Acute Decompensated Heart Failure

cardiac output

the amount of blood ejected out of the left ventricle per minutes (L/min)

4-6 L/min

normal cardiac output

cardiac index

Cardiac output divided by body surface area (BSA) (L/min/m2)

(SV x HR)/BSA

2.5-4 L/min/m^2

normal cardiac index

stroke volume

the amount of blood ejected from the left ventricle with each heartbeat. Dependent on preload, afterload, and contractility

EDV - ESV

SVR (systemic vascular resistance)

afterload; the force impeding ejection of blood from the left ventricle

CO x SVR

blood pressure equation

PCWP (pulmonary capillary wedge pressure)

may be used to estimate left arterial pressure in absence of intracardiac shunt, mitral valve disease, or severe pulmonary disease

LV end diastolic pressure (preload)

left arterial pressure measured by PCWP is a surrogate for ____________________

ADHF

new or worsening HF symptoms requiring hospitalization and ED visit

arrythmias

MI

hypertensive emergency

worsening of chronic HF (70% of cases)

triggering factors for ADHF

negative inotropes (beta blockers, non-DHP CCBs)

NSAIDs, steroids, TZDs (drugs that increase sodium retention)

new drugs that may be precipitating factors for ADHF

Failure to adhere to meds, sodium, or fluid restriction

Arrythmias

Ischemia

Levothyroxine or endocrine abnormalities

Uncontrolled HTN

renal dysfunction

Pulmonary embolism; embolism

drugs

precipitating causes of ADHF (FAILURED)

S3 gallop

cardiac auscultation that is indicative of ADHF

edema, jugular venous distension

seen in physical exam that is indicative of HF

bilateral opacity in butterfly pattern

cardiomegaly

chest X-ray findings in ADHF

orthopnea, dyspnea, paroxysmal nocturnal; early satiety

congestion symptoms in ADHF ("wet")

extreme fatigue; altered mental status

low perfusion symptoms in ADHF ("cold")

tachypnea, hypoxia (SpO2

signs of congestion in ADHF ("wet")

cool extremities, hypotension, narrow pulse pressure, worsening renal or hepatic function, decreased urine output

signs of low perfusion in ADHF ("cold")

high

probability of ADHF for patients with exertional dyspnea and evidence of fluid retention in a patient with a history of heart failure

New onset orthopnea and pulmonary edema on chest X-ray without fever in a patient with NO history of heart failure

intermediate

probability of ADHF for patients with symptoms of dyspnea with

no history of heart failure but

known cardiac disease or

diabetes

OR

Presenting with ECG abnormalities

low

probability of ADHF for patients with dyspnea but no evidence of cardiac disease and normal ECG

May have another explanation for dyspnea

elevated BNP

could be caused by heart failure OR pulmonary emboli, COPD, pulmonary hypertension

subset I

warm and dry patients (normal)

subset II

warm and wet patients (pulmonary congestion)

subset III

cold and dry patients (hypoperfusion)

subset IV

cold and wet patients (pulmonary congestion and hypoperfusion)

< 2.2 L/min/m^2

perfusion at rest that is indicative of hypoperfusion

cardiac index

used to determine perfusion

>18 mmHg

pulmonary capillary wedge pressure used is indicative of pulmonary congestion

PCWP

used to determine pulmonary congestion

diuretics

purpose is to reduce fluid volume

inotropes

purpose is to augment contractility

vasodilators

purpose is to decrease preload and afterload

bumetanide

furosemide

torsemide

diuretics used for treatment of ADHF

dobutamine

milrinone

inotropes used for treatment of ADHF

nitroglycerin

nitroprusside

nesiritide

vasodilators used for treatment of ADHF

wet/warm

wet/cold

for what types of ADHF patients are loop diuretics used?

