inpatient / cardiology

Acute Decompensated Heart Failure (ADHF)

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Pharmacology of Heart Failure (GDMT)

Pharmacology of Heart Failure (Diuretics) 

Best Practices for Inpatient Diuresis

Patients will often still be in ED when you first start diuretics for ADHF. Tell both the patient and nurse explicitly that you need strict I/Os to be collected. If AMS, poor mobilization, and male - consider a condom cath (RN will likely already have thought of this). 

Start by diursesing with 2x patient’s home dose. Give higher doses if the patient has CKD. You should also keep on spironolactone if they are already on, as it will help prevent hypokalemia. 

Assess response in 1 hour - if adequate dose, people will pee immediately and they will feel it. If they are not peeing, make sure you didn’t miss cardiogenic shock, then double the dose. 

If they are peeing, check the total output around 3-4 hours after dosing (ideally in the early afternoon). If they are not at least halfway to goal output, re-dose at double the dose, otherwise redose at the same dose. You should aim to redose before leaving for the day, and before 3 pm. Do not wait 6 hours, and do not leave diuresis decisions for the night team if it can be avoided. 

If you have reached 80-160mg Lasix BID and are worried about resistance, consider switching to a Lasix drip, to torsemide or Bumex, or adding a thiazide diuretic. If you are not on a cardiology floor can consult them for further guidance.

If switching to a different loop, 40mg PO Lasix = 10-20mg PO torsemide = 1mg PO bumex. Bumex has better oral availability which helps if you are concerned about gut edema.

If adding a thiazide (metolazone or chlorthalidone), classic teaching says to give 30 mins before. This is because thiazides are PO and we are often still giving IV loop, and PO takes longer to work. If you are giving both PO, they can be given at the same time. If they are given 30 mins apart, coordinate with nursing as it may take time for the less commonly used thiazide to come up from the pharmacy - don’t let this delay getting the patient the doses early in the day.

If the patient is alkalotic, can consider adding acetazolamide if K >4 (inhibits proximal tubule, delivers more bicarb to collecting tubules, leads to K wasting). Recent data suggest acetazolamide use with loop diuretics can lead to euvolemia quicker when compared to placebo.

Switch to PO regimen when symptoms resolve and JVP/edema is improved, NOT when they are at a “dry weight”. 

In an ideal world, we would trial PO for 24 hours to prove the dose will get the patient to net negative ~500cc - they will likely be net even at that dose at home (will eat more salt, drink more fluid, etc). The PO dose you trial should be based on the etiology of decompensation - if non-adherent, can trial home dose. If c/f resistance you can try a higher PO dose. 

Guidance for Discharge - Make sure the patient knows if any changes were made to the dose of their home diuretic. Instruct the patient to weigh themselves daily. If they note worsening lower extremity edema, an increase of 5+ lbs over a 3-4 day period, or 2-3lbs over 24-48 hours, take double the dose of their home diuretic and call their PCP or cardiologist.

What should we be monitoring for while diuresing?
‍Labs - BMP (potassium, bicarb/CO2, and creatinine). Development of gout symptoms in those at risk

Should we stop diuresing if the creatinine goes up? 
‍Many patients with ADHD will present with a prerenal AKI due to low effective circulating volume and decreased GFR. When you diurese, it takes some time to mobilize 3rd spaced fluid and the effective circulating volume may go down, leading to lower GFR and increased creatinine. More often than not this does not represent damage to the kidney but is rather reflective of the change in hemodynamics. If you want to protect the kidney, the goal is to get to euvolemia and the GFR should improve with normalized effective circulating volume. Trust your physical exam.

What physical exam components should inform diuresis decisions?
‍JVP (30-45 degree angle, double bounce), hepatojugular reflux (stays up 10+ seconds) LE edema, crackles (not specific for ADHF); also SOB and PND.

POCUS - look at heart to approximate squeeze, lungs to look for pulm edema (3+ B-lines in 2+ lung zones), volume (IVC diameter >2cm, collapses <50% with respiration).

Though not entirely clear, pitting edema is usually graded based on the depth of depression and time to rebound (in general - 3+ if 60+ seconds, 4+ if 2-3 minutes).

When should we switch to PO diuretics and plan for discharge?
‍Some would say the sweet spot for diuresis is when you see an increase in bicarb (contraction alkalosis) but no creatinine bump (AKI). This may give you an indication of approaching euvolemia, but you should really go based on the patient’s symptoms and exam.

