Initial workup
Hx, PE, ECG, CXR, B/W (lytes, Cr, CBC, +/- Trop/BNP)
- Unlikely to be AHF – consider other Dx
- Uncertain – Test BNP
- BNP <100 – consider other Dx
- BNP100-500 – consider use of AHF score, eg PRIDE
- BNP >500 – likely AHF – Tx
- Likely AHF – Tx
Consider Admission if
- NYHA3/4 with min improvement
- New dx of CHF
- Uncertain f/u
- O2<91%, SBP<90-100mmHg, HR>90bpm, RR>20
- ECG – ischemia, ventricular or atrial arrhythmia not under control
- Worsening renal function or comorbid conditions req Adm – syncope or pneumonia
Tx Goals
- Find etiology & precipitating factors
- Alleviate presenting symptoms
- Optimize meds
- Pt education & transition of care plan
- First 24 hr
- IV/PO diuretic
- +/- IV vasodilator, inotrope
- continue in the absence of c/i: ACEI/ARB, MRA, BB
- During Hospitalization
- IV/PO diuretic + ACEI/ARB
- +/- IV vasodilator, inotrope, MRA
- Continue in the absence of c/i: ARB, BB, Statin, Antiplatelet agents
- At discharge
- IV/PO diuretic, ACEI/ARB, BB
- +/- MRA, Statin, Antiplatelet, CRT, ICD
- Long-term f/u
- IV/PO diuretic, ARB/ACEI, BB
- +/- hydralazine/nitrate, statin, antiplatelet, revascularization
Diuretic Dosing
- eGFR>=60
- New CHF – Furosemide 20-40mg IV 2-3 times daily
- Established CHF – Furosemide bolus IV equivalent to po dose
- eGFR <60
- New CHF – Furosemide 20-80mg IV 2-3 times daily
- Established CHF – Furosemide bolus IV equivalent to oral dose
- Maintenance dose: lowest dose that allows for clinical stability
Suboptimal Response to diuretics
- Additional diuresis by on vol status – higher bolus more effective than freq lower doses
- Restrict salt and water
- Add another type of diuretic: thiazide (Metolazone 2.5-5mg ob/bid or HCZ 25-50mg) 30min before lasix, or spironolactone
- Positive inotropic agents if poor perfusion coexists with diuretic resistance
- HD if diuresis impeded by renal insufficiency
Assess progress
- Symptoms: Dyspnea,orthopnea, PND, overall well-being, fatigue
- Clinical findings: BP, RR, HR, O2 Sat, JVP, S3, rales, lower extremity edema
- Lab: Wt & net fluid balance, BUN, Cr, K+, Na+ BNP, Hgb
Criteria for discharge
- Presenting symptoms resolved
- VS stable (BP & HR) + Wt returned to “dry wt” & stable >24hr
- Inter-current cardiac and non-cardiac illness adequately dx and tx
- Chronic oral HF Tx initiated, titrated, optimized
- Pt education, d/c plan (labs, appt), primary care provider communication
- O2 Sat >=92%
- Consider O2 to inc FiO2, CPAP/BiPAP, Mechanical intubation
- Vol Overload
- IV Lasix 20-80mg bolus or infusion 5-20mg/hr
- SBP<90 / MAP <60mmHg
- Dopamine or vasopressor or Dobutamine
- SBP 90-100 / MAP 60-65 mmHg
- If low cardiac output – dobutamine or milrinone
- SBP >100 / MAP >65 mmHg
- add nitroglycerin IV/SL, nesiritide IV, nitroprusside IV
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