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Acute Heart Failure

Categories of Acute Heart Failure

  • Acute Decompensated HF
    • With signs and symptoms of AHF which are mild and do not complete criteria for cardiogenic shock, pulmonary edema, or hypertensive crisis
  • Hypertensive AHF
    • HF w/elevated BP and relatively preserved LV function with a CXR with acute pulmonary edema
  • AHF with Pulmonary Edema
    • Severe respiratory distress with crackles and orthopnea
  • High-Output Heart Failure
    • High CO, commonly with elevated HR 2/2 arrhythmia, Thyrotoxicosis, Anemia, Paget’s Disease, Iatrogenic
  • Right-Sided Heart Failure
    • Low CO with increased JVD, hepatomegaly, and hypotension
  • Cardiogenic Shock

Etiology

  • 80-85% are Chronic HF exacerbations due to:
    • Noncompliance
    • Uncontrolled hypertension
    • Rapid Afib
  • 15-20% are new onset Acute Coronary Syndrome (ACS)
    • ± MI, arrhythmias, Acute severe MR/AR
  • <1% but Increasing Incidence
    • Stress-Induced Cardiomyopathy
      • Catecholamine Excess
      • Post-menopausal women w/emotional stress, SAH, TBI
      • Dyspnea and chest pain ± ST changes, T wave inversion
      • Ballooning or hypokinesis of LV apex
      • May be unstable but resolves in days to weeks
      • Dobutamine is CI
    • Low-Output Heart Failure
      • Decompensated heart failure resulting from left ventricular dysfunction
      • Increased afterload and preload with decreased CO
  • Correction to: Drugs That May Cause or Exacerbate Heart Failure: A Scientific Statement From the American Heart Association

Labs

Management

  • 4 Main Arms of Management:
    • 1) Typical
      • Dry & Warm
      • High-Risk Features: Renal insufficiency, Biomarkers of injury, ACS, Arrhythmias, hypoxia, PE, infection
      • Hypertensive: Vasodilators
      • Normotensive: Diuretics
    • 2) Pulmonary Edema
      • Wet & Warm
      • Severe Pulmonary congestion with hypoxia
      • High-Risk Features: New onset arrhythmia, valvular disease, myocardial ischemia, CNS injury, Drug toxicity
      • Hypertensive: Vasodilators
      • Normotensive: Diuretics, O2, NIPPV
      • Congestion: Diuretics, Vasodilators, Ultrafiltration
    • 3) Low Output
      • Dry & Cold
      • Hypoperfusion w/ End organ damage
      • High-Risk Features: Low pulse pressure, cool extremities, cardiorenal syndrome, hepatic congestion
      • Fluid Challenge/Inotropes
      • Hypertensive: Vasodilators
      • Normotensive: Inotropic Therapy
    • 4) Cardiogenic Shock
      • Wet & Cold
      • Hypotension, low cardiac output, and end organ failure
      • High-Risk Features: Extreme distress, pulmonary congestion, Renal failure
      • Inotropic Therapy/Mechanical Circulatory Support
        • Systolic <90: Inotropes, Vasopressors, Diuretics, Circulatory support
        • Systolic >90: Vasodilators, Diuretics, Inotropes
  • Avoid BB in patients with Decompensated CHF or Bradycardia (Pulmonary edema will worsen, and slow down the HR)
    • Decrease by 50% if unresponsive to diuresis or discontinue BB
      • Daily electrolytes and CR/BUN
      • ± Thiazide
  • Diuretic Therapy
  • Diuretic Resistance
    • Metolazone
    • SGLT-2s
    • Acetazolamide
      • When these two trials are considered together, it is uncertain how acetazolamide led to an improvement in physical signs of fluid retention in the ADVOR trial, since the drug produced only a modest diuretic effect in ADVOR and no natriuretic effect in DIURESIS-CHF
      • ADVOR: Acetazolamide in Acute Decompensated Heart Failure with Volume Overload
        • Was not significant if LVEF ≤40%, Female, GFR ≥40, >60mg lasix daily, more volume overload (congestion >4)
        • Excluded anyone on >80mg lasix, must be on 40 or more
        • New diagnosed HF were excluded from the trial so results cannot be applied to them
        • Congestion scoring system used in this study used variables which are reflective of extracellular dehydration but not intracellular dehydration
          • Further research can be directed to replicating efficacy demonstrated here, and preferably with multiple measurements like quantum of natriuresis, diuretic efficiency, 6 hour cumulative sodium excretion or the natriuretic response prediction equation (NRPE)
      • Acetazolamide to increase natriuresis in congestive heart failure at high risk for diuretic resistance
        • To select a population at high risk for loop diuretic resistance, at least one out of three additional inclusion criteria had to be fulfilled: (i) serum sodium ≤ 135 mmol/L; (ii) serum urea/Cr ratio > 50; or (iii) admission serum Cr increase of > 0.3 mg/dL compared to a previous measurement within 3 months.
        • The two groups did not differ with respect to the primary endpoint, that is, urinary sodium excretion in the 24 h following randomization, and they also did not differ with respect to the degree of clinical decongestion or changes in NT-proBNP after 72 h, but worsening renal function was more commonly seen in the acetazolamide group
        • There was no difference in two groups with respect to the risk of death or heart failure hospitalization within the next 90 days, although the investigators reported some divergence months after treatment had been stopped
  • STRONG-HF: Rapid up-titration of GDMT and close f/u reduced risk of 180-day all-cause death or HF readmission in AECHF admits
  • Consider IV Vasodilators (Nitroglycerin, Nitroprusside)
    • Relieves dyspnea and tachycardia due to pulmonary edema
    • High BP (25%): Nitroglycerin or nitroprusside
      • Glycerin is safer, prusside (CN and Thiocyanate toxicity, Coronary steal syndrome in ACS)
      • Avoid Nitroprusside in renal failure
      • Nitro Tolerance after 24h possible
    • Normal BP (50%): Nitroglycerin or Nesiritide
      • Nesiritide, recombinant BNP (diuresis + vasodilators)
        • Binds heparin (not through same tube)
    • Vasodilator intolerance (hypotension, decreased urine output), mcc is pulmonary edema
      • Inodilators: Positive inotropic, vasodilators
        • Dobutamine (5ng up to 20), Milrinone (50ng, then up to 1.13, renally dosed), Levosimendan (12ng)