31 - Acute Heart Failure Flashcards
ADHF
Acute Decompensated Heart Failure
2 Characterizations
Rapidly developing symptoms of:
NEW ONSET HF
or
more commonly:
Gradually…
WORSENING of CHRONIC HF
S/Sx of ADHF:
WET
Class 2 or Class 4
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
S/Sx of ADHF:
COLD
Class 3 or CLASS 4
Low CO = POOR PERFUSION
↓Urine Output + ↑BUN/Scr
- *Cold + Clammy** extremeties
- *Narrow Pulse** Pressure
- *HypoTension_ / _Tachycardia**
↓Exercise Tolerance / Fatigue
Obtunded / AMS
Role of BNP in ADHF
↑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
What Hemodynamic Subset of ADHF?
WARM** + **WET
Adequate Perfusion + Volume Overloaded
Normal CO + Congested
CLASS 2
Warm + Wet
Diuretics** +/- **VASODILATORS
nitroglycerin or nitroprusside
What Hemodynamic Subset of ADHF?
- *COLD_ + _WET**
- POOR* Perfusion + Volume Overloaded
- LOW* CO + Congested
CLASS 4
COLD + Wet
Diuretics + INOTROPES
Dobutamine or Milrinone
- *ADHF**
- *IV LOOP DIURETICS**
Furosemide Dose for NAIVE PATIENTS
Initiate EARLY
Furosemide:
- *20-80mg IV**
- *q8-12h**
- *ADHF**
- *IV LOOP DIURETICS**
Furosemide Dose for CHRONIC PATIENTS
Initiate EARLY
TOTAL DAILY DOSE
is the
Initial IV dose
ADHF
IV Loop Diuretics
GOAL URINE OUTPUT
Each DOSE:
> 250-500mL within 2hrs of dose
Each DAY:
1.5 - 2 L NET diuresis
(output - input)
Intensification of IV Diuresis:
1st Step
if
inadequate response to INITIAL diuretic regimen
DOUBLE DIURETIC DOSE
Intensification of IV Diuresis:
2nd Step
if
inadequate response to INCREASED/DOUBLED diuretic dose
Administer as:
CONTINUOUS INFUSION
OR
Add a SECOND Diuretic
PO metolazone / PO spironolactone
IV chlorothiazide
Intensification of IV Diuresis:
3rd & Final Step
if
ALL STRATEGIES are UNSUCCESSFUL
Consider:
ULTRAFILTRATION
Hemodynamic Effects of
VASODILATORS
NitroGlycerin / NitroPrusside
Venous Dilation
↓ preload↓ PCWP, ↓ MAP ↓ LV workload
+
Arterial Dilation
↓afterload ↓MAP ↓force LV must pump agaisnt
====
↑CARDIAC OUTPUT
ADHF
IV VASODILATORS
NitroGlycerin / NitroPrusside
INDICATIONS
- *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
IV VASODILATORS
When/why would we use
NITROPRUSSIDE > Nitroglycerin
- *More severe ↑BP / ↑HTN**
- *Nitroprusside has more POTENT BP lowering effects**
- but is RENALLY cleared –> Cyanide/Thiocyanate Toxicity*
IV VASODILATORS
When/why would we use
NITROGLYCERIN > Nitroprusside
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**
ADHF:
HEMODYNAMIC EFFECTS
Of
IV INOTROPES
Dobutamine + Milrinone
↑Contractility + ↓Afterload
↑STROKE VOLUME
+
↑HEART RATE
=====
↑CARDIAC OUTPUT
ADHF:
IV INOTROPES
Dobutamine + Milrinone
INDICATIONS
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
IV INOTROPES
- *When/why would we use**
- *DOBUTAMINE > Milrinone?**
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
IV INOTROPES
- *When/why would we use**
- *MILRINONE > Dobutamine**
Need for:
MORE VASODILATION = HYPOTENSION
Milrinone has MORE vasodilation and is RENALLY cleared
ADR:
Proarrhythmia / Tachycardia
HYPOTENSION
ADHF:
IV INOTROPES
Dobutamine + Milrinone
PROS + CONS
PROS
↑ contractility + ↓afterload = ↑CO
Improved End-organ Persion + Diuresis
CONS
Tachycardia / Tachyarrhythmias
↑ Myocardial O2 Demand
HYPOTENSION
ADHF
When would we add:
IV INOTROPES
on top of
Diuretic + Vasodilator Therapy
even when NOT in SHOCK:
Add IV Inotropes = Dobutamine / Milrinone
if
Need for MORE DIURESIS
ADHF
When would we add:
IV VASODILATORS
on top of:
Diuretic + Inotrope Therapy
AKA:
IV VASOACTIVE THERAPY
Inotrope + Vasodilator + DIuretic
Low Cardiac Output
+ SHOCK+
hypotensive state SBP <90 + altered mental status
Would have:
Hemodynamic Monitoring As Well
Special Monitoring Parameters:
When would you want
CONTINUOUS TELEMETRY?
on top of normal DAILY monitoring:
Weight / Fluids / Vitals
ADHF SSx / Electrolytes / Renal Fxn
ARRHYTHMIAS
or
IV VASOACTIVE THERAPY
Cardiac SHOCK –>ALL 3: Inotrope + Diuretic + Vasodilator
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
SHOCK
or
HYPOTENSION
or
- *CLASS 4**
- *COLD + WET**
ADHF Discharge Criteria:
TRANSITIONS OF CARE for ALL PATIENTS
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
ADHF TOC:
Optimization of GDMT
guideline directed medication therapy
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**
