ACUTE DECOMPENSATED HF ADHF

ACUTE DECOMPENSATED HF ADHF

1. Signs/Symptoms

   • ADHF Signs and Symptoms Signs of Congestion and Hypoperfusion Why do they go into decompensation? did not take meds or did not follow diet so have fluid overload  Congestion DOE or at rest Orthopnea, PND Peripheral edema Rales Early satiety, N/V Ascites Jugular venousdistension Hepatojugular reflux
   •  Hypoperfusion  Fatigue  Altered mental status or sleepiness  Cool extremities  Worsening renal function  Narrow pulse pressure  Hypotension  Hyponatremia Workbook Page 2-26; Table
   • Guidelines are in ACC  AHA and other is Heart Failure Assoc of America
   • Risks for ADHF
     • i)nonadherence or poor diet restrictions ii)also, there are 88 meds which an increase the risk for ADHF- we should keep HF pts  safely away from such meds to decrease risk of ADHF example: a) NSAIDS b)Thiazolidines c)Steroids all these increase fluid overload thus risk of edema d) Verapamil and Diltiazem should not be used in HF Never want pt to be on Verapamil or Diltiazem if they have a reduced EF e) BB dose increase if they are NOT Euvolemic can cause AV node blockade and induce an exacerbation  of ADHF There are disease related reasons also - see p2 for table from Cardiology 1  (p10)
     • Common Precipitating Factors Medication Related  Nonadherence with meds  Recent addition of negative inotropic drugs  verapamil, diltiazem, beta blockers  Initiation of meds that increase salt retention  Steroids, TZDs, NSAIDs  Excessive alcohol or illicit drug use
     • Disease Related  Nonadherence with Na+ and fluid restriction  Acute myocardial ischemia  Uncorrected high BP  AF and other arrhythmias  Pulmonary embolus  Endocrine abnormalities  Concurrent infections  Other acute CV disorders
     • Diagnosis of ADHF
       • a)first get detailed history and do physical exam b)do BNP but cannot rely on it- must do physical exam BNP  or pro BNP will tell you if they are in fluid overload, it will differentiate bet COPD and HF. It will not tell you prognosis or how to treat the pt c) must do physical exam and use values and symptoms in a Forrester plot May be given values or just symptoms to tie up and make sense of. Must know signs and symptoms of congestion and hypoperfusion. Some will have both. d) what do you do with such symptoms and numbers? can fit them in 1 of 4 quadrants  e) look at values for PCWP , CI , SVR to see if ADHF exists  see p4
       • Congestion symptoms: see under signs and symptoms see ascites, edema, PND etc all showing signs of overload
       • signs of Hypoperfusion: this is different from congestion see reduced BP,  rise in SCr bc kidneys are not perfusing properly, pt has cold extremities bc blood not perfusing extremities well
       • Hemodynamic Parameters  BP = CO x SVR  CO = SV x HR  Stroke volume depends several factors  inotropy, afterload, preload Parameter Normal   ADHF CO            4-7            2-4 CI            2.8-3.6       1.3-2 PCWP   8-12 (15-18) 18-30 SVR   800-1200   1500-3000 Workbook Page 2
       • So see if pt is in ADHF: a)look at pulmonary  capillary wedge pressure >18 this means you have fluid overload(not everyone gets a PCWP value) b)CI is an indication of CO if CI <2.2  it shows less CO c) SVR >1500 high 
       • 2 times you will have poor CO a) if you have too much fluid..CO suffers.   b) if not enough fluid to be on the Frank Starling curve This is why if we know pt is not overloaded we may give a small fluid bolus 250ml or so to get them euvolemic and back on Frank- Starling curve and pt has improved CO after the bolus fluids
       • BNP levels
         • BNP < 100 pg/mL - HF unlikely >400 pg/mL - HF likely 100-400 pg/mL - Use clinical judgment NT-proBNP < 300 ng/mL - HF unlikely Age < 50 years, NT-proBNP >450 pg/mL - HF likely Age 50-75 years, NT-proBNP >900 pg/mL – HF likely Age 
         • O2 saturation
           • oxygen saturation 1 the fraction of the hemoglobin molecules in a blood sample that are saturated with oxygen at a given partial pressure ofoxygen. Normal saturation is 95% to 100%.2 percentage of hemoglobin-bound oxygen compared to total capacity of the hemoglobin.
           • CI level
             • see Q7 has leves p14 but CI= cardiac index CI <2.2 means ADHF
             • SVR
               • systemic vascular resistance SVR will be >15000

