Presentation/Workup
How is a diagnosis of heart failure exacerbation made?
Clinically. No specific lab value, imaging finding, or physical exam finding. Diagnosis is made based on overall clinical picture.
You should avoid initiating this type of medication in acute heart failure exacerbation.
Beta blocker
List LVEF cutoffs for HFpEF, HFmrEF, HFrEF
HFpEF: > 50%
HFmrEF: 41- 49%
HFrEF: 0-40%
This patient has diabetes and no other signs or symptoms of heart failure. What medication should be initiated for heart failure prevention?
SGLT-2 inhibitor
(ACE/ARB may be prescribed for renal protective effect, but not yet indicated for HF prevention.)
Optimize electrolytes to these parameters in cardiac patients.
Mag++ > 2
Phos > 3
K+ > 4
List at least 4 symptoms of heart failure you may find on ROS.
Dyspnea on exertion, orthopnea, lower extremity edema, cough, fatigue, tachycardia, weight gain, abdominal pain, sleep disturbance
Name 3 cardio protective Beta Blockers
Metoprolol
Carvedilol
Bisoprolol
Describe the treatment of class D heart failure
Needs advanced therapies: Transplant, LVAD, palliative/hospice
Patient presents with hx of CAD and new onset HF with EF of 38%. Last Echo 3 months ago with normal EF. What is different about your workup in this patient?
Consider that heart failure may be due to recent MI. Order ischemic workup.
Reasons to call the ICU in a patient with heart failure?
Hypotension, signs of cardiogenic shock
Severe hypoxia/need for NIPPV, Intubation
List at least 4 physical exam findings indicative of heart failure.
Lower extremity edema, JVD, crackles, wheezing, displaced PMI, hepato-jugular reflux, anasarca, S3
These two classes of medication are used in AHA stage A and B heart failure to reduce risk of progression.
SGLT2 - class A (at risk)
Add ACE/ARB for class B (signs of structural change)
Bonus: Add BB for hx of MI/ACS
Describe the difference between AHA Heart failure Stages and NYHA classification.
AHA - describes structural changes, progression of heart failure. (A, B, C, D). Does not reverse.
NYHA - describes symptomatology and functional status (I, II, III, IV) -can change depending on treatment.)
How would you titrate Lasix for a patient you are concerned may be developing renal injury from over diuresis?
Pause or decrease frequency. Lowering the dose is less likely to be effective as Lasix is usually given at minimal effective dose.
How to dose Lasix?
Titrate to effect. Give single dose, double the dose if no effect. More frequent administration of lower dose not as effective. Maximum single dose 80-200mg.
Describe 3 findings on chest X Ray compatible with a diagnosis of Heart Failure
Cardiomegaly, pulmonary vascular congestion, pleural effusions, Kerly B lines, "bat winging"
GDMT recommends starting this medication class in patients with LVEF < 40%
Arb/Neprilysin Inhibitor (eg. Entresto)
List the AHA Stages of Heart Failure
A - At risk of heart failure
B - Pre heart failure (structural change, no signs or symptoms)
C - Symptoms or signs (past or present)
D- Advanced Heart failure (refractory to medical therapy)
A patient previously diagnosed with HFrEF now has an improved EF greater than 40% after treatment. What medications would you like to change/remove?
Do not discontinue GDMT. Increases risk of heart failure relapse.
Initiating this treatment within 60 minutes of presentation in acute decompensated heart failure results in decreased hospital mortality.
Diuresis
What are age adjusted BNP cutoffs indicative of heart failure?
For patients age <50 = 450
ages 50 to 75= 900
age > 75 = 1800
Name all of the medication classes recommended in HFrEF GDMT with examples of each.
Cardio protective Beta Blocker
Mineralocorticoid Receptor Antagonist
SGLT-2
ACE/ARB
ARB/Neprilysin inhibitor
Loop diuretic (if congested)
Describe NYHA heart failure classification stages I - IV.
I - No symptoms
II - Mild sx, slight limitation in activity
III - No sx at rest, significant limitation in activity
IV - Sx at rest, severe limitation in activity
A patient is admitted for heart failure exacerbation due to missed medications and AKI. What etiology might you consider is the cause of AKI? What approach might you take?
Pre-renal intravascular volume depletion with third spacing of fluid. Consider cautious diuresis to improve both renal function and sx of heart failure.
Name 3 acceptable loop diuretics (and dosing) that can be administered for decompensated heart failure.
Furosemide 20-40mg +++
Bumetanide 1-2mg
Torsemide 10-20mg