF ADHF

Drugs, Doc, Depressants Infection (e.g., pneumonia, viral illness) Embolism (PE)

ADMISSION ORDERS Na restriction is 2-3 grams/daily Fluid restriction is 2 liters/daily. Labs: NTproBNP, CBC with differential, chem

7, TSH, UA, uric acid, LFT, FLP, Mg, Ca, Phos, troponin

IV loop diuretic is either continuous infusion or intermittent bolus scheduled BID or TID

Daily chem 7 and Mg while receiving IV diuretics or uptitrating meds

Daily weights on their HOME scale Daily orthostatic vitals while receiving IV

diuretics or uptitrating meds

ADMISSION ORDERS Chest Xray: PA and Lateral- NOT Portable!!! ECG: look at rhythm, evidence of ACS, and,

if HFrEF, look at the QRS duration IF CRT-D, ask for interrogation. Has

biventricular pacing been > 95%? Has ischemia evaluation ever been

performed? Therapy will depend on hemodynamic

profile If on digoxin, obtain trough dig level and

ensure its between 0.5-0.9

ADMISSION ORDERS Activate the HF power plan Activate the HF power plan Activate the HF power plan Activate the HF power plan Activate the HF power plan Activate the HF power plan Activate the HF power plan Activate the HF power plan

HEART FAILURE WITH PRESERVED EJECTION FRACTION

Signs/symptoms of HF + LVEF > 50% (perhaps > 41%)

Pathophysiology: Systolic (especially with exercise) and

Diastolic DysfunctionChronotropic IncompetenceLeft Atrial Dilation-> AFCombined Ventricular-Arterial Stiffening

Prognosis: Mortality about = to HFrEF, but HFpEF patients die of non CV causes

Prevalence: About 50% of HF is HFpEF

HFPEF Female:male = 2:1 More commonly associated with age,

hypertension, anemia, AF, obesity, DM Diagnosis of exclusion: Must rule out both CV

and non-CV diseases that masquerade as HFpEF

Signs/Sx of HF + preserved LVEF + all other diseases excluded= HFpEF

Gold standard way to diagnose HFpEF: exercise in the cath lab with PA catheter in place: Normal hemodynamics at rest, SIGNIFICANTLY

elevated filling pressures with exercise

HFPEF: DIFFERENTIAL DIAGNOSIS: CV DISEASES

Constrictive Pericarditis CAD Hypertrophic Cardiomyopathy Infiltrarive or Restrictive Cardiomyopathy RV myopathy Valvular Heart Disease High Output HF PAH PE

HFPEF DIFFERENTIAL DIAGNOSIS: NONCARDIOVASCULAR DISEASES

Pulmonary Disease Obesity Deconditioning Thyroid Disease Renal Artery Stenosis Anemia Neuromuscular Diseases

2013 ACCF/AHA HF GUIDELINES: HFPEF THERAPY: CLASS I

Systolic and diastolic BP should be controlled in patients with HFpEf in accordance with published clinical practice guidelines to prevent morbidity.

Diuretics should be used for relief of symptoms due to volume overload in patients with HFpEF.

2013 ACCF/AHA HF GUIDELINES: HFPEF THERAPY, CLASS IIA

Coronary revascularization is reasonable in patients with CAD in whom symptoms (angina) or demonstratable myocardial ischemia is judged to be having an adverse effect on symptomatic HFpEF despite GDMT.

Management of AF according to published clinical practice guidelines in patients with HFpEF is reasonable to improve symptomatic HF

2013 ACCF/AHA HF GUIDELINES: HFPEF THERAPY (CLASS IIA)

The use of beta-blocking agents, ACE inhibitors, and ARBs in patients with hypertension is reasonable to control BP in patients with HFpEF

POST GUIDELINE HFPEF NEWS: TOPCAT TRIAL RESULTS

N= 3445 TRIAL: Randomized, multi-center,

international, double blind, placebo controlled

INCLUSION: HFpEF patients at least 50 years of age with LVEF> 45%

DRUG: Spironolactone DOSE: 30-45 mg/ day FOLLOWUP: 3.3 years

POST GUIDELINE HFPEF NEWS: TOPCAT TRIAL RESULTS

Primary Endpoint: Composite of CV death, aborted cardiac arrest, or HF hospitalization

POST GUIDELINE HFPEF NEWS: ALDOSTERONE ANTAGONIST

TOPCAT trial: in HFpEF, spironolactone:

Did not improve the composite primary endpoint (composite of CV death, aborted sudden death, HF hospitalization)

