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The 1 st Kuwait-North American Update in Internal Medicine. Acute Decompensated Heart Failure in Hospitalized Patients. Michael M. Givertz, M.D. Medical Director, Heart Transplant/Mechanical Circulatory Support Brigham and Women ’ s Hospital Associate Professor of Medicine

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acute decompensated heart failure in hospitalized patients

The 1st Kuwait-North American Update in Internal Medicine

Acute Decompensated Heart Failure in Hospitalized Patients

Michael M. Givertz, M.D.

Medical Director, Heart Transplant/Mechanical Circulatory Support

Brigham and Women’s Hospital

Associate Professor of Medicine

Harvard Medical School

Boston, MA

the course of heart failure
The Course of Heart Failure

Goodlin et al., J Am Coll Cardiol 2009;54:386

trends in adhf morbidity mortality
Trends in ADHF Morbidity/Mortality

Chen et al., JAMA 2011;306:1669

markers of advanced disease and poor prognosis
Markers of Advanced Disease and Poor Prognosis
  • Severe (objective) exercise intolerance
  • ACE inhibitor or β-blocker intolerance
  • High-dose diuretics
  • RV failure, 2 pulmonary hypertension
  • Hyponatremia, anemia, hyperuricemia
  • Chronic kidney disease (CKD)
  • Cardiac cachexia
repeat hospitalizations and death
Repeat Hospitalizations and Death

6-12 months

Setoguchi et al., Am Heart J 2007;154:260

adhf who are they
ADHF: Who are They?
  • Older (mean age 70s)
  • ≈50% women
  • 40-50% preserved EF
  • Over 85% with chronic HF
  • Multiple co-morbidities
    • Hypertension
    • Diabetes
    • Chronic kidney disease
congestion not low output is the main finding in hospitalized patients
Congestion(Not Low Output) is the Main Finding in Hospitalized Patients

1Fonarow et al. Rev Cardiovasc Med 2003;4 Suppl 7:S21

2VMAC Investigators. JAMA 2002;287:1531

congestion is often unrecognized and precedes hospitalization




Congestion is Often Unrecognized and Precedes Hospitalization

Adamson et al., J Am Coll Cardiol 2003;41:565

Yu et al., Circulation 2005;112:841

cardiomems pressure measurement system
CardioMEMS: Pressure Measurement System

Dear Michael M. Givertz, MD

A new reading has come in for your patient, 31-003 C-Z which violated the alert threshold set up for "Mean Pressure above 20.0 mmHg". The reading was taken on 25 Jan 04:06 EST.

Systolic: 89

Diastolic: 51

Mean: 66

Heart Rate: 91

Pressure waveform is attached.

Thank you,

CardioMEMS Alert System

champion study hf hospitalizations
CHAMPION Study: HF Hospitalizations

p < 0.001, based on Negative Binomial Regression

HF Hospitalizations, no.

acc aha guidelines for adhf



Class I


Class II


Class III


Evidence A






Evidence B


Evidence B


Evidence B


Evidence C


Evidence C


Evidence C


ACC/AHA Guidelines for ADHF

Consensus opinion 72%, “Evidence” 28%

class i level of evidence a
Class I, Level of Evidence A
  • Concentrations of BNP1 or NT-proBNP2 should be measured in patients being evaluated for dyspnea in which the contribution of HF is not known. Final diagnosis requires interpreting these results in the context of all available clinical data and ought not to be considered a stand alone test.

Unfortunately, the routine use of serial natriuretic peptide measurements to monitor hemodynamics has not been shown to be helpful in improving the outcomes of the hospitalized patient with HF (ACC/AHA)

1Maisel et al., N Engl J Med 2002;347:161 (BNP Study)

2Januzzi et al., Am J Cardiol 2005;95:948 (PRIDE Study)

diuretics for adhf and fluid overload
Diuretics for ADHF and Fluid Overload
  • Treatment with IV loop diuretics should begin in the ED without delay, as early intervention may be associated with better outcomes (Level of evidence B).
  • If patients are already receiving loop diuretics, initial IV dose should equal or exceed chronic oral dose (Level of evidence C).
  • When a patient with congestion fails to respond to IV diuretics, consider increased dose of loop diuretic, addition of second diuretic, continuous infusion of loop diuretic (Level of evidence C)
dose study
DOSE Study

Felker et al., N Engl J Med 2011;364:797

dose study1
DOSE Study
  • 308 patients with ADHF
  • Randomized 2x2 to low vs. high-dose furosemide and IV bolus vs. continuous infusion
  • No differences at 72 hours in:
    • Global symptom assessment (1° efficacy endpoint)
    • Change in renal function (1° safety endpoint)

