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Congestive Heart Failure Management of Acutely Decompensated Patients

Objectives Present and critique a patient case Review the treatment guidelines of acute exacerbation of heart failure Assess the place in therapy and monitoring parameters of agents used to treat exacerbations of heart failure Review the role of spironolactone in treatment of congestive heart failure (CHF)

History Chief Complaint " I get out of breath“

History of Present Illness 49 year old African American male History of coughing with yellow sputum production for the past two and a half weeks Suffers from shortness of breath (SOB) while sleeping (2 pillows) walking (unable to walk up steps) at work

Past Medical History and Symptoms Past Medical History Possible COPD Cardiomegaly Tuberculosis History of abdominal pain and rectal bleeding

Review of symptoms (+) Chills (+) Productive cough (+) SOB with exertion

Family and Social History Family History Father- Death secondary to heart failure (HF) at age 56 Brother- Myocardial infarction (MI) at age 33 Sister- hypertension Grandmother- MI (unknown age or outcome)

Social History Smokes 1 pack per day (PPD) for 12 years Daily alcohol use (claimed 6 beers/day) Worked as stock boy

Vital Signs and Physical Exam Vital Signs BP 131/97 HR 114 RR 20 Pain (not recorded) Temp (not recorded)

Physical Exam Patient looks older than stated age HEENT - Scar on left cheek Neck - (+) jugular venous distention (JVD) Cardiovascular- (+) S3 gallop Extremities - Pulse 2+

Laboratory Values Date



























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Diagnostic Procedures 2-dimensional Echocardiogram Ejection Fraction (EF)= 5-10%

Electrocardiogram Left ventricular enlargement Sinus tachycardia

Chest X-ray (CXR) Cardiomegaly without acute infiltration, effusion or pneumothorax

Problem List 1. CHF exacerbation 2. Hypokalemia 3. Hypomagnesemia 4. Hepatitis 5. Insomnia 6. Stress ulcer prophylaxis 7. DVT prophylaxis 8. Primary disease prevention

Hospital Course 1. Acute Exacerbation of CHF Furosemide 20 mg intravenously daily on 2/17 Increased dose to 40 mg on 2/18 Discontinued on 2/20 Switched to furosemide 40 mg by mouth daily on 2/21

Lisinopril 5 mg by mouth daily on 2/17 Decreased dose to 2.5 mg on 2/18

Aspirin 325 mg by mouth daily on 2/17 Carvedilol 3.125 mg by mouth daily on 2/18 Topical nitrate (Nitroglycerin (NTG) ointment) 0.5 inch transdermally every 6 hours on 2/18 Ibuprofen 200 mg PO Q6H PRN for nitrate-induced headaches Discontinued on 2/19

Spironolactone 12.5 mg by mouth daily on 2/20

Hospital Course 2. Hypokalemia Potassium chloride 10 mEq intravenously for 2 doses on 2/17 Potassium chloride 40 mEq by mouth daily on 2/22 Monitor potassium level 3. Hypomagnesemia Magnesium sulfate 2 grams intravenously for one dose on 2/17 Magnesium oxide 800 mg by mouth twice a day for 3 days on 2/17 Magnesium oxide 400 mg by mouth twice a day on 2/22 Monitor magnesium levels

Hospital Course 4. Hepatitis Increased ALT and AST Hepatitis panel positive for hepatitis B and hepatitis C No treatment during hospital stay

Monitor liver function 5. Insomnia Zolpidem 5 mg by mouth at bedtime as needed Patient used 5 mg every night in hospital

6. Stress Ulcer Prophylaxis Esomeprazole 40 mg PO QD on 2/17 Discontinued on 2/17

Hospital Course 7. DVT Prophylaxis Sequential Compression Device

8. Primary Disease prevention None provided in hospital

Medications on Discharge Aspirin 325 mg by mouth daily Furosemide 40 mg by mouth daily Counseled on fluid restriction

Lisinopril 2.5 mg by mouth daily Magnesium oxide 400 mg by mouth daily Spironolactone 12.5 mg by mouth daily Potassium chloride 40 mEq by mouth daily Zolpidem 5 mg by mouth daily

Pathophysiology of Heart 1 Failure Increased stress on or decreased capacity of heart Myocardial cells hypertrophy to keep up with body’s requirements

Increased heart rate and arterial constriction

Reduced filling capacity due to heart wall thickening (reduced ejection fraction)

Activation of peripheral systems to compensate (ex. RAAS, increased norepinephrine)

Further damage and stress to myocardial cells

1. Carbajal Enrique V, Deedwania Prakash C. Chapter 18. Congestive Heart Failure. In: Crawford MH. CURRENT Diagnosis & Treatment in Cardiology, 2nd Edition. New York: McGraw-Hill; 2003. available at

Recognizing Acute Heart 2 Failure Patients with an acute exacerbation of heart failure need to be admitted to bring their HF under control Admission should be based primarily on signs and symptoms of acute HF Hypotension Deteriorating renal failure Altered mental status (MS) Dyspnea at rest New onset arrhythmias Acute coronary syndromes 2. Adams KF, Lindenfeld J. HFSA 2006 Comprehensive Heart Failure Guideline. Journal of Cardiac Failure. 2006; 12: e1-e122

