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ACUTE DECOMPENSATED HEART
FAILURE Daniel Sievers
PharmD Candidate, 2016
FDU School of Pharmacy
Preceptor: Maria Leibfried 1
OBJECTIVES
• Present a patient case on acute decompensated heart failure (ADHF)
• Discuss the epidemiology, etiology, and pathophysiology of ADHF
• Review the risk factors, clinical presentation, and diagnosis of ADHF
• Discuss the treatment guidelines for ADHF
• Discuss treatment options including drugs of choice and alternatives
• Review efficacy and monitoring parameters of therapy
• Critique therapy for the patient case and provide an assessment and plan
2
PATIENT CASE
3
PATIENT CASE
Demographics
• Patient initials: JF
• Age: 72
• Gender: M
• Height: 5’ 10”
• Weight: 318.6 lb (144.8 kg)
• BMI: 45.7
• IBW: 68.5 kg
• Hospital unit/room: CAR.B2A
• Admission Date: 12/07/15
4
PATIENT CASE
Subjective Information
Chief Complaint:
• Severe shortness of breath
• Weeping from the legs
History of Present Illness:
• JF was sent to the hospital after presenting to his primary care doctor earlier in the day where he
was found to be very short of breath with weeping from the legs and pedal edema +4
• Patient was noted to have a 20 pound weight gain in one week
• Patient has a past medical history of congestive heart failure
• Patient admits to being non-compliant with his medications
Social History
• Does not drink alcohol or smoke
5
PATIENT CASE
Allergies
•NKDA
Past Surgical History
•None
Objective Information
Past Medical History
• CHF
• MI x 2
• Insulin dependent diabetes mellitus type II
• Obesity
• Atrial fibrillation
6
PATIENT CASE
Objective Information (cont)
Labs
Within normal limits except for
• B-naturiuretic peptide: 308 (H)
• WBC: 3.70 (L)
• RBC: 3.84 (L)
• Hgb: 11.8 (L)
• Hct: 37.3 (L)
• MCV: 97.3 (H)
• Platelets: 126,000 (L)
• PT: 28.6 (H)
• CrCl = 71.8 (mild insufficiency)
Vitals
Within normal limits except for
•BP: 110/60 (L)
•Temp: 36.4 °C (L)
Physical Exam
Within normal limits except for
•Morbid obesity
•+4 bilateral extremity edema with blistering
Review of Systems
Within normal limits except for
•Dyspnea
7
PATIENT CASE
Objective Information (cont)
Home Medications
• Carvedilol (Coreg) 3.125 mg: 1 tablet by mouth twice daily
• Furosemide (Lasix) 80 mg: 1 tablet by mouth twice daily
• Insulin glargine (Lantus) 100 units/mL: 72 units sub-q daily
at bedtime and 50 units sub-q daily at 6:00 am
• Insulin aspart (Novolog) 100 units/mL: 7 units sub-q three
times daily
• Metformin (Glucophage) 850 mg: 1 tablet by mouth three
times daily
• Dofetilide (Tikosyn) 125 mcg: 1 capsule by mouth twice
daily
• Warfarin (Coumadin) 10 mg: 1 tablet daily at bedtime
• Tamsulosin (Flomax) 0.4 mg: 1 capsule by mouth twice
daily
• Terazosin (Hytrin) 2 mg: 1 capsule by mouth at bedtime
• Magnesium 250 mg: 1 tablet by mouth twice daily
• Pyridoxine (Vitamin B6) 50 mg: 1 capsule by mouth daily
Discharged Medications
• Carvedilol (Coreg) 3.125 mg: 1 tablet by mouth twice
daily
• Furosemide (Lasix) 80 mg: 1 tablet by mouth three
times daily
• Insulin glargine (Lantus) 100 units/mL: 30 units sub-q
at bedtime and 30 units sub-q daily at 6:00 am
• Metformin (Glucophage) 850 mg: 1 tablet by mouth
three times daily
• Dofetilide (Tikosyn) 125 mcg: 1 capsule by mouth twice
daily
• Warfarin (Coumadin) 10 mg: 1 tablet daily at bedtime
• Tamsulosin (Flomax) 0.4 mg: 1 capsule by mouth twice
daily
• Terazosin (Hytrin) 2 mg: 1 capsule by mouth at bedtime
• Magnesium 250 mg: 1 tablet by mouth twice daily
• Pyridoxine (Vitamin B6) 50 mg: 1 capsule by mouth
daily
