ACUTE DECOMPENSATED HEART FAILURE: 2010 HEART FAILURE SOCIETY OF AMERICA GUIDELINES

BART COX, M.D., FACC ASSOCIATE PROFESSOR OF MEDICINE UNIVERSITY OF NEW MEXICO SCHOOL OF MEDICINE DIRECTOR , ADVANCED HEART FAILURE PROGRAM

DISCLOSURES

NONE

ADHF: 2010 HFSA GUIDELINE DEFINITION

THE DIAGNOSIS OF ACUTE DECOMPENSATED HEART FAILURE (ADHF) SHOULD BE BASED PRIMARILY ON SIGNS AND SYMPTOMS

ADHF STATISTICS > 5.5 MILLION HF PATIENTS IN USA

>650,000 NEW HF CASES ANNUALLY

1 YEAR MORTALITY IS 20-30%

5 YEAR MORTALITY RATE OF 50-60%

ADHF STATISTICS

1 MILLION HOSPITAL ADHF ADMISSIONS ANNUALLY

ANOTHER 2 MILLION ANNUAL ADMISSIONS IN WHICH HF COMPLICATED THE PRIMARY DIAGNOSIS

30-50% OF PATIENTS DISCHARGED WITH ADHF WILL BE READMITTED WITHIN 3-6- MONTHS

ADHF STATISTICS 50% OF ADHF ADMISSIONS HAVE

LVEF>40% 50% OF ADHF ADMISSIONS HAVE LVEF <

40% AVERAGE PATIENT ADMITTED WITH

ADHF IS 75 YEARS OF AGE WITH SUBSTANTIAL COMORBIDITES

MOST COMMON CAUSE OF ADHF HOSPITALIZATION IS EXACERBATION OF CHRONIC HF

FIGURE 43-1

10 MINUTES OF BAD MEMORIES

FILLING PRESSURES LEFT VENTRICULAR FILLING PRESSURE: THE

PRESSURE IN THE LV CAVITY AT THE END OF DIASTOLE ◦ LV END DIASTOLIC PRESSURE (LVEDP) ◦ MEAN LA PRESSURE ◦ PCWP

RIGHT VENTRICULAR FILLING PRESURE: THE PRESSURE IN THE RV CAVITY AT THE END OF DIASTOLE ◦ RV END DIASTOLIC PRESSURE (RVEDP) ◦ MEAN RIGHT ATRIAL PRESSURE ◦ CVP

LEFT VENTRICULAR FILLING PRESSURE

CONGESTION AND FILLING PRESSURES SYMPTOMATIC CONGESTION IS DUE

TO INCREASED FILLING PRESSURES ◦ ELEVATED LEFT VENTRICULAR FILLNG

PRESSURES =SIGNS AND SX OF PULMONARY CONGESTION APPEAR ◦ ELEVATED RIGHT VENTRICULAR FILLING

PRESSURES = SIGNS AND SX OF SYSTEMIC CONGESTION APPEAR

TO RELIEVE CONGESTION, LOWER

FILLNG PRESSURES!!!

2 TYPES OF CONGESTION

PULMONARY CONGESTION ◦ DUE TO ELEVATED LEFT HEART FILLING

PRESSURES

SYSTEMIC CONGESION ◦ DUE TO ELEVATED RIGHT HEART FILLING

PRESSURES

SYMPOTMS OF PULMONARY CONGESTION

DYSPNEA

ORTHOPNEA

PND

SUPINE COUGH

SYMPTOMS OF SYSTEMIC CONGESTION

EDEMA

ABOMINAL OR HEPATIC SWELLING AND DISCOMFORT

ANOREXIA

EARLY SATIETY

SIGNS OF PULMONARY CONGESTION RALES WHEEZING PLEURAL EFFUSION HYPOXEMIA LEFT-SIDED S3 WORSENING MITRAL

REGURGITATION

SIGNS OF SYSTEMIC CONGESTION ELEVATED JVP HEPATOJUGULAR REFLUX RIGHT-SIDED S3 WORSENING TRICUSPID

REGURGITATION HEPATIC ENLARGEMENT/

TENDERNESS ASCITES EDEMA

PERFUSION= CARDIAC INDEX

NORMAL PERFUSION= NORMAL

CARDIAC INDEX

DIMINISHED PERFUSION = LOW CARDIAC INDEX

CARDIAC OUTPUT

CARDIAC OUPUT (CO) = HR X STROKE VOLUME ◦ 3 PARAMETERS OF STROKE VOLUME: PRELOAD (LVEDP OR RVEDP) CONTRACTILITY AFTERLOAD (THE ARTERIAL PRESSURE

