ADHF

Question 1

ADHF

Answer 1

• Occurs in patients with LV dysfxn history

- Evaluation reveals signs/sxs of pulmonary congestion, systemic congestion, and/or low CO

Question 2

Physical Exam/Lab Findings

Answer 2

• Increased lower extremity pitting edema
• Hepatomegaly
• JVD
• (+) HJR
• Rales/crackles
• Tachycardia
• Gallops
• Elevated BNP (> 100) - higher = higher in hospital mortality risk
• NT-proBNP > 450 for < 50 y.o. or >900 for > 50 y.o.

Question 3

ADHF Epidemiology

Answer 3

• After initial hospitalization, 50% readmitted within 6 months and 25-35% die within 12 months
• Most costly CV syndrome
• Mean LOS 5.3 days

Question 4

Causes of ADHF

Answer 4

• Non-adherence: medical, nutrition
• ADE: NSAIDs, decongestants, Alka-seltzer, B-agonist
• Undertreatment of HF: not on GDMT
• Progression of disease
• Acute MI: Check ECG and cardiac enzymes

Question 5

CO

Answer 5

• HR * SV
• Amount of blood ejected from left ventricle
• Normal: 4-8

Question 6

CI

Answer 6

• Cardiac Index
• CO/BSA
• Normal: 2.8-4.2

Question 7

PP

Answer 7

• Pulse Pressue
• Difference between SBP and DBP (SBP-DBP)
• <25% means SBP is inappropriately low/narrowed
• Narrow PP in ADHF is indicative of decrease CO or perfusion

Question 8

PAWP

Answer 8

• Pulmonary Artery Wedge Pressure
• Estimate of LV end-diastolic pressure (LVEDP)
• LVEDP is equal to its volume (preload)
• Normal PAWP < 12

Question 9

SVR

Answer 9

• Systemic Vascular Resistance
• Pressure left ventricle must overcome to eject blood (afterload)
• Normal: 900-1400

Question 10

ADHF Treatment Goals

Answer 10

1. Improve signs/sxs: decrease SOB, weight, and BNP and increase oxygenation
2. Stabilize the hemodynamic condition: decrease PCWP and increase CO
3. Decrease mortality

Question 11

Comorbidity Identification

Answer 11

• Class I recommendation to identify
  1. Acute coronary syndromes/coronary ischemia
  2. Severe HTN
  3. Atrial and ventricular arrhythmias
  4. Infections
  5. Pulmonary emboli
  6. Renal failure
  7. Medical or dietary nonadherence

Question 12

Hemodynamic Subsets

Answer 12

1. Warm (CI > 2.2) and dry (PCWP < 18): no signs of CHF
2. Warm and Wet (PCWP > 18)
3. Cold (CI < 2.2) and Dry: hypovolemic shock
4. Cold and Wet: cardiogenic shock

Question 13

Clinical Evidence of Congestion

Answer 13

• Weight gain
• Orthopnea
• (+) JVP
• Increasing S3
• Loud P2
• Edema
• Ascites
• Rales
• (+) HUR

Question 14

Clinical Evidence for Low Perfusion

Answer 14

• Narrow pulse pressure
• Cool forearms and legs
• ACEI related hypotension
• Declining serum Na
• Worsening renal fxn

Question 15

Warm/Dry Treatment

Answer 15

• Goals: Initiate or titrate GDMT therapy
• ACE or ARB or ARNI
• BB
• +/- aldosterone antagonist
• +/- SGLT2-i

Question 16

Warm and Wet Treatment

Answer 16

• Goal: Relieve congestion
• IV diuretics
• +/- vasodilators

Question 17

Cold and Dry Treatment

Answer 17

• Goal: Increase CO
• Fluids
• +/- IV inotropes
• +/- mechanical assistance (IABP or LVAD)

Question 18

Cold and Wet Treatment

Answer 18

• Goal: Increase CO and relieve congestion
• Adequate BP (SBP >= 90): IV diuretics +/- vasodilators
• Low BP (SBP < 90): IV inotropes + IV diuretics +/- mechanical assistance

