Acute CHF


Must consider contributing causes including MI, valve rupture, rapid AFib, thiamine deficiency, hyperthyroidism, sepsis, PE — if you miss these, the patient will have CRASHED on the floor.

Ruptured valve
Alcohol (thiamine depleted) / Anemia
Elevated BP

Other known causes include NSAID use (increases risk 2-fold), COPD exacerbation, dietary indiscretion, med non-compliance, PE

- Dyspnea of SUDDEN onset? (Favors MI, PE, valve rupture, etc.)
- Highest OR for dyspnea being from CHF:
weight gain 3.6
nocturia 2.4
paroxysmal nocturnal dyspnea 2.4
("Have you gained weight? Are you waking up to pee, or to gasp for breath?")

Low yield
- JVP & peripheral edema are seen in acute decompensated CHF from L ventricular dysfunction, but also in cor pulmonale from pulmonary HTN (i.e., from COPD damage).

  1. Sensitivity of JVP (which reflects RA pressure) for acute HF is around 20%.
  2. Sensitivity of leg edema 46%, specificity 76%

- Severe chronic HF often lack rales or alveolar edema (reduced pulm microvascular permeability, increased lymph flow), and hearing rales is very non-specific

  1. Sensitivity & specificity ~ 60%

- Hypontremia, anemia and renal failure are all concerning. Hyponatremia is a sign of failing circulatory homeostasis. Anemia can in fact be a driver of acute CHF.
[] BNP

  1. Half-life of BNP is ~ 20 mins, of NT-proBNP 120 mins
  2. Renally cleared
  3. Degree of elevation proportional to disease severity

- In Breathing Not Properly (BNP) Trial (1,600 patients):

  1. High NPV at cutoff of 100 pg/mL, but to get to 95% NPV need less than 30 pg/mL
  2. High PPV at cutoff of 500 pg

- In Pro-BNP Investigation of Dyspnea in the ED (PRIDE) trial:

  1. High NPV at 300 pg/mL
  2. High PPV at 900 pg/mL

[] Trop
[] Thiamine TSH Ferritin Transferrin Saturation
[] US for B-lines, cardiac evaluation (valve? PE?)
[] CXR
[] Formal Echo

Acute Treatment
[] CPAP 5-10 cm H2O (BiPaP if COPD)

  1. Good for the LV
  2. Reduces intubations & mortality
  3. Usually only an oxygenation problem, only see hypercarbia with concomittant COPD

[] Nitroglycerine IV
[] Reversible causes, i.e. valve surgery, abx, heparin & cath for MI, etc.

Subacute Treatment
[] Furosemide 40 mg IV 􏰀x 1 dose then PO (not to exceed 80 mg daily)
[] B-blocker (carvedilol)
[] Consider low-dose oral ACE inhibitor (NOT if worsening renal function)

[] IV iron if iron deficiency
[] Nutritional optimization (thiamine, etc.)
[] Consider ultrafiltration in select patients

- High-dose loop diuretics (>80 mg furosemide day)
- Diuretics in general with worsening renal function (cardiorenal syndrome)
- Morphine (OR for death of 5!)
- Inotropes (dobutamine, milrinone)
- Nesiritide, Nitroprusside
- Blood transfusion

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