management of acute heart...
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26.11.2019.
1
Sarinya Puwanant, MD, FASE
Medical Director Heart Failure and Transplant Cardiology King Chulalongkorn Memorial Hospital
MANAGEMENT OF ACUTE HEART FAILURE
C h u l a l o n g k o r n
HEART FAILURE & TRANSPLANT CARDIOLOGY
Case 58 Y/O M Ischemic CM, HFrEF; EF = 28%
58 year-old male with a h/o
HFrEF, LVEF =28%
CAD, S/P PCI with stent of RCA & LAD 3 yrs
LV thrombus
S/P CRTD removal 1 yr -Infected
March 2019 HF hospitalization
April 2019 NYHA I-II
July 2019 NYHA II; 6MW=392 m
Sept 2019- 2kgs↑, NYHA II
28 Oct 2019 ER visit due to AHF
Since then NYHA class III-IV, PND, 6kgs↑,
No angina
Medication
Furosemide (40) 2 bid
Enalapril (5) 2.5 bid
Spironolactone (25) 0.5 OD
Carvedilol (6.25) 1 bid
Warfarin (3) 0.5 OD
ASA 81 OD
Atorvastatin (40) OD
Addi K (750) 1 tid
26.11.2019.
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Case 58 Y/O M Ischemic CM, HFrEF; EF= 28%
BP 85/59 mmHg, HR 69/min regular, RR 28 - dyspnea, warm to touch, conscious.
O2 Sat 99% room air
BW 85 kgs
JVD ear lobe
Shifted LV apical beat to the left. S3+
Lungs minimal creptation BLL
Liver just palpable
No edema
ECG sinus tachycardia Flat T in most leads
LAB Nov
2019
April
2019
BUN 16 13
Cr 1.41 1.2
Na 139 138
K 3.8 3.6
Cl 109 102
Co2 26 25
INR 2.31 2.1
LDL 60
Hb 12
THAI HF Guidelines 2019
Cardiogenic shock or respiratory failure ?
Y
Specific cause Y
Consider ECG, labs, CXR, echocardiogram, lung ultrasound Then specific treatment
Evaluate for congestion and perfusion status
MAP > 65
MAP < 65
Discharge planning
Invasive monitoring, MCS
Improve
Y N
CONGESTION
PE
RF
US
ION
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Stepped care pharmacological approach
GOAL: Urine volume of 3 to 5 liters/day until clinical euvolemia
Initial approach –IV 2.5x previous PO furosemide dose (bid)
or alternatively the infusion approach
Not achieve UOP 3-5 L/day next level move
N Engl J Med 2017;377:1964-75
40mg/hr
How often ? • Depending upon patients' Status • Not that sick: 1 -2 hrs (spot urine Na) , 6 hrs, every shift-q 24 hrs
Diuretic Strategies in Patients with Acute Decompensated Heart Failure (DOSE TRIAL)
N Engl J Med 2011;364:797-805
N=306 , allow dose adjustment after 48 hrs 1 EP:= 72 hr Global VAS and Cr; 2 EP= 72 –hr (BW, fluid loss, SOB) favorable in high dose
2.5 x PO dose
1 x PO dose
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Decongestion 2.5x (lasix (40) 2x2) = 2.5x 160 mg= 400 mg IV lasix
80 mg IV bolus then 20 mg per hr (400 mg/24 hr= 17 mg/hr)
Target 3-5 L/day = 5 L/24 = 200 ml/hr
2 hrs 6 hrs
(22:00)
8 hr
(6:00)
URINE/hr No record 1200/6 hrs
(~200ml/hr)
1800/8 h
(~225 ml/hr)
TOTAL URINE
Accumulative No record 1200 2000 ml
BW (kgs) 85 84
S and S PND, Upright
RR =30
JVD –jaw
BP 85/59
PND, 5 pillows
RR =28
JVD –jaw
BP 87/55
BUN/Cr 16/.1.4 22/1.8
K 3.8 3.8
DIURETICS Lasix 20
mg/hr
Lasix 30
mg/hr Off lasix Lasix 30
mg/h
Lasix 10
mg/h
Lasix 125
mg IV bid
Lasix 80 mg
PO bid
24 hr
(6:00)
DAY 2 DAY 3
5500 ml 2800 ml 2500
81.5 79 77
JVD 10 cm
PND,15 ° bed
RR 25 cramp
BO 90/60
JVD 5 cm ,
flat, PND x1
BP 94/56
No JVD
No PND
BP 101/60
21/1.4 18/1.3 17/1.2
4.0 4.1 3.9
(~200-300
ml/hr)
WHAT IS NEXT?
