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

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Dec 06, 2022 137 likes •306 views

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

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Acute Decompensated Heart Failure

Matthew Trojan, MD

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Disclosures

 Consultant, St. Jude Medical

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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

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800 lb gorilla

 Acute decompensated heart failure is the leading cause

f 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

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Demographics

 Describe the average patient hospitalized for heart failure

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Clinical trials for hf

 Exclude patients who are hypertensive  Concentrate on patients with reduced EF

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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

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Decongestion

 Diuretic

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

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Do’s and Don’t’s

 Yes:

 Daily weights  Strict I&O  Daily lytes, Cr  O2 for hypoxia  2 gm NaCl  DVT Prophy

 Maybe

 Fluid restrict  Non-invasive positive pressure ventilation  Telemetry

 No

 Routine BNP  O2 for nonhypoxic  Routine invasive monitor  Routine inotropes

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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

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Renal Failure

 Strongest predictor of ARF in renal failure:

 A)Cardiac output  B)Pulmonary capillary wedge pressure  C)Central venous pressure  D)Systolic BP

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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

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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

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