Acute Decompensated Heart Failure Causes 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 HFpEF is the most common cause 50% of patients hospitalized with CHF Exertional dyspnea, orthopnea, lower extremity edema, but normal or near normal LVEF with objective evidence of diastolic dysfunction (abnormal LV filling pressures) by echo Labs ABG shows hypoxia, hypocapnia, and respiratory alkalosis Less specific than proBNP and PCWP Respiratory alkalosis (hyperventilation) often seen in contrast with COPD which has respiratory acidosis Elevated BNP has high sensitivity for AHFD, BNP > 100 is indicative Management 4 Main Arms of Management: 1) Typical High-Risk Features: Renal insufficiency, Biomarkers of injury, ACS, Arrythmias, hypoxia, PE, infection Hypertensive: Vasodilators Normotensive: Diuretics 2) Pulmonary Edema 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 3) Low Output Hypoperfusion w/ End organ damage High-Risk Features: Low pulse pressure, cool extremities, cardiorenal syndrome, hepatic congestion Hypertensive: Vasodilators Normotensive: Inotropic Therapy 4) Cardiogenic Shock Hypotension, low cardiac output, and end organ failure High-Risk Features: Extreme distress, pulmonary congestion, Renal failure Inotropic Therapy/Mechanical Circulatory Support 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 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) Diuretic Therapy Hypotension IV Vasopressor (norepinephrine) Useful in Pulmonary congestion for rapid dyspnea relief if preserved Blood pressure Low Blood Pressure: Cardiogenic shock Generally, presents with hypoperfusion (reduced urine output) Use in hypotension, endo-organ hypoperfusion, shock Most often due to Acute MI > tamponade, massive PE, acute mitral or aortic regurgitation If due to contractile failure Dobutamine + Norepinephrine to get MAP ≥65 w/ Mechanical circulatory support Intra-aortic Balloon Counter pulsation 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 1 Short-term intravenous milrinone for acute exacerbation of chronic heart failure: a randomized controlled trial Heart Failure