acute decompensated heart failure

list the 4 pathophysiology factors that contribute to HF

- increase Na and water retention
- vasoconstriction
- increase sympathetic activation that leads to tachycardia and increase contractibility
- ventricular hypertrophy and cardiac remodeling

name the 6 precipitating factors that contribute to acute decompensated HF

- non-adherence
- Na/fluid restriction non-compliance
- cardiac events
- anemia
- infection
- medication

which of the following DOES NOT exacerbation the risk of acute decompensated HF?
A. Verapamil
B. Diltiazem
C. Flecanide
D. Dofetilide
E. Amphetamines
F. Doxoubicin
G. Naproxen
H. Aspirin

H. Aspirin

JT is a 65 year old female, admitted to the ER with orthopnea, pulmonary rales, and appeared warm. Does this patient have ADHF and why?
A. No. She is warm and dry
B. Yes. She is warm and wet
C. Yes. She is cold and wet
D. No. She is cold and dry

B. Yes. She is warm and wet

true or false

90% of ADHF patients appeared cold and wet

false

QN is a 70 year old male, admitted to the ER with edema, pulmonary rales, narrowed pulse pressure, and hypotension. Classify this patient based on ADHF classification
A. Warm and dry
B. Warm and wet
C. Cold and dry
D. Cold and wet

D. Cold and wet

- othorpnea
- dyspnea with minimal exertion
- crackles
- S3 gallops
are signs and symptoms of

pulmonary congestion

- jugular venous distension
- GI discomfort
- ascites
are signs and symptoms of

systemic edema

- fatigue
- lethargy
- cool extremities
- pallor
- decreased urine output
- altered mental status
- hypotension
are signs and symptoms of

low cardiac output

what are some lab tests that we can use to diagnose ADHF?

- BNP or N-terminal pro BNP
- BUN/SCr/LFT
- Lactate
- CBC
- Thyroid function tests
- Troponin

BNP < 100 pg/mL is indicative of ______

exclusion of HF

which medication may precipitation ADHF?
A. Amlodipine
B. Furosemide
C. Naproxen
D. Amiodarone

C. Naproxen

how does NSAIDS exacerbate ADHF?

it increases Na and water retention

what would you expect to see in a patient with cold and dry ADHF?
A. S3 gallop
B. Orthopnea
C. Pitting edema
D. Cool extremities

D. Cool extremities

LV was admitted for HF, she had a 3 days hospital stay and ready to be discharged. At discharged, LV BP is 132/81 mmHg, normal perfusion and HR of 140 BPM. Upon discussion, you're plan for LV discharge is:
A. Continue LV home HF medication regimens
B. Hold LV in house for another day to monitor her HR and BP because it's at the high end
C. I don't know

A. Continue LV home HF medication regimens

KY SCr level is 1.3 mg/dL with SBP of 85 mmHg. She has a history of HF and has been on therapy of Entresto and Metoprolol Succinate. What is your plan for KY at admission?
A. Hold Entresto, okay to continue Metoprolol Succinate but only use with caution
B. Hold Entresto and Metoprolol Succinate. Initiate high dose Spironolactone as a preventative measure for edema
C. Hold both Entresto and Metoprolol Succinate because KY SBP < 90 mmHg and she has poor kidney function

A. Hold Entresto, okay to continue Metoprolol Succinate but only use with caution

true or false

BB should NOT be initiate in patients with ADHF unless they are euvolemic due to their acute negative inotropic nature

true

In what patient is safe to continue their HOME BB?
A. hemodynamic unstable patients with ADHF
B. warm and wet ADHF
C. symptomatic bradycardia
D. hypotensive patients

B. warm and wet ADHF

what is an indication for holding ACEi/ARB in patients admitted for ADHF?
A. Pitting edema
B. Hypokalemia
C. Bradycardia
D. Hypotension

D. Hypotension

true or false

KS came to the clinic being well perfused but with volume overload. She is diagnosed with HF and has been on BB and ARBs to manage her disease state. It is okay to continue her already ongoing BB, but would not recommend to initiate another BB regimen

true

when to use loop diuretics in patients with ADHF?

when patients are WET (with congestion)

true or false

there is no long-term survival benefits of loop diuretics

true

All of the following medications used to treat heart failure have been shown to reduce cardiovascular morbidity/mortality when used appropriately in patients with ADHF EXCEPT:
A. ACEi
B. ARBs
C. Beta blockers
D. Loop diuretics

D. Loop diuretics

what are 5 adverse side effects of loop diuretics?