AGAINST WHICH THE VENTRICLE MUST CONTRACT; SYSTEMIC VASC. RESISTANCE, AORTIC IMPEDENCE)

NORMAL VALUES

NORMAL CO=5 L/MIN

NORMAL CI=3 L/MIN/SQ. METERS

TO IMPROVE PERFUSION,INCREASE CARDIAC OUTPUT

1) OPTIMIZE HEART RATE AND RHYTHM

2) OPTIMIZE FILLING PRESSURE 3) INCREASE CONTRACTILITY 4) DECREASE AFTERLOAD

HFSA GUIDELINES: WHEN IS HOSPITALIZATION RECOMMENDED

EVIDENCE OF SEVERELY DECOMPENSATED HF ◦ ALTERED MENTAL STATUS, LOW BP,

WORSENING RENAL FUNCTION

DYSPNEA AT REST (02 SAT <90%) HEMODYNAMICALLY SIGNIFICANT

ARRHYTHMIA ACUTE CORONARY SYNDROMES

HFSA GUIDELINES: WHEN HOSPITALIZATION SHOULD BE CONSIDERED

MAJOR ELECTOLYTE DISTURBANCE ASSOCIATED COMORBID CONDITIONS REPEATED ICD FIRINGS NEWLY DIAGNOSED HF WITH

SIGNS / SX OF CONGESTION

TAKEHOME MESSAGE:HOSPITALIZATION FOR ADHF IS REQUIRED WHEN:

ADHF + SOMETHING ELSE NEW ONSET ADHF SIGNIFICANTLY WORSENING CONGESTION WHEN ADHF REQUIRES A PROCEDURE: ◦ SWAN / ULTRAFILTRATION ◦ CARDIOVERSION / PACEMEAKER ◦ CATHETERIZATION / PCI ◦ INTUBATE / OXYGENATE

WHAT ARE THE TREATMENT GOALS FOR ADHF ADMISSION?

HFSA GUIDELINES: TREATMENT GOALS FOR ADHF ADMISSION

SYMPTOMS ABATED (TX CONGESTIVE SYMPTOMS, FATIGUE)

DEHYDRATED (ACHIEVE EUVOLEMIA) OXYGENATED (RESTORE NORMAL 02

SATURATION) ANTICOAGULATED (IF INDICATED) MEDICATED (OPTIMIZE MEDS) EDUCATED (MEDS/ SELF-MANAGEMENT) OPERATED (REVASCULARIZE IF NEEDED)

TREATMENT GOALS FOR ADHF ADMISSION

DIAGNOSED (ETIOLOGY,

PRECIPITATING FACTORS)

DEVICED (ICD, CRT)

DISEASE MANAGED (IF AVAILABLE)

ETIOLOGY OF HF

PERICARDIAL DISEASE CORONARY DISEASE MYOCARDIAL DISEASE VALVULAR DISEASE ELECTRICAL DISEASE CONGENITAL DISEASE GREAT VESSEL DISEASE

COMMON PRECIPITATING FACTORS OF ADHF DIETARY AND MEDICATION RELATED

CAUSES PROGRESSIVE CARDIAC

DYSFUNCTION CARDIAC CAUSES NOT PRIMARILY

MYOCARDIAL IN ORIGIN NON-CARDIAC CAUSES ADVERSE CARDOVASCULAR EFFECTS

OF MEDICATIONS

COMMON PRECIPITATING FACTORS ARRHYTHMIAS (AF, A FLUTTER, SVT, VT) EXACERBATION OF HYPERTENSION MYOCARDIAL ISCHEMIA/INFARCTION ANEMIA THYROID DISEASE SIGNIFICANT DRUG INTERACTION RIGHT VENTRICULAR PACING PULMONARY DISEASE

THE 4 HEMODYNAMIC PROFILES

INITIAL CLINCIAL ASSESSMENT

FIRST HOSPITALIZATION PRIORITY: ASSESS LEVEL OF HEMODYNAMIC COMPROMISE ◦ PERFUSION (CARDIAC INDEX) ◦ CONGESTION (PCWP AND RA