Did decrease HF readmissions (p=0.04)

HEART FAILURE WITH REDUCED EJECTION FRACTION (LVEF<40%)

GDMT= GUIDELINE DIRECTED MEDICAL THERAPY

ACE INHIBITORS ANGIOTENSIN RECEPTOR BLOCKERS BETA BLOCKERS ALDOSTERONE ANTAGONIST DIURETICS NITRATE-HYDRALAZINE COMBINATION DIGOXIN OMEGA-3 POLYUNSATURATED FATTY ACID

(n3PUFA)

ACE INHIBITORS CLASS EFFECT CONTRAINDICATED WITH HISTORY OF

ACEI-INDUCED ANGIOEDEMA USE IN NYHA I-IV HOLD IF K>5, SBP<80, SIGNIFICANT AKI,

CREATININE > 2.5-3 MOST COMMON ADVERSE EFFECT:

COUGHBe sure cough is due to ACEI and not

pulmonary congestion or pulmonary disease

2013 ACCF/AHA HF GUIDELINES: DIURETICS (CLASS I)

Patients with HF admitted with evidence of significant fluid overload should be promptly treated with IV loop diuretics to reduce morbidity

If patients are already receiving loop diuretic therapy, the initial IV dose should be >their chronic oral daily dose and should be given as either intermittent boluses or continuous infusion

2013 ACCF/AHA HF GUIDELINES: DIURETICS (CLASS I)

Urine output and signs and symptoms of congestion should be serially assessed, and the diuretic dose should be adjusted accordingly to relieve symptoms, reduce volume excess, and avoid hypotension.

2013 ACCF/AHA HF GUIDELINES: DIURETICS (CLASS I)

The effect of HF treatment should be monitored with careful measurement of fluid intake and output, vital signs, body weight that is determined at the same time each day, and clinical signs and symptoms of systemic perfusion and congestion.

Daily serum electrolytes, BUN, and creatinine concentrations should be measured during the use of IV diuretics or active titration of HF medications

DIURETIC PEARLSDESTROYING DIURETIC RESISTANCEDiagnose it: are you sure they are wet?Dose it: Double the dose that failedDrip it: If intermittent bolus tx fails, switch to

continuous infusionDouble the nephron attack: Add metolazone or IV

chlorthiazideDevice it: Aquapheresis

DIURETIC PEARLS If you don’t know whether they are wet or

dry and the renal function is deteriorating with your current therapy, stop guessing: get a RIGHT HEART CATH

Remember: hypotension is NOT saline deficiency

If the renal function deteriorates with diuresis and the exam demonstrates persistent congestion: they aren’t dry- the diuresis has been too brisk

Always check orthostatic vitals to help decide volume status

2013 ACCF/AHA HF GUIDELINES: ACE INHIBITORS

ACE Inhibitors are recommended in patients with HFrEF and current or prior symptoms, unless contraindicated, to reduce morbidity and mortality

ACEI PEARL: Give once daily and give at night What do I start first: ACEI or beta

blocker? It doesn’t matter: your patient will decide

History of MI, CAD, a fib with RVR: beta blocker. Monitor renal function, K, orthostatic BP If hypotensive, decrease the diuretic

dose first Starting dose: Lisinopril 2.5-5 mg daily,

goal dose is 20-40 mg daily

BETA BLOCKERS Use only 1 of 3: carvedilol, metoprolol

succinate, or bisoprolol Start low and uptitrate every 2 weeks Monitor for adverse effects: bradycardia,

AV block, hypotension, worsening congestion, fatigue

If newly diagnosed HF, start beta blocker when off IV inotropes, IV vasodilators, IV diuretics

2013 ACCF/AHA HF GUIDELINES: BETA BLOCKERS (CLASS I)

Use 1 of the 3 beta blockers proven to reduce mortality (e.g., bisoprolol, carvedilol and sustained-release metoprolol succinate) is recommended for all patients with current or prior symptoms of HFrEF, unless contraindicated, to reduce mortality and morbidity

2013 ACCF/AHA HF GUIDELINES (CLASS I)

Initiation of beta-blocker therapy is recommended after optimization of volume status and successful discontinuation of intravenous diuretics, vasodilators, and inotroic agents

Beta blocker therapy should be initiated at a low dose and only in stable patients.

Caution should be used when initiating beta blockers in patients who have required inotropes during their hospital course.

2013 ACCF/AHA GUIDELINES: ALDOSTERONE ANTAGONISTS (CLASS I)

Aldosterone receptor antagonists are recommended in patients with NYHA II-IV HF and who have LVEF <35%, unless contraindicated, to reduce morbidity and mortality.

