Term
| Acute Decompensated Heart Failure (ADHF) |
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Definition
exacerbation of heart failure;
characterized by development of dyspnea from rapid accumulation of fluid within lung's interstitial and alveolar spaces due to acutely elevated cardiac filling pressures;
refers to pts w/ new or worsening S/sx caused by volume overload &/or hypoperfusion; |
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Term
| Precipitating Factors for ADHF |
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Definition
Cardiac:
- decompensation of chronic HF, ACS (MI), acute arrhythmia, uncontrolled HTN, valvular disorders, pulmonary embolism;
Metabolic:
- volume overload, anemia, infection, worsening renal function, major surgery;
Patient-Related:
- non-adherence (dietary Na restriction, fluid restriction, HF therapy/meds), OTC meds (NSAIDs) |
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Term
| Symptoms of Volume Overload |
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Definition
| SOB; orthopnea; paroxysmal nocturnal dyspnea (PND); dyspnea on exertion (DOE); early satiety; N/V |
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Term
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Definition
| increased JVD; pitting edema; weight gain; S3 or S4 gallop; rales; hepatojugular reflex (HJR); increased BNP; CXray: pulmonary congestion; Enlarged liver; |
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Term
| Symptoms of Hypoperfusion (low CO) |
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Definition
fatigue;
mental status changes; |
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Term
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Definition
cool extremities;
peripheral cyanosis;
hypotension;
tachycardia;
oliguria;
decreased renal function; |
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Term
| Forrester Classification Subset I (normal) - "Warm & Dry" |
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Definition
Cardiac Index (L/min/m^2): > 2.2;
Pulmonary Capillary Wedge Pressure (PCWP): < 18 mmHg; |
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Term
| Forrester Classification Subset II (pulmonary congestion) - "Warm & Wet" |
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Definition
Cardiac Index: > 2.2;
PCWP: > 18 mmHg;
Treatment:
- Start with diuretic;
- if adequate SBP, then add vasodilator; |
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Term
| Forrester Classification Subset III (hypoperfusion) - "Cold & Dry" |
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Definition
Cardiac Index: < 2.2;
PCWP: < 18 mmHg;
Treatment:
- give FLUIDS (judiciously) |
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Term
| Forrester Classification IV (pulmonary congestion + hypoperfusion) - "Cold & Wet" |
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Definition
Cardiac Index: < 2.2;
PCWP: > 18 mmHg;
Therapy:
- start with Diuretic;
- if adequate SBP (>90), add vasodilator +/- inotrope;
- if reduced BP (<90), use inotrope |
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Term
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Definition
> 100 pg/mL;
correlates with ADHF |
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Term
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Definition
> 300 pg/mL;
- correlates w/ ADHF |
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Term
| Guidelines for when to Measure BNP or NT-proBNP |
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Definition
These markers should be measured in pts evaluated for DYSPNEA if HF contribution is UNKNOWN;
final diagnosis REQUIRES more clinical data, NOT a stand alone test confirming ADHF |
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Term
| Electrolytes to Obtain at Baseline |
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Definition
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Term
| Renal Function to Obtain at Baseline |
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Definition
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Term
| Goals of Therapy for ADHF |
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Definition
1) symptomatic relief (congestion & hypoperfusion);
2) optimize oxygenation;
3) hemodynamic stabilization (decrease PCWP, increase CO);
4) discharge in a compensated state on PO therapy;
5) decrease pt length of stay; |
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Term
| Diuretics - loop diuretics (furosemide, bumetanide, torsemide) |
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Definition
decreases fluid volume;
1st line tx in pts w/ acute pulmonary congestion OR peripheral edema from FLUID OVERLOAD;
MoA: inhibits Na/Cl/K transport in loop of Henle, increases Na/H2O excretion --> Decrease Preload & pulmonary edema;
Monitoring Parameters:
- diuretic response (UO, wt, symptomatic relief);
- BMP: electrolytes (K), Mg;
- BP, orthostasis; |
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Term