PRESSURE)

RECOGNIZING THE FOUR HEMODYNAMIC PROFILES

CONGESTION = WET NO CONGESTION=DRY

NORMAL PERFUSION= WARM

DIMINISHED PERFUSION=COLD

PROFILES AND HEMODYNAMICS

DRY= PCWP <18 AND RA < 8

WET = PCWP >18 OR RA > 8

WARM= CI > 2.2

COLD= CI < 2.2

RECOGNIZING THE 4 HEMODYNAMIC PROFILES

2 HEMODYNAMIC COMPONENTS OF DECOMPENSATED HEART FAILURE: ◦ ELEVATED FILLING PRESSURES ◦ REDUCED CARDIAC OUTPUT (RARE)

THESE 2 COMPONENTS MAY NOT OCCUR TOGETHER

RECOGNIZING THE 4 HEMODYNAMIC PROFILES

IN THE MAJORITY OF PATIENTS,

FILLING PRESSURES HAVE BEEN INCREASING FOR AT LEAST 2 WEEKS

IT’S FAR EASIER TO ACCURATELY JUDGE FILLING PRESSURE THAN PERFUSION

2 MINUTE ASSESSMENT AND 4 HEMODYNAMIC PROFILES

PRINCIPLES OF THERAPY: FOCUS ON CONGESTION / FILLING PRESSURES IN WET PATIENTS

RELIEVE CONGESTION BY REDUCING FILLING PRESSURES

ABSENT CRITICAL ORGAN/RENAL/SYSTEMIC HYPOPERFUSION THAT LIMITS FILLING PRESSURE REDUCTION, IMPROVING CARDIAC OUTPUT DOES NOT WORK!!!

PRINCIPLES OF THERAPY: THE OPTIMAL FILLING PRESSURE

WITH LOW EF, OPTIMAL PCWP < 15-16 ◦ LOWERING FILLING PRESSURES -> IMPROVED

STROKE VOLUME ELEVATED FILLING PRESSURES: ◦ RESPONSIBLE FOR SX OF CONGESTION ◦ ACTIVATE NEUROHORMONES (RAS, SNS) ◦ INCREASE VALVULAR REGURGITATION ◦ RESPONSIBLE FOR PULMONARY HYPERTENSION ◦ CAUSE RIGHT VENTRICULAR DYSFUNCTION ◦ CAUSE ABNORMAL LV FILLING PATTERNS

FILLING PRESSURES AND STROKE VOLUME

STROKE VOLUME IMPROVED BY DECREASING MR

PROFILE A: WARM AND DRY

PROFILE B: WARM AND WET

PROFILE B: WET AND WARM MOST PATIENTS PRESENTING WITH ADHF

ARE PROFILE B GOAL OF TX: SX IMPROVEMENT BY

REDUCTION IN FILLING PRESSURES ◦ ELEVATED FILLING PRESSURES ARE DUE TO: INCREASED INTRAVASCULAR VOLUME INCREASED SVR BOTH

FOR MAJORITY, IV DIURETIC TX IS THE MAIN INTERVENTION ◦ MAY REQUIRE ADDITION OF METOLAZONE OR

IV CHLORTHIAZIDE

PROFILE B: ROLE FOR ADJUNCTIVE AGENTS USE OF ADJUNCTIVE THERAPIES BEYOND

DIURETICS HAS NOT BEEN DEMONSTRATED TO IMPROVE OUTCOMES IN HOSPITALIZED ADFH PATIENTS IN PROFILE B ◦ INOTROPES: ISCHEMIA, ARRHYTHMIAS, POSSIBLY

DEATH ◦ NTG: NEUTRAL OUTCOMES ◦ NESIRITIDE: EXPENSIVE PLACEBO ◦ ENDOTHELIN ANTAGONIST: NO IMPROVEMENT ◦ VASOPRESSIN ANTAGONISTS: NEGATIVE FLUID

BALANCE NOT SUSTAINED LONG-TERM

PROFILE B: VERY HIGH OR VERY LOW SYSTEMIC VASCULAR RESISTANCE(SVR)

