Acute Decompensated Heart Failure

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Acute Decompensated Heart Failure

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Acute decompensated heart failure
-DDx includes: COPD exacerbation vs ARDS vs PE.
-CHF due to orthopnea, increasing body weight, elevated BNP, lower extremity edema, hx of CHF, S3 gallop, bedside echo. CTA: negative for PE. 
-Precipitants of decompensation due to missed medications vs increased dietary sodium intake/alcohol, infarction/ischemia vs progressing renal failure vs pulmonary embolism.
-Patient’s baseline function is: NYHA class Xxxxx; Last echo with an EF of Xxxx%.
-Follow-up CXR, ECG, Echo, CMP, Mg, Phos, BNP, cardiac enzymes. If concerned for PE, will get CTA with contrast.
-Admit to telemetry; cardiac monitor.
–Start IV Lasix. Monitor UOP and renal function. Will start at 2.5xconverted usual daily dose to increase UOP; however, expect a transient increase in renal dysfunction.
–Nitroglycerin as needed, if requiring nitroprusside will monitor for cyanide toxicity.
–If in cardiogenic shock will consider adding dobutamine or milrinone.
–Oxygen support including Intermittent Bipap and CPAP. Will consider early intubation if NIV fails.
-Duonebs as needed.
–Strict I/Os and daily weight checks.
–Low sodium diet & fluid restriction < 2L/day.
-May benefit from coronary revascularization due to history of angina and may need implantable cardiac defibrillator placement. Discuss with cardiology.
-F/u BNP, cardiac enzymes, TSH, CBC, CMP, TSH, CXR, TTE.
–Patient is on ACE/ARB: hold if hypotensive. Consider changing to hydralazine & nitrates if renal decompensation occurs. 
–Beta blockers: reduce dose by at least 1/2 if mod HF, d/c if severe HF and/or need inotropes.
-Will need education upon discharge for lifestyle modifications including smoking cessation, restriction of alcohol consumption, salt restriction, weight reduction in this obese patient, as well as daily weight monitoring.
-Consult “Heart Failure Nurse specialist”, to decrease readmission. 
–Will initiate core measure to reduce CHF re-admission if EF <35%: including Metoprolol Succinate / Carvedilol, ACEI, Spironolactone, implantable defibrillator as well as consulting heart failure nurse specialist for post discharge close monitoring. 
-Schedule appointment  f/u in “heart failure clinic” within 7 days for Cardiac Rehabilitation.