Patients with NYHA II HF should have a history of prior CV hospitalization or elevated plasma natiuretic peptide levels to be considered for aldosterone receptor antagonists

2013 ACCF/AHA HF GUIDELINES: ALDOSTERONE ANTAGONIST

(CLASS I)

Creatinine should be <2.5 mg/dL in men or<2.0 mg/dL in women (or estimated GFR > 30 mL/min/1.73 sq meter) and K <5 mEq/L.

Careful monitoring of K, renal function, and diuretic dosing should be performed at initiation and closely followed thereafter to minimize risk of hyperkalemia and renal insufficiency.

2013 ACCF/AHA HF GUIDELINES: ALDOSTERONE ANTAGONIST

(CLASS I)

Aldosterone receptor antagonists are recommended to reduce morbidity and mortality following an acute MI in patients who have LVEF < 40% who develop symptoms of HF or have a history of diabetes mellitus, unless contraindicated.

ALDOSTERONE ANTAGONIST PEARLS

INDICATIONS LVEF < 35% +NYHA III-IV HF already on ACEI/ ARB +

diuretic + beta blocker LVEF < 40% + acute MI + either DM or current HF

CONTRAINDICATIONS K>5, creat > 2 in females, > 2.5 in males Never use combination of ACEI + ARB + aldosterone

antagonist FOLLOW UP LABS

When initiating, check chem 7 on day 3, day 7, 1 month, and q 3 months thereafter

When changing dose of ACEI, ARB, diuretic, or aldosterone antagonist, restart the cyclic monitoring

ALDOSTERONE ANTAGONIST PEARLS

Spironolactone starting dose = 12.5 -25 mg/day

Spironolactone goal dose= 25-50 mg/day

Eplerenone starting dose= 25 mg daily Eplerenone goal dose = 50 mgdaily Spironolactone adverse effects:

gynecomastia or breast tenderness, ED, menstrual irregularities

2013 ACCF/AHA HF GUIDELINES: ANGIOTENSIN RECEPTOR

BLOCKER (CLASS I)

ARBs are recommended in patients with HFrEF

with current or prior symptoms who are ACE inhibitor intolerant, unless contraindicated, to reduce morbidity and mortality

2013 ACCF/AHA HF GUIDELINES: ARB (CLASS IIA)

ARBs are reasonable to reduce morbidity and mortality as alternatives to ACEI as first line therapy for patients with HFrEF who are already taking ARBs for other indications, unless contraindicated

2013 ACCF/AHF HF GUIDELINES: ARBS (CLASS IIB)

Additions of an ARB may be considered in persistently symptomatic patiens with HFrEF who are already being treated with an ACEI and a begta blocker in whom an aldosterone antagonist is not indicated or tolerated

ARBS: PEARLS Only 3 ARBs have been studied and

shown to improve survival in HFrEF: valsartan, candesartan, and losartan

If ACEI is contraindicated due to high K or high creatinine, an ARB is by definition contraindicated

ACEI intolerance: moderate-severe cough ACEI-induced angioedema: small

incidence of cross reactivity. Start in the hospital, and don’t use if angioedema with ACEI involved the airway

ARBS: DOSING PEARLS VALSARTAN

Initial dose: 40 mg BIDGoal dose: 160 mg BID

CANDESARTAN Initial dose: 4 mg dailyGoal dose: 32 mg daily

LOSARTAN Initial dose: 25 mg dailyGoal dose: 150 mg daily

2013 ACCF/AHA HF GUIDELINES: DIGOXIN (CLASS IIA)

Digoxin can be beneficial in patients with HFrEF, unless contraindicated, to decrease hospitalizations for HF

PEARL: use with evidence based beta blocker to control ventricular response to a fib

PEARL: Use to decrease HF hospitalization if > 2 HF hospitalizations in the past year

PEARL: Use when NYHA II-IV symptoms persist when already treated with ACEI/ARB, beta blocker, diuretic, and aldosterone antagonist

DIGOXIN Keep trough level between 0.5-0.9 In African Americans, add digoxin

simultaneously or after nitrate-hydralazine combination if NYHA III-IV symptoms persist when already on ACE/ARB, beta blocker, diuretic, and aldosterone antagonist

2013 ACCF/AHA HF GUIDELINES: STATINS (CLASS III: NO BENEFIT)

Statins are not beneficial as adjunctive therapy when prescribed soley for the diagnosis of HF in the absence of other indications for their use.