VERY HIGH SVR > 2000 dyne/sec/cm-5 HOW TO RECOGNIZE ◦ HIGH BP ◦ VERY NARROW PULSE PRESSURE ◦ PA CATHETER MEASUREMENT

VERY LOW SVR (WITHOUT MEDS): LOW BP + REASONABLE PULSE PRESSURE + WARM EXTREMITIES

PROFILE C: COLD AND WET

PROFILE C: WET AND COLD

<3% OF PATIENTS PRESENT WITH CARDIOGENIC SHOCK

WET=CONGESTION COLD=INADEQUATE PERFUSION TX: MAY NEED TO WARM THEM UP

BEFORE DRYING THEM OUT ◦ DIURESIS WILL IMPROVE CARDIAC OUTPUT ◦ IN MANY CASES, DIURESIS IS NOT POSSIBLE

IF RENAL PERFUSION SEVERLY COMPROMISED

PROFILE C: IV VASODILATORS OR INOTROPES? CHOICE OF THERAPY DEPENDS ON

SYSTEMIC VASCULAR RESISTANCE ◦ IF SVR SIGNIFICANTLY ELEVATED:

VASODILATOR ◦ IF SVR NORMAL-LOW: INOTROPE

IF INOTROPES USED, KEEP THE DOSE

AS LOW AS POSSIBLE

PROFILE L:COLD AND DRY

PROFILE L: DRY AND COLD EXTEMELY RARE PRESENTATION REQUIRE PA CATHETER PLACEMENT TO

EVALUATE FILLING PRESSURES ◦ IF PCWP<12 OR RA PRESSURE <8: PO FLUID

REPLACEMENT OFF DIURETICS ◦ IF PCWP>16: PROFILE C ◦ IF PCWP 12-16 + NORMAL RA PRESSURE:

LIMITED OPTIONS INOTROPES AND VASODILATORS ONLY

TEMPORARY FIX; VAD/ TRANSPLANT BETA BLOCKERS MAY LEAD TO LATER

IMPROVEMENT IN LV FUNCTION

ADHF EVALUATION

HISTORY PHYSICAL EXAMINATION EKG PA AND LATERAL CHEST XRAY ECHOCARDIOGRAM LABS ISCHEMIA EVALUATION AS

APPROPRIATE

ADHF: THE HISTORY

CLASSIC SYMPTOMS DOE OR AT REST REDUCTION IN EXERCISE CAPACITY ORTHOPNEA PND OR NOCTURNAL COUGH EDEMA ASCITES OR SCROTAL EDEMA

ADHF: THE HISTORY

LESS SPECIFIC PRESENATION OF HF ◦ EARLY SATIETY, N&V, ABDOMINAL

DISCOMFORT ◦ WHEEZING OR COUGH ◦ UNEXPLAINED FATIGUE ◦ CONFUSION / DELERIUM ◦ DEPRESSION / WEAKNESS

ADHF HISTORY: WHAT TO INCLUDE ANGINA SX SUGGESTING AN EMBOLIC EVENT SX SUGGESTIVE OF SLEEP DISORDERED

BREATHING SX OF ARRHYTHMIA (PALPITATIONS) SX OF CEREBRAL HYPOPERFUSION

(SYNCOPE, PRESYNCOPE, LIGHTHEADEDNESS)

NYHA FUNCTIONAL CLASSIFICATION IN HF

CLASS I: NO FATIGUE, PALPITATIONS, OR DYSPNEA (FPD) WITH ORDINARY ACTIVITY

CLASS II: FPD WITH ORDINARY ACTIVITY CLASS IIIA:FPD WITH LESS THAN

ORDINARY ACTIVITY CLASS IIIB: FPD WITH MINIMAL ACTIVITY CLASS IV: FPD AT REST

SENSITIVITY OF EXAM FOR ELEVATED LEFT-SIDED FILLING PRESSURES IN LOW EF

RIGHT –SIDED FINDINGS ◦ JVP > 12 65% ◦ EDEMA >2+ 41% ◦ HJR 83% ◦ HEPATOMEGALY > 4 FB 15%

SENSITIVITY OF EXAM FOR ELEVATED LEFT-SIDED FILLING PRESSURES IN LOW LVEF

LEFT- SIDED FINDINGS ◦ ORTHOPNEA 86% ◦ RALES > “FEW @ BASES” 15% ◦ S3 63%

ADHF EVALUATION: ECHOCARDIOGRAM

SIZE, THICKNESS, AND FUNCTION OF BOTH VENTRICLES

FILLING PATTERN OF LV ATRIAL SIZE VALVULAR STRUCTURE AND FUNCTION PERICARDIUM GREAT VESSELS RVSP THROMBUS OR MASS

ADHF EVALUATION: EKG

ASSESS RHYTHM AND CONDUCTION ASSESS ELECTRICAL DYSSYNCHRONY,

ESPECIALLY IF LVEF < 35% (QRS DURATION)

