Acute Decompensated Heart Failure General

Question 1

BNP and NT-proBNP use

Answer 1

Useful for excluding ADHF in patients with dyspnea of unknown etiology (ADHF can be excluded when results are less than 100 pg/mL and less than 300 pg/mL, for BNP and NT-proBNP, respectively)

Question 2

Forrester Subset I description

Answer 2

Warm and Dry (compensated)
normal parameters
PCWP 15–18 mm Hgb and CI > 2.2 L/min/m2

Question 3

Forrester Subset I Treatment

Answer 3

Optimize guideline-directed medical therapies (PO medications)

Question 4

Forrester Subset II Description

Answer 4

Warm and Wet
pulmonary or peripheral congestion
PCWP > 18 mm Hg and CI > 2.2 L/min/m2

Question 5

Forrester Subset II Treatment

Answer 5

IV diuretics at a dose that equals or exceeds pre admission dose (up to 2.5-fold) ± IV vasodilators (venous) for rapid relief of pulmonary
congestion or (arterial) in the absence of hypotension

Question 6

Forrester Subset III Description

Answer 6

Cold and Dry
hypoperfusion ± orthostasis
PCWP 15–18 mm Hgb and CI < 2.2 L/min/m2

Question 7

Forrester Subset III Treatment

Answer 7

If PCWP < 15 mm Hg, IVF until PCWP = 15–18 mm Hg
If PCWP ≥ 15 mm Hg, SBP < 90 mm Hg, IV inotrope
If PCWP ≥ 15 mm Hg, SBP ≥ 90 mm Hg, IV vasodilator (arterial) ± IV vasopressor, if needed

Question 8

Forrester Subset IV Description

Answer 8

Cold and Wet
pulmonary/peripheral congestion + hypoperfusion
PCWP > 18 mm Hg and CI < 2.2 L/min/m2

Question 9

Forrester Subset IV Treatment

Answer 9

IV diuretics +
If SBP < 90 mm Hg, IV inotrope ± IV vasopressor if needed
If SBP ≥ 90 mm Hg, IV vasodilator (arterial)

Question 10

ACE inhibitors/ARBs, ARNIs Discontinuation in ADHF

Answer 10

Consider discontinuation if worsening renal function after recent drug initiation or increased symptomatic hypotension, severe hyperkalemia (K greater than 5.5 mEq/L)

Question 11

β-Blockers Discontinuation in ADHF

Answer 11

Consider discontinuation if ADHF caused by recent drug initiation or increase, evidence of new or worsening low output or cardiogenic shock, symptomatic hypotension or bradycardia

Question 12

Digoxin Discontinuation in ADHF

Answer 12

Consider discontinuation in symptomatic bradycardia, life-threatening arrhythmias, elevated concentrations, signs/symptoms of digoxin toxicity.
Avoid discontinuation unless there is a compelling reason to do so, because digoxin withdrawal
has been associated with worsening HF symptoms.

Question 13

Tolvaptan in ADHF

Answer 13

Should be viewed as “add on” therapy to aggressive diuresis and not as initial or adjunctive therapy
for fluid removal, Role in long-term management of HF remains unclear.