1. Inpatient Management of Heart Failure Mini-Lecture

2. Objectives -Learn how to assess jugular venous distension (JVD) to aid in assessment of acute decompensated heart failure (ADHF) -Interpret BNP in the setting of ADHF -Understand treatment options based on clinical presentation -Perform effective inpatient monitoring -Conduct a successful discharge -Know the natural history of HF

3. Jugular Venous Distension JVD: Indication of volume overload, especially on the right side of the heart

4. BNP –<100 high negative predictive value –>400 consistent with HF –A.fib, chronic HF, pulmonary HTN, renal failure  higher at baseline, so use higher cut- off for dx of ADHF –Lower in obese people at baseline, so use lower cut-off for dx of ADHF

5. Treatment: Who needs What? WARM AND DRY Compensated Optimize oral therapy Outpatient COLD AND DRY Low Flow State Inotropes, vasodilators, ?IABP ICU COLD AND WET Decompensated Diuretics, vasodilators, inotropes ICU WARM AND WET Congested Diuretics ED or Inpatient Adapted from Nohria,J Cardiac Failure 2000;6:64 CARDIAC OUTPUT PULMONARY CAPILLARY WEDGE PRESSURE ICU Floor Home

6. Treatment: General Medicine Floor Loop Diuretics –Administration: IV 20 -200 mg two or more times per day –Comments: Monitor for excess diuresis, electrolyte abnormalities. For those already on home lasix, give their usual oral dose in IV form, which is essentially a doubling of their home dose. ACE-I –Mechanism: Acute reduction in preload and afterload –Administration: Orally or IV. Escalate dose as BP tolerates. –Comments: Continue/start even in mild to moderate renal failure without hyperkalemia as renal failure will likely resolve with increased perfusion. Positive Pressure Ventilation –Mechanism: Alveolar recruitment and reducing preload and afterload. –Administration: CPAP or BIPAP –Comments: Hypoxic patients. Beta-blockers –Continue for patients already taking BB UNLESS hypotension, hypoperfusion. –For patients not taking BB, withhold during early management, but initiate prior to discharge. Aldosterone antagonists –Continue for patients already taking aldosterone antagonist. –For patients not taking an aldosterone antagonist who have an indication for therapy, initiate prior to discharge.

7. Treatment: ICU Nitrates –Mechanism: Acute decrease in filling pressure. At higher doses, arteriodilator. –Administration: as drip in the ICU –Comments: Oral and patch possible, but less efficacious and more difficult to titrate. Inotropes –Mechanism: Stimulation of the B1 adreoceptors of the heart, increasing contractility and cardiac output –Administration: as drip in ICU –Comments: Contraindicated in ischemic heart disease b/c increases oxygen demand. Use cautiously with a.fib.

8. Inpatient Monitoring At least daily –Weight –Intake and output –Symptoms and exam –Renal function and electrolytes More frequently –Vital signs

9. Disposition Planning Your patient is ready for dispo when… –Near optimal volume status achieved –Transition from IV to oral medications for at least 24 hours

10. Disposition: Case Example Mr. Jones: 64 yo AA male admitted for ADHF secondary to dietary noncompliance. Medical history significant for HF due to ischemic heart disease and CKD 2/2 chronic hypertension. He is ready for discharge and back to his baseline—SOB with minimal activity, but not at rest. His home medication regimen includes – carvedilol 12.5 mg BID – lisinopril 40 mg daily – ASA 81 mg daily – lasix 40 mg BID BP 115/70, HR 65, dry weight 200 lbs. PE: trace edema, JVD of 9 cm, and lungs are CTAB. Labs: BUN of 17, Creatinine 1.8, and Potassium of 4.6. Discharge EF is 35%. Appointment to see his PCP in three days.

11. Disposition Planning: New Guidelines Left ventricular Ejection Fraction Beta-blocker therapy ACE or ARB Postdischarge appointment Symptom and activity assessment and advice on symptom management. Patient self-care education. Counseling about implantable cardioverter defibrillators (ICDs)

12. Disposition: Lingering Questions Who needs hydralazine and nitrates? Who needs spironolactone? Who needs an ICD? Who needs a pacemaker?

13. Disposition: Case Example Mr. Jones: 64 yo AA male admitted for ADHF secondary to dietary noncompliance. Medical history significant for HF due to ischemic heart disease and CKD 2/2 chronic hypertension. He is ready for discharge and back to his baseline—SOB with minimal activity, but not at rest. His home medication regimen includes – carvedilol 12.5 mg BID – lisinopril 40 mg daily – ASA 81 mg daily – lasix 40 mg BID Labs: BUN of 17, Creatinine 1.8, and Potassium of 4.6. Discharge EF is 35%. Appointment to see his PCP in three days. 1.Is Mr. Jones on appropriate medications? Do any medications need to be added to Mr. Jones’ regimen? 2.What important discharge guidelines have been met already? 3.What important discharge guidelines need to be met before he is ready to go home?

14. Prognosis

15. Final Clinical Pearls Use physical exam (JVD) and ancillary tests(BNP) to assess ADHF Tailor treatment based on clinical presentation. Follow guidelines when planning for disposition HF is a waxing and waning disease that is ultimately fatal

16. References -American College of Cardiology Foundation (ACCF) American Heart Association (AHA) Physician Consortium for Performance Improvement® (PCPITM) Heart Failure Performance Measurement Set 2012 -Jain P, et al; Am Heart J 2003; 145: S3-17 -Allen LA, O’Conner CM; CMAJ 2007: 176 (6): 797-800 -Treatment of acute decompensated heart failure: Components of therapy in UpToDate. Wilson S Colucci, MD. Literature review current through: Apr 2012. | This topic last updated: Jan 26, 2012. -Seo,R Kam,L F Hsu Treatment of Heart Failure – Role of Biventricular Pacing for Heart Failure. SingaporeMedJ2003Vol44(3):114-122