ASSESS QTc INTERVAL DETECT MI OR ISCHEMIA DETECT LVH OR OTHER CHAMBER

ENLARGEMENT

ADHF EVALUATION: PA AND LATERAL CHEST XRAY

HEART SIZE PULMONARY CONGESTION PULMONARY PARENCHYMAL DISEASE PERICARDIAL OR VALVULAR

CALCIFICATION PLACEMENT OF IMPLANTED

CARDIAC DEVICE

ADHF: LABORATORY STUDIES CBC ELECTROLYTES, BUN, CREATININE,

GLUCOSE CALCIUM, MAGNESIUM URINALYSIS LIVER FUNCTION AND ALBUMIN THYROID FUNCTION URIC ACID FASTING LIPID PANEL BNP OR NT BNP

WHEN TO PLACE A SWAN

What I’m doing isn’t working…

it’s not going well….

I don’t know if they are wet or dry…

And I don’t want to make a mistake…

WHEN TO CONSIDER INVASIVE HEMODYNAMIC MONITORING:

HFSA GUIDELINES

THE ROUTINE USE OF INVASIVE HEMODYNAMIC MONITORING IN

PATIENTS WITH ADHF IS NOT RECOMMENDED

WHEN TO CONSIDER INVASIVE HEMODYNAMIC MONITORING:HFSA GUIDELINES

REFRACTORY TO INITIAL THERAPY AND

WHOSE VOLUME STATUS AND CARDIAC FILLING PRESSURES ARE UNCLEAR AND

HAS CLINICALLY SIGNIFICANT HYPOTENSION (TYPICALLY SBP <80-90 mm Hg

OR

WHEN TO CONSIDER INVASIVE HEMODYNAMIC MONITORING: HFSA GUIDELINES PATIENT IS BEING CONSIDERED FOR CARDIAC TRANSPLANT AND NEEDS ASSESSMENT OF DEGREE AND REVERSIBILITY OF PULMONARY HTN

OR WHEN DOCUMENTATION OF AN ADEQUATE HEMODYNAMIC RESONSE TO THE INOTROPIC AGENT IS NECESSARY WHEN CHRONIC OUTPATIENT INFUSION IS BEING CONSIDERED

GUIDELINE-ACCEPTED INDICATIONS FOR PA CATHETER PLACEMENT IN AN ADHF PATIENT

THERAPY ISN’T WORKING + VOLUME STATUS UNKNOWN + SBP <90

PRE-HEART TRANSPLANT WORKUP DOCUMENTING BENEFIT OF INOTROPE

BEFORE DISCHARGING ON CHRONIC INFUSION

DIURETICS

HFSA GUIDELINE:HOW TO DIURESE

DIURESES WITH IV LOOP DIURETIC ULTRAFILTRATION MAY BE USED IN

LIEU OF IV DIURETICS DIURESE UNTIL DRY DIURESE AT THE CORRECT RATE

HFSA GUIDELINES: WHAT TO MONITOR DURING DIURESIS MONITORING OF DAILY WEIGHTS,

INTAKE, AND OUTPUT IS RECOMMENDED TO ASSESS CLINICAL EFFICACY OF DIURETIC THERAPY.

ROUTINE USE OF A FOLEY CATHETER IS NOT RECOMMENDED FOR MONITORING VOLUME STATUS.

HFSA GUIDELINES: DIURETIC SIDE EFFECTS

OBSERVE FOR DEVELOPMENT OF DIURETIC-INDUCED SIDE EFFECTS

CHECK SERUM MAGNESIUM AND POTASSIUM LEVELS AT LEAST DAILY

OVERLY RAPID DIURESIS MAY BE ASSOCIATED WITH MUSCLE CRAMPS.

