Acute Decompensated Hf

Front 1

Are the number of hospitalizations for HF increasing or decreasing?

Back 1

increasing, 1 million annually

Front 2

What stage are refractory HF pts?

Back 2

stage D, typically class III or IV
persistent symptoms despite optimal tx with ACEI and BB

Front 3

What is decompensated HF or exacerbation of HF?

Back 3

pt with ne or worsening signs or symptoms, which are usually caused by volume overload and/or hypoperfusion and lead to additional medical care

Front 4

What is acute HF?

Back 4

pt with a sudden onset of s/s of HF in setting of previously normal cardiac function

Front 5

What clinical syndromes are seen in decompensated HF?

Back 5

systemic volume overload, low output, acute pulmonary edema

Front 6

What can cause decompensation?

Back 6

dietary indiscretion, medical noncompliance, noncardiac concurrent illness (infection), recurrent MI, atrial fibrillation, myocarditis, or acute valvular insufficiency,
large MI or sudden increase in BP in setting of LV dysfunction
severe LV systolic dysfunction associated with progressive worsening of cardiac output and refractoriness to tx

Front 7

What are predictors of in hospital mortality in acute decompensated HF?

Back 7

best: BUN greater than or equal to 43mg/dL
SBP less than 115mmHg, serum Cr 2.75mg/dL or higher
others: hyponatremia, elevations in troponin I, ischemic etiology, poor functional capacity, additional negative prognostic factors

Front 8

What is goal of tx in decompensated HF?

Back 8

relieve congestive symptoms or optimize volume status as well as tx symptoms of low CO, so pt is discharged in compensated state on PO drug
minimize risk of drug tx

Front 9

What risks from drug tx?

Back 9

diuretic induced electrolyte depeletion, hypotension from vasodilators, myocardial ischemia and arrhythmias from positive inotropes

Front 10

What is the more common presentation of HF?

Back 10

congestion

Front 11

What is the main symptom of fluid overload that best correlates with elevated pulmonary pressures?

Back 11

orthopnea

Front 12

What is the most reliable indicator of the pts volume status?

Back 12

jugular venous pressure: follow during hospitalization as an indicator of the efficacy of diuretic tx

Front 13

What is S3 gallop?

Back 13

represents ventricular filling, high diagnostic specificity for HF decompensation

Front 14

Dose pulmonary crackles and lower extremity edema have high specificity and sensitivity for the diagnosis of decompensated HF?

Back 14

no

Front 15

Is BNP used in diagnosis of acute decompensated HF?

Back 15

aid in diagnosis: plasma BNP is positively correlated with the degree of LV dysfunction and HF (used in differential diagnosis: asthma, COBD, or infection)
low BNP has a 96% predictive value for excluding HF
elevated prehospital discharge BNP associated with increased risk of worse long term outcome

Front 16

What is required to elevate BNP?

Back 16

any disease process that increases right heart pressures: pulmonary emboli, chronic obstructive lung disease, primary pulmonary HTN
mild increase: increasing age, female, renal dysfunction

Front 17

What is associated with a lower BNP?

Back 17

obesity

Front 18

When is admission to ICU required?

Back 18

hemodynamic instability requiring frequent monitoring of vital signs, invasive hemodynamic monitoring, or rapid titration of IV meds with concurrent monitoring to assure safe and effective outcomes

Front 19

When is hospitalization recommended?

Back 19

severely decompensated HF: hypotension, worsening renal function, altered mentation
dyspnea at rest: resting tachypnea, oxygen saturation less than 90%
hemodynamically significant arrhythmia: new onset of rapid atrial fibrillation
acute coronary syndromes

Front 20

When should hospitalization be considered?

Back 20

worsened congestion: even without dyspnea, wt gain 5kg or more
s/s pulmonary or systemic congestion: even in absence of wt gain
major electrolyte disturbance
comorbid conditions: pneumonia, pulmonary embolus, DKA, TIA/stroke
repeated implantable cardioverter defibrillator firings
previous undiagnosed HF with s/s of systemic or pulmonary congestion

Front 21

What is first step in management of decompensated HF?

