Acute Decompensated Heart FailureAcute Decompensated Heart Failure(ADHF)- Inpatient Management(ADHF)- Inpatient Management

Dr. Armaan Singh

ObjectivesObjectivesLearn to identify the signs and symptoms

of ADHF

Learn to interpret pertinent laboratory data and imaging

Learn the inpatient management of ADHF

Clinical Vignette Clinical Vignette

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

Clinical VignetteClinical VignettePMH: 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

Clinical VignetteClinical VignetteVS: Temp 36.5, HR 90, BP 108/72, RR 20, SpaO2

91% on RAPertinent 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

Clinical VignetteClinical VignetteCurrent presentation consistent with

acute decompensated heart failure (ADHF)

What labs should we order to help evaluate further?

Laboratory DataLaboratory DataCBC◦ 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

Laboratory DataLaboratory DataBNP◦ < 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

Clinical VignetteClinical VignetteAt this point, what imaging should be

obtained to further assist with management?

Imaging: EKGImaging: EKGImportant to look for underlying ◦ Ischemia◦ Arrhythmias

Imaging: Chest x-rayImaging: Chest x-rayEnlarged cardiac silhouette

Pulmonary edema

Pulmonary congestion◦ Cephalization◦ Kerley B lines◦ Peri-bronchial cuffing

Pleural effusions, typically bilateral

Clinical VignetteClinical VignetteShould an echocardiogram be repeated?

Imaging: EchoImaging: EchoTypically repeated no sooner than annually

Provides information regarding;◦ Ejection fraction◦ Diastolic dysfunction◦ Wall motion abnormalities◦ Chamber sizes◦ Pulmonary HTN◦ Ventricular dysynchrony

Clinical VignetteClinical VignetteHow should we begin our inpatient

management?

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

Clinical VignetteClinical VignetteWhat should we use to improve our

patient’s volume status?

Treatment: DiureticsTreatment: DiureticsRecommend to give intravenously initiallyTypically at least twice a dayAgents◦ 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

Clinical VignetteClinical VignetteThe 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?

Treatment: DiureticsTreatment: DiureticsIf 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

Clinical VignetteClinical VignetteThe 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?

Treatment: Beta blockersTreatment: Beta blockersTypically 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

Caveat: Blood pressureCaveat: Blood pressurePatients 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

Clinical VignetteClinical VignetteThe 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?

Medication AdjustmentMedication AdjustmentDiuretic◦ 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

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

Clinical VignetteClinical VignetteWhich patients benefit from combination

therapy with Isosorbide dinitrate/Hydralazine?

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

Transition to OutpatientTransition to Outpatient

Our patient’s discharge medsOur patient’s discharge medsFurosemide 40mg BID

Lisinopril 5mg daily

Carvedilol 3.125mg BID

Spironolactone 12.5mg daily

ASA 81mg daily

Summary Summary 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