DIURETIC SIDE EFFECTS HYPOKALEMIA HYPOMAGNESEMIA HYPONATREMIA HYPOTENSION NEUROHORMONAL ACTIVATION GOUT EXACERBATON HEARING LOSS INCREASED INCIDENCE OF DIG

TOXICITY

HFSA GUIDELINES: VOLUME OVERLOAD, RENAL DYSFUNCTION, AND DIURETIC USE

DURING DIURESIS, CAREFUL MONITORING FOR RENAL INSUFFICIENCY IS RECOMMENDED.

PATIENTS WITH MODERTE TO SEVERE RENAL DYSFUNCTION AND EVIDENCE OF FLUID RETENTION SHOULD CONTINUE TO BE TREATED WITH DIURETICS

Copyright ©2009 American College of Cardiology Foundation. Restrictions may apply.

Gheorghiade, M. et al. J Am Coll Cardiol 2009;53:557-573

The Cardio-Renal Syndrome

HFSA GUIDELINES: DESTROYING DIURETIC RESISTANCE

DIAGNOSE IT: ARE THEY TRULY WET? DECREASE THE Na AND FLUID INTAKE DOSE IT: INCREASE THE DOSE OF DIURETIC DRIP IT: SWITCH TO A CONTINUOUS INFUSION DOUBLE THE DIURETIC: ADD CHLORTIHIAZIDE DEVICE IT: CONSIDER ULTRAFILTRATION

DAILY CARE OF THE ADHF PATIENT

HFSA GUIDELINES:MONITORING RECOMMENDATIONS FOR HOSPITALIZED ADHF PATIENTS

WEIGHT (DAILY) FLUID I&O (AT LEAST DAILY) VITAL SIGNS: ORTHOSTATIC AND O2 SAT LABS: LYTES, BUN, Mg, CREATINNE (>DAILY) CONGESTIVE SIGNS (AT LEAST DAILY) CONGESTIVE SYMPTOMS (AT LEAST DAILY)

HFSA GUIDELINE: FLUID RESTRICTION RESTRICTING FLUID INTAKE TO 2

L/DAY IS USUALLY ADEQUATE FOR MOST HOSPITALIZED PATIENTS

FLUID RESTRICTION < 2 L/DAY IS RECOMMENDED IN PATIENTS WITH Na <130 mEq/L AND SHOULD BE CONSIDERED TO ASSIST IN TREATMENT OF FLUID OVERLOAD IN OTHER PATIENTS.

HFSA GUIDELINE: THE LOW SODIUM DIET

A 2 GRAM/DAY SODIUM DIET IS RECOMMENDED FOR MOST HOSPITALIZED PATIENTS

HFSA GUIDELINE: USE OF SUPPLEMENTAL OXYGEN IN ADHF ROUTINE ADMINISTRATION OF

SUPPLEMENTAL OXYGEN IN THE PRESENCE OF HYPOXIA IS RECOMMENDED

ROUTINE ADMINISTRATION OF SUPPLEMENTAL OXYGEN IN THE ABSENCE OF HYPOXIA IS NOT RECOMMENDED

HFSA GUIDELINE: USING NON-INVASIVE VENTILATION (NIV)

USE OF NON-INVASIVE POSITIVE PRESSURE VENTILATION MAY BE CONSIDERED FOR SEVERLY DYSPNIC PATIENTS WITH CLINICAL EVIDENCE OF PULMONARY EDEMA ◦ NIV IMPROVES DYSPNEA ◦ NIV LIKELY HAS NO IMPACT ON

INTUABION RATES OR MORTALITY

HFSA GUIDELINE: DVT PROPHYLAXIS IN THE ADHF PATIENT VENOUS THROMBOEMBOLSIM PROPHYLAXIS

WITH LOW DOSE UFH, LMWH, OR FONDAPARINUX TO PREVENT DEEP VENOUS THROMBOSIS(DVT) AND PULMONARY EMBOILISM IS RECOMMENDED FOR ADHF PATIENTS:

◦ WHO ARE NOT ALREADY ANTICOAGULATED

AND ◦ WHO HAVE NO CONTRAINDICATION TO

ANTICOAGULATION

HFSA GUIDELINE: DVT PROPHYLAXIS IN THE ADHF PATIENT VENOUS THROMBOLISM PROPHYLAXIS WITH A

MECHANICAL DEVICE (INTERMITTENT PNEUMATIC COMPRESSION DEVICES OR GRADED COMPRESSION STOCKINGS) TO PREVENT DVT AND PE SHOULD BE CONSIDERED FOR PATIENTS WHO AE ADMITTED TO THE HOSPITAL WITH ADHF AND ◦ WHO ARE NOT ALAREADY ANTICOAGULATED

