How to make the most out of hospital stay

Acute heart failure management: essentials for clinician

Veli-Pekka HarjolaFHFA, FESCHelsinki University Hospital, Finland

Conflicts of interest

• none declared

The common heart failure patient

• 75-year old man with• hypertension, lipid disorder, ex-smoker, anemia,

osteoarthrosis• AS, AFib, CAD, CKD, COPD, DM, TIA and …

Chioncel O. Am Heart J 2011;162:142

Use of iv therapies during first 48 hours and in-hospital mortality

Mebazaa A. Intensive Care Med (2011) 37:290–

Goals of treatment

McMurray J. European Journal of Heart Failure (2012) 14, 803–

Mobilize the patient

Risk assessment: Independent predictors of in-hospital mortality

Tavazzi L et al. EHJ 2006; 27:1207

Acute medication

• initial stabilization• goal-directed therapy with adequate doses

– furosemide iv or infusion– nitrate infusion or patches

Check-list for management of AHF1. ensure vital functions2. evaluate volume and filling status,

hypoperfusion & clinical profile3. optimize myocardial oxygen

consumption and delivery 4. start CPAP, iv-furosemide, nitrate5. study the cause and mechanism of

HF (echocardiography)6. treat precipitating factors7. continuosly check the response to

therapy often and increase intensity rapidly as needed (levosimendan)

Cardiac cause

• echocardiography– bed-side in ED– comprehensive on ward

• ischemic heart disease– how to interpret troponins– coronary angiogram: to whom and when

• indications for CRT, ICD?• telemetry

Inhospital monitoring

• Patient should be weighed daily and have an accurate fluid balance chart completed

• Standard noninvasive monitoring of pulse, respiratory rate and blood pressure should be performed

• Renal function and electrolytes should be measured daily

• Pre-discharge measurement of BNP is useful for post-discharge planning

Mebazaa A. Published on-line in Eur J HF and EHJ 2015

Decongestion and 60-day riskof ED visit, re-hospitalization, or death

Kociol HD. Circ HF 2014

4 lbs=1.8kg

Use of echo and ultrasound techniques vs symptoms for monitoring?

Thoracic FAST protocol vs VAS- 70 AHF patients- followed up with serial FAST protocol &VAS scores 0,12,24,48h and discharge- The FAST protocol was positive if E/e`was >15 and a congestive LUS - (bilateral B-lines (BL) or pleural fluid (PF) right sided or

bilaterally)- “Responders" became asymptomatic at rest and capable of

walking > 20 meters during hospital stay- LUS was considered normalized when absent of PF and

bilateral BL Öhman J 1; Harjola V-P 2; Lassus J 3; Karjalainen P. HFA 2015.

Rapid improvement of symptoms, filling pressures and pulmonary congestion estimated by combined echo and lung

US protocol during early course of AHF treatment

Öhman J 1; Harjola V-P 2; Lassus J 3; Karjalainen P. HFA 2015.

Goals of treatment

McMurray J. European Journal of Heart Failure (2012) 14, 803–

Mobilize the patient

Prognostic medication

HefREF• betablockers, ACEI/ARB,

spironolactone/eplerenone, ivabradine according to guidelines

• decompensated CHF: continue at the highest possible dose

• in de-novo: start low, aim high• good opportunity for up-titration in both

Maggioni AP. EJHF 2010; 12:1076

Role of beta-blockers in patients admitted for worsening heart failure

Orso F. EJHF 2009; 11: 77

before admission / during hospital stay

Oral medication in normo/hypertension

Appropriate adjustment by kalemia and renal function

Mebazaa A. Published on-line in Eur J HF and EHJ 2015

Long term medication

HefREF• adequate treatment of underlying disease

(hypertension)• rate control of Afib• symptomatic medication (diuretics)

Concomitant medication

• Anticoagulation in afib patients• Antidiabetics• Bronchodilators • NSAIDs• Antidepressants

• Harms, interactions – clean up the drug list !

Goals of treatment

McMurray J. European Journal of Heart Failure (2012) 14, 803–

Mobilize the patient

That’s what it’s all about !

ThankThank youyou

Back up slide

Change from admission to dischargeAll Responders

Non-responders

Patients 70 39 (56 %) 31 (44%) PLUS responsiveness (%) 59 85 (PPV 80%) 26 (NPV 79%) <0.001Δ E/e` 3,01 4,44 1,09 0.004Δ IVC (grades 1-3) 0,53 0,74 0,26 0.012Final E/e 17,9 15,3 21,2 <0.001Final IVC 0,69 0,38 1,10 <0.001Cumul. fluid loss (kg/liters) 2,91 3,89 1,59 <0.001Δ systolic blood pressure (mmHg) 18,6 26,7 4,65 0,001Δ MAP (mmHg) 11,1 20,0 -0,10 <0.001Δ pulse (/min) 10,2 17,0 1,71 0.002

HFA 2015. Öhman J 1; Harjola V-P 2; Lassus J 3; Karjalainen P 1