# Acute Decompensated Heart Failure
# HFrEF vs. HFpEF with EF ***
-- ABCs: is the patient in cardiogenic shock requring inotropes or pressors (levo then dobutamine vs milrinone) in ICU (SBP <90 for >30 minuts)? Do they have pulm edema requiring BIPAP? Do they need a cath for possible ACS or to help with guidance of volume management?
-- Chart Check: last echo, home regimen, fill history
-- HPI Intake: baseline (city blocks, flights of stairs), timing and severity of symptoms (DOE, PND, orthopnea, LE edema), home regimen and adherence, diet and salt intake, NSAID use
-- Can't Miss: cardiogenic shock (lactate, narrow pulse pressure, cold, low BP, tachy), pulmonary edema
-- Admission Orders: daily weights, telemetry, NT-proBNP, EKG, CXR, iron studies, sodium-restrcited diet, 2L fluid restriction if hyponatremic or sever HF
-- Initial Treatment to Consider: IV diuretics at 2x home dose, afterload reduction if HTN or pulm edema, continue home BB, ACE/ARB, spiro if BP and renal fx allows, IV iron if qalifies
-- History: *** ACC/AHA Stage: A risk factors, B structure but no sxs, C symptoms, D refractory/terminal; NYHA Class: I no limitations, II normal activity, III minimal activity, IV symptoms at rest; last echo, dry weight, current weight, diuretic adherence, salt intake, NSAID or steroid use
-- Clinical: *** PND (LR 2.6), orthopnea (LR 2.2), DOE (LR 1.3)
-- Exam: *** pulse pressure, tachycardia, warm/cold, dry/wet, AMS, volume (JVD - LR 5.1, edema, hepatojugular reflux, POCUS), crackles, S3 (LR 11)
-- Data: *** NT-pro-BNP, trop, lactate, Echo, EKG, CXR (edema LR 12), iron studies
-- Etiology/DDx: *** ADHF: dietary, medication adherence, ischemia, arrythmia, HTN, meds (NSAIDs, steroids, CCB), infection, AKI, drugs (EtOH, cocaine), valvular disease;
The patient's HPI is notable for ***. Exam showed ***. Labwork and data were notable for ***. Taken together, the patient's presentation is most concerning for ***, with a differential including ***.
-- f/u EKG, trop, NT-pro-BNP, CBC, BMP, Mg, iron studies, lactate
-- in ADHF only get echo if concern for clinical or functional change, or it has been a while since last echo
-- Daily CBC, BMP, Mg - replete PRN for K >4 and Mg >2
-- Strict I/O’s, daily weights, continuous telemetry
-- New Dx heart failure: Ischemic workup - EKG, trop, stress test, LHC; Non-ischemic workup - lipid, HgbA1c, iron studies, ANA, RF, HIV, SPEP/UPEP/SFLC, TSH w/ free T4; if complete mystery or evidence of cardiac sarcoid, amyloid can get a cardiac MRI/PET
-- O2 goal >90%; current ***; NIPPV if acute pulmonary edema
-- Preload: diurese with IV *** with goal net neg *** 2L (1L if HFpEF); (start with ~2x home dose, higher if renal failure; 40 lasix = 10-20 torsemide = 1 bumex); switch to PO when sxs resolve and JVP/edema improve
-- Afterload: *** isosorbide dinitrate, hydralazine, captopril (mostly if severe HTN, pulm edema)
-- Inotropy: *** if cold (inodilators: dobutamine, milrinone; inopressors: dopamine, norepi, epi)
-- BB: *** carvedilol, metoprolol; continue inpatient if not cardiogenic shock)
-- ACE/ARB/ARNI: *** continue unless significant AKI; switch to ARNI if Class II/III
-- MRA: *** NYHA class II-IV, as long as CrCl > 30, K < 5; consider in HFpEF
-- SGLT2: *** dapagliflozin, empagliflozin; EF < 35% regardless of DM
-- Iron: 200mg IV iron (ferritin <100 OR ferritin <300 + TSat <20%, OR iron <13)
-- ICD: *** after 3-6 months of GDMT: B and EF <30%, C and EF <35% or prior VT/VF
-- CRT: *** C and LVEF < 35% AND QRS > 150 (ex: LBBB), or need pacing
-- Advanced therapies: *** Imeplla, balloon pump, LVAD, transplant
Over the 24 hours, the patient has put out *** cc, and was net negative *** after being treated with *** suggesting the patient [is/is not] sensitive at this dose. Since admission, they are net negative a total of *** and have lost *** lbs.
My exam this morning showed *** [JVP, edema] suggesting the patient is [still overloaded/euvolemic/dry].
Today, I’d like to (we’ve already) diurese(d) with IV *** with a goal net negative *** [at least 2L for HFrEF or ~1L if HFpEF]. We will plan to assess output by *** and redose or go to *** [higher dose, add thiazide, etc] as needed.
PDF coming soon!
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.
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.