AND ◦ WHO HAVE A CONTRAINDICATION TO

ANTICOAGULATION

VASODILATORS

IV VASODILATORS USED IN ADHF

NITROGLYCERIN

NITROPRUSSIDE

ASCEND-HF

No significant ↑ in major improvement in shortness of breath with nesiritide compared with placebo at 6 (15.0% vs. 13.4%) and 24 hours (30.4% vs. 27.5%)

At 30 days, death or CHF hospitalization: 9.4% vs. 10.1%; all-cause mortality: 3.6% vs. 4.0%, (p > 0.05)

Worsening renal failure: 31.4% vs. 29.5%, p = 0.11; symptomatic hypotension: 7.1% vs. 4.0%, p < 0.001

Trial design: Patients presenting with acute decompensated CHF and requiring intravenous treatment were randomized to receive intravenous infusion of nesiritide or placebo, in addition to standard therapy. Patients were followed for 30 days.

Results

Conclusions

Presented by Dr. Adrian Hernandez at AHA 2010

(p = 0.31)

Nesiritide (n = 3,564)

Death or CHF hospitalization

• Nesiritide was associated with none to minimal improvements in dyspnea at 6 and 24 hours; clinical outcomes including death and repeat hospitalizations similar; no increase in renal failure with nesiritide

• Largest trial with this medication; no signal of harm as noted by earlier smaller trials; clinical utility is likely minimal

0

50

100

%

9.4 10.1

(p > 0.05)

3.6 4.0

5

All-cause mortality

Placebo (n = 3,577)

0

10

%

HFSA GUIDELINE: TREATING ADHF PATIENTS WITH ACUTE PULMONARY EDEMA OR SEVERE HYPERTENSON

INTRAVENOUS VASODILATORS (NITROGLYCERIN OR NITROPRUSSIDE) ARE RECOMMENDED FOR RAPID SYMPTOM RELIEF IN PATIENTS WITH ACUTE PULMONARY EDEMA OR SEVERE HYPERTENSION

HFSA GUIDELINES: USING IV VASODIALTORS IN ADHF IN THE ABSENCE OF SYMPTOMATIC

HYPOTENSION, IV NITROGLYCERIN OR NITROPRUSSIDE MAY BE CONSIDERED AS AN ADDITION TO DIURETIC THERAPY FOR RAPID IMPROVEMENT OF CONGESTIVE SYMPOTMS IN PATIENTS ADMITTED WITH ADHF.

HFSA GUIDELINES: OTHER USES OF IV VASODILATORS

INTRAVENOUS VASODILATORS (NITROPRUSSIDE OR NITROGLYCERIN) MAY BE CONSIDERED IN PATIENTS WITH ADHF WHO HAVE PERSISTENT SEVERE HF DESPITE AGGRESSIVE TREATMENT WITH DIURETICS AND STANDARD ORAL THERAPIES

INOTROPES: BEATING A DEAD HORSE

WHEN TO USE IV INOTROPES

IV INOTROPES (MILRINONE OR DOBUTAMINE) MAY BE CONSIDERED TO RELIEVE SYMPTOMS AND IMPROVE END-ORGAN FUNCTION IN PATIENTS WITH ADVANCED HF +LOW OUTPUT SYNDROME + UNRESPONSIVE TO/INTOLERANT OF DIURETICS AND VASODILATORS

ADVANCED HEART FAILURE REQUIRING INOTROPES

LV DILATION

REDUCED LVEF

DEFINITION OF LOW OUTPUT SYNDROME IN AN ADVANCED HF PATIENT DIMINISHED PERIPHERAL PERFUSION OR

END-ORGAN DYSFUNCTION +

MARGINAL SBP (<90 mm Hg) / SYMPTOMATIC HYPOTENSION DESPITE ADEQUATE FILLING PRESSURES

HFSA GUIDELINES: INOTROPE USE

IV INOTROPES MAY BE CONSIDERED IN THE SETTING OF: ◦ ADVANCED HF

+ ◦ LOW OUTPUT SYNDROME

+ ◦ INTOLERANT TO VASODILATORS

OR ◦ POOR RESPONSE TO IV DIURETICS

OR ◦ WORSENING RENAL FUNCTION

2 THINGS YOU MUST KNOW BEFORE STARTING AN INOTROPE: INTRAVENOUS INOTROPES (MILRINONE

OR DOBUTAMINE) ARE NOT RECOMMENDED UNLESS THE PA CATHETER READINGS OR CLEAR CLINICAL SIGNS DEMONSTRATE: ◦ LEFT HEART FILLING PRESSURES ARE

