Inpatient Heart Failure Inpatient Heart Failure
Management:
Management:
Risks & Benefits Risks & Benefits
Dr. Kenneth L. Baughman Dr. Kenneth L. Baughman
Professor of Medicine Professor of Medicine Harvard Medical School Harvard Medical School
Director, Advanced Heart Disease Section Director, Advanced Heart Disease Section
Brigham & Women's Hospital Brigham & Women's Hospital
Harvard
Medical School
Inpatient Heart Failure Management Inpatient Heart Failure Management
Most common DRG > 65 years old Most common DRG > 65 years old
Today Today ’ ’ s focus s focus
Exacerbation of established CHFExacerbation of established CHF
Not Not
New onsetNew onset
Acute ischemiaAcute ischemia
MechanicalMechanical
Inpatient Heart Failure Management Inpatient Heart Failure Management
Outline Outline
Indications for hospitalizationIndications for hospitalization
Etiology of exacerbationEtiology of exacerbation
Risk stratificationRisk stratification
Modifications of standard therapyModifications of standard therapy
Management of refractory CHFManagement of refractory CHF
IV diureticsIV diuretics
Indications for hemodynamic monitoringIndications for hemodynamic monitoring
Vasodilatos/InotropesVasodilatos/Inotropes
Mechanical Mechanical –– UF, VAD, IABPUF, VAD, IABP
Discharge planningDischarge planning
Inpatient Heart Failure Management Inpatient Heart Failure Management
Indications for hospitalization Indications for hospitalization
Congestion Congestion – – symptoms, weight gain symptoms, weight gain
Low output Low output – – mentation mentation , renal perfusion , renal perfusion
Arrhythmia Arrhythmia
Co Co - - morbid conditions morbid conditions
Electrolyte abnormalities Electrolyte abnormalities
Inpatient Heart Failure Management Inpatient Heart Failure Management
Etiology of exacerbation Etiology of exacerbation
Noncompliance Noncompliance
Cardiac deterioration Cardiac deterioration
Toxins Toxins – – alcohol, medications alcohol, medications
Non cardiac Non cardiac
ThyroidThyroid
InfectionInfection
PulmonaryPulmonary
Inpatient Heart Failure Management Inpatient Heart Failure Management
Risk stratification Risk stratification
Fonarow
Fonarow GC, JAMA 2005; 293: 572GC, JAMA 2005; 293: 572
Inpatient Heart Failure Management Inpatient Heart Failure Management
Decomposition categories Decomposition categories
Congestion & output Congestion & output
Nohria A, Stevenson L, Nohria A, Stevenson L,
Wet & warm Wet & warm Dry & warm
Dry & warm
Wet & cold Wet & cold Dry & cold
Dry & cold
Inpatient Heart Failure Management Inpatient Heart Failure Management
Standard management Standard management
NaCl NaCl limitation (2 grams) limitation (2 grams)
Fluid restrict (2 liters) Fluid restrict (2 liters)
Oxygen Oxygen
Diuretics Diuretics
Vasodilators Vasodilators
Beta blockers Beta blockers
Inpatient Heart Failure Management Inpatient Heart Failure Management
Diuretics Diuretics
Intravenous Intravenous
Dose IV = 2x oral (except torsemideDose IV = 2x oral (except torsemide))
LasixLasix 40 IV = 80 orally40 IV = 80 orally
Frequency Frequency –– 22--3x/day bolus 3x/day bolus
Continuous infusionContinuous infusion
“ “ Stacking Stacking ” ”
Inpatient Heart Failure Management Inpatient Heart Failure Management
Continuous infusion vs. bolus Continuous infusion vs. bolus
Cochrane Database 2004: (1): CD003178 Cochrane Database 2004: (1): CD003178
RR 0.52 RR 0.52 Decreased mortality
Decreased mortality
p < 0.001 p < 0.001 Decreased LOS
Decreased LOS
p 0.005 p 0.005 Decreased
Decreased ototoxicityototoxicity
p 0.50 p 0.50 Decreased electrolyte toxicity
Decreased electrolyte toxicity
p < 0.01 p < 0.01 Stable effect
Stable effect –– volume & volume & diuresisdiuresis
Cochrane analysis Cochrane analysis Advantages