Recognizing Acute Heart 2 Failure Other signs and symptoms that may require admission Worsened congestion without dyspnea Major electrolyte disturbances Associated comorbid conditions Repeated internal cardiac defibrillator firings Previously undiagnosed HF with signs and symptoms

2. Adams KF, Lindenfeld J. HFSA 2006 Comprehensive Heart Failure Guideline. Journal of Cardiac Failure. 2006; 12: e1-e122

Treating Acute HF Goals of treatment


Monitoring Parameters

Weight Relief of signs and symptoms Fluid intake and output (I&O) Normal volume status Vital Signs Understand etiology of Signs patient’s HF Symptoms Identify factors leading to Electrolytes acute exacerbation Renal function Provide optimal chronic BUN therapy SCr Identify patients that require CrCl revascularization Educate patient on disease and try to initiate disease 2. Adams KF, Lindenfeld J. HFSA 2006 Comprehensive Heart Failure Guideline. Journal of Cardiac Failure. 2006; management program 12: e1-e122

Treating Acute HF


Non-pharmacologic methods Fluid Restriction (<2 L/day) Indicated if patient has [Na+]< 130 mEq/L May be considered in patients without hyponatremia If patient has [Na+]< 125 mEq/L tighter restriction may be required

Oxygen Only recommended in patients with hypoxia

2. Adams KF, Lindenfeld J. HFSA 2006 Comprehensive Heart Failure Guideline. Journal of Cardiac Failure. 2006; 12: e1-e122


IV Loop Diuretics

Example Furosemide Torsemide Bumetanide


Recommended for all Weight patients hospitalized with Ins and Outs ADHF Relief of congestive signs and symptoms (edema, dyspnea, elevated jugular venous pressure)

Nitroglycerin (NTG) Recommended for IV patients with severe Vasodilator Nitroprusside Nesiritide hypertension or acute s

pulmonary edema Optional therapy for all HF without hypotension

IV Inotropes Milrinone Dobutamine

Efficacy Parameters

Optional therapy in patients with low output syndrome and low LVEF or dilated left ventricle May be useful if SBP <90 mmHg or if unresponsive to other agents NOT recommended unless left filling pressures are elevated

Relief of congestive signs and symptoms

Toxicity Parameters Blood pressure Serum electrolytes Serum creatinine (SCr) Blood urea nitrogen (BUN) Creatinine Clearance (CrCl) Muscle cramps Blood Pressure Headache SCr BUN CrCl Thiocyanate toxicity (Nitroprusside) Blood Pressure ECG for tacchyarrhythmias

2. Adams KF, Lindenfeld J. HFSA 2006 Comprehensive Heart Failure Guideline. Journal of Cardiac Failure. 2006; 12: e1-e122

Discharge Criteria


Before discharge, patients are recommended to have All exacerbating factors addressed Near-optimal fluid status Near-optimal pharmacological therapy Switched to oral diuretic medications Received personal and family counseling on disease Follow-up in clinic within 7-10 days 2. Adams KF, Lindenfeld J. HFSA 2006 Comprehensive Heart Failure Guideline. Journal of Cardiac Failure. 2006; 12: e1-e122

The Effect of Spironolactone on Morbidity and Mortality in Patients with severe heart failure: The 3 RALES trial

3. Pitt B, Zannad F, Remme WJ, Cody R, Castaigne A, Perez A, Palensky J, Wittes J, The Randomized Aldactone Evaluation Study Investigators. The Effect of Spironolactone on Morbidity and Mortality in Patients with Severe Heart Failure. New England Journal of Medicine. 1999; 341: 709-717

Role of Spironolactone in CHF Purpose To find if spironolactone 25 mg by mouth daily significantly reduces the risk of any-cause death in severe heart failure patients receiving standard therapy

Design and Methods Double-blind, randomized, two-arm multi-center study Arm 1: 25-50 mg spironolactone once daily by mouth (N=841) Arm 2: Matching placebo (N=822)

Endpoints Primary: Death from any cause Secondary

Combined incidence of death from cardiac causes or hospitalizations for cardiac causes Hospitalization from cardiac cause Change in NYHA stage

Role of Spironolactone in CHF Inclusion Criteria: NYHA Class IV heart failure within past 6 months NYHA Class III or IV at time of enrollment Diagnosis of heart failure at least 6 weeks before enrollment Being treated with an ACE inhibitor and a loop diuretic Had a left ventricular ejection fraction (LVEF) <35% within six months prior to enrollment

Exclusion Criteria: Co-morbidities that affect treatment (talk them, do not write on slide) Serum Creatinine > 2.5 mg per deciliter Serum potassium concentration of > 5.0 mmol/liter

Role of Spironolactone in CHF Primary Endpoint Any-cause Death 30% relative risk reduction

Secondary Endpoints Death from cardiac causes and from hospitalizations due to cardiac causes 32% reduction Hospitalization from cardiac cause 30% reduction Change in NYHA Class Greater percentage of patients improved with spironolactone Fewer percentage of patients worsened with spironolactone Safety Increased serum creatinine and potassium Greater number of cases of hyperkalemia

Complications of Inappropriate Use of Spironolactone in Heart Failure: When an Old Medicine Spirals 4 Out of New Guidelines

4. Bozkurt B, Agoston I, Knowlton, AA. Complications of inappropriate use of spironolactone in heart failure: when an old medicine spirals out of new guidelines. J Am Coll Cardiol. 2003 Jan 15; 41(2): 211â&#x20AC;&#x201C;214.

