1. Acute Decompensated Heart Failure (ADHF)- Inpatient Management
Jennifer Kumar
February 2014

2. Objectives Learn to identify the signs and symptoms of ADHF
Learn to interpret pertinent laboratory data and imaging
Learn the inpatient management of ADHF

3. Clinical Vignette

4. Clinical Vignette
62 year old Caucasian male with PMH of ischemic cardiomyopathy (EF 25%), CAD, HTN presents with two week history of dyspnea
Previously able to walk 2 miles, currently cannot walk more than 10 feet before developing DOE
PND 3 times per night
4 pillow orthopnea
Increasing lower extremity edema
ROS: loss of energy, loss of appetite, 10# weight gain

5. Clinical Vignette
PMH: ischemic cardiomyopathy (EF 25%, based on echocardiogram 6 months prior), CAD (s/p MI with PCI in 2002), HTN
Home medications: ASA 81mg daily, Lisinopril 5mg daily, Lasix 40mg daily
Allergies: NKDA
ROS: denies CP, denies dizziness, denies palpitations

6. Clinical Vignette
VS: Temp 36.5, HR 90, BP 108/72, RR 20, SpaO2 91% on RA
Pertinent physical exam:
General: appears uncomfortable, able to speak short sentences
HEENT: Jugular venous distension at 10cm
CVS: PMI displaced laterally to mid-axillary line in the 6th ICS, (-) heaves, thrills, RRR, (+) S3, (-)S4, (-) murmurs or rubs
Chest: loss of tactile fremitus at the base with dullness to percussion, (+) rales throughout bottom half of lung fields bilaterally
Abdomen: distended, (+) mild fluid wave, (+) hepatojugular reflux,
Extremities: 2+ pitting edema up to knees bilaterally, cool to touch, 2+ DP and PT pulses
To assess JVP:
Patient reclining with head elevated 45 ° Measure elevation of neck veins above the sternal angle
Add 5 cm to measurement since right atrium is 5 cm below the sternal angle.
- Normal CVP <= 8 cm H2O
- Light should be tangential to illuminate highlights and shadows. Neck should not be sharply flexed. Using a centimeter ruler, measure the vertical distance between the angle of Louis and the highest level of jugular vein pulsation. A straight edge intersecting the ruler at a right angle may be helpful.

7. Clinical Vignette
Current presentation consistent with acute decompensated heart failure (ADHF)
What labs should we order to help evaluate further?

8. Laboratory Data CBC BMP LFT Troponin
Anemia, infection can precipitate ADHF
BMP
Hyponatremia- poor prognostic sign
Elevated creatinine- impaired renal perfusion
LFT
May be elevated due to congestive hepatopathy
Troponin
Ischemia can precipitate HF
Troponin may be mildly elevated in HF as well from demand ischemia

9. Laboratory Data BNP Toxicology screen TSH
< 100 strongly suggestive against HF
>400 suggestive of HF exacerbation
However may be falsely elevated in:
Renal disease, atrial fibrillation, pulmonary HTN
May be falsely low in:
Obese patients, HFPEF
Toxicology screen
In select patients, as drug abuse can trigger exacerbation
TSH
Untreated thyroid disease can precipitate exacerbation

10. Clinical Vignette
At this point, what imaging should be obtained to further assist with management?

11. Imaging: EKG
Important to look for underlying
Ischemia
Arrhythmias

12. Imaging: Chest x-ray Enlarged cardiac silhouette Pulmonary edema
Pulmonary congestion
Cephalization
Kerley B lines
Peri-bronchial cuffing
Pleural effusions, typically bilateral

13. Clinical Vignette
Should an echocardiogram be repeated?

14. Imaging: Echo Typically repeated no sooner than annually
Provides information regarding;
Ejection fraction
Diastolic dysfunction
Wall motion abnormalities
Chamber sizes
Pulmonary HTN
Ventricular dysynchrony

15. Clinical Vignette
How should we begin our inpatient management?

16. Non-pharmacologic Management
Daily weight
Strict I’s and O’s
Low sodium diet (<2g daily)
Fluid restriction
Typically only for patients with hyponatremia

