Decompensated HF (Heeter)

What are precipitating factors for ADHF?

(ADHF = acute decompensated heart failure)

• meds

• dietary non-compliance

• arrhythmias

• uncontrolled HTN

• myocardial ischemia/infarction

• anemia

• endocrine abnormalities

• infection

• pulmonary emboli

• excessive alcohol/drug use

Meds that precipitate ADHF tend to do 3 things.

1. promote fluid retention

2. negative inotropic effects

3. exhibit direct cardiotoxicity

describe meds that belong to each category?

1. promote fluid retention → NSAIDs, glitazones, steroids

2. negative inotropic effects → non-DHP CCBs, nifedipine, flecanide, sotalol, b-blockers, itraconazole

3. exhibit direct cardiotoxicity → anthracyclines, amp B, clozapine, stimulants

WHAT ARE S/SX OF VOLUME OVERLOAD?

• must know these

• orthopnea/paroxysmal nocturnal dyspnea (PND)

• pitting edema

• weight gain

• ascites

• DOE/SOB

• S3 gallop

• crackles in lung fields

• increased BNP

• positive JVD (jugular vein distension)

• positive HJR (hepatojugular reflex)

WHAT ARE S/SX OF REDUCED CARDIAC OUTPUT (CO)?

• must know these

• (these are more nonspecific and harder to determine compared to volume overload s/sx)

• fatigue

• hypotension

• narrow pulse pressure

• pallor/cyanosis

• cold extremities

• prerenal AKI (increased BUN:SCr ratio)

• decreased urine output (<0.5 ml/kg/hr)

• altered mental status

• poor appetite, nausea

Decreased renal fxn = 1st sign of decreased CO

To confirm ADHF what’s the main laboratory test/cardiac biomarker we are going to order?

What levels confirm HF?

• BNP or pro-BNP

  • BNP >100 pg/mL

  • pro-BNP >300 pg/mL

Invasive hemodynamic monitoring aka right heart catheterization (Swan-Ganz catheter) measures what 2 main things?

What does each indicate?

1. pulmonary capillary wedge pressure (PCWP) → indicator of volume status

2. cardiac index (CI) → indicator of cardiac output’

   • CI = CO/BSA

   • CO = volume of blood pumped in 1 min

What is a normal PCWP? What level indicates fluid overload?

• heeter said to know

• PCWP > 18 mmHg = fluid overload

• normal PCWP = <12 mmHg

A CI <______ ml/min/m2 = poor perfusion

2.2

What are the two main clinical axes in Forrester staging?

What are the s/sx for each?

• heeter- “know forrester staging criteria and how to stage pts.”

• Congestion (Wet vs. Dry)

  • volume overload s/sx

• Perfusion (Warm vs. Cold)

  • reduced CO s/sx

What are the 4 Forrester hemodynamic subsets?

• heeter- “know forrester staging criteria and how to stage pts.”

1. Subset 1: Warm & Dry

   • PCWP 15-18mmHg & CI > 2.2 L/min/m²

2. Subset 2: Warm & Wet

   1. PCWP >18mmHg & CI > 2.2 L/min/m²

3. Subset 3: Cold & Dry

   1. PCWP 15-18mmHg & CI < 2.2 L/min/m²

4. Subset 4: Cold & Wet

   1. PCWP >18mmHg & CI < 2.2 L/min/m²

Evaluating a pts. chronic HF tx (aka the meds they were on before being admitted to the hospital) in the acute setting is necessary.

How do we adjust the pts. diuretic when admitted?

hold at home PO dose and initiate IV loop diuretic if volume overload

Evaluating a pts. chronic HF tx (aka the meds they were on before being admitted to the hospital) in the acute setting is necessary.

Which 3 BB have mortality benefit in HFrEF

How do we adjust the pts. beta blocker when admitted?

• Metoprolol Succinate, Carvedilol, Bisoprolol

• WE DO NOT WANT TO D/C THE B-BLOCKER (most of the time)

• exceptions:

  • really really really low bp or if dose was just increased then go back down

Evaluating a pts. chronic HF tx (aka the meds they were on before being admitted to the hospital) in the acute setting is necessary.

How do we adjust the pts. ACE/ARB/MRA when admitted?

d/c if seeing kidney ADRs

• AKI (↑ SCr, BUN, or ratio)

• Hyperkalemia

• Oliguria (low urine output)

Evaluating a pts. chronic HF tx (aka the meds they were on before being admitted to the hospital) in the acute setting is necessary.

How do we adjust the pts. digoxin when admitted?

• WE DO NOT WANT TO D/C DIGOXIN (most of the time)

• exceptions: if pt. is experiencing digoxin toxicity or bradycardia

• Typically decrease dose → discontinuation = worsening HF

PRACTICE:
Which of the following medications is most important for ADHF patients to NOT to d/c when being admitted to the hospital?

SATA

a. furosemide

b. lisinopril

c. valsartan

d. metoprolol

e. digoxin

d, e

FYI: which forrester subset is the most common in pts.? (~2/3)

wet and warm (subset 2)

How is subset 2 aka warm and wet treated?

