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Inpatient Management of Heart Failure. Mini-Lecture. 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

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Presentation Transcript
objectives
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

jugular venous distension
Jugular Venous Distension
  • JVD: Indication of volume overload, especially on the right side of the heart
slide4
BNP
  • 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
treatment who needs what
Treatment: Who needs What?

WARM AND DRY

Compensated

Optimize oral therapy

Outpatient

WARM AND WET

Congested

Diuretics

ED or Inpatient

Home

Floor

COLD AND DRY

Low Flow State

Inotropes, vasodilators, ?IABP

ICU

COLD AND WET

Decompensated

Diuretics, vasodilators, inotropes

ICU

CARDIAC OUTPUT

ICU

ICU

PULMONARY CAPILLARY WEDGE PRESSURE

  • Adapted from Nohria,J Cardiac Failure 2000;6:64
treatment general medicine floor
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.
treatment icu
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.
inpatient monitoring
Inpatient Monitoring
  • At least daily
    • Weight
    • Intake and output
    • Symptoms and exam
    • Renal function and electrolytes
  • More frequently
    • Vital signs
disposition planning
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
disposition case example
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
    • carvedilol12.5 mg BID
    • lisinopril40 mg daily
    • ASA 81 mg daily
    • lasix40 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.
disposition planning new guidelines
Disposition Planning: New Guidelines
  • Left ventricular Ejection Fraction
  • Beta-blocker therapy
  • ACE or ARB
  • Postdischargeappointment
  • Symptom and activity assessment and advice on symptom management.
  • Patient self-care education.
  • Counseling about implantable cardioverter defibrillators (ICDs)
disposition lingering questions
Disposition: Lingering Questions
  • Who needs hydralazine and nitrates?
  • Who needs spironolactone?
  • Who needs an ICD?
  • Who needs a pacemaker?
disposition case example1
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.
    • Is Mr. Jones on appropriate medications? Do any medications need to be added to Mr. Jones’ regimen?
    • What important discharge guidelines have been met already?
    • What important discharge guidelines need to be met before he is ready to go home?
final clinical pearls
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
references
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,RKam,L F Hsu Treatment of Heart Failure – Role of Biventricular Pacing for Heart Failure. SingaporeMedJ2003Vol44(3):114-122