17. Clinical Vignette
What should we use to improve our patient’s volume status?

18. Treatment: Diuretics Recommend to give intravenously initially
Typically at least twice a day
Agents
Furosemide
Can give home dose as IV (2:1 po to IV ratio)
Titrate up based on response (goal net negative 1.5-2L daily on average)
Bumetanide
Alternative to Furosemide in tolerant patients
40 mg IV Lasix = 1 mg IV Bumetanide = 1mg po Bumetanide

19. Clinical Vignette
The patient is now receiving 40mg Furosemide IV twice a day
What could be done next if the patient did not respond to Furosemide?
How often should his electrolytes be monitored?

20. Treatment: Diuretics If not responding to initial diuretic dose:
Can titrate dose up further
Older patients, underlying renal dysfunction may require higher doses
Can consider adding Metolazone for additional effect
Thiazide diuretic
Monitoring of electrolytes closely
Check potassium and magnesium at least daily
If aggressive diuresis, check at least twice daily

21. Clinical Vignette
The patient did not come in on a beta blocker, but this has been shown to improve long-term mortality in heart failure
Should we begin a beta blocker at this time?
Which beta blocker (if any) should we choose?

22. Treatment: Beta blockers
Typically not initiated during acute exacerbation
Continue if already on
Stopping can worsen RAAS activation
If SYMPTOMATIC hypotension, can decrease the dose
Options
Carvedilol: lowest dose 3.125mg BID
Metoprolol XL: lowest dose 25mg daily
Titrate to goal HR of 60 bpm
Or as much as BP can tolerate

23. Caveat: Blood pressure
Patients with heart failure frequently have a lower BP than the general population
Due to reduced cardiac output
Not unusual to see patient’s with reduced EF to have a SBP in the 80s-100s
Use of medications which can lower BP is not contraindicated in these populations
However, need to ensure patient does not have lightheadedness, orthostatic hypotension

24. Clinical Vignette The patient has been having an appropriate diuresis
Clinically, patient reports improvement in shortness of breath and now able to walk without DOE
PE: resolution of rales, peripheral edema
How should the diuretic dose be adjusted?
What medications should be added to his regimen prior to discharge?

25. Medication Adjustment
Diuretic
Patient should be transitioned to po regimen
Can base the po on the dose of the IV dose
E.g. Furosemide 40mg IV BID  40mg po BID
Should monitor for at least 24 hours on po to ensure proper response

26. Chronic medical management
ACEI/ARB
Shown to improve mortality
Already on Lisinopril, can titrate up further as tolerated
Consider decreasing dose or discontinuing if: SYMPTOMATIC hypotension, AKI, hyperkalemia
Spironolactone
Shown to improve mortality (RALES trial)
Indications: EF <30% and NYHA Class II OR EF <35% and NYHA Class III/IV
Benefits: enhances diuresis, minimizes K wasting
Dosing: lowest: 12.5mg, titrate up as tolerated
Digoxin
Reduces rate of hospital admissions
No significant effect on mortality  no longer used as frequently now

27. Clinical Vignette
Which patients benefit from combination therapy with Isosorbide dinitrate/Hydralazine?

28. Treatment: Isosorbide dinitrate/Hydralazine
Added to standard therapy for heart failure
Efficacious and increases survival among black patients with heart failure
Dosing:
Isosorbide dinitrate/Hydralazine
20mg/37.5mg TID

29. Transition to Outpatient

30. Our patient’s discharge meds
Furosemide 40mg BID
Lisinopril 5mg daily
Carvedilol 3.125mg BID
Spironolactone 12.5mg daily
ASA 81mg daily

31. Summary Identify clinical signs and symptoms of ADHF Pertinent labs
Sodium, creatinine, troponin, BNP
Relevant imaging
EKG, CXR, echocardiography
Treatment
Diuresis, BB, ACEI/ARB, Spironolactone, Digoxin, Isosorbide dinitrate/Hydralazine
Transition to outpatient
Strict instructions, close-follow-up