2. using ADHF quadrants

   • p11 of Cardiology 1 ADHF Quadrants Congestion at Rest? Low Perfusion at Rest? No Yes I. Warm & Dry PCWP normal CI normal (compensated) IV. Cold & Wet PCWP elevated CI decreased III. Cold & Dry PCWP low/normal CI decreased (Hypoperfused ) No Yes II. Warm & Wet PCWP elevated CI normal CI 2.2 PCWP 18 Workbook Page 2-26
   • FIRST QUESTION OT ASK: DOES PT HAVE CONGESTION AT REST THINK WET AND DRY THINK RIGHT (WET) AND LEFT (DRY)DRY ON LEFT   WET ON RIGHT 1)1ANSWER YES THEN THEY ARE IN QUADRANT II AND IVTHEY WILL BE ON THE RIGHT SIDE AND BE WET2)ANSWER NO THEY WILL BE IN QUADRANT 1 AND IIITHEY WILL BE ON LEFT SIDE AND WILL BE DRY
   • SECOND QUESTION ASK IF THEY HAVE HYPOPERFUSION AT REST THINK WARM AND COLDTHINK ABOVE (WARM)AND BELOW (COLD) 1)ANSWER YES THEY WILL BE IN QAUDRANTS III AND IV AND WILL BE COLD BECAUSE NOT GETTING BLOOD OUT TO DIFFERENT AREAS 2) ANSWER NO THEY WILL BE IN QUADRANTS 1 AND II AND THEY WILL BE WARM 
   • WHICH IS THE ONE WE SEE MOSTLY? WARM AND WET (QUADRANT II) THEY ARE WET SO FLUID OVERLOADED BUT DON'T HAVE HYPOPERFUSION SO TO GET FLUIDS OUT CHOOSE DIURETICS FIRST Which one is 2nd most: one below it Wet and Cold
   • IF THEY ARE WET BUT HYPOPERFUSED (COLD) WE TRY VASODILATORS IF THEY HAVE A BP TO WORK WITH IF CAN'T USE VASODILATORS OR POOR BP THEN NEED INOTROPIC DRUGS
   • PEARLS IN ADHF TRT: 1) KEEP THEM ON SAME ACEI AND BB DOSE AS AT HOME- THESE IMPROVE MORTALITY 2) DO NOT INCREASE BB NOW IN ADHF.  (bb CAN ONLY BE INCREASED IF PT IS EUVOLEMIC BUT WE ARE IN ADHF SO CO IF OFF AND WAS CAUSED BY TOO MUCH FLUID OR TOO LITTLE FLUID SO PT IN ADHF IS DEFINITELY NOT EUVOLEMIC- SO DO NOT INCREASE BB IN ADHF) DO NOT DECREASE BB OR STOP BB UNLESS THE INITIATION WITH BB OR INCREASED DOSE CAUSED ADHF
   • PEARLS... 3) DO NOT CHANGE THE DOSE OF ACEI EVEN IF SCR CHANGES. ON;Y IF SCR IS >30% HIGHER THEN YOU WOULD DECREASE DOSE  OR DC ACEI
   • 4)
   • 4) CAUTION WITH DIGOXIN: DIGOXIN IS RENALLY DOSED AND SCR INCREASES IN ADHF
   • Practical use
     • 1. know the quadrants 2. know elements of hypotension, and congestion so you can fit pt in the quadrants (Table) 3. know what meds are appropriate and exclusions. Know which med is first etc, which is last4. know how to read the levels (table for that)
     • They use a Swan-Ganz catheter to read off PCWP, CI etc but don't routinely use this catheter...it's a pulmonart artery catheter but do place it if : Unclear volume status  Hypotension (SBP<80)  Worsening renal function during therapy  Refractory to initial treatment check for ADHF  PCWP will be >18 CI will less than 2.2 SVR will >1500
     • patient case 7 had BP close to <80, worsening SCr , confusion etc so this catheter would be placed for his worsening symptoms