Advantages
Inpatient Heart Failure Management Inpatient Heart Failure Management
1.1. LoopLoop
2.2. Late distalLate distal
3.3. Early distalEarly distal
4.4. Proximal (toxicity)Proximal (toxicity)
amiloride amiloride torsemide
torsemide
triamterene triamterene ethacrynic
ethacrynic acidacid
eplerenon eplerenon metolazone
metolazone bumetinide
bumetinide
spironolactone spironolactone thiazide
thiazide furosemide
furosemide acetazolamide
acetazolamide
Late distal Late distal Early distal
Early distal LoopLoop
Proximal Proximal
Inpatient Heart Failure Management Inpatient Heart Failure Management
Standard therapy modifications Standard therapy modifications
DiureticsDiuretics
Efficacy Efficacy –– symptoms, congestionsymptoms, congestion
Toxicity Toxicity –– systemic under perfusion (renal), electrolytessystemic under perfusion (renal), electrolytes
BNP vs. clinically guidedBNP vs. clinically guided
VasodilatorsVasodilators
Maximize when “Maximize when “drydry””
Beta blockersBeta blockers
Continue if possibleContinue if possible
Reduce doseReduce dose
Stop if sympathomimeticStop if sympathomimetic usedused
Inpatient Heart Failure Management Inpatient Heart Failure Management
Predischarge initiations of beta blockers in patients Predischarge initiations of beta blockers in patients
hospitalized for decompensated heart failure hospitalized for decompensated heart failure
Gattis WA JACC 2004; 43: 1534 Gattis WA JACC 2004; 43: 1534
Inpatient Heart Failure Management Inpatient Heart Failure Management
Refractory CHF
Refractory CHF – – Phase I Phase I
IV TNGIV TNG
Nesiritide (BNP)Nesiritide (BNP)
MilrinoneMilrinone
Dopamine/Dopamine/dobutaminedobutamine
Inpatient Heart Failure Management Inpatient Heart Failure Management
Nesiritide in ADHF Nesiritide in ADHF
Colucci
Colucci WS NEJM 2000; 343: 246WS NEJM 2000; 343: 246
127 patients127 patients
Hemodynamic Hemodynamic monitoring
monitoring
RandomizedRandomized
PlaceboPlacebo
0.015 mcg/kg 0.015 mcg/kg
NesiritideNesiritide
0.030 mcg/kg 0.030 mcg/kg
Six hour infusionSix hour infusion
5%5%
38%38%
Fatigue Fatigue
12%12%
53%53%
Dyspnea Dyspnea
+ 14%
+ 14%
+ 67%
+ 67%
Global clinical Global clinical
+ 2%+ 2%
10%10%
PCWP (mmHg) PCWP (mmHg)
Placebo Placebo BNPBNP
Inpatient Heart Failure Management Inpatient Heart Failure Management
Short term risk of death after treatment with Short term risk of death after treatment with
Nesiritide for DHF Nesiritide for DHF
Sackner
Sackner--Bernstein JD JAMA 2005; 293: 1600Bernstein JD JAMA 2005; 293: 1600
Inpatient Heart Failure Management Inpatient Heart Failure Management
Risk of worsening renal function with Nesiritide in Risk of worsening renal function with Nesiritide in
patients with ADHF patients with ADHF
Sackner
Sackner--Bernstein JD Circulation 2005; 111: 1487Bernstein JD Circulation 2005; 111: 1487
Inpatient Heart Failure Management Inpatient Heart Failure Management
Safety and feasibility of using serial infusions of Safety and feasibility of using serial infusions of
Nesiritide for CHF in outpatients Nesiritide for CHF in outpatients
Yancy
Yancy CA AJC 2004; 94: 595CA AJC 2004; 94: 595
210 patients210 patients
CreatineCreatine 1.81.8
EF 28%EF 28%
Randomized to weeklyRandomized to weekly
PlaceboPlacebo
0.005 mcg/kg 0.005 mcg/kg
NesiritideNesiritide
0.010 mcg/kg 0.010 mcg/kg
Outcomes Outcomes –– NSNS
Significant adverse Significant adverse events
events –– NSNS
Higher risk Higher risk -- eventsevents
Inpatient Heart Failure Management Inpatient Heart Failure Management
Effect of Nesiritide vs. Dobutamine on short term Effect of Nesiritide vs. Dobutamine on short term
outcomes in treatment of patients with ADHF outcomes in treatment of patients with ADHF
Silver MA JACC 2002; 39: 798 Silver MA JACC 2002; 39: 798
