Acutely Decompensated Heart Failure Brian W. Hardaway, MD February 22, 2014 Financial Disclosures ✤ None An 81 year old female with history of HTN presents to the ED with sudden onset of severe shortness of breath. BP is 185/110, HR 105bpm, RR 20, O2 sat 92%. Physical exam reveals bilateral rales and CXR demonstrates pulmonary edema. What is her heart failure profile? A. Warm & Dry B. Warm & Wet C. Cold & Dry D. Cold & Wet 63 yo male with ischemic cardiomyopathy (EF 15%) who was recently discharged from BUMC with ADHF returns to your clinic 2 weeks later for post-hospital follow up. He complains of fatigue, confusion and nausea. His weight has been stable (no weight gain since discharge). BP (90/60). He has conversational dyspnea. Examination demonstrates JVD to the jaw, clear lungs, (+) S3, + pulsatile liver and ascites, no edema. What is his profile? A. Warm & Dry B. Warm & Wet C. Cold & Dry D. Cold & Wet Objectives ✤ Define the syndrome of ADHF ✤ Identify common precipitants of ADHF ✤ Review signs and symptoms ✤ Recognize patient profiles in ADHF ✤ Review treatment options & strategies Definition ✤ "a family of syndromes characterized by new or worsening signs or symptoms of heart failure leading to hospitalization or unscheduled medical care” Felker GM et al, AHJ 2001 ✤ " a gradual or rapid change in heart failure signs and symptoms resulting in a need for urgent therapy" Gheorghiade, M et al. Circulation 2006 Hospitalization for Heart Failure ✤ 1,000,000 admissions per year in the US with the primary diagnosis of HF ✤ 3 000 000 admissions per year with primary or secondary diagnosis of HF 3,000,000 ✤ Post discharge event rate (readmissions / death): 35% at 60 days ✤ Most frequent cause of hospitalization in the elderly ✤ Accounts for ~10% of all hospitalizations in the U.S. ✤ ~$37 billion annually is spent on managing episodes of decompensation Key Precipitants ✤ Non-compliance ✤ ✤ Poorly controlled HTN ✤ ✤ Ischemia / ACS ✤ A. fib or other arrhythmias ✤ Worsening renal function ✤ Pulmonary emboli ✤ ✤ Negative inotropic drugs Drugs that increase salt retention Excessive EtOH or illicit drug usage Infections Signs & Symptoms ✤ Jugular Venous Distention ✤ S3 ✤ R l or Pl Rales Pleurall effusion ff i ✤ Edema ✤ Ascites ✤ Hepatojugular Reflux ✤ Dyspnea Patient Profiles Low Perfusion (Cold) Cool extremities H Hypotensive t i Renal Dysfunction Obtunded Tachycardia Congestion (Wet) Low Perfusiion Congestion at Rest? No Yes No Warm & Dry W Warm & Wet W t Yes Cold & Dry Cold & Wet Goals of Therapy ✤ Relieve Symptoms ✤ Optimize fluid status ✤ Identify etiology ✤ Identify precipitating factors ✤ Optimize chronic oral therapy ✤ Minimize side effects ✤ Educate patient / family Treatment Strategies ✤ Maintenance of GDMT ✤ Diuretics ✤ Ultrafiltration ✤ Vasodilators ✤ Arginine Vasopressin Antagonists ✤ Inotropes ✤ Mechanical Circulatory Support Maintenance of Guideline Directed Medical Therapy ✤ In patients with HFrEF experiencing a symptomatic exacerbation of HF requiring hospitalization during chronic maintenance treatment with GDMT it is recommended that GDMT be continued in the absence of GDMT, hemodynamic instability or contraindications. Class I (LOE B). ✤ Intitiation of Beta-blocker therapy is recommended after optimization of volume status and successful discontinuation of IV diuretics, vasodilators and inotropic agents. beta blocker therapy should be initiated at a low dose and only in stable patients. Caution should be used when initiating beta blockers in patients who have required inotropes during their hospital course. Class I (LOE B). Diuretics ✤ ✤ ✤ ✤ ✤ Patients admitted with HF and with evidence of significant fluid overload should be treated with intravenous loop diuretics. Class I (LOE B) If patients are already receiving loop diuretic therapy, the initial intravenous dose should equal or exceed their chronic oral daily dose and should be given as either intermittent boluses or continuous infusion. Urine output and d signs i and d symptoms off congestion i should h ld b be serially i ll assessed, d and d the h di diuretic i dose d should h ld be b adjusted dj d accordingly to relieve symptoms, reuse volume excess, and avoid hypotension. Class I (LOE B) The effect of HF treatment should be monitored with careful measurement of fluid intake and output, vital signs, body weight that s determined at the same time each day, and clinical signs and symptoms of systemic perfusion and congestion. Daily serum electrolytes, urea nitrogen, and creatinine concentrations should be measured during the use of IV diuretics or active titration of CHF meds. Class I (LOE C) When diuresis is inadequate to relieve congestion the diuretic regimen should be intensified using either a. higher doses of loop diuretics; b. addition of a second diuretic (such as metolazone, spironolactone or intravenous chlorothiazide). Class IIa (LOE B) Low dose dopamine infusion may be considered in addition to loop diuretic therapy to improve diuresis and better preserve renal function and renal blood flow. Class IIb (LOE B). Diuretics ✤ Associated with a variety of potential problems including: ✤ Electrolyte abnormalities ✤ Diuretic resistance ✤ Worsening renal function ✤ Activation of RAAS and SNS Cardiorenal Syndrome ✤ A complex syndrome with multiple conflicting definitions resulting in an inadequate understanding of the disease. Cardiorenal Syndrome ✤ The most simplistic definition is impaired renal function that is directly due to the decreased renal perfusion in heart failure (low output heart failure) or