3. TRT

   • WE USE DRUGS AT TIME OF ADHF FOR SYMPTOM RELIEF ONLY NOT TO IMPROVE MORTALITY (NON OF THESE DRUGS WILL DO THIS)
   • Loop Diuretics
     • 40mg Fusosemide=1mg bumetinide=10-20mg torsemide Furosemide has a 50% oral bioavailability. Torsemide and Bumetinide are 1:1 when switching from  po to ivi. in warm and wet quadrant - need iv/infusion loop diuretics it provides symptomatic relief - relieve SOB etc For furosemide give 2-2.5 x po dose and aim for 1L fluid loss daily. Usually max dose - 120mg bid - not much benefit after that in ADHF
     • Loop Diuretics have a CEILING EFFECT this means they reach a point where they have reached max benefits but get more SE . For this reason use 120mg bid Furosemide max usually and can add metolazone for additional benefit
     • Vasoldilators
       • when do we add vasodilators? Added if pt still has symptoms on a BB.  Vasodilators reduce preload rapidly First add Diuretic if  in wet and warm quadrant If BP is okay can add vasodilator to improve symptoms
       • Nitroglycerine is venous dilating at lower doses but arterial dilating as doses are higher Nitroprusside and  Neseritide are both venous and arterial
       • how do vasodilators work? Nitroglycerin is mailnly venous and so reduces preload then at higher doses it becomes arterial. the other 2 have arterial action as well so can increase CO. BP=CO x SVRSVR= SV X HRArterial Vasodiltors  reduce SVR and the body compensates by increasing CO 
       • why do we have to have a good BP to start vasodilators? They can reduce BP ( cause hypotension)
       • Where are they used? Nitroglycerine is used in ER usually as it reduces preload.  Neseritide is very different from Nitroglycerine and it is used in ICU. It can cause hypotension.- so avoid bolus dose to avoid hypotension  Nitroprusside: can get CN poisoning with poor renal function
       • Inotrope
         • last choice bec assoc with more mortality(only using these instead of vasodilators if BP is not so good- if had a workable BP - could use vasodilators NG etc) Milrinone or Dobiutamine? most of these pts are on a BB so need caution .  If you use Dobutamine (beta agonist) and it will be blocked by BB . so need a higher dose of Dobutamine which puts the pt at risk of arrhythmias.  Sometimes, we have to use it though if BP is really low. Other than that , since most ADHF pt's are on BB at home we choose Milrinone unless BP is super low. Dobutamine is great though as it is short acting(short t 1/2)Dobutamine is easy to dose .5mcg/kg/min but  because most of these pts are on BB we go to Milrinone(PDE inhibitor) it increases CO not by Beta action but by increasing Ca  and cAMP  
         • Milrinone.. why is it better than Dobutamine if BP is lower?  because most of these pts are on BB we go to Milrinone(PDE inhibitor) it indirectly affects  CO not by Beta action but by increasing cAMP  and increasing Ca smooth muscle contraction  .Milriinone will cause  decrease  in SVR which is okay bc pt 7 has high SVRMilrinone does this bc it is an ionodilator so can be vasodilating too which is okay because he has a high SVRso when we draw up the SVR we are going to get aindirect increase in CO- most patients will tolerate Milrinone for this reason even if BP is marginal
         • watch renal function with Milrinone- has to be  renally dosed.  T1/2 is prolonged with Milrinone (vs Dobutamine),  t1/2 = 1 hr doses of Milrinone are 0.1 to 0.75mcg/kg/min Question 7 is using a renaly adjusted dose of 0.2mcg/kg/minAlso watch PLT as Milrinone can cause thrombocytopenia
         • Decision between Dobutamine and Milrinone is based on fact that higher doses of Dobutamine are needed for a pt on BB at home(most of these ADHF pts will have a BB) this can be a risk for increased risk of arrhythmias on Dobutamine and  also keep in mind the risk  for hypotension while on Milrinone- but in patient 7 - his SVR is high enough so his BP won't drop too much Risk of  thrombocytopenia with Milrinone so when deciding if it right for your pt- look at PLT first
         • Vasopressin Antagonists
           • Vasopressin Antagonists  For managing hyponatremia  Corrects euvolemic or hypervolemic sodium  No status improvement (clinical, mortality, etc.)  Hyponatremia returns  after therapy  Tolvaptan  15 mg PO daily; titrated to 30-60 mg as needed  Binds to V2 receptor, in the renal tubule (water reabsorption regulation)  Initiate in hospital; limit treatment to 30 days (FDA 2013)  CI with CYP 3A4 inhibitors and in liver disease  Role in long term HF management is discouraged based upon lack of efficacy and cost
           • Tolvaptan must be used for 30 days max per FDA bc of effect on liver function Hyponatremia in ADHF makes prognosis poor and correcting Na is good (by using vaptans) but it is a short lived effect- low Na less than 128mmol/L  returns after trt is dc'd. Cost $300/pill for 15mg qd tab. Used rarely Hospital case- used it because did not want to increase diuretics and by getting rid of fluids would actually increase Na and pt was already hypervolemic so could not add more fluids to dilute Na levels so needed Tolvaptan

