Inpatient Management of

Heart Failure
Mini-Lecture

Objectives
-Learn how to assess jugular venous distension
(JVD) to aid in assessment of acute
decompensated heart failure (ADHF)
-Interpret BNP in the setting of ADHF
-Understand treatment options based on
clinical presentation
-Perform effective inpatient monitoring
-Conduct a successful discharge
-Know the natural history of HF

Jugular Venous Distension

JVD: Indication of volume overload,
especially on the right side of the heart

BNP
BNP
<100 high negative predictive value
>400 consistent with HF
A.fib, chronic HF, pulmonary HTN, renal
failure higher at baseline, so use higher cutoff for dx of ADHF
Lower in obese people at baseline, so use
lower cut-off for dx of ADHF

Treatment: Who needs What?

Hom
e WARM AND WET Floor
Congested

CARDIAC OUTPUT

WARM AND DRY

Compensated

Optimize oral therapy

Diuretics

Outpatient

ED or Inpatient

COLD AND DRY ICU COLD AND WET

Low Flow State

Decompensated

Inotropes, vasodilators, ?IABP

Diuretics, vasodilators,
inotropes

ICU

ICU

ICU

PULMONARY CAPILLARY WEDGE PRESSURE

Adapted from Nohria,J Cardiac Failure

Treatment: General Medicine Floor

Loop Diuretics
Administration: IV 20 -200 mg two or more times per day
Comments: Monitor for excess diuresis, electrolyte abnormalities. For those already on
home lasix, give their usual oral dose in IV form, which is essentially a doubling of their
home dose.

ACE-I
Mechanism: Acute reduction in preload and afterload
Administration: Orally or IV. Escalate dose as BP tolerates.
Comments: Continue/start even in mild to moderate renal failure without hyperkalemia as
renal failure will likely resolve with increased perfusion.

Positive Pressure Ventilation

Mechanism: Alveolar recruitment and reducing preload and afterload.
Administration: CPAP or BIPAP
Comments: Hypoxic patients.

Beta-blockers
Continue for patients already taking BB UNLESS hypotension, hypoperfusion.
For patients not taking BB, withhold during early management, but initiate prior to
discharge.

Aldosterone antagonists
Continue for patients already taking aldosterone antagonist.
For patients not taking an aldosterone antagonist who have an indication for therapy,
initiate prior to discharge.

Treatment: ICU
Nitrates
Mechanism: Acute decrease in filling pressure. At higher
doses, arteriodilator.
Administration: as drip in the ICU
Comments: Oral and patch possible, but less efficacious
and more difficult to titrate.

Inotropes
Mechanism: Stimulation of the B1 adreoceptors of
the heart, increasing contractility and cardiac
output
Administration: as drip in ICU
Comments: Contraindicated in ischemic heart disease
b/c increases oxygen demand. Use cautiously with a.fib.

Inpatient Monitoring
At least daily
Weight
Intake and output
Symptoms and exam
Renal function and electrolytes

More frequently
Vital signs

Disposition Planning
Your patient is ready for dispo when
Near optimal volume status achieved
Transition from IV to oral medications for at
least 24 hours

Disposition: Case Example

Mr. Jones: 64 yo AA male admitted for ADHF secondary to dietary

noncompliance.
Medical history significant for HF due to ischemic heart disease
and CKD 2/2 chronic hypertension.
He is ready for discharge and back to his baselineSOB with
minimal activity, but not at rest.
His home medication regimen includes

carvedilol 12.5 mg BID

lisinopril 40 mg daily
ASA 81 mg daily
lasix 40 mg BID

BP 115/70, HR 65, dry weight 200 lbs.

PE: trace edema, JVD of 9 cm, and lungs are CTAB.
Labs: BUN of 17, Creatinine 1.8, and Potassium of 4.6.
Discharge EF is 35%.
Appointment to see his PCP in three days.

Disposition Planning: New

Guidelines

Left ventricular Ejection Fraction

Beta-blocker therapy
ACE or ARB
Postdischarge appointment
Symptom and activity assessment and
advice on symptom management.
Patient self-care education.
Counseling about implantable cardioverter
defibrillators (ICDs)

Disposition: Lingering Questions

Who needs hydralazine and nitrates?

Who needs spironolactone?
Who needs an ICD?
Who needs a pacemaker?

Disposition: Case Example

Mr. Jones: 64 yo AA male admitted for ADHF secondary to dietary

noncompliance.
Medical history significant for HF due to ischemic heart disease and CKD
2/2 chronic hypertension.
He is ready for discharge and back to his baselineSOB with minimal
activity, but not at rest.
His home medication regimen includes

carvedilol 12.5 mg BID

lisinopril 40 mg daily
ASA 81 mg daily
lasix 40 mg BID

Labs: BUN of 17, Creatinine 1.8, and Potassium of 4.6.

Discharge EF is 35%.
Appointment to see his PCP in three days.
1. Is Mr. Jones on appropriate medications? Do any medications need to be added to
Mr. Jones regimen?
2. What important discharge guidelines have been met already?
3. What important discharge guidelines need to be met before he is ready to go home?

Prognosis

Final Clinical Pearls

Use physical exam (JVD) and
ancillary tests(BNP) to assess ADHF
Tailor treatment based on clinical
presentation.
Follow guidelines when planning for
disposition
HF is a waxing and waning disease
that is ultimately fatal

References
-American College of Cardiology Foundation (ACCF) American Heart Association (AHA)
Physician Consortium for Performance Improvement (PCPITM) Heart Failure
Performance Measurement Set 2012
-Jain P, et al; Am Heart J 2003; 145: S3-17
-Allen LA, OConner CM; CMAJ 2007: 176 (6): 797-800
-Treatment of acute decompensated heart failure: Components of therapy in UpToDate.
Wilson S Colucci, MD. Literature review current through: Apr 2012. | This topic last
updated: Jan 26, 2012.
-Seo,R Kam,L F Hsu Treatment of Heart Failure Role of Biventricular Pacing for Heart
Failure. SingaporeMedJ2003Vol44(3):114-122