31 - Acute Heart Failure

Question 1

ADHF
Acute Decompensated Heart Failure

2 Characterizations

Answer 1

Rapidly developing symptoms of:
NEW ONSET HF
or
more commonly:
Gradually…
WORSENING of CHRONIC HF

Question 2

S/Sx of ADHF:

WET
Class 2 or Class 4

Answer 2

VOLUME OVERLOAD = CONGESTION

Weight Gain
EDEMA - Peripheral & Pulmonary
Bilateral Apical RALES RRR
↑BNP
JVD + HJR
↑BUN/SCR - for BOTH

Cough / Dyspnea@rest / PND
Anorexia-Nausea-Early Satiety

Question 3

S/Sx of ADHF:

COLD
Class 3 or CLASS 4

Answer 3

Low CO = POOR PERFUSION

↓Urine Output + ↑BUN/Scr

• *Cold + Clammy** extremeties
• *Narrow Pulse** Pressure
• *HypoTension_ / _Tachycardia**

↓Exercise Tolerance / Fatigue
Obtunded / AMS

Question 4

Role of BNP in ADHF

Answer 4

↑BNP in “WET” = Volume Overload
associated with WORSE outcomes

Causes ↑BNP than Expected:

• *Age / ACS / AFib**
• *SACUBITRIL/VALSARTAN Use**
• *Sepsis / Renal insufficiency**

Causes ↓BNP than Expected:
OBESITY / EDEMA

Question 5

What Hemodynamic Subset of ADHF?

WARM** + **WET
Adequate Perfusion + Volume Overloaded
Normal CO + Congested

Answer 5

CLASS 2
Warm + Wet

Diuretics** +/- **VASODILATORS
nitroglycerin or nitroprusside

Question 6

What Hemodynamic Subset of ADHF?

• *COLD_ + _WET**
• POOR* Perfusion + Volume Overloaded
• LOW* CO + Congested

Answer 6

CLASS 4
COLD + Wet

Diuretics + INOTROPES
Dobutamine or Milrinone

Question 7

• *ADHF**
• *IV LOOP DIURETICS**

Furosemide Dose for NAIVE PATIENTS

Answer 7

Initiate EARLY

Furosemide:

• *20-80mg IV**
• *q8-12h**

Question 8

• *ADHF**
• *IV LOOP DIURETICS**

Furosemide Dose for CHRONIC PATIENTS

Answer 8

Initiate EARLY

TOTAL DAILY DOSE
is the
Initial IV dose

Question 9

ADHF
IV Loop Diuretics

GOAL URINE OUTPUT

Answer 9

Each DOSE:
> 250-500mL within 2hrs of dose

Each DAY:
1.5 - 2 L NET diuresis
(output - input)

Question 10

Intensification of IV Diuresis:

1st Step
if
inadequate response to INITIAL diuretic regimen

Answer 10

DOUBLE DIURETIC DOSE

Question 11

Intensification of IV Diuresis:

2nd Step
if
inadequate response to INCREASED/DOUBLED diuretic dose

Answer 11

Administer as:
CONTINUOUS INFUSION
OR
Add a SECOND Diuretic
PO metolazone / PO spironolactone
IV chlorothiazide

Question 12

Intensification of IV Diuresis:

3rd & Final Step
if
ALL STRATEGIES are UNSUCCESSFUL

Answer 12

Consider:
ULTRAFILTRATION

Question 13

Hemodynamic Effects of
VASODILATORS
NitroGlycerin / NitroPrusside

Answer 13

Venous Dilation
↓ preload↓ PCWP, ↓ MAP ↓ LV workload
+
Arterial Dilation
↓afterload ↓MAP ↓force LV must pump agaisnt

====
↑CARDIAC OUTPUT

Question 14

ADHF

IV VASODILATORS
NitroGlycerin / NitroPrusside

INDICATIONS

Answer 14

• *Class 2** = Warm + WET
• generally reserved for patients with* HF-rEF, preserved is more preload sensisitive

Pulmonary EDEMA** +/- **severe HTN

Need for:
Rapid improvement of Symptoms

refractory to IV diuresis:
Pulmonary Congestion

Question 15

IV VASODILATORS

When/why would we use
NITROPRUSSIDE > Nitroglycerin

Answer 15

• *More severe ↑BP / ↑HTN**
• *Nitroprusside has more POTENT BP lowering effects**
• but is RENALLY cleared –> Cyanide/Thiocyanate Toxicity*

