Acute decompensated heart failure

Define ADHF

sudden worsening of heart failure symptoms and signs that requires urgent medical eval/ treatment

Evidence of Volume/Fluid Overload

Weight gain > 10 kg
Signs and symptoms of congestion

Evidence of Low Cardiac output

Extreme fatigue

Hypotension

Narrow pulse pressure

Cool extremities

Evidence of Hypoperfusion

Worsening renal or hepatic function

Altered mental status

Other CV Diseases That Could Compromise Hemodynamic Status

Uncontrolled hypertension

Myocardial ischemia or infarction

Valvular disease

Arrhythmia (e.g., atrial fibrillation with RVR,

ventricular tachycardia, repeated ICD shocks)

Other Conditions That Could Compromise Hemodynamic Status

Severe electrolyte deficiency (K, Mg)

Acute exacerbation of pulmonary disease (e.g., asthma, COPD, PE)

Infection (e.g., pneumonia, urosepsis)

Symptomatic hypothyroidism or hyperthyroidism

Use of medications with negative inotropic effects (e.g., Non-DHP CCBs)

Warm & Dry

 normal perfusion + normal congestion

Warm & Wet

normal pefusion + congestion

Cold & Wet

low perfusion + congesion

Cold & Dry

low perfusion + normal congestion 

What lab test is most commonly used to assess for volume status in ADHF?

 B-type natriuretic peptide

BNP levels tend to (increase/decrease) when a patient is volume overloaded. 

increase

First line-therapy for volume overload in ADHF?

IV loop diuretic

Why is IV loop diuretic therapy preferred over PO?

Faster and more predictable absorption

Vasodilators can be used as an adjunct in patients with

Acute pulmonary edema

Severe hypertension

Congestion refractory to diuretics alone

Patients should generally limit sodium intake to

< 2-3 g/day

Before discharge, patients must be transitioned from IV to

PO regimen

Ideal management of ADHF includes:

Optimization of GDMT

Optimal communication with patients, caregivers, and healthcare providers with each transition

Outpatient follow-up with a collaborative, multidisciplinary team

Treatment decisions in ADHF are based on the presence or absence of:

Systemic congestion

Hypoperfusion

When to avoid vasodilator use

systemic hypotension (SBP < 90)

elevated ICP

Nitroglycerin IV Vasodilatory Effect

Venous > arterial

Nitroglycerin IV Place in Therapy

Active myocardial ischemia

Nitroglycerin considerations

Tachyphylaxis (within 24 – 48 hours of continuous use)

Drug interactions (heparin, PDE-5 inhibitors)

Nitroprusside IV elimination

Cyanide (hepatic)

thiocyanate (renal)

Nitroprusside IV place in therapy

Alternative to inotropes in dec CO with inc SVR

Absence of end-organ dysfunction

Nitroprusside IV considerations

AVOID in recent MI without persistent congestive symptoms

Slow taper when transitioning to PO therapy (rebound effect)

Loop Diuretics initial IV dose

1 – 2.5 x PO home dose

Ms. K is a 70-year-old female admitted for ADHF. She has been decongested, transitioned to oral diuretics, and is stable for discharge. What is the most important counseling point to include at discharge?

Monitor weight daily and call provider if >3 lbs gained in 24 hrs

Mr. P is admitted with ADHF and severe hypertension (BP 210/120 mmHg) and acute pulmonary edema. He is started on IV furosemide, but his respiratory distress continues.

Which adjunctive therapy is most appropriate?

IV nitroglycerin infusion ( a venodilator that produces rapid relief of pulmonary congestion)

Ms. L is a 64-year-old with ADHF. She is on furosemide 40 mg PO daily at home. She is admitted with pulmonary edema and weight gain of 10 lbs. You are asked to recommend initial diuretic therapy.

Which is the most appropriate initial recommendation?

Furosemide 40 mg IV once daily

Mr. R is a 72-year-old male with a history of HFrEF (EF 25%) admitted with worsening shortness of breath. On exam, he has 3+ pitting edema, pulmonary crackles, and orthopnea. His blood pressure is stable, his extremities are warm, and his urine output is normal.

Based on his presentation, which hemodynamic subset does he fall into?

Warm & Wet