Acute Decompensated Heart

Failure
(ADHF)- Inpatient Management

Jennifer Kumar
February 2014

Objectives

Learn to identify the signs and

symptoms of ADHF

Learn to interpret pertinent laboratory

data and imaging

Learn the inpatient management of

ADHF

Clinical Vignette

Clinical Vignette

62 year old Caucasian male with PMH of ischemic

cardiomyopathy (EF 25%), CAD, HTN presents with
two week history of dyspnea

Previously able to walk 2 miles, currently cannot walk

more than 10 feet before developing DOE

PND 3 times per night

4 pillow orthopnea

Increasing lower extremity edema

ROS: loss of energy, loss of appetite, 10# weight gain

Clinical Vignette

PMH: ischemic cardiomyopathy (EF

25%, based on echocardiogram 6
months prior), CAD (s/p MI with PCI in
2002), HTN

Home medications: ASA 81mg daily,

Lisinopril 5mg daily, Lasix 40mg daily

Allergies: NKDA

ROS: denies CP, denies dizziness,

denies palpitations

Clinical Vignette
VS: Temp 36.5, HR 90, BP 108/72, RR 20,
SpaO2 91% on RA
Pertinent physical exam:

General: appears uncomfortable, able to speak short

sentences
HEENT: Jugular venous distension at 10cm
CVS: PMI displaced laterally to mid-axillary line in
the 6th ICS, (-) heaves, thrills, RRR, (+) S3, (-)S4, (-)
murmurs or rubs
Chest: loss of tactile fremitus at the base with
dullness to percussion, (+) rales throughout bottom
half of lung fields bilaterally
Abdomen: distended, (+) mild fluid wave, (+)
hepatojugular reflux,
Extremities: 2+ pitting edema up to knees bilaterally,
cool to touch, 2+ DP and PT pulses

Clinical Vignette

Current presentation consistent with

acute decompensated heart failure
(ADHF)

What labs should we order to help

evaluate further?

Laboratory Data

CBC
Anemia, infection can precipitate ADHF

BMP
Hyponatremia- poor prognostic sign
Elevated creatinine- impaired renal perfusion

LFT
May be elevated due to congestive hepatopathy

Troponin
Ischemia can precipitate HF
Troponin may be mildly elevated in HF as well from
demand ischemia

Laboratory Data

BNP
< 100 strongly suggestive against HF
>400 suggestive of HF exacerbation
However may be falsely elevated in:
Renal disease, atrial fibrillation, pulmonary HTN

May be falsely low in:

Obese patients, HFPEF

Toxicology screen
In select patients, as drug abuse can trigger
exacerbation

TSH
Untreated thyroid disease can precipitate
exacerbation

Clinical Vignette

At this point, what imaging should be

obtained to further assist with
management?

Imaging: EKG

Important to look for underlying

Ischemia
Arrhythmias

Imaging: Chest x-ray

Enlarged cardiac silhouette

Pulmonary edema

Pulmonary congestion
Cephalization
Kerley B lines
Peri-bronchial cuffing

Pleural effusions, typically bilateral

Clinical Vignette

Should an echocardiogram be
repeated?

Imaging: Echo

Typically repeated no sooner than

annually

Provides information regarding;

Ejection fraction
Diastolic dysfunction
Wall motion abnormalities
Chamber sizes
Pulmonary HTN
Ventricular dysynchrony

Clinical Vignette

How should we begin our inpatient

management?

Non-pharmacologic
Management

Daily weight

Strict Is and Os

Low sodium diet (<2g daily)

Fluid restriction
Typically only for patients with
hyponatremia

Clinical Vignette

What should we use to improve our

patients volume status?

Treatment: Diuretics
Recommend to give intravenously
initially
Typically at least twice a day
Agents

Furosemide
Can give home dose as IV (2:1 po to IV ratio)
Titrate up based on response (goal net
negative 1.5-2L daily on average)

Bumetanide
Alternative to Furosemide in tolerant patients
40 mg IV Lasix = 1 mg IV Bumetanide = 1mg

Clinical Vignette

The patient is now receiving 40mg

Furosemide IV twice a day

What could be done next if the patient

did not respond to Furosemide?

How often should his electrolytes be

monitored?

Treatment: Diuretics

If not responding to initial diuretic dose:

Can titrate dose up further
Older patients, underlying renal dysfunction may
require higher doses

Can consider adding Metolazone for

additional effect
Thiazide diuretic

Monitoring of electrolytes closely

Check potassium and magnesium at least daily
If aggressive diuresis, check at least twice daily

Clinical Vignette

The patient did not come in on a beta

blocker, but this has been shown to
improve long-term mortality in heart
failure

Should we begin a beta blocker at this

time?

Which beta blocker (if any) should we

choose?

Treatment: Beta blockers

Typically not initiated during acute

exacerbation

Continue if already on
Stopping can worsen RAAS activation
If SYMPTOMATIC hypotension, can decrease
the dose

Options
Carvedilol: lowest dose 3.125mg BID
Metoprolol XL: lowest dose 25mg daily
Titrate to goal HR of 60 bpm
Or as much as BP can tolerate

Caveat: Blood pressure

Patients with heart failure frequently

have a lower BP than the general
population
Due to reduced cardiac output

Not unusual to see patients with

reduced EF to have a SBP in the 80s100s

Use of medications which can lower BP

is not contraindicated in these
populations
However, need to ensure patient does not
have lightheadedness, orthostatic

Clinical Vignette

The patient has been having an appropriate

diuresis

Clinically, patient reports improvement in

shortness of breath and now able to walk
without DOE

PE: resolution of rales, peripheral edema

How should the diuretic dose be adjusted?

What medications should be added to his

regimen prior to discharge?

Medication Adjustment

Diuretic
Patient should be transitioned to po
regimen
Can base the po on the dose of the IV
dose
E.g. Furosemide 40mg IV BID 40mg po BID

Should monitor for at least 24 hours on po

to ensure proper response

Chronic medical management

ACEI/ARB
Shown to improve mortality
Already on Lisinopril, can titrate up further as tolerated
Consider decreasing dose or discontinuing if: SYMPTOMATIC
hypotension, AKI, hyperkalemia

Spironolactone
Shown to improve mortality (RALES trial)
Indications: EF <30% and NYHA Class II OR EF <35% and NYHA
Class III/IV
Benefits: enhances diuresis, minimizes K wasting
Dosing: lowest: 12.5mg, titrate up as tolerated

Digoxin
Reduces rate of hospital admissions
No significant effect on mortality no longer used as frequently
now

Clinical Vignette

Which patients benefit from

combination therapy with Isosorbide
dinitrate/Hydralazine?

Treatment:
Isosorbide dinitrate/Hydralazine
Added to standard therapy for heart
failure
Efficacious and increases survival among
black patients with heart failure
Dosing:
Isosorbide dinitrate/Hydralazine
20mg/37.5mg TID

Transition to Outpatient

Our patients discharge meds

Furosemide 40mg BID

Lisinopril 5mg daily

Carvedilol 3.125mg BID

Spironolactone 12.5mg daily

ASA 81mg daily

Summary

Identify clinical signs and symptoms of ADHF

Pertinent labs
Sodium, creatinine, troponin, BNP

Relevant imaging
EKG, CXR, echocardiography

Treatment
Diuresis, BB, ACEI/ARB, Spironolactone, Digoxin,
Isosorbide dinitrate/Hydralazine

Transition to outpatient
Strict instructions, close-follow-up