Download Inpatient Management of Heart Failure

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
-Perform effective inpatient monitoring
-Conduct a successful discharge
-Know the natural history of HF
Jugular Venous Distension
• JVD: Indication of volume overload,
especially on the right side of the heart
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 cutoff for dx of ADHF
– Lower in obese people at baseline, so use
lower cut-off for dx of ADHF
Treatment: Who needs What?
CARDIAC OUTPUT
WARM AND DRY
Home
WARM AND WET
Compensated
Congested
Optimize oral therapy
Diuretics
Outpatient
ED or Inpatient
COLD AND DRY
ICU
COLD AND WET
Low Flow State
Decompensated
Inotropes, vasodilators, ?IABP
Diuretics, vasodilators, inotropes
ICU
ICU
Floor
ICU
PULMONARY CAPILLARY WEDGE PRESSURE
Adapted from Nohria,J Cardiac Failure 2000;6:64
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
• 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
• At least daily
– Weight
– Intake and output
– Symptoms and exam
– Renal function and electrolytes
• More frequently
– Vital signs
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
•
•
•
•
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.
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)
Disposition: Lingering Questions
•
•
•
•
Who needs hydralazine and nitrates?
Who needs spironolactone?
Who needs an ICD?
Who needs a pacemaker?
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.
2.
3.
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?
Prognosis
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
-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