4. Question 5

   • Patient Case #5 72 YOM admitted for ADHF  HPI:  Dyspnea on exertion (30 ft  10 ft)  Orthopnea (2 pillows  4 pillows)  Bilateral lower extremity edema (3+)  Weight gain 13 kg = 30 lbs in 3 weeks  Dietary nonadherence  PMH:  IDCM, LVEF 25%  Paroxysmal atrial fibrillation  Hyperlipidemia
   • Patient Case #5  Pertinent Labs:  BNP 2300 (0-50), K+ 4.9  BUN 32, SCr 2 (baseline 1.9 mg/dL)  AST 40, ALT 42, INR 1.3, PTT 42  BP 108/62 mmHg, HR 82 BPM, O2 sat 95%  Home Medications:  carvedilol 12.5 mg 2 times/day  lisinopril 40 mg/day  furosemide 80 mg two times/day  spironolactone 25 mg/day  digoxin 0.125 mg/day Workbook Page 2-32; Answer
   • atient Case #5 Which regimen is best for treating his ADHF? A. Carvedilol 25 mg BID B. Nesiritide 2 mcg/kg IVB, 0.01 mcg/kg/min C. Furosemide 120 mg IV BID D. Milrinone 0.5 mcg/kg/min
   • Answer: C Furosemide iv
   • discussion: 1) high BNP 2300 2)BP ok 3)O2 sats = 95% not at baseline so having some symptoms of SOB so he has symptoms of fluid overload so need diuretics He is on Furosemide po but once admitted we go for IV Loop Diuretics and increase dose 2-2.5 times po dose and aim for 1L fluid loss each day
   • If still not getting better: SCr works can add Metoloazone - added an agent Still have BP to work with so can choose a vasodilator  Nitroglycerine will quickly reduce preload
   • Question 6
     • Patient Case # 6 In addition to a one-time dose of IV CTZ, which regimen is most appropriate for this patient? A. Nitroglycerin 20 mcg/minute B. Sodium nitroprusside 0.3 mcg/kg/minute C. Dobutamine 5 mcg/kg/minute D. Milrinone 0.5 mcg/kg/minute
     • In addition to a one-time dose of IV CTZ, how else should his ADHF be treated? A. Nitroglycerin 20 mcg/minute B. Sodium nitroprusside 0.3 mcg/kg/minute C. Dobutamine 5 mcg/kg/minute D. Milrinone 0.5 mcg/kg/min Patient
     • answer 6 bc want to rapidly reduce preload need nitroglycerine
     • Patient Case # 6 In addition to a one-time dose of IV CTZ, which regimen is most appropriate for this patient? A. Nitroglycerin 20 mcg/minute B. Sodium nitroprusside 0.3 mcg/kg/minute C. Dobutamine 5 mcg/kg/minute D. Milrinone 0.5 mcg/kg/minute
     • Question 7
       • Patient Case #7 same pt The patient initially responds with 2 liters of urine output overnight and weight decreased by 1 kg next day  However, by day 5:  UOP diminished  Serum creatinine has risen to 4.3 mg/dL  Drowsy & confused mental status  Cool, cyanotic extremities  BP 89/58, HR 98
