Presentation/Workup
How is a diagnosis of heart failure exacerbation made?
What is 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/shock.
What is beta blockers
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
K+ > 4
List at least 6 symptoms of heart failure exacerbation.
What are dyspnea on exertion, orthopnea, lower extremity edema, cough, fatigue, tachycardia, weight gain, abdominal pain, sleep disturbance
Name 3 evidence-based cardio protective Beta Blockers
What are: Metoprolol succinate, Carvedilol, Bisoprolol
Name the advanced surgical option treatments of class D heart failure
DAILY DOUBLE: describe each one and tell us one pro and one con to each.
Patient presents with hx of CAD and new onset HF with EF of 38%. Last Echo 3 months ago with normal EF. What should we consider has happened in that time and what work up would be ordered?
What is a recent MI that needs an ischemic workup.
Reasons to send a HF pt to ICU?
What are hypotension, signs of cardiogenic shock, severe hypoxia/need for NIPPV, Intubation
List at least 6 physical exam findings indicative of heart failure.
What are 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.
What are SGLT2 - class A (at risk)
Add ACE/ARB for class B (signs of structural change)
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.)
What might the provider do with Lasix for a patient you are concerned may be developing renal injury from over diuresis?
What is pause or decrease frequency.
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.
Name the 3 main findings on chest XRay compatible with a diagnosis of Heart Failure
What is cardiomegaly, pulmonary vascular congestion, pleural effusions
GDMT recommends starting this medication class in patients with LVEF < 40%
What is ARNI (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 expect a provider to change?
What is NONE! Providers should 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 is the mnemonic that indicates an advanced heart failure consult is warranted.
DAILY DOUBLE: Break down the letters of the mnemonic.
What is INEEDHELP (Inotropes, NYHA IV, End organ dysfunction, EF <20%, Defibrillator shocks, HF hospitalizations, Edema, Low blood pressure, Progressive intolerance of GDMT)
Name all of the medication classes recommended in HFrEF GDMT with examples of each.
What are Beta Blocker, Mineralocorticoid Receptor Antagonist (MRA), SGLT2, ACE/ARB/ARNI
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. They are hypervolemic and have an AKI. What may the HF NP order that would surprise a non-HF nurse?
What is diuretics
Name 3 acceptable loop diuretics (and dosing) that can be administered for decompensated heart failure. Also, can you name the dose equivalents?
DAILY DOUBLE: Give the PO maximum daily doses of each
Lasix, Bumex, Torsemide Lasix 40 = Bumex 1 = Torsemide 20
DD: Lasix 600mg, Bumex 10mg, Torsemide 200mg