What is the relative risk reduction of ACEi’s/beta blockers for HFrEF? CHF Exacerbations C.L.I.P.S. What is it? Structural/functional impairment of ventricular filling or ejection of blood HFrEF: EF ≤40%, HFpEF: EF ≥50%, HFpEF borderline: EF 41-49% Exacerbation = New or worsening signs/symptoms of HF (ie acute dyspnea/volume overload) What causes it? New onset versus chronic CHF with acute decompensation Med noncompliance, diet, acute infection, ACS, thyroid abnormalities, uncontrolled HTN, cardiomyopathies, valve disease, arrhythmias What will it look like? History: Progressive Dyspnea, abdominal/peripheral congestion Exam: JVD, hepatojugular reflux, peripheral edema, pulmonary crackle, S3, hypertensive emergency, cardiogenic shock Who makes these recommendation? ACCF/AHA/NYHA How do we work up? ABCs – stable? Focused H&P Labs: CBC, UA, electrolytes (Ca, Mg, PO4), BNP, BUN, Cr, glucose, TSH (Heart failure power plan) – case specific: screening for hemochromatosis, HIV, troponin, fasting lipids, LFTs, lactate Studies: EKG, CXR, TTE, pulmonary POCUS? (pulm edema) GDMT: What is the relative risk reduction of ACEi’s/beta blockers for HFrEF? ACEI 20% Beta Blocker 31% Carvedilol Metoprolol XL Bisoprolol Updated 4/2/2018

In HFrEF, do we continue beta blocker during ADHF? CHF Exacerbations C.L.I.P.S. In HFrEF, do we continue beta blocker during ADHF? Mild– yes Moderate – yes, can decrease 50% Severe – decrease by 50% versus D/C if hypotension, bradycardia, need for inotropes Abrupt discontinuation = increased mortality What do we do? HEART FAILURE POWER PLAN (HFPP) DVT ppx Cardiac monitoring, I/Os, daily weights, fluid restrict (2L) – on HFPP Heart Failure Society of America recs: identify etiology, treat fluid overload, optimize volume status, optimize chronic meds, address precipitating factors, minimize med side effects Which Diuretics do we use to optimize volume status? Loop Diuretics: Lasix IV, Bumex IV, Ethacrynic Acid IV Doses: Lasix naïve – start with 20mg IV and inc until adequate response, h/o Lasix use – ≥ PO dose, adjust PRN for response Lasix 40mg = Bumex 1mg = Ethacrynic acid 50mg Goal: >1L UOP in first 3-4 hrs Hospital Discharge Repeat H/H, BNP “Guideline-Directed Medical Treatment” (GDMT) – ACEi and/or beta blocker 1 week follow-up, PHQ9, cardiac rehab referral, heart failure education, self care Med Rec with Cards Pharmacist