Role of Spironolactone in CHF Purpose To investigate the appropriateness and complications of spironolactone use for heart failure in clinical practice

Design and Methods Retrospective, chart-review single-cohort study

Objectives Primary Adherence to RALES study inclusion/exclusion criteria Determination if management followed RALES trial criteria Determination of the incidence of complications Secondary Adverse events related to hyperkalemia Incidence of hypotension Correlation between appropriate management index and specialization and training level of providers

Role of Spironolactone in CHF Primary objective results Many patients did not meet RALES inclusion and exclusion criteria 25.6% of patients had NYHA stage III or IV CHF 54.8% of patients had LVEF < 35

Most patients were on therapy similar to RALES protocol 90% of patients on loop diuretics 80% of patients on ACE inhibitors

Risk of complications was increased compared to RALES protocol Patients were on higher doses than therapy used in the RALES trial 40% of patients continued inappropriately on potassium supplements Greater percentages of patients had co-morbidities Less than 40% of patients received appropriate follow-up

Role of Spironolactone in CHF Secondary objective results Most adverse effects were seen at greater rates compared to the RALES trial 21% of patients discontinued compared to 8% with the RALES trial Serious hyperkalemia occurred in 12% of patients compared to 2% in the RALES trial 25% of patients developed renal insufficiency 31% of patients developed hyponatremia

Cardiologists were provided care most adherent to the RALES criteria Internists were shown to have the lowest adherence

Critique of Case 1. CHF Acute Management2 IV diuretics appropriately used HFSA guidelines do not indicate use of topical NTG Fluid status not monitored closely

Discharge and chronic therapy2,5 Chronic aspirin use is not recommended for CHF patients by the AHA/ACC guidelines Chronic potassium and magnesium supplementation not recommended by AHA/ACC guidelines Spironolactone appropriate for patient Isosorbide dinitrate or hydralazine should be considered Catheterization upon discharge and follow-up in clinic is appropriate for patient 2. Adams KF, Lindenfeld J. HFSA 2006 Comprehensive Heart Failure Guideline. Journal of Cardiac Failure. 2006; 12: e1-e122 5. Hunt et al. ACC/AHA 2005 guideline update for the diagnosis and management of chronic heart failure in the adult- summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2005;112: 1825â&#x20AC;&#x201C;1852.

Critique of Case 1. DVT Prophylaxis6 Patient should have received enoxaparin 40 mg subcutaneously every day

3. Stress Ulcer Prophylaxis Patient does not meet criteria for prophylaxis

4. Primary Disease Prevention Patient should receive influenza vaccination Patient should receive smoking cessation counseling 6. Geerts WH, Pineo GF, Heit JA, Bergqvist D, Lassen MR, Colwell CW, Ray JG. Prevention of Venous Thromboembolism: The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004 September; 126 (3): 338S-400S

Additional Notes The following slides portray information provided in the ADHF treatment chart with a larger font

Treating Acute HF IV Loop diuretics Provide symptomatic relief and normalize volume Monitor weight and I&O to measure diuretic efficacy Foley catheter to measure output is not required but may be done if very close monitoring is indicated

Monitor for hypotension, electrolyte imbalance, and worsening renal function Serum potassium and magnesium should be monitored and replaced as needed

Options for unresponsive patients include Fluid and/or salt restriction Increased IV diuretic dose Continuous infusion of IV diuretic Addition of second diuretic

Treating Acute HF IV Nitrates Recommended in patients with severe hypertension or acute pulmonary edema Optional therapy as adjunct therapy in all acute HF patients without hypotension Provides rapid relief of congestive symptoms Monitor for hypotension through frequent BP checks Hypotensive patients should have medication held until hypotension is resolved

Treating Acute HF IV Inotropes An option for therapy in patients with low output syndrome as well as a low LVEF or dilated LV May be most useful in patients with SBP< 90 mmHg Hypotension despite adequate filling pressure Unable to take or unresponsive to vasodilators Unable to take or poorly responding to diuretics

Not preferred for adjunct therapy Not recommended unless left heart filling pressures are elevated Monitor for hypotension by frequent BP checks Tachyarrhythmia by continuous monitoring of cardiac rhythm

If either adverse effect occurs, consider dose reduction or drug discontinuation

Management of Acutely Decompensated Heart Failure