HFrEF exacerbation (Assessment and Plan)
Author: William J Gibson MD, PhD
History of HFrEF (last TTE XX;LVEF XX%) secondary to XX [ischemia,non-ischemic dilated cardiomyopathy, non-ischemic restrictive cardiomyopathy] . Current exacerbation most likely precipitated by [medication/dietary non-compliance(40%)]. Possible other etiologies (although less likely): ischemia/infarction(15%), HTN, renal failure -> inc. preload, drugs/toxins (eg etoh), new structural/valvular pathology, no history COPD, low suspicion for PE. [Dry/wet] and [warm/cold] on exam. Weight on admission XX lb ; dry weight reportedly XX lb.
Dx:
- EKG, trend troponins, CXR
- tele; strict I/O; cardiac diet (2L fluid, 2g Na); daily weights
- BID BMP/Mg
- TTE (always if first presentation, repeat if concern for new structural/functional changes)
- If new: perform ischemic workup (stress test, cath), if no evidence of ischemia on TEE: A1c, lipid panel, TSH, iron studies, SPEP, ANA, consider MRI.
Tx:
Contractility:
Preload: IV lasix BID or PO torsemide BID or Bumex drip (0-2 mg/hr). If diuresis inadequate with these agents can give metolazone 30 min before loop diuretic.
Afterload: captopril Q8H (titrate quickly and then convert to lisinopril), or . ACE first line as mortality benefit in all. Isordil/hydralazine has mortality benefit in blacks.
Neurohormonal blockade: Continue home [spironolactone/eplerenone]. Spironolactone and eplerenone inhibit aldosterone and decrease mortality in randomized trials (RALES trial; EMPHASIS-HF trial). Hold if AKI.
References:
Jondeau G, Neuder Y, Eicher JC, et al. B-CONVINCED: Beta-blocker CONtinuation Vs. INterruption in patients with Congestive heart failure hospitalizED for a decompensation episode. Eur Heart J. 2009;30(18):2186-92.
RALES trial: Pitt B, Zannad F, Remme WJ, et al. The effect of spironolactone on morbidity and mortality in patients with severe heart failure. Randomized Aldactone Evaluation Study Investigators. N Engl J Med. 1999;341(10):709-17.
EMPHASIS-HF trial: Zannad F, Mcmurray JJ, Krum H, et al. Eplerenone in patients with systolic heart failure and mild symptoms. N Engl J Med. 2011;364(1):11-21.