26.11.2019.

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Sarinya Puwanant, MD, FASE

Medical Director Heart Failure and Transplant Cardiology King Chulalongkorn Memorial Hospital

MANAGEMENT OF ACUTE HEART FAILURE

C h u l a l o n g k o r n

HEART FAILURE & TRANSPLANT CARDIOLOGY

Case 58 Y/O M Ischemic CM, HFrEF; EF = 28%

58 year-old male with a h/o

HFrEF, LVEF =28%

CAD, S/P PCI with stent of RCA & LAD 3 yrs

LV thrombus

S/P CRTD removal 1 yr -Infected

March 2019 HF hospitalization

April 2019 NYHA I-II

July 2019 NYHA II; 6MW=392 m

Sept 2019- 2kgs↑, NYHA II

28 Oct 2019 ER visit due to AHF

Since then NYHA class III-IV, PND, 6kgs↑,

No angina

Medication

Furosemide (40) 2 bid

Enalapril (5) 2.5 bid

Spironolactone (25) 0.5 OD

Carvedilol (6.25) 1 bid

Warfarin (3) 0.5 OD

ASA 81 OD

Atorvastatin (40) OD

Addi K (750) 1 tid

26.11.2019.

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Case 58 Y/O M Ischemic CM, HFrEF; EF= 28%

BP 85/59 mmHg, HR 69/min regular, RR 28 - dyspnea, warm to touch, conscious.

O2 Sat 99% room air

BW 85 kgs

JVD ear lobe

Shifted LV apical beat to the left. S3+

Lungs minimal creptation BLL

Liver just palpable

No edema

ECG sinus tachycardia Flat T in most leads

LAB Nov

2019

April

2019

BUN 16 13

Cr 1.41 1.2

Na 139 138

K 3.8 3.6

Cl 109 102

Co2 26 25

INR 2.31 2.1

LDL 60

Hb 12

THAI HF Guidelines 2019

Cardiogenic shock or respiratory failure ?

Y

Specific cause Y

Consider ECG, labs, CXR, echocardiogram, lung ultrasound Then specific treatment

Evaluate for congestion and perfusion status

MAP > 65

MAP < 65

Discharge planning

Invasive monitoring, MCS

Improve

Y N

CONGESTION

PE

RF

US

ION

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Stepped care pharmacological approach

GOAL: Urine volume of 3 to 5 liters/day until clinical euvolemia

Initial approach –IV 2.5x previous PO furosemide dose (bid)

or alternatively the infusion approach

Not achieve UOP 3-5 L/day next level move

N Engl J Med 2017;377:1964-75

40mg/hr

How often ? • Depending upon patients' Status • Not that sick: 1 -2 hrs (spot urine Na) , 6 hrs, every shift-q 24 hrs

Diuretic Strategies in Patients with Acute Decompensated Heart Failure (DOSE TRIAL)

N Engl J Med 2011;364:797-805

N=306 , allow dose adjustment after 48 hrs 1 EP:= 72 hr Global VAS and Cr; 2 EP= 72 –hr (BW, fluid loss, SOB) favorable in high dose

2.5 x PO dose

1 x PO dose

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Decongestion 2.5x (lasix (40) 2x2) = 2.5x 160 mg= 400 mg IV lasix

80 mg IV bolus then 20 mg per hr (400 mg/24 hr= 17 mg/hr)

Target 3-5 L/day = 5 L/24 = 200 ml/hr

2 hrs 6 hrs

(22:00)

8 hr

(6:00)

URINE/hr No record 1200/6 hrs

(~200ml/hr)

1800/8 h

(~225 ml/hr)

TOTAL URINE

Accumulative No record 1200 2000 ml

BW (kgs) 85 84

S and S PND, Upright

RR =30

JVD –jaw

BP 85/59

PND, 5 pillows

RR =28

JVD –jaw

BP 87/55

BUN/Cr 16/.1.4 22/1.8

K 3.8 3.8

DIURETICS Lasix 20

mg/hr

Lasix 30

mg/hr Off lasix Lasix 30

mg/h

Lasix 10

mg/h

Lasix 125

mg IV bid

Lasix 80 mg

PO bid

24 hr

(6:00)

DAY 2 DAY 3

5500 ml 2800 ml 2500

81.5 79 77

JVD 10 cm

PND,15 ° bed

RR 25 cramp

BO 90/60

JVD 5 cm ,

flat, PND x1

BP 94/56

No JVD

No PND

BP 101/60

21/1.4 18/1.3 17/1.2

4.0 4.1 3.9

(~200-300

ml/hr)

WHAT IS NEXT?