Inpatient Heart Failure Management Inpatient Heart Failure Management
Milrinone Milrinone
PhosphodisterasePhosphodisterase inhibitorinhibitor
VasodilatorVasodilator
InotropeInotrope
DoseDose
Load 50mcg/kgLoad 50mcg/kg
Drip 0.375 Drip 0.375 –– 0.750 mcg/kg/min0.750 mcg/kg/min
Inpatient Heart Failure Management Inpatient Heart Failure Management
Short term intravenous milrinone for acute Short term intravenous milrinone for acute
exacerbation of chronic heart failure exacerbation of chronic heart failure
Cuffe
Cuffe MS JAMA 2002; 287: 1541MS JAMA 2002; 287: 1541
Inpatient Heart Failure Management Inpatient Heart Failure Management
Dopamine Dobutamine Dopamine Dobutamine
General General
SympathomimeticsSympathomimetics –– betabeta11 > beta> beta22 > alpha> alpha
InotropesInotropes
Increase cardiac output, mild resistanceIncrease cardiac output, mild resistance
Toxicity dose dependentToxicity dose dependent
Specific Specific
Dopamine Dopamine –– renal vascular effectsrenal vascular effects
Dobutamine Dobutamine -- eosinophiliaeosinophilia
Inpatient Heart Failure Management Inpatient Heart Failure Management
MechanicalMechanical
UltrafiltrationUltrafiltration
Biventricular pacingBiventricular pacing
IABPIABP
Left ventricular assistLeft ventricular assist
ReplacementReplacement
Heart transplantHeart transplant
End stage 10%
End stage 10%
Advanced 20%
Advanced 20%
Standard 70%
Standard 70%
Inpatient Heart Failure Management Inpatient Heart Failure Management
Indications for hemodynamic monitoring Indications for hemodynamic monitoring
Refractory CHF Refractory CHF
Volume status unknown Volume status unknown
Use of any Use of any vasoactive vasoactive agent agent
Hypotension (with or without renal Hypotension (with or without renal insufficiency)
insufficiency)
Inpatient Heart Failure Management Inpatient Heart Failure Management
Patients with heart failure Patients with heart failure 60 60 - - 90 day mortality 8.6% 90 day mortality 8.6%
60 60 - - 90 day rehospitalization 29.6% 90 day rehospitalization 29.6%
Mortality Mortality
AgeAge
CreatinineCreatinine
Lung diseaseLung disease
Liver diseaseLiver disease
Low BPLow BP
Low NaLow Na
Lower wtLower wt
DepressionDepression
Readmission & death Readmission & death
CreatinineCreatinine
BP (systolic)BP (systolic)
HemoglobinHemoglobin
Lung diseaseLung disease
Inpatient Heart Failure Management Inpatient Heart Failure Management
Refractory Heart Failure Refractory Heart Failure
All therapies beyond standard treatment All therapies beyond standard treatment
increase mortality
increase mortality
Inpatient Heart Failure Management Inpatient Heart Failure Management
Discharge planning Discharge planning
Stable weight & electrolytes 24Stable weight & electrolytes 24--48 hours48 hours
Off inotropes Off inotropes –– 2424--48 hours48 hours
Off IV diuretics Off IV diuretics –– 2424--48 hours48 hours
Stable oral regimen 24 hoursStable oral regimen 24 hours
Exacerbating etiology correctedExacerbating etiology corrected
Patient and family educationPatient and family education
Early followEarly follow--upup
Disease managementDisease management
Inpatient Heart Failure Management Inpatient Heart Failure Management
Outline Outline
Indications for hospitalizationIndications for hospitalization
Etiology of exacerbationEtiology of exacerbation
Risk stratificationRisk stratification
Modifications of standard therapyModifications of standard therapy
Management of refractory CHFManagement of refractory CHF
IV diureticsIV diuretics
Indications for hemodynamic monitoringIndications for hemodynamic monitoring
Vasodilatos/InotropesVasodilatos/Inotropes
Mechanical Mechanical –– UF, VAD, IABPUF, VAD, IABP
Discharge planningDischarge planning