ADHF - Assess
Three signs or symptoms of systemic and/or pulmonary congestion present in this patient
Symptoms: c/o new onset shortness of breath, waking up at night gasping for air (PND)
Signs: RR 26 O2 sat 92%; S3; b/l rales in lung bases; +JVD; 3+ pitting edema in b/l LE; chest x-ray: b/l pleural effusion; PCWP 22 mmHg
Name, dose, route and frequency for initial therapy in this patient to manage her volume overload
Furosemide 40 mg IV bolus x 1
Statin benefit group per ACC/AHA lipid guidelines and patient’s ASCVD risk score
Individuals 40-75 years of age, LDL 70-189 mg/dL, without clinical ASCVD or diabetes; ASCVD risk score 21%
True/False: Invasive hemodynamic monitoring is recommended in ALL patients with ADHF
False
Adverse effect of nitroprusside with liver impairment
Cyanide toxicity
Three signs and symptoms of hypoperfusion present in this patient
Signs: decreased BP (BP 100/70), cold and clammy extremities, worsening renal function (increased from 1.0 to 1.6), CI < 2.2
Urine output goal in 2 hours for after receipt of initial diuretic therapy
> 500 mL
Medication therapy plan for lipid management
Rosuvastatin 20-40 mg po daily; Atorvastatin 40-80 mg po daily
Contraindication to use of IV nitroprusside
SBP < 90
Adverse effect of IV positive inotrope that requires ECG monitoring
Arrhythmias
Hemodynamic subset this patient fits into
Cold and Wet (Subset IV)
Medication therapy needed to manage hypoperfusion
Dobutamine or Milrinone
Type of HF, Stage of HF and NYHA Functional Class
HFrEF of < 40%, ACC/AHA Stage C HF, NYHA Functional Class III
One diuretic that can be added to furosemide to overcome diuretic resistance
Metolazone, Chlorothiazide IV
First line therapy for a patient with CI < 2.2 and PCWP < 15
IV fluids
Possible etiology/precipitating factor for ADHF in this patient
Doxorubicin – Anthracycline therapy (for breast cancer)
Two monitoring parameters with medication therapy for volume overload
Improvement in signs and symptoms, input / output (urine output), weights, BUN / SCr, K+, Mg+, Na+ (daily) and BP, HR continuously
Recommendation for enalapril therapy at this time during inpatient stay while patient is currently receiving management for current hemodynamic subset (i.e. not yet optimized with ADHF management)
Discontinue enalapril (patient has signs of hypoperfusion and worsening renal function)
First line therapy for volume overload
Loop diuretics (IV)
Medication therapy for a patient with CI < 2.2 and PCWP 15 – 18
Positive inotropes (IV)
Goal CI and PCWP in this patient
CI > 2.2 and PCWP 15 - 18
Two monitoring parameters with medication therapy for hypoperfusion
Monitor BP, HR, ECG continuously (on cardiac monitor), PCWP, CI continuously (with Swan-Ganz catheter)
Medication therapy plan (name, dose, route, frequency) for “Fluid Status” and “Pharmacotherapy” management of this patient’s CHF once volume status is optimized and hypoperfusion resolves
Fluid status: Furosemide 40 – 80 mg po daily – bid Pharmacotherapy: Switch enalapril to Entresto® 24/26 mg po bid and initiate metoprolol succinate 12.5-25 mg po daily (or carvedilol 3.125 mg po bid or bisoprolol 1.25 mg po daily)
Place in therapy for dopamine
Cardiogenic shock, marked hypotension
One contraindication to continuation of a patient’s home Entresto® therapy acutely during active management of ADHF (i.e. still receiving therapy for ADHF management and not yet optimized with its management)
AKI, hemodynamic instability (SBP < 90), hypoperfusion