Question 19

ADHF General Management

Answer 19

• Oxygen for hypoxemia
• Check vital signs, weight, signs/sxs of perfusion and congestion
• Daily electrolyes, BUN, SCr when using IV diuretics or active titration of HF meds
• Low sodium (2gm/day) is recommended for most hospital patients
• Fluid restriction (<2L/day) is recommended in moderate hyponatremia (<130) patients and should be considered in fluid overloaded patients

Question 20

Chronic Medications in ADHF

Answer 20

• Continue GDMT treatment in absence of hemodynamic instability or CI
• Hold/reduce BB should be considered if recently initiated or increased dose. Also consider in marked volume overload or low CI
• If renal fxn significantly worsening, consider holding/reducing ACEI/ARBs/ARNIs/Aldosterone antagonists until improved

Question 21

Diuretics

Answer 21

• Class I
• Significant fluid overload => IV loop diuretics
• If using loop diuretics, intial IV dose should equal or exceed chronic PO dose (2.5 * current oral dose)
• Can be intermittent bolus or CI
• Urine output and signs/sxs should be continually assessed
• Titrate diuretic dose based on sxs and volume status

Question 22

Diuretic Monitoring/Goals

Answer 22

Monitor

• K+ and Mg
• BUN/Cr
• BP
• Is and Os
• Daily weights
• Volume status
• CO: overdiuresis can decrease CO

Goals

• Weight loss at least 1kg/day
• Overdiuresis can reduce CO and worsen renal fxn

Question 23

Inadequate Diuresis

Answer 23

• Can increase loop diuretic dose or add second diuretic (thiazide)
• Sequential nephron blockage: Metolazone or Chlorothiazide with loop as well

Question 24

Vasodilators

Answer 24

• If symptomatic hypotension is absent: IV nitroglycerin, nitroprusside, or nesiritide can be considered
• Relieve dyspnea in ADHF patients
• Used adjuvant with diuretics

Question 25

Nitroprusside/Nitroglycerin

Answer 25

- Reduce preload and therefore PCWP - Nitroglycerin preferred when CO isn't severely compromised or other inotropics are being administered - Nitroprusside preferred in increase SVR patients - Decrease glycerin doses if SBP decreases <90-100 - Taper prusside to avoid rebound HTN

Question 26

Nitros AE/Monitoring

Answer 26

AE - Headache - Dizziness - Reflex tachycardia - Hypotension - Thiocyanate toxicity (prusside) Monitoring - Vitals - HF sxs

Question 27

Nesiritide

Answer 27

- Recombinant BNP - Promotes vasodilation, natiuresis, and diuresis - Reduces PCWP and SVR, increases CO - AE: Hypotension (CI: SBP < 90) - Monitor: vitals and renal fxn - Safe, but not very effective, limited role in ADHF

Question 28

IV Inotopes

Answer 28

- Class IIb: may reasonable if patients present with severe systolic dusfxn, low BP, and significantly depressed CO to maintain perfusion - Class III: without the above presentations and if significantly depressed CO w/ or w/o congestion, the inotropes are potentially harmful

Question 29

Dobutamine

Answer 29

- IV Inotrope - Potent B1/B2 agonist - Predominate effect is (+) inotropy/chronotropy to increase CO and vasodilation which decrease SVR

Question 30

Dopamine

Answer 30

- IV Inotrope - Effects B, alpha, and DA receptors - Have to increase doses to get to B/alpha effects (medium = B and high =alpha)

Question 31

Milrinone

Answer 31

- Inodilator - IV Inotrope - PDE3-i - Increases intracellular cAMP to increase intracellular calcium and increase contractility/CO - Slower onset than dopamine/dobutamine, requires loading dose - Longest high life, titration is difficult

Question 32

Inotrope Monitoring

Answer 32

- Vitals - Urine output - K+ - Telemetry (arrhythmias)

Question 33

Anticoagulation

Answer 33

- Class I | - All ADHF patients should receive VTE prophylaxis as long as risk-benefit ratio is favorable

Question 34

BB Initiation

Answer 34

- Class I to start after volume status optimization and D/C of diuretics, vasodilators, and inotropes - Start at low doses - Caution in those who required inotropes during their hospital stay - Recent evidence supports sacubitril/valsartan in ADHF patients if hemodynamically stable (SBP > 100 for 66 hours without interventions)