• Potassium Chloride SR (K-Dur) 20 mEq: 1 tab by mouth
daily
8
PATIENT CASE
Objective Information (cont)
Radiology
• Chest X-Ray (12/07/15)
• Cardiomegaly with borderline pulmonary vascular congestion
• Echocardiogram (12/08/15)
• Low Left ventricular systolic function and presence of diastolic dysfunction
• Ejection fraction of 30-35%
• Left and right atriums are mildly dilated
Diagnosis
• Exacerbation of congestive heart failure
9
ACUTE DECOMPENSATED HEART
FAILURE
INTRODUCTION
• Definition: “new or worsening signs or symptoms (often as a result of volume
overload and/or hypoperfusion) requiring additional medical care such as
emergency department visits and hospitalizations”
• Also referred to as exacerbation of heart failure
11
EPIDEMIOLOGY
• Heart failure is the leading cause of hospitalization for those aged 65 and older
• Acute decompensation represents 70% of HF hospitalizations
• Typical patients characteristics include
• Elderly
• Equally male or female
• Have comorbidities such as hypertension. chronic kidney disease, and chronic
obstructive pulmonary disease (COPD)
• Equally have preserved or impaired left ventricular (LV) ejection fraction
• 50% risk of re-hospitalization at 6 months
• 1-year mortality rate of 30%
12
ETIOLOGY
• Non-compliance with medication, diet, or fluid restriction
• Acute myocardial infarction (MI)
• New or worsening A.Fib
• Infection
• Untreated or uncontrolled high blood pressure
• Pulmonary embolism
• Medications that cause salt or water retention
• NSAIDs, steroids, thiazolidinediones (pioglitazone, rosiglitazone)
• Negative inotropic drugs
• Calcium channel blockers, beta blockers
CLINICAL PRESENTATION
• Dyspnea and fatigue
• Reduced exercise tolerance
• Volume overload/fluid retention
• Pulmonary edema, peripheral edema, pulmonary rales, S3 gallop
• Hypoperfusion
• Hypotension, renal insufficiency, shock, end organ dysfunction
• Orthopnea
• Tachypnea
• Hypoxia
HEMODYNAMIC CLASSIFICATION
• Warm and Dry: adequate perfusion,
no signs of volume overload
• Warm and Wet: adequate perfusion,
signs of volume overload
• Cold and Dry: inadequate perfusion,
no signs of volume overload
• Cold and Wet: inadequate perfusion,
signs of volume overload
15
LABORATORY AND DIAGNOSTIC
TESTS
• History and physical exam
• Identify precipitating factors
• Cardiac auscultation for heart sounds and murmurs
• S3 gallop indicates increased left ventricle volume - high specificity for
heart failure decompensation
• Pulmonary auscultation for rales
• Evaluation for peripheral edema
LABORATORY AND DIAGNOSTIC
TESTS • Medication history
• Echocardiogram
• Identify LVEF and structural changes
• B-natriuretic peptide (BNP) level
• Correlated with degree of left ventricular dysfunction and HF
• Normal < 100 pg/mL
• May be elevated in other conditions such as pulmonary embolism,
pulmonary hypertension, chronic obstructive pulmonary disease
TREATMENT
TREATMENT
• Goals
• Provide symptomatic relief
• Optimize volume status and cardiac output
• Minimize risk of treatment side effects
TREATMENT
• Treatment of ADHF largely depends on clinical presentation and hemodynamic
classification
• All patients should be evaluated to determine if their current HF treatment with
oral medication is optimized
• Current treatment with beta-blockers, and ACE inhibitors should be continued
during hospitalization unless there is symptomatic hypotension
TREATMENT
Warm and Dry: Adequate perfusion with no congestion
• Goal: Optimize patient’s chronic HF medication
• Determined by HF stage
• Typical medications include
