Acute Decompensated Heart Failure Flashcards
At what BNP and proBNP levels should you exclude ADHF?
BNP <100 pg/mL, proBNP <300 pg/mL
Note: proBNP preferred in pts getting angiotensin receptor neprilysin inhibitors (ARNI) - BNP conc.s may be affected by ARNI
List normal reference ranges for: MAP, HR, CO, CI, PCWP
MAP: 60-80 mmHg
HR: 60-80 bpm
CO: 4-7 L/min
CI: 2.8-3.6 L/min/m^2
PCWP: 8-12 mmHg (15-18 in heart failure)
What are some common signs/symptoms of Congestion (elevated PCWP) in HF? (9)
- Peripheral edema
- Early satiety, nausea, vomiting
- Dyspnea on exertion or at rest
- Rales
- Orthopnea, paroxysmal nocturnal dyspnea
- Ascites
- Hepatomegaly, splenomegaly
- Juglar venous distention
- Hepatojugular reflex
What are some common signs/symptoms of Hypoperfusion (low CO) in HF? (9)
- Cold extremities
- Worsening renal function
- Narrow pulse pressure
- Hypotension
- Hyponatremia
- Fatigue
- Altered mental status, sleepiness
What category is a patient in when CI >2.2 and PCWP 15-18? Treatment?
Category I, Compensated: Warm and Dry
Ideal for HF pts (normal parameters)
Tx: optimize current meds of diuretics, ACEi/ARBs/ARNIs, etc
What category is a patient in when CI >2.2 and PCWP >18? Treatment?
Category II, Warm and Wet: Pulmonary or peripheral congestion
Tx: IV diuretics +/- IV (venous) vasodilators
*Continued Sxs warrant use of other methods to overcome diuretic resistance
What category is a patient in when CI <2.2 and PCWP 15-18? Treatment?
Category III, Cold and Dry: Hypoperfusion +/- orthostasis
Tx:
1. PCWP <15 mmHg –> IVF until PCWP = 15-18
2. PCWP >15 mmHg, SBP <90 mmHg –> IV inotrope +/- IV vasopressor, if needed
3. PCWP >15 mmHg, SBP >90 mmHg –> IV vasodilator (arterial) +/- IV vasopressor, if needed
What category is a patient in when CI <2.2 and PCWP >18? Treatment?
Category IV, Cold and Wet: Pulmonary congestion + Hypoperfusion
Tx:
Everyone gets IV diuretic +
1. SBP >90 –> IV vasodilator (arterial)
2. SBP <90 –> IV inotrope +/- IV vasopressor, if needed
List drug classes of chronic HF meds that should be continued in the setting of acute decompensation, unless contraindicated?
- ACE inhibitors/ARBs, ARNIs
- Beta-blockers
- Digoxin
When should ACEi/ARBs and ARNIs be considered for discontinuation in ADHF?
Worsening renal function
Increased symptomatic hypotension
Hyperkalemia (K >5.5 mEq/L)
When should Beta-blockers be considered for discontinuation in ADHF?
Symptomatic hypotension or bradycardia
ADHF caused by starting or increasing B-Blocker dose
New or worsening low output or cardiogenic shock
When should beta-blockers be started in chronic HF?
Start after volume status is optimized (pt is stable, euvolemic) and IV diuretics, vasodilators and inotropic agents have been discontinued
When should digoxin be considered for discontinuation in ADHF?
Symptomatic bradycardia
Life-threatening arrhythmias
Elevated digoxin concentration (goal range 0.5-0.8 ng/mL)
S/Sx of digoxin toxicity
Avoid discontinuation unless there is reason to do so; abrupt D/C –>worsening HF symptoms
When should diuretics be used in ADHF?
Use to treat “wet” Subset II or IV heart failure (pulmonary/peripheral edema)
1st line for managing fluid overload in ADHF
Give high-dose IV diuretic (2.5x of PO dose) to remove fluid
When should vasodilators be used in ADHF?
When to avoid?
Use w/ diuretics to manage pulmonary congestion (wet) HF
-Subset II or IV
Used to relieve dyspnea in those with stable BP
Avoid in pts w/ symptomatic hypotension (Ex. SBP <90 mmHg)