2013 ACCF/AHA HF GUIDELINES: OMEGA 3 PUFA (CLASS IIA)

Omega 3 polyunsaturated fatty acid supplementation is reasonable to use as adjunctive therapy in patients with NYHA class II-IV symptoms and HFrEF or HFpEF, unless contraindicated, to reduce mortality and cardiovascular hospitalization

2013 ACCF/AHA GUIDELINES: VENOUS THROMBOEMBOLISM PROPHYLAXIS

A patient admitted to the hospital with decompensated HF should receive venous thromboembolism prophylaxis with an anticoagulant medication if the risk-benefit ratio is favorable (CLASS I)

2013 ACCF/AHA HF GUIDELINES: ARGININE VASOPRESSIN ANTAGONIST

In patients hospitalized with volume overload, including HF, who have persistent severe hyponatremia and are at risk for or having active cognitive symptoms despite water restriction and maximization of GDMT, vasopressin antagonist may be considered in the short term to improve serum Na concentration in hypervolemic, hyponatremic states with either a V2 receptor selective or a nonselective vasopressin antagonist ( CLASS IIb)

HYPONATREMIA IN HF Due to volume excess, diuretics,

neurohormones Fluid restriction in ALL HF patients: 2

liters/day unless Na is < 130 Fluid restriction for Na < 130: 1.5 liters/day

ACE inhibitors are drugs of choice for hyponatremia

Vasopressin antagonist are used in hyponatremia + neurocognitive symptoms No long term benefit, watch for hypotension Neurocognitive symptoms: falls, attention

deficits

2013 ACCF/AHA HF GUIDELINES: HOSPITAL DISCHARGERECOMMENDATIONS

Initiate GDMT or documentation of contraindication

Documentation of the precipitating factor of ADHF + barriers to care + support limitation

Assessment of volume status and BP Optimization of chronic HF therapy

2013 ACCF/AHA HF GUIDELINES: DISCHARGE RECOMMENDATIONS Renal function and electrolytes Management of comorbid conditions HF education, self care, emergency

plans, and adherence Palliative or hospice care Follow up visit within 7-14 days +

telephone follow-up within 3 days of hospital discharge

Use clinical risk-prediction tools and or biomarkers to identify higher-risk patients

HOSPITAL DISCHARGE: PRACTICAL PEARLS

Be sure HF power plan was activated Document the HF clinic appointment .

Schedule by calling 925-6530 Your job is to START or uptitrate GDMT,

not escalate dose at light speed! Document the NTproBNP and H/H on the

day of discharge Document the weight on their home

scale on discharge day Discharge Summary: dictate the day of

discharge

HOSPITAL DISCHARGE: PRACTICAL PEARLS

Have they been stable on the new regimen for 24 hours without a significant change in weight, renal function, orthostatic symptoms, or BP?

If they required inotropes, they require a minimum of 48 hours on stable po meds before discharge

PHQ 9 completed, addressed, and documented

Discharge questionnaire completed

HOSPITAL DISCHARGE: PRACTICAL PEARLS

40-70% have sleep disordered breathing: order overnight oximetry or schedule sleep study before discharge

Evaluate for ischemia Document the LVEF

HOSPITAL DISCHARGE: PRACTICAL PEARLS

GDMT FOR HFrEF (LVEF < 40%): Evidence based beta blocker (carvedilol, metoprolol

succinate, bisoprolol) ACEI ARB if ACEI intolerant due to cough Aldosterone antagonist if k<5 and Creat < 2 in female

and < 2.5 in male AND they will follow up with outpatient monitoring

n3PUFA Digoxin if > 2 HF admissions in the past year. Keep level

0.5-0.9 Sliding scale of diuretics based on weight Nitrate-hydralazine if creat or K precludes ACEI/ARB,

ACEI-induced angioedema, hypotension precludes ACEI/ARB, or African American NYHA III-IV on diuretic/beta blocker/ACEI/aldosterone antagonist

HOSPTIAL DISCHARGE: PRACITCAL PEARLS

If discharging on 02, document the PULMONARY diagnosis responsible for hypoxia. Heart Failure NEVER requires daytime home

02 absent R->L shuntNocturnal 02 perfectly appropriate while

awaiting sleep studyThe only cardiac reason for home 02: right

to left shunt (Eisenminger physiology) documented by catheterization

HOSPITAL DISCHARGE: PRACTICAL PEARLS

Document that you have referred this patient to cardiac rehabWe are now reimbursed for HFrEF with LVEF

< 35% If LVEF is > 35%, refer to cardiac rehab

anyway!