CARDIORENAL SYNDROME
Plasma Norepinephrine
Nore
pin
ephri
ne (
ng/m
L)
0
900
800
700
600
Time
C 10' 20' 1'h 2'h
Plasma Renin Activity
Renin
Activi
ty (
ng ·
mL
-1 ·
h-1
)
0
16
12
10
8
Time
C 10' 20' 1'h 2'h
18
14
Plasma AVP
Arg
inin
e V
asopre
ssin
(pg/m
L)
0
10
8
7
5
Time
C 10' 30' 1'h 2'h
9
6
* *
* *
*
* *
*
* *
*
*
J A C C : H E A R T F A I L U R E V O L . 3 , N O . 2 , 2 0 1 5
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CARDIORENAL SYNDROME
J Am Coll Cardiol. 2009 February 17; 53(7): 589–596 Am Heart J 2018;204:163-73
J Am Coll Cardiol. 2009 February 17; 53(7): 589–596
THAI HF Guidelines 2019
Cardiogenic shock or respiratory failure ?
Y
Specific cause Y
Consider ECG, labs, CXR, echocardiogram, lung ultrasound Then specific treatment
Evaluate for congestion and perfusion status
MAP > 65
MAP < 65
Discharge planning
Invasive monitoring, MCS
Improve
Y N
CONGESTION
PE
RF
US
ION
26.11.2019.
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Second agents: Diuretics for symptomatic relief
Nat Rev Cardiol 2015;12:184–192.
C h u l a l o n g k o r n
HEART FAILURE & TRANSPLANT CARDIOLOGY
6. Tolvaptan (Aquaretics) • Vasopressin antagonist
Vasodilator Inotrope - NA
2 hrs 6 hrs
(22:00)
8 hr
(6:00)
URINE/hr No record 1200/6 hrs
(~200ml/hr)
1800/8 h
(~225 ml/hr)
TOTAL URINE
Accumulative No record 1200 2000 ml
BW (kgs) 85 84
S and S PND, Upright
RR =30
JVD –jaw
BP 85/59
(67)
PND,5 pillows
RR =28
JVD –jaw
BP 87/55
(66)
BUN/Cr 16/.1.4 22/1.8
K 3.8 3.8
DIURETICS Lasix 20
mg/hr
Lasix 30
mg/hr Lasix 10
mg/h
Lasix 30
mg/h
(~200-300
ml/hr)
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THAI HF Guidelines 2019
Y
Y
MAP > 65
MAP < 65
Y N
Discharge Planning • Life saving med • Multidisciplinary care • Make sure precipitating
cause has been fixed
Burden and Significance of Incomplete DECONGESTION in Acute HF DOSE-AHF and CARESS-HF ANALYSIS in 496 PATIENTS
16%
32% 52%
High Grade Orthodema
Low Grade Orthodema
No Orthodema
Congestion Status at Discharge
Points
Orthopnea >=2 pillows 2
<2 pillows 0
Edema
trace 0
Moderate 1
Severe 2
Score 3-4
Score 1-2
Score =0
P=0.038
Circ Heart Fail. 2015;8:741-748.
C h u l a l o n g k o r n
HEART FAILURE & TRANSPLANT CARDIOLOGY
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Hemodynamic congestion precedes clinical congestion by days and weeks and can persist after relief of symptoms
C h u l a l o n g k o r n
HEART FAILURE & TRANSPLANT CARDIOLOGY
Diuresis
RA 15
PCWP 30
RA 8
PCWP 20
RV 45/15
LV 110/30
• I feel better • I want to go home
AT REST exertion
RA 10
PCWP 25-28
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Challenges in decongestion in AHF
Clinical congestion ≠ hemodynamic congestion
Extremely difficult decongestion marker-spectrum>binary
Redistribution vs. volume overload
CRS
Recommendation of guidelines : B-C level of evidences
C h u l a l o n g k o r n
HEART FAILURE & TRANSPLANT CARDIOLOGY
Conclusions
Optimal management of acute HF is challenging.
Congestion is the main reason for HF admissions and readmission
Hemodynamic congestion is often difficult to recognize, delaying appropriate intervention.
Congestion may contribute to progression of HF and main obstacle for OMT.
26.11.2019.
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THANK YOU
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