how to make the most out of hospital stay
TRANSCRIPT
How to make the most out of hospital stay
Acute heart failure management: essentials for clinician
Veli-Pekka HarjolaFHFA, FESCHelsinki University Hospital, Finland
Conflicts of interest
• none declared
The common heart failure patient
• 75-year old man with• hypertension, lipid disorder, ex-smoker, anemia,
osteoarthrosis• AS, AFib, CAD, CKD, COPD, DM, TIA and …
Chioncel O. Am Heart J 2011;162:142
Use of iv therapies during first 48 hours and in-hospital mortality
Mebazaa A. Intensive Care Med (2011) 37:290–
Goals of treatment
McMurray J. European Journal of Heart Failure (2012) 14, 803–
Mobilize the patient
Risk assessment: Independent predictors of in-hospital mortality
Tavazzi L et al. EHJ 2006; 27:1207
Acute medication
• initial stabilization• goal-directed therapy with adequate doses
– furosemide iv or infusion– nitrate infusion or patches
Check-list for management of AHF1. ensure vital functions2. evaluate volume and filling status,
hypoperfusion & clinical profile3. optimize myocardial oxygen
consumption and delivery 4. start CPAP, iv-furosemide, nitrate5. study the cause and mechanism of
HF (echocardiography)6. treat precipitating factors7. continuosly check the response to
therapy often and increase intensity rapidly as needed (levosimendan)
Cardiac cause
• echocardiography– bed-side in ED– comprehensive on ward
• ischemic heart disease– how to interpret troponins– coronary angiogram: to whom and when
• indications for CRT, ICD?• telemetry
Inhospital monitoring
• Patient should be weighed daily and have an accurate fluid balance chart completed
• Standard noninvasive monitoring of pulse, respiratory rate and blood pressure should be performed
• Renal function and electrolytes should be measured daily
• Pre-discharge measurement of BNP is useful for post-discharge planning
Mebazaa A. Published on-line in Eur J HF and EHJ 2015
Decongestion and 60-day riskof ED visit, re-hospitalization, or death
Kociol HD. Circ HF 2014
4 lbs=1.8kg
Use of echo and ultrasound techniques vs symptoms for monitoring?
Thoracic FAST protocol vs VAS- 70 AHF patients- followed up with serial FAST protocol &VAS scores 0,12,24,48h and discharge- The FAST protocol was positive if E/e`was >15 and a congestive LUS - (bilateral B-lines (BL) or pleural fluid (PF) right sided or
bilaterally)- “Responders" became asymptomatic at rest and capable of
walking > 20 meters during hospital stay- LUS was considered normalized when absent of PF and
bilateral BL Öhman J 1; Harjola V-P 2; Lassus J 3; Karjalainen P. HFA 2015.
Rapid improvement of symptoms, filling pressures and pulmonary congestion estimated by combined echo and lung
US protocol during early course of AHF treatment
Öhman J 1; Harjola V-P 2; Lassus J 3; Karjalainen P. HFA 2015.
Goals of treatment
McMurray J. European Journal of Heart Failure (2012) 14, 803–
Mobilize the patient
Prognostic medication
HefREF• betablockers, ACEI/ARB,
spironolactone/eplerenone, ivabradine according to guidelines
• decompensated CHF: continue at the highest possible dose
• in de-novo: start low, aim high• good opportunity for up-titration in both
Maggioni AP. EJHF 2010; 12:1076
Role of beta-blockers in patients admitted for worsening heart failure
Orso F. EJHF 2009; 11: 77
before admission / during hospital stay
Oral medication in normo/hypertension
Appropriate adjustment by kalemia and renal function
Mebazaa A. Published on-line in Eur J HF and EHJ 2015
Long term medication
HefREF• adequate treatment of underlying disease
(hypertension)• rate control of Afib• symptomatic medication (diuretics)
Concomitant medication
• Anticoagulation in afib patients• Antidiabetics• Bronchodilators • NSAIDs• Antidepressants
• Harms, interactions – clean up the drug list !
Goals of treatment
McMurray J. European Journal of Heart Failure (2012) 14, 803–
Mobilize the patient
That’s what it’s all about !
ThankThank youyou
Back up slide
Change from admission to dischargeAll Responders
Non-responders
Patients 70 39 (56 %) 31 (44%) PLUS responsiveness (%) 59 85 (PPV 80%) 26 (NPV 79%) <0.001Δ E/e` 3,01 4,44 1,09 0.004Δ IVC (grades 1-3) 0,53 0,74 0,26 0.012Final E/e 17,9 15,3 21,2 <0.001Final IVC 0,69 0,38 1,10 <0.001Cumul. fluid loss (kg/liters) 2,91 3,89 1,59 <0.001Δ systolic blood pressure (mmHg) 18,6 26,7 4,65 0,001Δ MAP (mmHg) 11,1 20,0 -0,10 <0.001Δ pulse (/min) 10,2 17,0 1,71 0.002
HFA 2015. Öhman J 1; Harjola V-P 2; Lassus J 3; Karjalainen P 1