       • Q7..... A Swan-Ganz hemodynamic catheter is placed:  Pulmonary capillary wedge pressure (PCWP)  30 (8-12 mmHg, 15-18 mmHg in HF)  Cardiac index (CI)  1.5 (2.8-3.6 L/min/m2 )  Systemic vascular resistance (SVR)  2650 (800-1200 dynes/sec/cm-5) Patient Case #7 Workbook Page 2-32; Answer: Page 2-57 Which regimen is most appropriate for his current
       • Which regimen is most appropriate for his current symptoms? A. Milrinone 0.2 mcg/kg/min B. Dobutamine 5 mcg/kg/min C. Nesiritide 2 mcg/kg bolus, then 0.01 mcg/kg/min D. Phenylephrine 20 mcg/min
       • Answer: Milrinone (A) it's a renaly adjusted dose
       • Discussion: 1. pt has the markers all for decompensated HF 2. BP dropped systolic in the 90's 3. PCWP, CI, SVR all show ADHF 4. Pt is now in quadrant 4 (2nd most common quad) see p 14 shows this box highlighted for case 7 so will use an inotrope (if  you had an okay  BP, you could do a vasodilator but problem is has a low BP) 5. Use Milrinoen or Dobutamine Dobutamine is a beta agonist and he is on an BB at home(carvedilol) so dobutamine  so will have to give a higher Dobutamine dose dose to overcome BB effects but this will risk arrhythmias. Sometimes if BP is really low we will use Dobutamine anyways Dobutamine is great though as it is short acting(short t 1/2)Dobutamine is easy to dose 0.5mcg/kg/min BUT  because most of these pts are on BB we go to Milrinone(PDE inhibitor) it indirectly affects  CO not by Beta action but by increasing cAMP  and increasing Ca smooth muscle contraction  . Milriinone will cause  decrease  in SVR which is okay bc pt 7 has high SVR Milrinone does this bc it is an ionodilator so can be vasodilating too which is okay because he has a high SVR so when we draw up the SVR we are going to get aindirect increase in CO- most patients will tolerate Milrinone for this reason even if BP is marginal
       • ADHF Quadrants and Treatment Congestion at Rest? Low Perfusion at Rest? No Yes I. Warm & Dry PCWP normal CI normal (compensated) Optimize oral medications IV. Cold & Wet PCWP elevated CI decreased III. Cold & Dry PCWP low/normal CI decreased (Hypoperfused ) Inotropic Drugs Dobutamine Milrinone Normal SVRI High SVRI No Yes II. Warm & Wet PCWP elevated CI normal DIURETICS +/- IV Vasodilators (venous) Natriuretic Peptides Nesiritide or Vasodilators Nitroprusside Nitroglycerin