Acute respiratory distress 2/2 acute decompensated systolic LV heart failure – (HFrEF)
Cause of CHF exacerbation:____
Baseline function is:—————; the Last echo was————-
H&P performed, see above.
-CXR, ECG, Echo (if none recently), CBC w/ diff, CMP, Mg/Phos, BNP, cardiac enzymes. If concerned for PE will get CTA w/ contrast.
In the ED pt received:
–The patient is warm & Wet
-Admit to telemetry; Cardiac monitor
–Lasix: Start IV Lasix (as renal function tolerates) to optimize volume status. Monitor UOP. Consider furosemide dose 2.5x usual daily dose to increase UOP, however, expect a transient increase in renal dysfunction. Furosemide IV to PO conversion is 1:2 (i.e., 20 mg IV = 40mg PO).
–KCL 20mg PO BID (as proactive replacement of K+ in this pt who will be losing K+ on Lasix)
–Morphine – limited data to support use. May depress respiratory drive.
–Nitrates (venodilators) as needed.
–Oxygen: Cont. pulse ox and Oxygen to keep sat> 92%
-Duonebs as needed
–Position pt with the head of the bed up as needed. Pt sitting up & legs dangling over the side of bed lead to decrease preload.
–Quantify INs/OUTs: –Strict I/Os and Daily weight checks.
–Restrict sodium & fluid intake: Low sodium diet (1g Na diet) & Fluid restriction < 2L/day
-f/u BNP and cardiac enzymes
-Am labs/Imaging: F/u CBC, CMP(esp. K+, BUN/Cr), TSH, CXR, TTE
-CHF Meds (is patient on the right CHF meds)?: Home-med adjustments: – ACE/ARB: hold if HoTN. Consider changing to hydralazine & nitrates if renal decompensation occurs. –Beta blockers: reduce dose by at least 1/2 if mod HF, d/c if severe HF and/or need inotropes.
-*Lifestyle modifications education provided to the patient including smoking cessation, restriction of alcohol consumption, salt restriction, weight reduction in this obese patient, as well as daily weight monitoring to detect fluid accumulation before it becomes symptomatic.
-Consult “Heart Failure Nurse” – will help prevent readmissions.
–Core measure to reduce CHF re-admission if EF <35%: Metoprolol Succinate / Carvedilol, ACEI, Spironolactone.
-Post-discharge f/u in “heart failure clinic” within 7 days for Cardiac Rehabilitation.
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Important Links.
- Diuretics and Diuresis.
- Classification and Treatment of Chronic Heart Failure.
- Treatment of Chronic Heart Failure.
- Mechanism of Action of ACE inhibitors in Heart Failure and MI.
- Beta-Blockers Studied in Heart Failure.
- Precipitants of Acute Heart Failure.
- Preload and Afterload.
**Hyponatremia is a poor prognostic indicator.
Sample case:
71 yo male with a Hx of HTN, HLD, more than 60pk yr tobacco abuse, and 5cm Asc. AA presents with a 3d Hx of SOB, possible S3 on exam, BNP of 2870, and radiographic imaging suggestive of CHF.
BNP
In a patient you suspect CHF, what serologic test would you do to help detect left ventricular dysfunction? BNP!
BNP is secreted from the cardiac ventricles in response to ventricular volume expansion and pressure overload. The major source of BNP is the cardiac ventricles, and b/c of the minimal presence of BNP in storage granules, its release is directly proportional to ventricular dysfunction. BNP reliably predicts the presence or absence of left ventricular dysfunction on an echocardiogram.
“One study has shown a near-linear relationship between admission BNP levels and in-hospital mortality (SOR B). For patients with BNP levels ≥5000 pg/mL, in-hospital mortality was 8.5%”
Observational studies suggest that follow-up within 7 days of hospital discharge results in lower readmission rates.