1:2

IV:PO conversion for furosemide

1:1

IV:PO conversion for bumetanide

>200 mg/day

considered loop diuretic failure if it does not provide adequate diuresis

thiazide diuretic (metolazone or chlorthiazide)

can be added to overcome loop diuretic resistance

metolazone

used to overcome diuretic resistance and in combination with loop diuretics; cheaper than chlorothiazide

give 2.5 to 5 mg/day 30-60 minutes before IV loop diuretic

chlorothiazide

used to overcome diuretic resistance and in combination with loop diuretics; single IV dose is very expensive

give 250-500 mg once or twice daily 30-60 minutes before IV loop diuretic

20:1

BUN/SCr ratio >__________ is suggestive of pre-renal AKI

ins and outs

electrolytes

SCr and BUN

vitals

weight

monitoring parameters while on diuretic

warm and wet

cold and wet

cold and dry if euvolemic with SBP >90

when vasodilators are indicated in ADHF

nitroglycerin

causes primarily venous dilation; first choice for most patients with symptoms of systemic and pulmonary congestion; Can cause tachyphylaxis

nitroprusside

causes both venous and arterial dilation; first choice for patients with HTN or severe mitral regurgitation; Can produce toxic metabolites

hypotension, dose related headache, tachyphylaxis

adverse reactions for nitroglycerin

hypotension, reflex tachycardia, coronary steal, toxic metabolites

adverse reactions for nitroprusside

PDE-5 inhibitors

sGC stimulators

DDIs for nitrates

hypotension

right ventricular infarction

hypovolemia

increased intracranial pressure

nitrates precautions and contraindications

cold and wet

cold and dry

when inotropes are indicated in ADHF

dobutamine

inotrope that increases contractility (positive inotropic support) and slight peripheral vasodilation; provides symptomatic relief, improvement in end-organ function in advanced HF, and patients in shock

adrenergic agonist (B1 > B2 > a1)

MOA of dobutamine

ventricular arrythmias; +/- hypotension

adverse reactions of dobutamine

increase HR and contractility (positive inotropy

beta 1 receptor function

vasodilation of vasculature; bronchodilation

beta 2 receptor function

vasoconstriction of smooth muscle vasculature

alpha 1 receptor function

milrinone

inotrope that autments myocyte calcium utilization and has moderate peripheral vasodilation; results in HF symptom relief, improvement in end-organ function in advanced HF, and patients with shock

arrhythmia, hypotension, thrombocytopenia

adverse reactions of milrinone

PDE3 inhibitor

milrinone MOA

dobutamine

inotrope that is used in renal dysfunction; has concern for hypotension

milrinone

inotrope that is used in pulmonary hypertension or if there is a poor response to dobutamine because of chronic beta blockade

hyponatremia: Na+ __________ mEq/L

fluid restriction

administer diuretics

maximise other GDMT as appropriate

management of hyponatremia for all patients

lethargy, confusion, seizure, coma

severe/symptomatic hyopnatremia

vaptans (vasopressin receptor antgonists)

management of hyponatremia for severe/symptomatic patients

potent CYP3A4 inhibitors

vasopressin receptor antagonists are contraindicated with potent ___________________

conivaptan, tolvaptan

vasopressin receptor antagonists

weight

fluid balance

signs and symptoms of congestion and/or low output

electrolytes

renal function

troponin

should be monitored daily in ADHF patients

vitals

should be monitored every 1-3 hours in ADHF patients

BNP, NT-proBNP

should be monitored at admission and at discharge

hyperkalemia, oliguria, hypotension (symptomatic)

when ARNIs/ACEIs/ARBs should be held while inpatient

bradycardia, hypotension

when beta blockers should be held while inpatient

hyperkalemia, hypotension (symptomatic)

when aldosterone antagonists should be held while inpatient

hypovolemia, AKI

when SGLT-2 inhibitors should be held while inpatient

loop diuretics, digoxin

GDMT that should be continued while inpatient

diuretics

if a patient required _________________ treatment during hospitalization for HF, discharge regimen should include a plan for adjustment to decrease hospitalizations