ADHF

Question 1

What are ADHF progressions?

Answer 1

HFpEF → HFrEF → Pulmonary congestion → RV dysfunction → Systemic congestion

Question 2

What are symptoms of low output?

Answer 2

1. Altered mental status
2. Fatigue
3. GI symptoms
4. Decreased UO

Question 3

What are the signs of low output?

Answer 3

1. Tachycardia
2. Hypotension (hypertension)
3. Narrow pulse pressure
4. Cool extremities
5. Pallor
6. Cachexia

Cold signs

Question 4

What are the symptoms of volume overload?

Answer 4

1. dyspnea
2. orthopnea
3. paroxysmal nocturnal dyspnea
4. ascites
5. gastrointestinal symptoms

Question 5

What are the signs of volume overload?

Answer 5

Wet
1. Rales
2. JVD
3. Abdominojugular reflux
4. S3 gallop
5. Peripheral edema

Question 6

How do we test for low output?

Answer 6

1. Elevated LFTs and sCr
2. Venous O2 <60%
3. Elevated serum lactation
4. CI <2.2 w/o SVR >1400

Question 7

How do we test volume overload?

Answer 7

1. Negative predictive
2. BNP <100, NBNP <300
3. Serum Na <130
4. PCWP >18
5. Elevated ALP, GGT

Question 8

Recreate the Swan-Ganz Pulmonary artery cateter (PAC)?

Answer 8

Question 9

What is PCWP? Systemic vascular resistance?

Answer 9

Preload; Afterload

Question 10

Describe the correlation between CI and PCWP? CI and SVR?

Answer 10

Question 11

What is the indication for hospitalization of ADHF based on fluid overload?

Answer 11

Weight gain >10 kg
S/s of congestion

Question 12

What is the indication for hospitalization of ADHF based on low CO?

Answer 12

1. extreme fatigue
2. Hypotension, narrow pulse pressure
3. Cool extremities

Question 13

What is the indication for hospitalization of ADHF based on organ hypoperfusion?

Answer 13

1. Worsening renal or hepatic function
2. Altered mental status

Question 14

What is the indication for hospitalization of ADHF based on CVD and hemodynamic status?

Answer 14

1. MI or ischemia
2. Arrhythmia

Question 15

What are the goals of ADHF therapy?

Answer 15

1. Relieve symptoms
2. Improve hemodynamic stability
3. Reduce short-term mortality
4. Address precipitating factors

Question 16

When would you use chronic meds during hospitalization?

Answer 16

Absence of cardiogenic shock or symptomatic hypotension → continue all GDMT for HF

Question 17

What chronic meds can be used during hospitalization?

Answer 17

1. β-Blocker therapy may be temporarily held or dose-reduced if recent initiation or up-titration is responsible for acute decompensation
2. Renal dysfunction → temporarily hold ACEi, ARB, ANRI, aldosterone antagonists
3. Digoxin should only be discontinued if serum concentrations cannot be safely maintained within the desirable range

Question 18

What is Subset 1 and how do you treat it?

Answer 18

Warm and dry

Question 19

What is subset II and how do you treat it?

Answer 19

Question 20

What is subset III and how do you treat it?

Answer 20

Question 21

What is subset IV and how do you treat it?

Answer 21

Question 22

What is normal MAP?

Answer 22

70-110 mmHg

Question 23

What is normal CO?

Answer 23

4-6 L/min

Question 24

Using a chart, describe how ADHF drugs affect PCWP, CI, and SVR?

Answer 24

Question 25

What is the acute treatment for ADHF?

Answer 25

Question 26

What is the longterm treatment for ADHF?

Answer 26

Question 27

How do you adjust loop diuretic dose for ADHF patients being admitted vs their home dose?

Answer 27

take 1-2.5 times the amount of their home dose

Question 28

What are diuretics used for in ADHF?

Answer 28

Increasing PCWP

Question 29

What are the loops indicated for ADHF?

Answer 29

Question 30

What are the thiazides indicated for ADHF?

Answer 30

Question 31

What are VD used ADHF management? Effects?

Answer 31

Question 32

What are the inotropes used for ADHF? Receptor Affinity and effects?

Answer 32

1. Dobutamine 2. Milrinone 3. Dopamine

Question 33

Desicrbe the development of ADHF?

Answer 33

Volume overload/low CO → New or worsening signs/symptoms → Medical intervention required

Question 33

How many people are hospitalized for HF annually?

Answer 33

1 million

Question 34

Label the type of mechanical support

Answer 34

Intra-aortic balloon pump (IABP)

Question 35

Label the type of mechanical support

Answer 35

Impella percutaneous ventricular assist device (VAD)

Question 36

Label the type of mechanical support

Answer 36

TandemHeart device

Question 37

Label the type of mechanical support

Answer 37

CentriMag VAD

Question 38

What is the purpose of a durable MCS? What medications are used?

Answer 38

1. Capable of providing up to 10 L/min of CO 2. Chronic antithrombotic regimen that balances the risk of device thrombosis and bleeding Warfarin and antiplatelets

Question 39

How do prepare hospital discharge?

Answer 39

1. IV → PO 2. GDMT is stable & IV inotropes/vasodilators have been discontinued for at least 24 hours 3. Comorbid conditions have been addressed, to include anemia 4. Discussions of palliative/hospice care

Question 40

What are the steps of transition of care?

Answer 40

1. Counsel patients and caregivers 2. Appropriate follow-up should be scheduled 3. Consider referral to a formal disease management program

Question 41

When is it appropriate to follow up with a patient?

Answer 41

1. Appointment at 7-10 days post discharge 2. Nurse visit or phone call at 3 days for select patients (telehealth) 3. Pertinent follow-up labs

Question 42

What should you counsel patients and caregivers on?

Answer 42

1. Changes to GDMT medication regimen 2. Dietary sodium restriction and education 3. Monitoring body weight daily 4. Parameters for when to titrate diuretics 5. Smoking cessation (counseling, cessation aids prescribed)