Acute Decompensated Heart Failure and Transitions of Care

Question 1

What are the two presentations

Answer 1

Rapidly developing symptoms of new-onset heart failure, gradual worsening of chronic heart failure

Question 2

T/F: To be considered heart failure there must be ejection fraction less than 50%

Answer 2

True

Question 3

What causes of ADHF

Answer 3

Respiratory infection, Ischemia/ACS, Arrhythmia, uncontrolled HTN, nonadherence to meds, worsening renal function, nonadherence to diet

Question 4

What are “wet” (volume overload) symptoms

Answer 4

peripheral edema, pulmonary edema, cough, worsening DOE (difficulty breathing) and orthopnea (difficulty breathing laying down), anorexia/early satiety

Question 5

What are “cold” (low cardiac output) symptoms

Answer 5

decreased urine output, elevated BUN/SCr, tachycardia, cold and clammy extremities, decreased exercise tolerance, fatigue

Question 6

What peptide is a marker for increased preload

Answer 6

BNP

Question 7

What are ways that can alter the BNP

Answer 7

Obesity (lower), renal insufficiency, acute coronary syndrome, atrial fibrillation

Question 8

What are the four hemodynamic subsets of ADHF

Answer 8

Class 1: Warm (good cardiac output/good perfusion), dry (good volume)
Class 2: Warm, wet (volume overload)
Class 3: cold (low cardiac output/bad perfusion), dry
Class 4: cold, wet

Question 9

What are the two most common presentations for ADHF

Answer 9

Class 2 and Class 4

Question 10

T/F: Negative ionotropes including beta-blockers make heart failure worse

Answer 10

False: Negative ionotropes excluding beta-blockers make heart failure worse

Question 11

What are the three types of drugs that will be used to deal with acute heart failure

Answer 11

Loop Diuretics, Inotropes, Vasodilators

Question 12

What would the dose of IV loop diuretics be if this is there first time with HF, chronic HF patients, maximum dose

Answer 12

20-80 mg IV every 8-12 hours, total daily dose is equal to the INITIAL IV dose, 200-250 mg dose

Question 13

What is the goal urine output for each dose when using IV loop diuretics to treat HF, each day

Answer 13

250-500 mg within 2 hours of dose, 1.5-2 L of NET diuresis

Question 14

What is the initial reason to increase IV diuretics, how can it be treated

Answer 14

Inadequate response to initial diuretic regimen, double the IV dose

Question 15

What should be done if there is an inadequate response to the increase diuretic dose

Answer 15

Continous fusion OR add metalazone by mouth, spironolactone by mouth, or chlorothiazide IV

Question 16

What is the last resort if all IV diuresis options fail

Answer 16

Consider ultrafiltration

Question 17

When would it be okay to add an IV vasodilator to a treatment regimen for AHF, indications

Answer 17

Symptomatic hypotension is absent/ Acute pulmonary edmema, need for rapid improvement of symptoms, pulmonary congestion refreactory to IV diuresis

Question 18

What are the two IV vasodilators that are used, what is the MOA

Answer 18

Nitroglycerin and Nitroprusside, Nitrous oxide donors

Question 19

T/F: There is no reduction in re-hospitalization or mortality when using IV vasodilators for AHF

Answer 19

True

Question 20

Which IV vasodilator is preferred in patients with coronary ischemia, balanced arterio-/venodilation (more potent)

Answer 20

Nitroglycerin, nitroprusside

Question 21

what are the indications for using IV inotropes

Answer 21

Diminshed peripheral perfusion or end-organ dyfunction, marginal systolic BP (greater than 90), symptomatic hypotension, palliative therapy for Stage D patients

Question 22

T/F: Long term use of inotropes lowers mortality

Answer 22

False: Long term use without proper indications is associated with increased mortality

Question 23

What is the MOA of inotropes, what are the IV inotropes

Answer 23

Increase cAMP increasing myocardial contractility/ Dobutamin and milrinone

Question 24

Which is IV inotrope that it is more likley to cause hypotension due to vasodilation and is eliminated renally, has vasodilation at higher doses and hepatically eliminated

Answer 24

Milrinone, dobutamine

Question 25

What adverse effects of using either IV inotrope

Answer 25

Proarrhythmia and tachycardia, coronary ischemia

Question 26

What drug class are used for Class 2, Class 3, and Class 4 for ADHF

Answer 26

Class 2: Diuretics +/- vasodilators
Class 3: Inotropes +/- vasopressors
Class 4: Inotropes + diuretics

Question 27

What are pharmacological options patients should also receive for VTE prophylaxis/non pharmacological prophylaxis

Answer 27

Unfractionated Heparin, LMWH, Fondaparinux/Intermittent pneumatic compression devices and compression stockings

Question 28

T/F: Weight, fluid intake/output, electrolytes, and renal function should be checked daily

Answer 28

True

Question 29

T/F: If a patient goes to the hospital for AHF they should be given an improved regimen

Answer 29

True