Maximizing Heart Failure Care

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Maximizing Heart Failure Care

• Patient Case Scenarios

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Case 1

• Presentation
• 69-year-old male with history of COPD presents in
  ED with SOB at rest, cough, diaphoretic 15-yr
  history of HTN smoked 40 pack-years denies CP
  discharged 5 years ago
• Medications fluticasone/salmeterol inhaler
  albuterol inhaler amlodipine, 10 mg qd
  celecoxib, 200 mg qd
• Physical exam BP, 110/78 mm Hg HR, 94 bpm RR,
  28 breath/min scattered wheezes JVP not well
  seen II/VI HSM ext 1 edema ECG LBBB CXR
  bilateral basilar infiltrates, CM, possible
  pneumonia

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Case 1 (contd)

• Hospital Course
• In ED, started on oxygen, cefoxitin, and
  erythromycin hydration progressive respiratory
  distress CXR shows worsening interstitial
  infiltrates patient transferred to ICU
• Following intubation, BP drops to 89/60 mm Hg
  right heart catheterization performed to evaluate
  for sepsis
• RHC PA, 68/42 mm Hg PCWP, 38 mm Hg RA, 16 mm
  Hg CO, 3.0 L/min SVR, 1440 dyne-s-cm-5
• IV nesiritide, 2 µg/kg bolus, followed by a
  fixed-dose infusion of 0.01 µg/kg/min
  furosemide, 40 mg IV antibiotics and IV fluids
  discontinued

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Case 1 (contd)

• Hospital Course
• At 2 hours BP, 95/60 mm Hg PAP, 48/28 mm Hg
  PCWP, 20 mm Hg RA, 10 mm Hg CO, 4.6 L/min/m2
  SVR, 1070 dyne-s-cm-5 urine output, 0.8 L FiO2
  reduced to 40
• Bedside echo LVEF, 2530 LVEDD, 65 mm
  moderate MR LV thrombus troponin, 0.12 pg/mL
• At 6 hours BP, 90/60 mm Hg PA 40/22 mm Hg PCWP
  14 mm Hg RA, 6 mm Hg CO, 4.8 L/min SVR, 1066
  dyne-s-cm-5 extubated captopril started, 6.25
  mg q6, uptitrated at interval doses at 18 hours,
  nesiritide discontinued

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Case 1 (contd)

• Hospital Course
• At 24 hours, left heart catheterization and
  coronary angiography performed LVEF, 30 mild
  MR LVEDP, 18 mm Hg mild coronary artery luminal
  irregularities
• Converted to lisinopril, 20 mg qd started on
  warfarin carvedilol, 3.125 mg bid aldactone,
  12.5 mg qd simvastatin, 20 mg qhs
• Discharged home on day 3

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Case 1 (contd)

• Follow-up
• Patient returns to clinic at 1 week feeling
  improved
• Carvedilol titrated up at 2-week intervals to 2.5
  mg bid
• Asymptomatic during next 2 months never
  restarted bronchodilators PFTs show only mild
  restrictive defect, no evidence of obstructive
  disease COPD diagnosis discontinued
• During next year, no hospitalizations or ED visits

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Case 2

• Presentation
• 72-year-old female with new-onset CHF complaining
  of SOB at rest 1 week prior, patient notes DOE,
  orthopnea, edema denies CP diaphoretic 10-yr
  history of HTN PTCA 5 years ago
• Medications aspirin, 81 mg qd amlodipine, 5 mg
  qd HCTZ,12.5 mg qd vitamin E
• Physical exam BP, 130/85 mm Hg HR, 90 bpm RR,
  24 beat/min basilar rales JVP, 12 cm II/VI
  HSM S4 ext 2 edema ECG LVH CXR CHF

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Case 2 (contd)