Back 21

ascertain that optimal tx with PO meds has been achieved

Front 22

What is tx if fluid retention is evident?

Back 22

aggressive diuresis: IV diuretic may be necessary

Front 23

Is ACEI and BB continued in decompensated HF?

Back 23

yes, d/c BB if dose initiation or up titration was responsible for the decompensated state
d/c ACEI or BB if cardiogenic shock or symptomatic hypotension

Front 24

What tx are held in renal dysfunction, especially oliguria or hyperkalemia?

Back 24

ACEI, ARB, aldosterone antagonist

Front 25

What is target trough for digoxin in decompensated HF?

Back 25

0.5-1ng/mL

Front 26

What is essential for assuming optimal response to tx while avoiding AE in decompensated HF?

Back 26

close monitoring
daily: wt, strict fluid I & O, HF s/s, orthostatic BP
frequently: electrolyte depletion, symptomatic hypotension, renal dysfunction
vital signs: multiple times/day

Front 27

Is foley catheter placement recommended in decompensated HF?

Back 27

only if close monitoring of urine output is needed

Front 28

When should wt be measured?

Back 28

after voiding in the morning, account for possible increased food intake

Front 29

What signs of decompensated HF should be monitored daily?

Back 29

edema, acites, pulmonary rales, hepatomegaly, increased jugular venous pressure, hepatojugular reflux, liver tenderness

Front 30

What symptoms of decompensated HF should be monitored daily?

Back 30

orthopnea, paroxysmal nocturnal dyspnea, nocturnal cough, dyspnea, fatigue

Front 31

What electrolytes should be monitored daily?

Back 31

K, Mg, Na

Front 32

What is wet HF?

Back 32

s/s of fluid overload: orthopnea, dyspnea with minimal exertion, systemic congestion (GI discomfort, ascites, peripheral edema)

Front 33

What is dry HF?

Back 33

s/s of low cardiac output: extreme fatigue and tiredness, poor appetite, nausea, early satiety,
worsening renal function and decline in serum Na

Front 34

Do most pts present with wet or dry HF?

Back 34

wet

Front 35

Can pt present with s/s of dry and wet HF?

Back 35

yes: low output symptoms may not be obvious until congestion is optimally treated

Front 36

What is the minimal noninvasive standard of care for critically ill pts with cardiopulmonary decompensation?

Back 36

ECG monitoring, continuous pulse oximetry, urine flow monitoring, and automated BP recording

Front 37

What is used for continuous and acurate assessment of arterial pressure?

Back 37

peripheral or femoral arterial catheters

Front 38

When is invasive hemodynamic monitoring considered?

Back 38

pts who are refractory to initial tx, whose volume status is unclear, or who has clinically significant hypotension such as SBP less than 80mmHg, or worsening renal function despite therapy

Front 39

What is invasive hemodynamic monitoring usually performed with?

Back 39

a flow directed pulmonary artery or Swan-Ganz catheter placed percutaneously through a central vein and advanced through the right side of the heart and into the pulmonary artery

Front 40

How is the pulmonary artery occlusion pressure measured?

Back 40

inflation of a balloon proximal to the end port allow the catheter to "wedge" yielding the pulmonary artery occlusion pressure

Front 41

What does the pulmonary artery occlusion pressure estimate?

Back 41

pulmonary venous pressure and, in the absence of intracardiac shunt, mitral valve disease or pulmonary disease, the LV diastolic pressure

Front 42

What is risk of death at 1 year for wet warm and wet cold compared to dry warm?

Back 42

wet warm: 2 fold risk
wet cold: 2.5 fold risk

Front 43

What is subset I pts?

Back 43

CI and pulmonary artery occlusion pressure within generally acceptable ranges, lowest mortality of any subset

Front 44

What tx for subset I?

Back 44

maximize PO tx and monitoring

Front 45

Can pt with significant LV dysfunction still present in subset I?

Back 45

yes

Front 46

Who are subset II pts?

Back 46

adequate CI but pulmonary artery occlusion pressure is greater than 18mmHg
likely to have pulmonary congestion (wet HF)

Front 47

What is goal in subset II?