CARDIORENAL SYNDROME

Plasma Norepinephrine

Nore

pin

ephri

ne (

ng/m

L)

0

900

800

700

600

Time

C 10' 20' 1'h 2'h

Plasma Renin Activity

Renin

Activi

ty (

ng ·

mL

-1 ·

h-1

)

0

16

12

10

8

Time

C 10' 20' 1'h 2'h

18

14

Plasma AVP

Arg

inin

e V

asopre

ssin

(pg/m

L)

0

10

8

7

5

Time

C 10' 30' 1'h 2'h

9

6

* *

* *

*

* *

*

* *

*

*

J A C C : H E A R T F A I L U R E V O L . 3 , N O . 2 , 2 0 1 5

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CARDIORENAL SYNDROME

J Am Coll Cardiol. 2009 February 17; 53(7): 589–596 Am Heart J 2018;204:163-73

J Am Coll Cardiol. 2009 February 17; 53(7): 589–596

THAI HF Guidelines 2019

Cardiogenic shock or respiratory failure ?

Y

Specific cause Y

Consider ECG, labs, CXR, echocardiogram, lung ultrasound Then specific treatment

Evaluate for congestion and perfusion status

MAP > 65

MAP < 65

Discharge planning

Invasive monitoring, MCS

Improve

Y N

CONGESTION

PE

RF

US

ION

26.11.2019.

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Second agents: Diuretics for symptomatic relief

Nat Rev Cardiol 2015;12:184–192.

C h u l a l o n g k o r n

HEART FAILURE & TRANSPLANT CARDIOLOGY

6. Tolvaptan (Aquaretics) • Vasopressin antagonist

Vasodilator Inotrope - NA

2 hrs 6 hrs

(22:00)

8 hr

(6:00)

URINE/hr No record 1200/6 hrs

(~200ml/hr)

1800/8 h

(~225 ml/hr)

TOTAL URINE

Accumulative No record 1200 2000 ml

BW (kgs) 85 84

S and S PND, Upright

RR =30

JVD –jaw

BP 85/59

(67)

PND,5 pillows

RR =28

JVD –jaw

BP 87/55

(66)

BUN/Cr 16/.1.4 22/1.8

K 3.8 3.8

DIURETICS Lasix 20

mg/hr

Lasix 30

mg/hr Lasix 10

mg/h

Lasix 30

mg/h

(~200-300

ml/hr)

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THAI HF Guidelines 2019

Y

Y

MAP > 65

MAP < 65

Y N

Discharge Planning • Life saving med • Multidisciplinary care • Make sure precipitating

cause has been fixed

Burden and Significance of Incomplete DECONGESTION in Acute HF DOSE-AHF and CARESS-HF ANALYSIS in 496 PATIENTS

16%

32% 52%

High Grade Orthodema

Low Grade Orthodema

No Orthodema

Congestion Status at Discharge

Points

Orthopnea >=2 pillows 2

<2 pillows 0

Edema

trace 0

Moderate 1

Severe 2

Score 3-4

Score 1-2

Score =0

P=0.038

Circ Heart Fail. 2015;8:741-748.

C h u l a l o n g k o r n

HEART FAILURE & TRANSPLANT CARDIOLOGY

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Hemodynamic congestion precedes clinical congestion by days and weeks and can persist after relief of symptoms

C h u l a l o n g k o r n

HEART FAILURE & TRANSPLANT CARDIOLOGY

Diuresis

RA 15

PCWP 30

RA 8

PCWP 20

RV 45/15

LV 110/30

• I feel better • I want to go home

AT REST exertion

RA 10

PCWP 25-28

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Challenges in decongestion in AHF

Clinical congestion ≠ hemodynamic congestion

Extremely difficult decongestion marker-spectrum>binary

Redistribution vs. volume overload

CRS

Recommendation of guidelines : B-C level of evidences

C h u l a l o n g k o r n

HEART FAILURE & TRANSPLANT CARDIOLOGY

Conclusions

Optimal management of acute HF is challenging.

Congestion is the main reason for HF admissions and readmission

Hemodynamic congestion is often difficult to recognize, delaying appropriate intervention.

Congestion may contribute to progression of HF and main obstacle for OMT.

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THANK YOU