Health Dictionary
Reliable, easy-to-read patient information on common medical conditions — written in plain language, free of jargon, and grounded in current evidence. Browse the most frequent diagnoses, understand what they mean for everyday life, and learn which steps and questions help you have a focused conversation with your doctor.
HFrEF exacerbation (Assessment and Plan)
Introduction
Author: William J Gibson MD, PhD
History of HFrEF (last TTE XX;LVEF XX%) secondary to XX [ischemia,non-ischemic dilated cardiomyopathy, non-ischemic restrictive cardiomyopathy] . Current exacerbation most likely precipitated by [medication/dietary non-compliance(40%)]. Possible other etiologies (although less likely): ischemia/infarction(15%), HTN, renal failure -> inc. preload, drugs/toxins (eg etoh), new structural/valvular pathology, no history COPD, low suspicion for PE. [Dry/wet] and [warm/cold] on exam. Weight on admission XX lb ; dry weight reportedly XX lb.
Dx:
– EKG, trend troponins, CXR
– tele; strict I/O; cardiac diet (2L fluid, 2g Na); daily weights
– BID BMP/MgÂ
– TTE (always if first presentation, repeat if concern for new structural/functional changes)
– If new: perform ischemic workup (stress test, cath), if no evidence of ischemia on TEE: A1c, lipid panel, TSH, iron studies, SPEP, ANA, consider MRI.
Tx:
Contractility:
Preload: IV lasix BID or PO torsemide BID or Bumex drip (0-2 mg/hr). If diuresis inadequate with these agents can give metolazone 30 min before loop diuretic.
Afterload: captopril Q8H (titrate quickly and then convert to lisinopril), or . ACE first line as mortality benefit in all. Isordil/hydralazine has mortality benefit in blacks.
Neurohormonal blockade: Continue home [spironolactone/eplerenone]. Spironolactone and eplerenone inhibit aldosterone and decrease mortality in randomized trials (RALES trial; EMPHASIS-HF trial). Hold if AKI.
References:
Jondeau G, Neuder Y, Eicher JC, et al. B-CONVINCED: Beta-blocker CONtinuation Vs. INterruption in patients with Congestive heart failure hospitalizED for a decompensation episode. Eur Heart J. 2009;30(18):2186-92.
RALES trial: Pitt B, Zannad F, Remme WJ, et al. The effect of spironolactone on morbidity and mortality in patients with severe heart failure. Randomized Aldactone Evaluation Study Investigators. N Engl J Med. 1999;341(10):709-17.
EMPHASIS-HF trial: Zannad F, Mcmurray JJ, Krum H, et al. Eplerenone in patients with systolic heart failure and mild symptoms. N Engl J Med. 2011;364(1):11-21.