Acute Decompensated Heart Failure
Acute decompensated HF, de novo
[Age]-yo [M/F] with PMH of..., presenting with
days constant/intermitent *** progressively worsening/improving
CC: (DOE,PND,orthopnea)
PP: SOB with orthopnea, PND, LE edema, weight gain, fatigue, and ↓ exercise tolerance.
PN: (CP,fever,purulent cough,palpitation,recent travel/immobilization)
pertinent SHx: tobacco, EtOH, drug use
Etiology: unclear at this time likely dietary, medication non adherence. will consider ischemia, arrythmia, HTN, meds (NSAIDs, steroids, CCB), infection, AKI, drugs (EtOH, cocaine), valvular disease;
Risk factors includ: CAD/HTN/DM, prior HF, CKD, valvular disease, arrhythmias (AF), medication/diet nonadherence, excess salt/fluid intake, recent infection, alcohol/drug use (e.g., cocaine), NSAID use
initial DATA: (BNP, trop, lactate, Echo, EKG, CXR (edema LR 12),)
pending DATA: lipid paneal, TSH, A1c, iron paneal, iron studies
MEDS:
DDX: HF exacerbation vs ACS vs pneumonia vs PE vs arrhythmia vs COPD/asthma exacerbation vs renal failure/volume overload vs medication/diet nonadherence
COURSE:
Admission Orders: (BNP, Trop, daily BMP and Mag, lipid paneal, TSH, A1c, iron paneal), daily weights, telemetry, strict I&Os, EKG, CXR, iron studies, sodium-restrcited diet, 2L fluid / 2g Na restriction, echo if hasn't done in a year, PT/OT/Heart failure RN
Plan
Lasix ___ mg IV once, reassess and redose as needed.
if no response in an hour double dose
if not meeting daily goal in 3-4 hours double the dose
consider Metolazone 5-10mg PO every other day or chlorthalidone(Diuril) 250-500 IV daily if not responding to Lasix (30–60 min prior)
consider Acetazolamide daily for few days for contraction alkalosis
Diuresis goal 1-2L daily
Strict I/O’s, daily weights, continuous telemetry
Daily CBC, BMP, Mg - replete PRN for K >4 and Mg >2
Recheck BMP/Mg if diuretic dose or frequency increases.
f/u A1c,TSH,T4,Iron studies.
Heart healthy diet, <2g Na, 2L fluid restriction
O2 goal >90%; current ***; NIPPV if acute pulmonary edema
PT/OT/Heart failure RN
GDMT optimization
Continue BB if hemodynamically stable; avoid in cardiogenic shock. Hold if HR <60, SBP <90, or heart block
Hold ACEi/ARB/ARNI if BP is soft (to allow diuresis) or with significant AKI; HOLD if SBP <90, K >5, Cr >2.5
continue MRA: as long as CrCl > 30, K < 5; consider in HFpEF
SGLT2: dapagliflozin, empagliflozin; EF < 35% regardless of DM, continue or start early if stabilized
Starting pts on low dose of multiple agents preferred to max on DC
HOLD all if shock,needing pressers, worsning AKI, resp failure
Iron: 200mg IV iron x5 doses daily (Total ~1 g repletion) (ferritin <100 OR ferritin <300 + TSat <20%, OR iron <13)
consult cards for ICD: if after 3-6 months of GDMT and EF <35% or prior VT/VF or CRT for LVEF < 35% AND QRS > 150 (ex: LBBB), or need pacing
switch to PO diuretics when sxs resolve and JVP/edema improve 24 hr goal (net negative ~500 ) prior to DC
Referral to cardiac rehabilitation on discharge
will Instruct the patient to weigh themselves daily ; if +5 lb (3–4 d) or +2–3 lb (24–48 h) or ↑ edema → double diuretic & call PCP/cardiology.
HFpEF GDMT (what to start)
SGLT2 inhibitor (FIRST-line) → empagliflozin or dapagliflozin - (main proven benefit)
Loop diuretic → for volume overload (symptom control)
ACEi/ARB or ARNI → for BP control ± benefit
MRA (spironolactone) → ↓ hospitalizations (selected pts)
Approach to diuretic
from ED stric I/O pt and RN
lasix x2 home (40 lasix = 10-20 torsemide = 1 bumex)
Assess response in 1 hour - If not peeing double the dose. ir peeing check total output 3-4 hours after If they are not at halfway to goal re-dose at double the dose, and check BMP in afternoon.
If you have reached 80-160mg Lasix BID worried about resistance, consider switching to a Lasix drip, to torsemide or Bumex, or adding a thiazide diuretic.
thiazide (metolazone or chlorthalidone), classic teaching says to give 30 mins before. This is because thiazides are PO and we are often still giving IV loop, and PO takes longer to work. If you are giving both PO, they can be given at the same time.
If the patient is alkalotic, can consider adding acetazolamide if K >4 (inhibits proximal tubule, delivers more bicarb to collecting tubules, leads to K wasting).
trial PO for 24 hours beofre DC with net negative ~500cc - they will likely be net even at that dose at home (will eat more salt, drink more fluid, etc). The PO dose you trial should be based on the etiology of decompensation - if non-adherent, can trial home dose. If c/f resistance you can try a higher PO dose.
40mg PO Lasix = 10-20mg PO torsemide = 1mg PO bumex. Bumex has better oral availability which helps if you are concerned about gut edema.
Bumetanide 1mg IV = Furosemide 40mg IV (Torsemide not available IV),Bumetanide 1mg PO = Torsemide 20mg PO = Furosemide 80mg PO
sweet spot for diuresis is when you see an increase in bicarb (contraction alkalosis) but no creatinine bump (AKI). This may give you an indication of approaching euvolemia, but you should really go based on the patient’s symptoms and exam.
Instruct the patient to weigh themselves daily. If they note worsening lower extremity edema, an increase of 5+ lbs over a 3-4 day period, or 2-3lbs over 24-48 hours, take double the dose of their home diuretic and call their PCP or cardiologist.
Basic Info
HF with reduced EF (HFrEF): HF with an LVEF of ≤40%
HF with mildly reduced EF (HFmrEF): HF with an LVEF of 41% to 49%
HF with preserved EF (HFpEF): HF with an LVEF of ≥50%
HF with recovered EF (HFrecEF): HF with a baseline LVEF of ≤40%, a ≥ 10-point increase from baseline LVEF, and a second measurement of LVEF of >40%
NY Heart Association (NYHA) Functional Classes
Class I: No symptoms
Class II: Slight limitation, Comfortable at rest
Class III: Marked limitation, Comfortable at rest, less than ordinary activity causes symptoms of HF (such as walking short distances).
Class IV: Unable to perform any physical activity without symptoms, or symptoms of HF at rest.