Acute Decompensated Heart Failure Matthew Trojan, MD Disclosures - PowerPoint PPT Presentation

Acute Decompensated Heart Failure Matthew Trojan, MD

Disclosures  Consultant, St. Jude Medical

Organization  Definition of the problem  Evaluation and triage  Management consideration  Transition to outpatient  At least 25% of talk will be time for question answer, so get the questions ready  I also may call on members of the audience

800 lb gorilla  Acute decompensated heart failure is the leading cause of hospitalization for patients age 65 and older (1,000,000 per year)  Mortality from HF is doubled for 12 months following hospitalization  10% at 30 days, 20-40% at 12 months  Risk is additive  2 hospitalization= 4x risk  Hospitalization and rehospitalization represents the majority of the cost of caring for HF patients  ICD’s, angiography, etc vs cost of inpatient care  ~ 20% readmit at 30 days, 50% at 6-12 months

Demographics  Describe the average patient hospitalized for heart failure

Clinical trials for hf  Exclude patients who are hypertensive  Concentrate on patients with reduced EF

Triage  Clinical diagnosis of signs and symptoms  Routine usage BNP NOT recommended  BNP should be used when clinical diagnosis is uncertain  Pitfalls of BNP: renal, elderly, significant COPD, obese, hyperacute HF

Decongestion  Diuretic  IV dose should be greater or equal to PO dosage  40 BID does NOT equal 80 qd  Gtt vs intermittent bolus

Do’s and Don’t’s  Yes: pressure inotropes ventilation  Daily weights  Telemetry  Strict I&O  Daily lytes, Cr  No  O2 for hypoxia  Routine BNP  2 gm NaCl  O2 for  DVT Prophy nonhypoxic  Maybe  Routine  Fluid restrict invasive monitor  Non-invasive  Routine positive

Other meds  If preserved EF (> 45% ) no evidence to support ACE-I or B-blocker over other therapies  ACE-I and afterload and orthostasis and Cr/ GFR  Compensatory tachycardia and B-blocker and fluid retention  NTG, Nipride, Neseritide  V= IR  Spironolactone

Renal Failure  Strongest predictor of ARF in renal failure:  A)Cardiac output  B)Pulmonary capillary wedge pressure  C)Central venous pressure  D)Systolic BP

Abdominal compartment syndrome  Patient with HF , will admit and diurese… .evidence of intravascularly dry, will give IVF  Concept of perfusion pressure  120/ 70, CVP 5= 87-5= 82 mmHg  140/ 90, CVP 20, IAP 10= 107-20-10= 76  90/ 60, CVP 25, IAP 15= 70-25-15= 30  90/ 60, CVP 5, IAP 15= 70-5-15= 50  ACE-I effect afferent, NSAID effect efferent  Nephrology Associates 541 485 6478

Discharge criteria  Predischarge BNP vs treat to BNP  Identify and rectify precipitant  Euvolemia  Address revascularization  Assess EF  Optimize oral meds  Education (tobacco, weights, edema, meds, Na, fluid)  8 glasses/ day is a No-no  Admissions beget readmissions

Questions?