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 I’s and O’s

Low sodium diet (<2g daily)

Fluid restriction
◦ Typically only for patients with hyponatremia
Clinical Vignette

What should we use to improve our
patient’s 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 1.52L 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 patient’s 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 patient’s 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