ELEVATED ◦ CARDIAC INDEX IS SEVERELYIMPAIRED

HFSA GUIDELINES: WHAT TO MONITOR WHEN ADMINISTERING AN INOTROPE

FREQUENT BLOOD PRESSURE MONITORING

CONTINUOUS MONITORING OF CARDIAC RHYTHM

IF VASODILATORS CAN BE TOLERATED, DO I USE

INOTROPES OR VASODIALTORS?

HFSA GUIDELINES: IV VASODILATORS VS. INOTROPES

WHEN ADJUNCTIVE THERAPY IS NEEDED FOR ADHF PATIENTS WITHOUT LOW OUTPUT SYNDROME, ADMINISTRATION OF VASODIALTORS SHOULD BE CONSIDERED INSTEAD OF IV INOTROPES

HFSA GUIDELINES:EVALUATING THE COMMON PRECIPITATING FACTORS OF ADHF

IT IS RECOMMENDED THAT PATIENTS ADMITTED WITH ADHF UNDERGO EVALUATION FOR THE FOLLOWING PRECIPITATING FACTORS: ◦ ATRIAL FIBILLATION OR OTHER ARRHYTHMIA ◦ EXACERBATION OF HYPERTENSION ◦ MYOCARDIAL ISCHEMIA OR INFARCTION ◦ ANEMIA ◦ THYROID DISEASE ◦ SIGNIFICANT DRUG INTERACTION

WHEN TO DISCHARGE

PLANNING FOR HOSPTIAL DISCHARGE 30- 50% OF PATIENTS DISCHARGED

WITH DX OF ADHF ARE REHOSPITALIZED WITHIN THE NEXT 3-6 MONTHS

FAILURE TO MEET DISCHARGE CRITERIA CONTRIBUTES TO REHOSPITALIZATION RATE

IT IS COST EFFECTIVE TO REMAIN IN HOSPITAL

HOSPTIAL DISCHARGE: DESIGNING THE ORAL REGIMEN

HOW WILL THIS TIME BE DIFFERENT? START SPIRONOLACTONE SEVERAL DAYS

BEFORE DISCHARGE ADD NITRATES/HYDRALAZINE TO AFRICAN

AMERICANS APPROPRIATELY STOP BETA BLOCKERS IN COLD PATIENTS,

CONTINUE IN OTHERS DON’T INITATE BETA BLOCKERS IF

RECENTLY COLD

HOSPITAL DISCHARGE: PATIENT EDUCATION INITATED AND CONTINUED

THROUGHOUT HOSPITALIZATION PARTICIPATE IN DAILY RITUAL OF

WEIGHT AND I&O DON’T CONCENTRATE ON WHAT

THEY CAN’T DO WHAT CAN THEY DO? KEEP DRY,

KEEP ACTIVE, KEEP GOALS WHEN TO CALL AND WHO TO CALL

DISCHARGE CIRTERIA FOR PATIENTS ADMITTED WITH ADHF EXACERBATING FACTORS ADDRESSES EUVOLEMIC STATE ACHIEVED TRANSITION FROM IV TO ORAL

DIURETIC SUCCESSFULLY COMPLETED PATIENT AND FAMILY EDUCATION

COMPLETED, INCLUDING CLEAR DISCHARGE INSTRUCTIONS

DISCHARGE CRITERIA FOR PATIENTS ADMITTED WITH ADHF LVEF DOCUMENTED SMOKING CESSATION COUNSELING

INITIATED NEAR OPTIMAL PHARMACOLOGIC THERAPY

ACHIEVED, INCLUIDING ACE INHIBITOR AND BETA BLOCKER (FOR PATIENTS WITH REDUCED LVEF), OR INTOLERANCE DOUCMENTED

FOLLOW-UP CLINIC VISIT SCHEDULED, USUALLY FOR 7-10 DAYS