- hypotension
- organ hypoperfusion
- excess Mg and K depletion (can lead to arrhythmia)
- diuretic resistance by increasing Na reabsorption
- otoxicity

patients A and B are admitted in the ER for HF symptoms. They both appeared warm and wet. Patient A is naive to Lasix while patient B has been taken Furosemide 80 mg PO BID for 5 years. What are the in house IV Lasix dosing for each patient and how to titrate them if Lasix is not well tolerated?

patient A: 20 mg IV BID, titrate up by increment of doubling dose if not well tolerated until patient reached 80mg IV BID

Patient B: 80 mg IV BID, titrate up by increment of 20mg if not well tolerated

what is the volume goal when putting patients on IV Lasix?

net loss of at least 1-2L QD

patient is on Furosemide 40mg PO BID at home. What dose would you recommended for patients who are warm and wet ADHF?
A. 20 mg IV BID
B. 40 mg IV BID
C. 40 mg PO BID
D. 80 mg IV BID

B. 40 mg IV BID

how to monitor loop diuretic efficacy and safety?

- fluid balance (UOP)
- daily weight
- K and Mg
- BUN/SCr
- signs and symptoms of edema

how would you approach if patient is not tolerating the Lasix dose well (UOP or weight loss not at goal)?

- if < 40 mg IV BID: doubling the IV dose
- if ≥ 80 mg IV BID: increase by increment of 20 mg or consider TID dosing
- if on very high dose of IV Lasix: consider adding on thiazide diuretics for synergy effects

if patient is deemed to have immediate diuresis (UOP net loss not at goal) after receiving the first Lasix IV 40 mg dose. What do you do?
A. Increase dose to 80 mg IV BID
B. Adjust frequency (BID to TID)
C. Add metolazone PO
D. Start sodium nitroprusside

A. Increase dose to 80 mg IV BID

- focus on venous dilation
- significant effects on preload
- high dose reduce afterload
- maintains and improves CO
- continuous infusion in ICU
- resistance in 24-48 hours
- short-term adjunction use only

nitroglycerine

- equal effects on arterial and venous dilation
- effects on preload and afterload
- decrease BP
- cause reflex tachycardia and vasoconstriction with extended use
- caution in renal and hepatic disease

sodium nitroprusside

- mimics of BNP
- effects on arterial and venous dilation
- effects on preload and afterload
- promotes diuresis
- no change in clinical endpoints
- have been discontinued

nesitiride

when to use vasodilator in HF therapy?

- in patients with refractory ADHF following appropriate DIURETIC adminsitration
- as adjunction therapy to diuretic in patient with dyspnea WITHOUT hypotension (SBP > 110 mmHg)
- beneficial to patients with acute hypertension (BP 220/140 mmHg) and acute pulmonary edema

when should we adjust dosing frequency if patient are on Lasix IV?

when patient lose 600-900 mL in the first 6 hours but UOP net loss still not at goal (e.g. 1-2 L QD)

true or false

prophylaxis of VTE therapies (e.g. heparin, enoxaparin) are always initiated for patients that were admitted for HF.

true

- no signs and symptoms of congestions
- higher mortality compared to warm and wet
- treatment focus on increase CO

dry and cold

treatment plan includes:
- inotropes
- replacing intravascular fluid with caution if dehydrated (IV bolus of 250ml)

dry and cold

true or false

pre-renal AKI are often seen in patients with dry and cold ADHF

true

- signs and symptoms of congestion
- highest mortality risk
- treatment focuses on relieving symptoms, increasing CO, reducing PCWP, maintaining/supporting BP

cold and wet

treatment plan includes
- diuretics
- vasodilators
- inotropic agents
- vasopressors (if shock presents)

cold and wet

treatment plan includes
- diuretics
- vasodilators

warm and wet

which of the drugs following stimulate beta receptors to catalyze APT to cAMP?
A. Propanolol
B. Metoprolol succinate
C. Dobutamine
D. None of the above

D. Dobutamine

which of the following drugs inhibit phosphodiesterase to reduce the degradation of cAMP?
A. Amlodipine
B. Labetalol
C. Milrinone
D. Flecainide

C. Milrinone

- tachycardia
- ventricular arrhythmia
- hypotension
- hypertension

are the adverse side effects of

dobutamine

which of the following drugs is a non-selective beta agonist?
A. Amlodipine
B. Labetalol
C. Dobutamine
D. Milrinone

C. Dobutamine

__________ acts on B1 receptor and carries out inotropic/chronotropic effects

A. low dose dopamine
B. mediume dose dopamine
C. high dose dopamine

B. medium dose dopamine

- tachycardia
- arrhythmia
- angina
- peripheral vasoconstriction
- tissue necrosis

are the adverse side effects of

dopamine

- arrhythmia
- hypotension
- angina
- thrombocytopenia

are the adverse side effects of

milrinone

what adverse effect common to all the inotropes (dobutamine, dopamine, milrinone)?
A. hypotension
B. tachycardia
C. arrhythmia
D. thrombocytopenia

C. arrhythmia

which inotrope does NOT have beta agonist activity?
A. dobutamine
B. dopamine
C. milrinone

C. milrinone

choose the most appropriate drug for patient who is cold & wet ADHF with shock and low SBP

A. dobutamine
B. dopamine
C. milrinone
D. none of the above

B. dopamine

what is the urine output goal for patient with HF in an outpatient setting?

A. negative 1-2 L per day
B. negative 600-900 mL per day
C. negative 500 mL per day

C. negative 500 mL per day