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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)
        • Inotropic Therapy
    • 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
  • Short-term intravenous milrinone for acute exacerbation of chronic heart failure: a randomized controlled trial