Does using thiazides lead to worse outcomes? 
Some literature suggests using thiazides worsens clinical outcomes (including AKI), but this is likely confounded by the fact that the only people who use these are likely those who have resistance and worse overload.

If You Remember Nothing Else

Decompensated heart failure is the most common reason for inpatient admission for adults in the United States. You need to ensure the patient is not in cardiogenic shock (cold). Provided the patient's heart function is at baseline and they are simply overloaded, the mainstay of treatment if aggressive diuresis. Bolus early in the AM and check response within 1 hour to see if the patient responded, and re-dose by the early afternoon if not at goal. Diurese based on symptoms and your volume exam, not based on weight alone. Continue diuresing through mild elevation in creatinine as it rarely indicates an intrinsic AKI in most situations. If not responding to higher doses of loop diuretics, switch to a drip or augment with thiazide diuretics. Replenish K and Mg to not fall behind with diuresis. Continue and/or uptitrate the patient's GDMT while admitted to set the up for success upon discharge. Instruct the patient to call their PCP or cardiologist if they notice worsening LE edema or gain ~3-5 lbs over ~3-4 days.
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Clinical Pearls

• ADHF is the most common cause of hospitalizations in patients >65; >1 million annually in U.S
• For those with moderate to high diuretic use at home, Median LOS for ADHF is ~5 days, Median time alive and out of hospital (ED, readmission) is ~50 days
• Medications that improve outcomes are considered Guideline-Directed Medical Therapy (GDMT) and include BB’s, ACE/ARB/ARNI, spironolactone, SGLT2i, hydral w/ nitrate in AA’s; diuretics and digoxin improve symptoms but do not improve mortality
• For those with moderate to high diuretic use at home, Median LOS for ADHF is ~5 days, Median time alive and out of hospital (ED, readmission) is ~50 days
• ADHF unlikely if NT-proBNP <300 (NPV 98%); likely if >900 and >50yo (odds raio 44); might be falsely low in obese patients, less useful in CKD/dialysis patients; NT-proBNP alone is better than clinical judgment alone at diagnosing ADHF
• Exam - Crackles are not specific; should instead rely more on volume (JVP) and symptoms like orthopnea; S3 Heart Sound is a specific ADHF exam finding: ventricular gallop, “kentucky”, happens during passive filling of LV - blood striking compliant LV, present in HF (but can also be normal), best heard with the bell at cardiac apex - it has LR of 11 and is very highly specific, not sensitive; JVP - can be done sitting completely up (considered elevated if above clavicle) or 30-45 degrees, turn head, look for double bounce, make sure its not the carotid, attempt hepatojugular reflux (will stay elevated for 10+ seconds); POCUS can help differentiate from COPD exacerbation - look at heart to approximate squeeze, lungs to look for edema (3+ B-lines in 2+ lung-zones), intra-vascular volume (IVC diameter >2cm, collapses <50% with respiration); Pitting edema grading based on the depth of depression and time to rebound (3+ if 60+ seconds, 4+ if 2-3 minutes)
• 30-50% of HF patients are iron deficient (closer to 70-80% for ADHF); IV iron decreases symptoms, increases functional capacity, and increases QOL
• PO iron is ineffective in HF (high hepcidin levels block intestinal absorption)
• Loop diuretics work on proximal tubule, thiazides on distal tubule (Hyper-GLUC)
• The sweet spot for diuresis is an increase in bicarb (contraction alkalosis) but no creatinine bump (AKI)
• Diurese as early in the day as possible, check 3-4 hours later, redose ASAP and by 2-3 PM the latest (don’t leave a task for night team, and don’t make people get up to pee all night); if not putting out the expected volume, double the dose
• If you are on >80mg IV Lasix BID, consider drip (10mg/hr all the way to 80mg/hr) and getting cards input to also consider a thiazide such as metolazone
• Loop diuretics might lead to hypokalemia - get out ahead of it to not lose time based on having to pull back diuresis; adding spironolactone can also help offset these losses
• 23% of patients being treated with diuretics will have worsening renal function (creatinine clearance), with a mild-moderate Cr bump, but most do not have tubular damage (by other metrics, like NAG) (Circulation)
• If you have hypotension or bradycardia on admission and have to remove GDMT, lower BB dose first, then take it off, then remove ACE/ARB
• When on PO diuretics, trial 24 hours before going home - try to get net neg 500cc to get a sense of what dose they will prob be net even at home (since they will eat more salt, drink more fluid, etc)
• Heart Failure is a terminal disease - cardiac transplant is the only cure, but a majority of patients are not candidates; if not a candidate for LVAD or transplant, contact palliative care
• Mechanical Circulatory Support - short term (IABP, Impella, VA-ECMO) or bridges to more long term options like LVAD
• Nutmeg liver - ischemia and fatty degeneration from hepatic venous congestion
• “HF Cells” contain hemosiderin in sputum due to intra-alveolar bleeding with edema
• Kussmaul Sign - JVD during inspiration

