Acute Decompensated Heart Failure

Acute Decompensated Heart Failure(ADHF)- Inpatient ManagementJennifer Kumar

February 2014

ObjectivesLearn 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 Vignette62 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 gainClinical 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 VignetteVS: Temp 36.5, HR 90, BP 108/72, RR 20, SpaO2 91% on RAPertinent physical exam: General: appears uncomfortable, able to speak short sentencesHEENT: Jugular venous distension at 10cmCVS: PMI displaced laterally to mid-axillary line in the 6th ICS, (-) heaves, thrills, RRR, (+) S3, (-)S4, (-) murmurs or rubsChest: loss of tactile fremitus at the base with dullness to percussion, (+) rales throughout bottom half of lung fields bilaterallyAbdomen: distended, (+) mild fluid wave, (+) hepatojugular reflux,Extremities: 2+ pitting edema up to knees bilaterally, cool to touch, 2+ DP and PT pulses To assess JVP: Patient reclining with head elevated 45 Measure elevation of neck veins above the sternal angle Add 5 cm to measurement since right atrium is 5 cm below the sternal angle.- Normal CVP 400 suggestive of HF exacerbationHowever may be falsely elevated in: Renal disease, atrial fibrillation, pulmonary HTNMay be falsely low in:Obese patients, HFPEF

Toxicology screenIn select patients, as drug abuse can trigger exacerbation

TSHUntreated thyroid disease can precipitate exacerbation

Clinical VignetteAt this point, what imaging should be obtained to further assist with management?

Imaging: EKGImportant to look for underlying IschemiaArrhythmias

Imaging: Chest x-rayEnlarged cardiac silhouette

Pulmonary edema

Pulmonary congestionCephalizationKerley B linesPeri-bronchial cuffing

Pleural effusions, typically bilateral

Clinical VignetteShould an echocardiogram be repeated? Imaging: EchoTypically repeated no sooner than annually

Provides information regarding;Ejection fractionDiastolic dysfunctionWall motion abnormalitiesChamber sizesPulmonary HTNVentricular dysynchrony

Clinical VignetteHow should we begin our inpatient management? Non-pharmacologic ManagementDaily weight

Strict Is and Os

Low sodium diet (