HEART FAILURE Flashcards
MANAGEMENT
02:
NC, Venti Mask, BiPAP PRN, Titrate Sp02 > 92%
NITROGLYCERINE:
SL 0.4 mg q 5 min
Titrate to target BP
THEN
0.2-0.7 mcg / kg / min IV
Start at 50-75 mcg / min Titrate up to 200 mcg / min
Titrate to symptoms
Maintain SBP >/100 mmHg
Stop if BP < 100 mmHg
ADRs: HoTN, Headache
Avoid in severe AS, phosphodiesterase inhibitor
FUROSEMIDE:
No prior use: 20 - 80 mg IVP
Prior Use: 1 to 2.5 times the patient’s previous total daily oral dose, divided in half and given IV bolus q 12 h
If no effect by 20-30 min, increase subsequent dose
ADRs: K & Mg depletion, hyperuricemia, hypovolemia, ototoxicity, prerenal azotemia
Morphine 2-5 mg IV
BED UPRIGTH
URINE CATHETER IN.
Monitor Urine output.
INVESTIGATIONS
CBC
Electrolytes
Creatinine
Ferritin
TSH
Troponin
BNP or N-terminal pro-BNP
CXR
ECG
POCUS
Echocardiography
MONITOR
1)Reassess patient’s O2 requirements in 1-2 hours.
2) Volume assessment with each step
3) Monitoring of electrolytes, renal function, symptoms and vital signs
4) Daily weights
5) Urine output not often accurate or obtainable
DISCONTINUE
CCB
NSAIDS
DOCUMENTATION
CLINICAL FEATURES
Dyspnea on Exertion (sn 84%)
Fatigue w/ less exertion
Weight Gain (>2 kg in 2d or 3 kg in 7 days)
Orthopnea (sp 76-84%) (LR 2.6)
PND (sp 76-84%) (LR 2.2)
Ankle Edema (sp 76-84%)
S3 (LR+ 11)
Abdominojugular reflux (LR+ 6.4)
Jugular Venous Distension (LR+ 5.1)
Pulmonary crackles (LR+2.8), Rales
Pitting Edema (LR+2.3)
PRECIPITANTS
HTN
MI
Arrythmia
Sepsis
Anemia
Emotional / Physical Stress
Diet
Pregnancy
Thyrotoxicosis
Myocarditis
Valve Dysfunction
Pulmonary Embolism
Drugs: BB, CCB, Steroids, NSAIDS
Cardiac Tamponade
RISK FACTORS: MC
CHF (LR+ 5.8)
MI (LR+3.1)/Ischemic Heart Disease
Systemic HTN / LVH Arrhythmias (esp. Afib with RVR)
CXR FEATURES
Pulmonary Venous Redistribution
Cardiomegaly
Pulmonary Edema
Pleural Effusion
Kerley b lines
POCUS
Questions to ask:
1) Are there signs of pulmonary congestion
2) Are there signs of volume overload by measuring the size of the inferior vena cava and its collapsibility
3) Is the left ventricular ejection fraction low or normal?
POCUS FEATURES
Sonographic B Lines
IVC size > 2 cm or collapsibility index of < 50%
Reduced Ventricular ejection fracture
NT-proBNP CUTOFFS
< 300 pg/ml - HF unlikely
= 300-900 pg/ml - HF possible, but other diagnoses need to be considered (age 50-75)
= 300-1800 pg/ml - HF possible, but other diagnoses need to be considered (age > 75)
> 900 pg/ml - HF likely (age 50-75)
> 1800 pg/ml - HF likely (age > 75)
BNP CUT OFFS
< 100 pg/ml - HF unlikely
= 100-400 pg/ml - HF possible but other diagnoses need to be considered
> 400 pg/ml - HF likely
PRIDE SCORE
(likelihood of HF </5 low, 6-8 intermediate, 9-14 high)
Age > 75 (1)
Orthopnea (2)
Lack of Cough (1)
Current Use of Loop Diuretic (1)
Rales on lung exam (1)
Lack of Fever (2)
Elevated NT-proBNP (4)
Interstitial Edema on CXR (2)
DISPOSITION: ADMISSION
NYHA III-IV
Persistent hypoxia, hypotension, tachycardia, tachypnea despite intervention (minimal improvement):
02 saturation on room air <91%
SBP <90 - 100 mmHg
HR > 90
RR > 20
ECG evidence of ischemia, ventricular arrythmia, atrial arrythmia NOT under control
Worsening renal function
New diagnosis of heart failure
DISPOSITION: DISCHARGE
NYHA II
Symptoms significantly improved
02 saturation on room air >/92%
SBP >100 mmHg or similar to prior
HR < 90
RR </ 20
ECG Baseline
Renal Function Stable
Established Etiology and Precipitant
Established follow up
OUTPATIENT MANAGEMENT: HFrEF
ARNI or
ACEi/ARB then
substitute ARNI
Valsartan
Start: 40 mg BID
Target: 160 mg BID
Perindopril
Starting Dose: 2-4 mg daily
Target Dose: 4-8 mg daily
Ramipril
Starting Dose: 1.25-2.5 mg BID
Target Dose: 5 mg BID
ARNI: ENTRESTO
50 - 100 mg bid
200 mg bid
Converting ACEi/ARB to ARNI
Stop ACEi
Wait at least 36 hrs after last dose
Then start ARNI
Stop ARB
No washout period
Start when next dose would have been due
BETA BLOCKER
Metoprolol XL (succinate)
Starting Dose: 12.2-25 mg daily
Target Dose: 200 mg daily
Metoprolol (tartrate)
Starting Dose: 12.5 mg bid
Target Dose: 25-50 mg bid
MRA
SGLT2i
Empagliflozin
Starting Dose 10 mg daily
Target Dose 10-25 mg daily
MINERALICORTICOID
Spironilactone
Start Dose: 12.5 mg daily
Target Dose: 25-50 mg daily
IVABRADINE
Consider if HR > 70 and Sinus Rhythm
Start: 2.5-5 mg BID
Target: 7.5 mg BID
DIGOXIN
Consider if Suboptimal rate control for AF, or persistentsymptoms despite optimized GDMT
Start: 0.0625-0.125mg daily
Monitor for toxicity
DDX: ELEVATED NT pro-BNP
Age
Body Mass
Pulmonary HTN
Pulmonary Embolism
Pneumonia
Sepsis
Renal Failure
DDX: FLUID RETENTION
Dependent Edema
DVT
Hypoprotenemia
Liver Failure / Cirrhosis
Portal Vein Thrombosis
Renal Failure
Nephrotic Syndrome
CHF
ECHOCARDIOGRAPHY
Decreased left ventricular (LV) ejection fraction (EF)
Increased LV end-systolic and end-diastolic diameter
LVH
Wall motion abnormalities and diastolic dysfunction
Increased right ventricular (RV) size and/or
RV dysfunction
Valve dysfunction
Elevated pulmonary arterial pressures (PAP)