• know this

reduce preload → loop diuretics ± vasodilators

Preferred loop diuretic for subset 2 aka warm and wet?

furosemide

Furosemide PO: IV is ___:___.

2:1

Bumetanide PO: IV is ___:___.

1:1

Duration of action of Furosemide (Lasix)?

4-6 hrs (Lasix)

How is diuretic resistance to loop diuretics managed?

• increase DOSE of loop diuretic

• initiate add-on therapy with thiazide

Preferred thiazide diuretic to initiate for loop diuretic resistance?

Metolazone PO

• alts: hydrochlorothiazide PO, chlorothiazide PO/IV

Administration considerations with thiazide-type diuretics for loop diuretic resistance?

TAKE METOLAZONE 30 MIN BEFORE LOOP

What is the I/O (intake/output) goals when taking diuretics for subset II aka warm and wet?

• heeter → know this

>500 mL within 1st 2 hours for Scr <2.5 mg/dL

>250 mL within 1st 2 hours for Scr >2.5 mg/dL

(ex. we give dose, and within 1st 2hrs we should see 500 mL of urine)

When do we consider adding a vasodilator for subset 2 aka warm and wet?

• refractory volume overload

• acute pulmonary edema

• severe HTN

basically → works faster than diuretics to help decrease fluid overload…

What is the preferred IV vasodilator for subset 2 aka warm and wet?

Nitroglycerin (NTG)

ADRs of nitroglycerin?

Tachyphylaxis and HA

What are 2 alternative vasodilators that are only used for subset 3 and 4?

Nesiritide and Sodium Nitroprusside

Do each of the following effect arterials, venous, or both?

• Nitroglycerin

• Sodium Nitroprusside

• Nesiritide

• Nitroglycerin → venous

• Sodium Nitroprusside → both

• Nesiritide → both + natriuresis

What is the major drawback with sodium nitroprusside?

metabolized to Cyanide/Thiocyanate → potentially fatal cyanide toxicity

• Cyanide- Hepatic

• Thiocyanate- Renal

What is a non-pharm intervention for fluid overload?

When do we consider it?

• ultrafiltration

  • rapid fluid removal

• consider when:

  • diuretic resistance

  • worsening renal impairment following diuretics

  • worsening renal impairment despite IV vasodilator and/or inotrope therapy

HF is most commonly associated with

a. hypovolemic hypernatremia

b. hypovolemic hyponatremia

c. hypervolemic hyponatremia

d. hypervolemic hypernatremia

c. (effects 1 in 5 pts. hospitalized)

What vasopressin antagonists are indicated for hypervolemic/euvolemic hyponatremia in SIADH, cirrhosis, or HF?

What must the serum sodium be?

• Tolvaptan

• serum Na+ must be <125 mEq/L to be indicated

What is the general tx approach to “cold” patients aka subset 3 and 4?

• measure SBP and volume status

• treat based on type of ADHF and ± hypotension

• consider invasive monitoring parameters in severely ill pts. requiring IV Vasodilators/Inotropes/and or vasopressors

  • IV vasodilators → Nesiritide and Sodium Nitroprusside

    • use in select pts. with low CO

  • IV inotropes → Dobutamine, Milrinone

    • increase CO

    • consider when need for temp Maintenace of end-organ perfusion in pts. with cardioshock or severely depressed CO and low SBP and can’t use IV vasodilators

    • bridge therapy for HF pts. for MCS or transplant

    • palliative care for HF pts who are not eligible for MCS or transplant

Dobutamine MOA?

Non-selective beta agonist

• decreases ventricular filling pressure

• ↑ CO & Contractility

Milrinone MOA?

inhibits PDE-3

• ↑ Contractility

• Vasodilatory properties (cAMP)

What is the tx for subset 3 cold and dry?

• orthostatic or PCWP ≤15 mmHg

• no orthostasis or PCWP 15-18 mmHg

  • SBP <90 mmHg vs. SBP ≥90

• orthostatic or PCWP ≤15 mmHg → IV fluids

• no orthostasis or PCWP 15-18 mmHg

  • SBP <90 mmHg → IV inotrope ± vasopressor

  • SBP ≥90 → IV vasodilator

What is the tx for subset 4 cold and wet?

• SBP <90 mmHg vs. SBP ≥90?

• SBP <90 mmHg → IV inotrope ± vasopressors + IV diuretic ± PAC

• SBP ≥90 mmHg → IV diuretic ± vasodilator

Tx summary FYI:

Follow-up Treatment: GDMT

VTE prophylaxis

• UFH, LMWH, Fondaparinux

Beta-Blockers

• Start or continue after optimization of volume status and successful discontinuation of IV diuretics, vasodilators, and inotropic agents

  • Start low and go slow!

ACEi/ARB

• Start/continue in stable patients prior to hospital change

Add aldosterone antagonist in patients w/ NYHA class II-IV HF & LVEF ≤ 35% unless contraindicated

• Reduces morbidity and mortality