Acute on Chronic Systolic or Diastolic Congestive Heart Failure admission

Scenario:

Patients have a history of CHF most of the time. New onset CHF is also seen in ER. They develop pedal edema gradually at home but recently they might have had more shortness of breath, tiredness, more swelling, cough, PND or orthopnea, etc. Not uncommonly, patients ate lot of salted chips, pretzels, or drank soup bought from store with high salt content immediately before they present in ER. This is relatively common. Some patients keep drinking a lot of water like they always did when they were young.

EMS:

Oxygen via Nasal cannula or Non Rebreather mask depending on necessity.

Lasix if diagnosis is very clear to the EMS staff.

EKG

ER:

Routine labs plus BNP, EKG, CXR

Oxygen

IV Lasix 40-80 mg x 1, Foley catheter placement (if patient is too symptomatic to get up and urinate but needs to be removed ASAP after admission)

ABG, BiPap or Intubation if necessary–>ICU if intubated

By Hospitalist:

Observe in Telemetry floor. Can make them inpatient if patient has severe electrolyte disturbances, tachycardia, hypotension, worsening kidney function or if requiring BiPap etc.

Low salt diet-2gm Sodium diet, fluid restriction to 1500ml.

Continue IV Lasix 40-60mg Q 2-3 times a day [Bumex can also be used].

Input/Output.

Daily weights.

Bed rest.

Cardiac Enzymes [Troponin I] Q3hrs 2 or 3 times.

2D ECHO

Lipid Panel in AM labs.

Elevate legs with pillows above heart level and also elevate head of the bed to help with breathing

Cardiology consult

ACEI or ARB if EF <40%-for after load reduction.

Coreg or Toprol XL, Start Beta Blockers at low doses and when patient is euvolemic.

If  patient is ‘Cold and Wet’ (known by touching the legs ), decrease or hold Beta blocker, cold and wet (low perfusion and congestion) are the sickest so may need ICU treatment depending on the situation.

Hydralazine ( for after load reduction) and Nitrates   esp. if African American Patients.

IV Lasix +/-Metolazone.

Spironolactone (in NYHA Class 3 and 4) if required and if patient’s kidney function tolerates.

Morphine IV to help with reducing preload, heart rate, and possibly afterload.

DVT prophylaxis with SQ Lovenox or SQ Heparin [in CKD patients].

Nephrology evaluation if patient has cardiorenal syndrome.

ICD-Implantable Cardioverter Defibrillator placement if EF is <=35%.

?Anticoagulation if large akinetic LV segment, EF<30%.

Digoxin ?

Inform patients not to eat too much of salty chips, pretzels, canned soup etc. Many patients eat them.

By Nurses:

They give Influenza [if it is the season] and Pneumococcal vaccines.

Pharmacist: 

CHF education-fluid restriction, monitoring weight, medication compliance (Some patients don’t like to take Lasix as they are bothered by frequent need to urinate) .

Case Manager: 

Oxygen set up at home if required based on 6 Minute walking desat study, if required. Patients may also benefit from Nocturnal desat study to see if they need oxygen during sleep.

Check BNP just before discharge so that baseline BNP is documented for future reference.

Earn CME from UpToDate: Approach to diagnosis and evaluation of acute decompensated heart failure in adults

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