Dr. Michelle Kittleson shares insights on managing acute decompensated heart failure, discussing jugular venous pressure exams, diuresis, and hospital discharge. Other topics include book recommendations, evaluation and diagnosis of heart failure, diuretic dosing, and interventions in heart failure prevention.
Adjust diuretic therapy based on response and electrolyte monitoring.
Tailor diuresis approach based on heart failure subtype (HFrEF vs. HFpEF).
Consider advanced treatment options if diuretic therapy alone is insufficient.
Deep dives
Management Approach: Loop Diuretics
The initial approach to diuresis in patients with heart failure involves the use of loop diuretics, such as furosemide or bumetanide, administered intravenously. Furosemide is often the preferred choice due to its cost-effectiveness. The dose should be tailored to the individual patient, starting with two to two and a half times the outpatient dose. Aggressive diuresis is recommended, aiming for a minimum of two liters negative balance per day. The response to diuretics should be assessed early, and if the desired diuresis is not achieved, a switch to a furosemide drip may be considered to maintain the desired response.
Monitoring and Adjusting Diuresis
Monitoring electrolytes, such as sodium, potassium, and creatinine, is crucial when initiating and adjusting diuretic therapy. Daily measurements of these electrolytes are recommended to guide the management of fluid and electrolyte balance. Aggressive diuresis should be balanced with the patient's clinical status, blood pressure, potassium levels, and renal function. Adjustments to the diuretic regimen should be made based on the patient's response and tolerance to the therapy.
Different Approaches for Heart Failure Subtypes
When managing heart failure, it is essential to consider the specific subtype. For heart failure with reduced ejection fraction (HFrEF), diuresis can be more aggressive, aiming for higher negative fluid balance. However, in heart failure with preserved ejection fraction (HFpEF), diuresis should be more conservative, focusing on symptom relief rather than extensive fluid removal. The underlying pathophysiology and clinical characteristics of each subtype should guide the therapeutic approach.
Considerations for Advanced Treatment Options
In cases where diuretic therapy alone is insufficient to achieve the desired response, considering advanced treatment options may be necessary. This could include the use of additional medications such as mineralocorticoid receptor antagonists or thiazide diuretics to achieve sequential nephron blockade. These treatment decisions should be individualized based on the patient's clinical condition, response to therapy, and potential adverse effects.
Managing Medications and Diuretics in Heart Failure Patients
One of the key points discussed in the podcast episode is the importance of managing medications and diuretics in heart failure patients. The speaker highlights the significance of keeping the potassium and magnesium levels within appropriate ranges to prevent dangerous arrhythmias. They also discuss the use of oral magnesium to alleviate side effects of diuretics. The speaker emphasizes the need to continue guideline-directed medical therapy during hospitalization, including beta-blockers and renin-angiotensin-aldosterone system inhibitors. They provide criteria for when to consider discontinuing beta-blockers and the importance of assessing kidney function. Additionally, they mention the use of inotropes and pulmonary artery catheterization in certain situations.
Transitioning Care and Follow-up in Heart Failure Patients
The podcast episode also addresses the transition of care and follow-up for heart failure patients. They stress the importance of clear endpoints for treatment, such as resolution of symptoms and normalization of jugular venous pressure. The speaker discusses the challenges of determining a patient's self-reported dry weight and recommends using admission and discharge weights as reference points. They encourage follow-up within one week of discharge to assess medication efficacy and confirm stable kidney function. Furthermore, they touch on the use of SGLT2 inhibitors and the benefits of these medications in heart failure management.
Does the thought of managing acute decompensated heart failure (ADHF) give you paroxysmal nocturnal dyspnea? Recline for a bit while Dr. Michelle Kittleson MD, PhD @MKittlesonMD (Cedars Sinai) takes us through the Zen of jugular venous pressure (JVP) exams, how to approach diuresis, and the fine points of hospital discharge. This knowledge food is easier to swallow than an oral potassium replacement. Enjoy this Curbsiders classic and stay tuned this Wednesday, September 1, 2021 for a brand new CHF Triple Distilled episode.