• ACE inhibitors (lisinopril, enalapril)
• Beta blockers (carvedilol, metoprolol succinate, bisoprolol)
• Diuretics (furosemide, torsemide, bumetanide)
• Aldosterone antagonists (spironolactone, eplerenone)
TREATMENT
Warm and Wet: Adequate perfusion with congestion
• Goal: Reduce congestion and volume overload
• Initial therapy: IV loop diuretics that are equal to or exceed the patient’s current
chronic oral daily dose
• should be started in the ER as soon as possible
• the dose may be increased or a thiazide diuretic may be added to relieve
symptoms
• IV vasodilators can be added if there is no symptomatic hypotension to help
improve symptoms such as dyspnea
TREATMENT
Cold and Dry: Hypoperfusion with no congestion
• Goal: alleviate signs and symptoms of hypoperfusion and prevent end organ
damage
• IV vasodilators if SBP > 90 and no symptomatic hypotension
• IV inotropes for symptom relief and/or end organ dysfunction
• especially useful in patients with SBP < 90 or symptomatic hypotension
TREATMENT
Cold and Wet: Congestion and hypoperfusion
• Patients with this profile have the worst prognosis and is a common finding in
patients with end stage heart failure
• If SBP < 90, symptomatic hypotension, worsening renal function, or
unresponsive/intolerant to IV vasodilators
• Combination of IV inotrope plus IV diuretic
• Cardiac output should be treated first before removing excess fluid
• If patient does not fall into the characteristics above
• IV loop diuretic +/- IV vasodilator
TREATMENT: LOOP DIURETICS
Generic Name Brand Mechanism Dose Side Effects
Furosemide Lasix
Inhibits reabsorption of
sodium and chloride in the
loop of Henle and distal renal
tubule, causing increased
excretion of water
Initial: 20-40 mg/dose once
or twice daily based on
patient’s response.
Maximum of 200 mg/dose
Caution in patients
with sulfa allergy
Torsemide Demadex
Inhibits reabsorption of
sodium and chloride in the
loop of Henle and distal renal
tubule, causing increased
excretion of water
Initial: 10-20 mg; may
repeat every 2 hours with
double the dose as
needed.
Caution in patients
with sulfa allergy
Bumetanide Bumex
Inhibits reabsorption of
sodium and chloride in the
loop of Henle and distal renal
tubule, causing increased
excretion of water
Initial: 0.5-1 mg, may
repeat in 2-3 hours for up
to 2 doses max dose of 10
mg daily
Caution in patients
with sulfa allergy
TREATMENT: VASODILATORS
Generic Name Brand Mechanism Dose Side Effects
Nitroprusside Nipride Arterial and venous dilator
Initial dose 0.1–0.25
mcg/kg/min and titrate to
response
Hypotension,
headache,
tachycardia, cyanide
and thiocyanate
toxicity, myocardial
ischemia
Nitroglycerin Nitro-bid,
Nitrostat
Venous dilator and
arteriole dilator at higher
doses
Initial dose 5–10 mcg/min
and titrate to response
Hypotension,
headache,
tachycardia, tolerance
to hemodynamic
effects
Nesiritide Natrecor
B-type natriuretic peptide
that increases diuresis, as
well as an arterial and
venous dilator
Initially 2 mcg/kg bolus
followed by 0.01
mcg/kg/min infusion; can
increase to 0.03
mcg/kg/min
Hypotension,
headache when used
in combination with
diuretics
TREATMENT: INOTROPES
Generic Name Brand Mechanism Dose Side Effects/Notes
Dopamine Intropin
Dose-dependent agonist of
dopamine, beta, and alpha
1receptors
• 1-5 mcg/kg/minute, Increased
renal blood flow, urine output
• 5-10 mcg/kg/minute, Increased
cardiac contractility, cardiac
output
• >10 mcg/kg/minute, alpha
effects predominate:
vasoconstriction, increased
blood pressure, heart rate,
cardiac contractility, cardiac
output due to beta-adrenergic
effects.