Back 47

reduce pulmonary congestion by lowering pulmonary artery occlusion pressure
reduce filling pressures without reducing CO, increasing HF, or further activating neurohormones

Front 48

What result if decrease pulmonary artery occulusion pressure excessively?

Back 48

significant decrease in CI

Front 49

What should pulmonary artery pressure be lowered to?

Back 49

normal is 5-12mmHg, higher pressures of 15-18mmHg needed for HF pt to optimize CI while avoiding pulmonary congestion

Front 50

Why can pulmonary artery occlusion pressure be lowered to 15-18mmHg with little decrease in CI?

Back 50

Frank-Starling curve is flatter at higher pulmonary artery occlusion pressure values

Front 51

What tx for goal in subset II?

Back 51

IV agents that reduce preload: loop, nitroglycerin, nesiritide
very rapid decrease in preload, may take longer for s/s of pulmonary congestion to resolve

Front 52

What is 1st line tx for pt admitted with fluid overload?

Back 52

loop diuretic: achieve desirable volume status without causing a rapid reduction in intravascular volume resulting in symptomatic hypotension or renal dysfunction

Front 53

How much fluid if hyponatremic (less than 130mEq/L)?

Back 53

less than 2L/day

Front 54

When are IV vasodilators considered in addition to diuretics for rapid symptoms resolution?

Back 54

acute pulmonary edema or severe HTN, as well as in pts who fail to respond to aggressive tx with diuretics

Front 55

When should vasodilators be avoided?

Back 55

symptomatic hypotension, low left heart filling pressure

Front 56

What is considered if pt doesn't respond to diuretics or vasodilators?

Back 56

IV inotropic tx

Front 57

What is considered subset III?

Back 57

CI less than 2.2L/min/m2 and normal pulmonary artery occlusion pressure

Front 58

How does subset III present?

Back 58

no evidence of pulmonary congestion
s/s of peripheral hypoperfusion: decreased urine output, weakness, peripheral vasoconstriction, weak pulses

Front 59

What is mortality rate of subset III compared to pt without hypoperfusion?

Back 59

4x higher

Front 60

What is goal of subset III tx?

Back 60

alleviate s/s of hypoperfusion by increasing CI and perfusion to essential organs

Front 61

What is tx for subset III?

Back 61

mild LV dysfunction: IV fluid may be all that is needed to achieve CI above 2.2L/min/m2
IV positive inotropic agens: dobutamine, milrinone
and/or arterial vasodilators: nitroprusside, NTG

Front 62

When are IV inotropes recommended?

Back 62

symptom relief of end organ dysfunction in pts with LV dysfunction and low cardiac output syndrome

Front 63

What monitoring for inotropes?

Back 63

frequen BP monitoring and continuous monitoring for arrhythmias (d/c or lower dose)

Front 64

Who should avoid inotropes?

Back 64

low left heart filling pressures

Front 65

Should inotropes or vasodilators be considered first?

Back 65

vasodilators

Front 66

Should inotropic tx be used in the broad decompensated HF population?

Back 66

no

Front 67

What is used to "bridge" pts with cardiogenic shock to heart transplantation or left ventricular assist device?

Back 67

inotropes

Front 68

What is subset IV pt?

Back 68

CI less than 2.2L/min/m2 and pulmonary artery occlusion pressure higher than 18mmHg
worst prognosis of any subset

Front 69

How does subset IV pt present?

Back 69

symptoms of "wet" and low output HF

Front 70

What are tx goal in subset IV?

Back 70

alleviate s/s by increasing CI above 2.2L/min/m2 and reducing pulmonary artery occlusion pressure to 15-18mmHg while maintaining and adequate MAP

Front 71

What is tx for subset IV?

Back 71

diuretic plus positve inotrope
nitroprusside is particularly useful because of mixed arterial venous vasodilating effects
significant hypotension: inotropic agent with vasopressor activity

Front 72

Is subset II pulmonary congestion of hypoperfusion?

Back 72

pulmonary congestion

Front 73

Is subset III pulmonary congestion or hypoperfusion?

Back 73

hypoperfusion

Front 74

fig 16-8 16-10 pg 203

Back 74

203