overzealous diuresis… But Wait.....There Wait There’ss More ! Mullens et al, JACC 2009 (53) 589-596 CVP Systolic Blood Pressure Cardiac Index Pulmonary Capillary Wedge Pressure Ultrafiltration ✤ ✤ Ultrafiltration may be considered for patients with obvious volume overload to alleviate congestive symptoms and fluid weight. Class IIb (LOE B) Ultrafiltration may be considered for patients with refractory congestion not responding to medical therapy. Class IIb (LOE C) Vasodilators ✤ ✤ If symptomatic hypotension is absent, intravenous nitroglycerin, nitroprusside, or nesiritide may be considered an adjuvant to diuretic therapy for reef of dyspnea in patients admitted with acutely decompensated CHF. Class IIb (LOE A). In patients with evidence of severely symptomatic fluid overload in the absence of systemic hypotension hypotension, vasodilators such as intravenous nitroglycerin, nitroprusside or nesiritide can be beneficial when added to diuretics and/or in those who do not respond to diuretics alone. Class IIb (Level of Evidence: A) Vasodilators Cardiac Output = MAP – CVP SVR Vasodilators Inotropes ✤ ✤ ✤ ✤ Short term continuous IV inotropic support may be reasonable in those hospitalized patients presenting with documented severe systolic dysfunction who present with low blood pressure and significantly depressed cardiac output to maintain systemic perfusion and preserve end organ performance. Class IIb (LOE B) Long term continuous IV inotrope support may be considered as palliative therapy for symptom control in select patients with stage D HF despite optimal GDMT and device therapy who are not eligible for either MCS or cardiac transplantation. Class IIb (LOE B). Long term use of either continuous or intermittent, IV parenteral positive inotropic agents, in the absence of specific indications or for reasons other than palliative care, is potentially harmful in the patient with HF. Class III (LOE B). Use of parenteral inotropic agents in hospitalized patients without documented severe systolic dysfunction, low blood pressure, or impaired perfusion and evidence of significantly depressed cardiac output, with or without congestion, is potentially harmful. Class III (LOE B). Arginine Vasopressin Antagonists ✤ In patients hospitalized with volume overload, including HF, who have persistent severe hyponatremia and are at risk for or having active cognitive symptoms despite water restriction and maximization of GDMT, vasopressin antagonists may be considered in the short term to improve serum sodium concentration in hypervolemic, hyponatremic states with either a V2 receptor selective or a non-selective vasopressin antagonist. Class IIB (LOE B) PA Catheters ✤ ✤ Invasive hemodynamic monitoring should be performed to guide therapy in patients who are in respiratory distress or with clinical evidence of impaired perfusion in whom the adequacy or excess of intracardiac filling pressures cannot be determined from clinical assessment. assessment Class I (Level of Evidence: C) Invasive hemodynamic monitoring can be useful for carefully selected patients with acute HF who have persistent symptoms despite empiric adjustment of standard therapies, and a. whose fluid status, perfusion, or systemic or pulmonary vascular resistances are uncertain. b. whose systolic pressure remains low, or is associated with symptoms, despite initial therapy, c. whose renal function is worsening with therapy d. who require parenteral vasoactive agents or e. who may need consideration for advanced device therapy or transplantation. Class IIa (Level of Evidence: C) PA Catheters ✤ Routine use of invasive hemodynamic monitoring in normotensive patients with acute decompensated HF and congestion with symptomatic response to diuretics and vasodilators is not recommended. Class III (Level of Evidence: B) Questions An 81 year old female with history of HTN presents to the ED with sudden onset of severe shortness of breath. BP is 185/110, HR 105bpm, RR 20, O2 sat 92%. Physical exam reveals bilateral rales and CXR demonstrates pulmonary edema. What is her heart failure profile? A. Warm & Dry B. Warm & Wet C. Cold & Dry D. Cold & Wet All of the following are appropriate treatments for the the “warm & wet” heart failure profile except: A. Furosemide B. Nitroprusside B Nit id C. Dobutamine D. Spironolactone E. Dietary Sodium Restriction 63 yo male with ischemic cardiomyopathy (EF 15%) who was recently discharged with ADHF returns to your clinic 1 week later for post-hospital follow up. He complains of fatigue, confusion and nausea. His weight has been stable (no weight gain since discharge). BP (85/60). He has conversational dyspnea. Examination demonstrates JVD to the jaw, clear lungs, (+) S3, + pulsatile liver and ascites, no edema. His BNP is 2000. What is his profile? A. Warm & Dry B. Warm & Wet C. Cold & Dry D. Cold & Wet 48 yo male with HTN and HFpEF (45% 2 years ago) who is admitted with progressive exertional dyspnea (NYHA Class IIIb), orthopnea and lower extremity edema. He is on GDMT and takes his medications regularly. His BP is 130/90mmHg, irregularly irregular rhythm, III/VI apical systolic murmur. All of the following diagnostic tests are indicated except: A. ECG B. PA catheter insertion C. Echocardiogram D. BNP Thank You Supplemental Reading 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Yancy et al., Circulation. 2013;128:e240-e327 HFSA 2010 Comprehensive Heart Failure Practice Guideline. Journal of Cardiac Failure 2010;16:e1-e194 2010;16:e1 e194
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