| Dosing IV Lasix if Pt took dose prior to Hospital Admission |
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Definition
IV route for ADHF: short-term vasodilation & decrease in PCWP --> symptomatic relief;
Give PO home dose as IV bolus dose --> MAX dose: 180 mg as single dose;
Goal: defined by urine output (UO);
- Goal for Pt w/ Normal Renal fcn: >500 mL urine within 1st 2 hrs of IV Lasix;
- Goal for Pt w/ Renal Insufficiency (SCr >2.5): >250 mL urine within 1st 2 hrs of IV Lasix;
If goal urine output is NOT achieved:
- double dose (MAX single dose: 360 mg);
- ADD a THIAZIDE diuretic (metolazone or chlorothiazide);
- continuous IV infusion; |
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Term
| Dosing IV Lasix if Pt DID NOT take Lasix PRIOR to Admission |
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Definition
IV route for ADHF: short-term vasodilation & decrease in PCWP --> symptomatic relief;
If pts SCr < 2: start w/ 40 mg IV;
If pts SCr > 2: start w/ 80 mg IV;
Goal: defined by urine output (UO);
- Goal for Pt w/ Normal Renal fcn: >500 mL urine within 1st 2 hrs of IV Lasix;
- Goal for Pt w/ Renal Insufficiency (SCr >2.5): >250 mL urine within 1st 2 hrs of IV Lasix;
If goal urine output is NOT achieved:
- double dose (MAX single dose: 360 mg);
- ADD a THIAZIDE diuretic (metolazone or chlorothiazide);
- continuous IV infusion; |
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Term
| Vasodilators - nitroglycerin (NTG), nitroprusside (Nitropress), nesiritide (Natrecor) |
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Definition
decreases preload & afterload;
Indication:
- use in combo w/ diuretic therapy for ADHF pts NOT RESPONDING to diuretics ALONE;
- fot pts WITHOUT symptomatic HYPOtension;
MoA: arteriovenous vasodilation --> hemodynamic stabilization; |
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Term
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Definition
MoA:
- venous > arterial vasodilation;
Limitations:
- hypotension, HA, TACHYPHYLAXIS, reflex tachycardia, titration required;
Notes:
- DRUG OF CHOICE if pt presents w/ ADHF and has NEW ONSET ACS |
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Term
| nitroprusside (Nitropress) |
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Definition
MoA:
- venous & arterial;
Limitations:
- hypotension, TOXIC METABOLITES, reflex tachycardia, difficul titration;
Notes:
- CYANIDE/THIOCYANTE TOXICITY: avoid in renal insufficiency, limit dose to <3 mcg/kg/min, limit duration to <3 days; |
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Term
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Definition
MoA:
- venous and arterial;
Limitations:
- hypotension, LONG HALF-LIFE (can give on gen-med floor);
Notes:
- recombinant human BNP;
- vasodilatory & natriuretic effects;
- hypotension is dose-related; |
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Term
| Guidelines for Vasodilators - NTG, nitroprusside, nesiritide |
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Definition
In absence of symptomatic HYPOtension, IV NTG, nitroprusside, or nesiritied considered as ADD-ON to diuretic therapy for rapid improvement of congestive SYMPTOMS in pts admitted w/ ADHF (requires freq. BP monitoring);
IV vasodilators (NTG or nitroprusside) & diuretics are RECOMMENDED for rapid symptom relief in pts w/ acute pulmonary edema or severe hypertension; |
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Term
| Inotropes - dopamine, dobutamine, milrinone (Primacor) |
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Definition
increases CO;
Indications:
- pts in ADHF who display S/sx of low CO; |
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Term
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Definition
MoA: beta-receptor agonist;
Monitor: ECG;
Limitations: tachycardia, proarrhythmias, mortality concern (requires constant EKG monitoring);
NOT a vasodilator;
DO NOT use in pta taking Beta-Blockers;
Drug DOES NOT accumulate in renal dysfunction - no dose adjustment needed; |
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Term
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Definition
MoA: Type-III phosphodiesterase inhibitor;
Monitor: EKG (constant);
Limitations: tachycardia, proarrhythmias, mortality concern, hypotension;
This drug IS a VASODILATOR;
Can USE WITH a Beta-Blocker;
ACCUMULATES in renal dysfunction (Dose adjust); |
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Term
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Definition
IV drugs used to relieve symptoms & improve end-organ dysfunction in pts w/ advanced HF characterized by LV dilation, reduced LVEF, AND diminished peripheral perfusion or end-organ dysfunction;
Use if pts have:
- marginal SBP (<90 mmHg), symptomatic hypotension, OR are unresponsive to or intolerant of IV vasodilators;
When adjunctive therapy is needed in pts w/ ADHF, administration of VASODILATORS should be considered INSTEAD of IV inotropes; |
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