• Hospital Course
• In ED, IV furosemide, 40 mg
• 2 hours continued SOB UO, 750 mL plan to
  admit Na, 136 mg/mL BUN, 45 mg/dL Cr, 1.9
  mg/dL BNP, 1230 pg/mL troponin lt 0.04 ng/mL
• Cardiology initiates IV nesiritide, 2 µg/kg
  bolus, followed by a fixed-dose infusion of 0.01
  µg/kg/min repeat dose of furosemide, 40 mg,
  given 1 hour later
• 6 hours SOB resolved BP, 125/80 mm Hg HR, 80
  bpm RR, 14 breath/min JVP, 8 cm lungs clear
  UO, 1.2 L repeat K, 4.0

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Case 2 (contd)

• Hospital Course
• 10 hours patient requests discharge on symptom
  improvement nesiritide discontinued patient
  monitored for 2 more hours ambulated without
  SOB no orthostatic hypertension found appt made
  for next day in heart failure clinic
• 12 hours discharged on lisinopril, 5 mg
  aldactone, 12.5 mg furosemide, 40 mg po qd
  aspirin, 81 mg simvastatin, 40 mg diet 2 g Na
  monitoring daily weights

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Case 2 (contd)

• Follow-up
• Next day no SOB no dizziness tolerating
  medications weight down 2 kg overnight BP,
  115/70 mm Hg HR, 78 bpm JVP, 7 cm trace edema
• Echo LVEF, 25 mod MR LVEDD, 80 mm lisinopril
  increased to 10 mg carvedilol, 3.125 mg bid,
  started
• Meds titrated over next 3 months lisinopril, 20
  mg qd carvedilol, 25 mg bid spironolactone, 25
  mg qd furosemide, 10 mg qd aspirin, 81 mg qd
  simvastatin, 40 mg qd
• 6 months no ED visits, no hospitalizations
  class I Echo LVEF, 30 LVEDD, 70 mm LDL, 86
  mg/dL HDL, 52 mg/dL BNP, 42 pg/mL

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Case 3

• Presentation
• 56-year-old male with ischemic heart failure
  presents with DOE, orthopnea, edema denies CP
  exam with JVD and 3 edema Cr, 2.1 mg/dL up from
  1.5 mg/dL history of AMI and CABG 10 years ago,
  and PTCA 5 years ago
• Medications aspirin, 325 mg losartan, 50 mg/d
  furosemide, 120 mg bid KCl, 40 mEq bid
  furosemide increased to 200 mg bid
• Physical exam BP, 110/70 mm Hg HR, 88 bpm RR,
  24 breath/min basilar rales JVP, 12 cm II/VI
  HSM S4 ext 3 edema ECG unchanged Cr, 2.4
  mg/dL

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Case 3 (contd)

• Hospital Course
• In ED, IV started patient placed on cardiac
  monitor nesiritide, 2 µg/kg IV bolus, followed
  by a fixed-dose infusion of 0.01 µg/kg/min dose
  of furosemide, 80 mg IVP, given 1 hour later
• 4 hours SOB resolved BP, 105/65 mm Hg HR, 80
  bpm RR, 14 breath/min JVP, 8 cm lungs clear
  UO, 750 mL
• 6 hours total UO, 1.1 L nesiritide
  discontinued patient monitored for 30 min
  ambulated without SOB orthostatic VS checked
  appt for next day in outpatient office

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Case 3 (contd)

• Follow-up
• Next day no SOB no orthopnea tolerating
  medications weight down 11 lb BP, 110/68 mm Hg
  HR, 78 bpm JVP, 7 cm trace edema losartan
  increased to 50 mg bid simvastatin, 40 mg,
  started weight down 3 lb no SOB minimal
  orthopnea Cr, 1.8 mg/dL
• Meds titrated over next 3 months losartan, 50 mg
  bid metoprolol XL, 50 mg/d spironolactone, 12.5
  mg/d furosemide, 100 mg bid aspirin, 325 mg qd
  simvastatin, 40 mg qd
• 9 months patient presents to PCP with SOB
  missed last 2 follow-up appointments admits to
  dietary indiscretion weight up 10 lb patient
  refuses admission and requests IV infusion at
  office the next day