Trials and Literature

• Value of NT-proBNP - ADHF unlikely if NT-proBNP <300 (NPV 98%); likely if >900 if >50yo (odds ratio 44), NT-proBNP alone is better than clinical judgment alone at diagnosing ADHF (Am J Cardiol, 2005)
• Role of Clinical Exam in ADHF (JACC Heart Fail, 2018)
• What outcomes do we care most about? Most clinical outcomes in cardiology trials focus on overall survival, heart attack, stroke, dialysis, QOL; readmissions, need for inotropy, and hospital LOS are others. Many trials have the primary outcome as a “composite” outcome that includes clinical and non-clinical outcomes - try to see if the clinical outcome is meaningfully contributing to the composite outcome.
• DOSE Trial - furosemide IV bolus vs. drip; Rationale - small studies suggested drip better for renal fx and total diuresis; 308 patients with moderate to high diuretic use at home - bolus q12 hours vs. drip at home dose vs 2.5x home dose; At 72 hours - no difference in symptoms, change in creatinine; no difference in LOS or time out of hospital; Issues - not generalizable to low diuretic home dose, allowed for adjustments after 48 hours of treatment but endpoints analyzed at 72 hours (NEJM, 2011)
• FAIR-HF Trial - IV iron (ferric carboxymaltose) regardless of anemia in patients with HF; Rationale - many HF patients have fatigue, dyspnea, and poor QOL; 459 patients (75 sites in 11 countries) Class II or III, EF<40%, iron deficiency - 2:1 iron vs. placebo; Endpoints: self-reported patient global assessment at 24 weeks; distance walked in 6 minutes, health-related quality of life; 50% much or moderately improved vs. 28% placebo; 47% decreased NYHA class vs 30% placebo; improved 6-minute walk, QOL; Similar rates of death, hospitalization, AEs; Issues - almost 100% white, more of treatment arm was getting AC (NEJM, 2009)
• ADVOR Trial - addition of acetazolamide to loop diuretic resulted in greater incidence of successful early decongestion compared to placebo (NEJM, 2022)
• B-CONVINCED Trial - stopping vs. continuing home BB when admitted for ADHF; No change in outcomes inpatient; More likely to be taking BB 3 months after admission if continue IP (90 vs. 76%) (Eur Heart J, 2009) 
• Should continue pretty much all GDMT if BP and renal function allows it - better 1-year mortality if add GDMT while in hospital, worse 1-year mortality if take something away (Pharmacotherapy, 2018)
• GOURMET-HF Trial - low-salt diet after hospitalization for HF; Rationale: low salt helps with HTN, not so sure if it helps with HF; Small study, ~66 patients; Not significant, but trended toward significance - 11% vs. 27% readmissions; Might actually increase harm if not on an ACE/ARB (Circ Heart Fail, 2018)
• Though volume overload is an indication for acute dialysis, stepping up diuresis is a better option for renal function than initiating RRT in ADHF (NEJM, 2012)

Other Resources

• Osmosis Article on Pitting Edema
• Curbsiders Podcast - #230 Acute Decompensated Heart Failure
• Michelle Kittleson on Twitter
• CORE IM Podcst - 5 Pearls on Inpatient Heart Failure
• Run the List Podcast - Heart Failure
• Glass Health Originals - ADHF Illness Script
• Clinical Problem Solvers - Congestive Heart Failure (HFrEF) Dx Schema
• Curious Clinicians Podcast - Gut Edema and Lasix - absorption issues may be related to delayed gastric empyting instead of the classic teaching of gut edema

Video