Management in patients with Acute Decompensated Heart Failure
Acute Decompensated Heart Failure
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Transcript of Acute Decompensated Heart Failure
Acute Decompensated Heart Failure
Acute Decompensated Heart Failure(ADHF)- Inpatient ManagementJennifer Kumar
February 2014
ObjectivesLearn to identify the signs and symptoms of ADHF
Learn to interpret pertinent laboratory data and imaging
Learn the inpatient management of ADHF Clinical Vignette Clinical Vignette62 year old Caucasian male with PMH of ischemic cardiomyopathy (EF 25%), CAD, HTN presents with two week history of dyspnea
Previously able to walk 2 miles, currently cannot walk more than 10 feet before developing DOE
PND 3 times per night
4 pillow orthopnea
Increasing lower extremity edema
ROS: loss of energy, loss of appetite, 10# weight gainClinical VignettePMH: ischemic cardiomyopathy (EF 25%, based on echocardiogram 6 months prior), CAD (s/p MI with PCI in 2002), HTN
Home medications: ASA 81mg daily, Lisinopril 5mg daily, Lasix 40mg daily
Allergies: NKDA
ROS: denies CP, denies dizziness, denies palpitations
Clinical VignetteVS: Temp 36.5, HR 90, BP 108/72, RR 20, SpaO2 91% on RAPertinent physical exam: General: appears uncomfortable, able to speak short sentencesHEENT: Jugular venous distension at 10cmCVS: PMI displaced laterally to mid-axillary line in the 6th ICS, (-) heaves, thrills, RRR, (+) S3, (-)S4, (-) murmurs or rubsChest: loss of tactile fremitus at the base with dullness to percussion, (+) rales throughout bottom half of lung fields bilaterallyAbdomen: distended, (+) mild fluid wave, (+) hepatojugular reflux,Extremities: 2+ pitting edema up to knees bilaterally, cool to touch, 2+ DP and PT pulses To assess JVP: Patient reclining with head elevated 45 Measure elevation of neck veins above the sternal angle Add 5 cm to measurement since right atrium is 5 cm below the sternal angle.- Normal CVP 400 suggestive of HF exacerbationHowever may be falsely elevated in: Renal disease, atrial fibrillation, pulmonary HTNMay be falsely low in:Obese patients, HFPEF
Toxicology screenIn select patients, as drug abuse can trigger exacerbation
TSHUntreated thyroid disease can precipitate exacerbation
Clinical VignetteAt this point, what imaging should be obtained to further assist with management?
Imaging: EKGImportant to look for underlying IschemiaArrhythmias
Imaging: Chest x-rayEnlarged cardiac silhouette
Pulmonary edema
Pulmonary congestionCephalizationKerley B linesPeri-bronchial cuffing
Pleural effusions, typically bilateral
Clinical VignetteShould an echocardiogram be repeated? Imaging: EchoTypically repeated no sooner than annually
Provides information regarding;Ejection fractionDiastolic dysfunctionWall motion abnormalitiesChamber sizesPulmonary HTNVentricular dysynchrony
Clinical VignetteHow should we begin our inpatient management? Non-pharmacologic ManagementDaily weight
Strict Is and Os
Low sodium diet (