Question 16

IV VASODILATORS

When/why would we use
NITROGLYCERIN > Nitroprusside

Answer 16

Nitroglycerin is preffered in patients with:
CORONARY ISCHEMIA

• *NOT RENALLY CLEARED**
• *Nitroglycerin is only liver elimination**, preferred for Renal Patients

ADRs:

• *Tachyphylaxis - 20% resistance**
• *Reflex Tachycardia + Headache**

Question 17

ADHF:
HEMODYNAMIC EFFECTS
Of
IV INOTROPES
Dobutamine + Milrinone

Answer 17

↑Contractility + ↓Afterload

↑STROKE VOLUME
+
↑HEART RATE

=====
↑CARDIAC OUTPUT

Question 18

ADHF:
IV INOTROPES
Dobutamine + Milrinone

INDICATIONS

Answer 18

CLASS 4 = WET + COLD

Severe HF-rEF who present with:
LOW Blood Pressure** + **significantly DEPRESSED Cardiac Output
↓BP + ↓CO

Indication:
IMPROVE FORWARD FLOW for:
Diminished peripheral perfusion or end-organ dysfunction
Marginal Systolic BP < 90mmhg
Symptomatic HYPOtension
pallitive therapy for STAGE D patients

Question 19

IV INOTROPES

• *When/why would we use**
• *DOBUTAMINE > Milrinone?**

Answer 19

concerned about:

• *RENAL CLEARANCE**
• *Dobutamine is HEPATIC, Milrinone is 90% renal cleared**
• *HYPOTENSION CONCERN**
• *Dobutamine is LESS hypotensive than Milrinone**

ADR:
Proarrhythmia / Tachycardia / Tachyphalaxis
Hypotension @ HIGH doses

Question 20

IV INOTROPES

• *When/why would we use**
• *MILRINONE > Dobutamine**

Answer 20

Need for:
MORE VASODILATION = HYPOTENSION
Milrinone has MORE vasodilation and is RENALLY cleared

ADR:
Proarrhythmia / Tachycardia
HYPOTENSION

Question 21

ADHF:
IV INOTROPES
Dobutamine + Milrinone

PROS + CONS

Answer 21

PROS
↑ contractility + ↓afterload = ↑CO
Improved End-organ Persion + Diuresis

CONS
Tachycardia / Tachyarrhythmias
↑ Myocardial O2 Demand
HYPOTENSION

Question 22

ADHF

When would we add:
IV INOTROPES
on top of
Diuretic + Vasodilator Therapy

Answer 22

even when NOT in SHOCK:
Add IV Inotropes = Dobutamine / Milrinone
if
Need for MORE DIURESIS

Question 23

ADHF

When would we add:
IV VASODILATORS
on top of:
Diuretic + Inotrope Therapy

AKA:
IV VASOACTIVE THERAPY
Inotrope + Vasodilator + DIuretic

Answer 23

Low Cardiac Output
+ SHOCK+
hypotensive state SBP <90 + altered mental status

Would have:
Hemodynamic Monitoring As Well

Question 24

Special Monitoring Parameters:

When would you want
CONTINUOUS TELEMETRY?
on top of normal DAILY monitoring:
Weight / Fluids / Vitals
ADHF SSx / Electrolytes / Renal Fxn

Answer 24

ARRHYTHMIAS

or

IV VASOACTIVE THERAPY
Cardiac SHOCK –>ALL 3: Inotrope + Diuretic + Vasodilator

Question 25

Special Monitoring Parameters:

When would you want
INVASIVE HEMODYNAMIC MONITORING
Pulmonary Artery Catheter
on top of normal DAILY monitoring:
Weight / Fluids / Vitals
ADHF SSx / Electrolytes / Renal Fxn

Answer 25

SHOCK

or

HYPOTENSION

or

• *CLASS 4**
• *COLD + WET**

Question 26

ADHF Discharge Criteria:
TRANSITIONS OF CARE for ALL PATIENTS

Answer 26

OPTIMIZE GDMT
maximize drug therapy, IV –> PO diuretic

F/U Clinic 7-10 days

Address Exacerbating Factor + Near OPTIMAL Volume

LV-EF documented

Smoking cessation

Question 27

ADHF TOC:
Optimization of GDMT
guideline directed medication therapy

Answer 27

Initiation / Continuation / Titration
ACE/ARB + BB

PO Diuretic Adjustment
↑Dose or change to more BV agent (Furosemide -> Dobutamide)
+ADD+ THIAZIDE

• *Addition of other GDMT**
• *MRA / Hydralazine-nitrate / ARNI / Ivabridine / digoxin**