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
4

3 times per night

pillow orthopnea

Increasing
ROS:

lower extremity edema

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:
ROS:

NKDA

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 6 th
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
po Bumetanide

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 80s-100s

Use

of medications which can lower BP is

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

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
Lisinopril

40mg BID

5mg daily

Carvedilol

3.125mg BID

Spironolactone
ASA

12.5mg daily

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