Should be used only in
patients with marked
systemic hypotension or
cardiogenic shock
Dobutamine Dobutrex
Beta 1 and II receptor agonist and
weak alpha 1 agonist; increases
cardiac output and produces
vasodilation
2.5–20 mcg/kg/min
Not useful to increase
blood pressure in
hypotensive patients
Milrinone Primacor
Inhibits phosphodiesterase III,
resulting in positive inotropic and
vasodilating effects
0.125–0.75 mcg/kg/min
Useful for patients
receiving beta blockers
due to positive inotropic
effects are not mediated
by β-receptors;
MONITORING
• Fluid intake and output
• Vital signs, and body weight at the same time each day
• Signs and symptoms of hypoperfusion (hypotension, renal insufficiency) and
congestion (edema, ascites, rales)
• Serum electrolytes, BUN, serum creatinine daily
X
✔
✔
✔
X
CRITIQUE
Treatment
• Treatment was based on hemodynamic classification of warm and wet
• Patient given:
• Furosemide Inj (1 mg/mL) 120 mg @ 10 mL/hr IV Q 12 hrs
• Received twice daily for the entire length of stay (4 days)
• Carvedilol 3.125 mg po bid for the entire length of stay
CRITIQUE Assessment
• JF is a 72 y/o obese M with a PMH of CHF
• He is non-compliant with his medications and his chronic HF treatment is not
optimized, the combination of which likely led to the acute decompensation of his
HF
• Treatment for ADHF
• Treatment with furosemide was appropriate: administered and dosed correctly
• Chronic therapy was not optimized on presentation to the ED or at discharge
• Carvedilol dose was not optimized
• ACE inhibitor was not given due to “low blood pressure”
• Aldosterone blocker was not given
CRITIQUE
Plan
• Recommend increasing the dose of carvedilol to 6.25 mg twice daily and doubling the dose every
2 weeks as tolerated to a maximum dose of 50 mg twice daily
• Since an ACE inhibitor was not given due to “low blood pressure” - recommend discontinuing
terazosin due to bp lowering effect and duplicate therapy with tamsulosin
• Recommend initiation of an ACE inhibitor such as lisinopril at 2.5 mg once daily and titrating the
dose at 10 mg intervals every 2 weeks to a target dose of 40 mg daily
• Recommend initiation of an aldosterone antagonist: “recommended for patients with elevated
plasma natriuretic peptide levels and postmyocardial infarction patients with LVEF ≤40% who
develop HF symptoms or have a history of diabetes mellitus”
• Recommend spironolactone at 12.5 mg once daily and titrate to a maintenance dose of 50
mg once daily
REFERENCES
Rodgers JE, Reed BN. Chapter 5. Acute Decompensated Heart Failure. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG,
Posey L. eds. Pharmacotherapy: A Pathophysiologic Approach, 9e. New York, NY: McGraw-Hill; 2014.
http://accesspharmacy.mhmedical.com/content.aspx?bookid=689&Sectionid=48811454. Accessed December 15, 2015.
Parker RB. Heart Failure. In: Chyka P, Boucher B, Franks A, Waddell J. The APhA Complete Review for Pharmacy. 11th ed.
Washington, DC: American Pharmacists Association; 2015.
Furosemide. Lexicomp Online. Walters Kluwer. http://online.lexi.com.libaccess.fdu.edu/lco/action/doc/retrieve/docid/patch_f/6959.
Accessed December 16, 2015
Torsemide. Lexicomp Online. Walters Kluwer. http://online.lexi.com.libaccess.fdu.edu/lco/action/doc/retrieve/docid/patch_f/7792.
Accessed December 16, 2015.
Bumetanide. Lexicomp Online. Walters Kluwer. http://online.lexi.com.libaccess.fdu.edu/lco/action/doc/retrieve/docid/patch_f/6480.
Accessed December 16, 2015.
Carvedilol. Lexicomp Online. Walters Kluwer. http://online.lexi.com.libaccess.fdu.edu/lco/action/doc/retrieve/docid/patch_f/6545.
Accessed December 17, 2015.
Lisinopril. Lexicomp Online. Walters Kluwer.
http://online.lexi.com.libaccess.fdu.edu/lco/action/doc/retrieve/docid/patch_f/7185#f_dosages. Accessed December 17, 2015.
Spironolactone. Lexicomp Online. Walters Kluwer. http://online.lexi.com.libaccess.fdu.edu/lco/action/doc/retrieve/docid/patch_f/7699.
Accessed December 17, 2015.
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QUESTIONS?
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