Felker et al., N Engl J Med 2011;364:797

death rehospitalization or ed visit
Death, Rehospitalization, or ED Visit

Felker et al., N Engl J Med 2011;364:797

cardiorenal syndrome worsening renal function during treatment of adhf
Cardiorenal Syndrome:Worsening Renal Function During Treatment of ADHF

Increase in creatinine ≥ 0.3 mg/dl

Occurs in 15-30% of admissions

Risk factors:

Older age


Baseline renal dysfunction

May be associated with adverse outcomes during the hospitalization and post-discharge

Gottlieb et al., J Card Fail 2002;8:136

Forman et al., J Am Coll Cardiol 2004;43:61

transient vs persistent worsening renal function
Transient vs. Persistent Worsening Renal Function



N = 467 with ADHF, WRF in 115 (24%)

Aronson et al., J Card Fail 2010;16:541

ultrafiltration an attractive alternative to diuretics
Ultrafiltration: An Attractive Alternative to Diuretics
  • More effective way to restore sodium balance1
    • removal of isotonic vs. hypotonic saline
  • No effect on serum electrolytes
  • Rapid and predictable fluid removal
  • Does not stimulate neurohormones
  • May restore diuretic responsiveness and improve long-term outcomes2

1Jessup and Costanzo, J Am Coll Cardiol 2009;53:597

2Agostoni et al., J Am Coll Cardiol 1993;21:424

minimally invasive ultrafiltration
Minimally Invasive Ultrafiltration

FDA approved, portable device

Non-ICU, routine nursing

PICC or central line

UNLOAD (sponsor-initiated)

Greater weight loss at 48 hours compared to IV diuretics (5 vs. 3.1 kg; p < 0.001)

Decreased HF hospitalization at 90 days

Costanzo et al., J Am Coll Cardiol 2007;49:675

carress study

N = 188 with ADHF, Cre ↑ ≥ 0.3, persistent congestion

Randomized to UF vs. stepped pharmacologic care

Bart et al., N Engl J Med 2012;367:2296

carress study primary endpoint
CARRESS Study: Primary Endpoint

Cre ↑ 0.23

Cre ↓ 0.04

Bart et al., N Engl J Med 2012;367:2296

carress adverse events
CARRESS: Adverse Events
  • More patients in UF group (72%) had SAEs compared to stepped pharmacologic care (57%)
    • Renal failure
    • Bleeding
    • IV catheter-related
  • No difference in 60-day mortality or rate of death or HF rehospitalization

Bart et al., N Engl J Med 2012;367:2296

options for diuretic resistant patients
Options for Diuretic Resistant Patients
  • Vasodilators
    • IV Nitroprusside, nitroglycerin
    • Hydralazine/nitrates
  • Positive inotropes
    • Dobutamine
    • Milrinone
    • Dopamine (renal-dose vs. higher doses)
  • Mechanical circulatory support
d obutamine interpatient variability
Dobutamine: Interpatient Variability

Colucci et al., Circulation 1986;73:III175

tolerance to not all inotropes
Tolerance to (Not All) Inotropes

N = 20, severe chronic HF, CI 1.63 L/min/m2

Mager et al., Am Heart J 1991;121:1974

is there really a role for low dose dopamine
Is There Really a Role for Low-Dose Dopamine?

N = 380 with ADHF and estimated GFR 15-60 ml/min

Randomized to dopamine 2 mcg/kg/min vs. placebo

Chen et al., JAMA 2013:310:2533

rose study
ROSE Study

No effect on symptoms, 60-day readmission or 180-day mortality

More tachycardia

Chen et al., JAMA 2013:310:2533

worst prognosis with inotrope dependence
Worst Prognosis with Inotrope Dependence

Community-based Clinical trial

Hershberger, J Card Fail 2003;9:180 Rogers, J Am Coll Cardiol 2007;50:741

adhf is a good time to address risks and co morbidities
ADHF is a Good Time to Address Risks and Co-Morbidities
  • Arrhythmias or conduction disease
    • consider ICD for primary prevention
    • AF: consider amiodarone/CV, ablation
    • LBBB: consider CRT*
  • Risk of thromboembolism: need for anticoagulation or anti-platelet therapy
  • Anemia, diabetes, obesity, sleep apnea
  • Advanced directives

*should NOT be used as a “bail-out”

dying with hf is rarely unexpected
Dying with HF is Rarely Unexpected
  • N = 160
  • Mean age 60, 74% male
  • Mean duration of HF: 5 years
  • 40% died in hospital, 10% with hospice
  • Within 6 months of death:
    • 93% NYHA class III or IV
    • 74% hospitalized at least once
    • mean Na 128, Cre 3.1, Hct 30

Teuteberg et al, J Card Fail 2006;12:47

comprehensive discharge instructions
Comprehensive Discharge Instructions

Six key aspects of care

  • Diet
  • Medications (adherence and uptitration)
  • Activity level
  • Follow-up appointments
  • Daily weights
  • What to do if HF worsens?