Five things to consider when your patient “stalls” in hospitalJonathan HowlettLibin Cardiovascular InstituteCV Resp SCN

Five things to consider when your patient “stalls” in hospitalJonathan HowlettLibin Cardiovascular InstituteCV Resp SCN Speaker DisclosureDr. Jonathan Howlett•Relationships with commercial interests:•Grants/Research Support: AstraZeneca, Merck, Servier, Pfizer, Novartis, Medtronic, Bayer•Speakers Bureau/Honoraria:Bayer, Servier, Boerhinger Ingleheim, Novartix•Consulting Fees: General Electric, Government of Canad & Alberta, Novo Nordisk, AstraZeneca, Merck, Servier, Pfizer, Novartis, St Jude, Bayer•Medical Advisory Board:Cardiol MrsHF•73 Female, ICM LVEF 34%, last hospitalized Feb ’19•Meds: ACE, BB, diuretic, CCB, statin, ASA•Admitted to ED with AHF•Warm feet, alert, appropriate•HR 54, BP 140/68, SaO2 89% R/A•JVP elevated, bilateral crackles and peripheral edema•Na 131, K 3.9, Hgb 115, •creatinine 147, NT pro BNP 8455 pg/ml Mrs. HF-subsequent course•Given NTG long acting formulation, continued other meds, added amlodipine•IV furosemide 60 mg bid with no weight loss•Symptoms unchanged, still on supplemental O2•Alert but cool extremities•BP 100/80, HR 86•Na 130, K 3.9, Creatinine increased to 200 (147) What would your next option be?1.Intensify loop dose2.Change furosemide to infusion at 10 mg/hour3.Add thiazide4.Add MRA5.Add SGLTiAlert but cool extremitiesBP drop to 100/80, HR 86Na 130, K 3.9, Creatinine increased to 200 (147)On ACE, BB, Furosemide iv boluses, ntg Five considerations:•Know what a ‘good’ trajectory looks like•Know how to use diuretic strategies•Know the volume status, measure I/O•Know why patients ‘stall’•Know a few tricks , Hollenberget al: JACC 20 19, 74(15):1966-20 11 80% of casesGood prognosisEarly ambulationEarly optimization 10-15% of casesFatiguePoor prognosisOlder, Low BPRight sidedCardio-renal 5-10% of cases Clinically improved-NO AKI, called ‘pseudo WRF’ Not Clinically improved-AKI PresentIn the setting of sCr> 27 increase umol/L from baseline Indication of Clinical HF ImprovementImprovement•Symptoms•NYHA class < III•Improved dyspnea/orthopnea•Lower FIO2 requirement•Ambulating•Stable hemodynamics •HR60-90•SBP 100-130 mmHg•Renal function•Creatinine stable, or•Increase < 27 umol/L from admission•Volume•Urine output > 3 l/24 hours•Improved signs of congestion•Weight loss > 1.0 kg/24 hours Stalled/worsening•Symptoms•Increased FIO2 requirement•Worsening dyspnea•Syncope/ orthostasis•Ischemic chest pain, other new symptom•Unstable hemodynamics •HR< 50 bpm or > 120 bpm•SBP < 90 mmHg or > 180 mmHg)•Renal function•Increase creatinine > 50 umol/L from admission•Volume/electrolytes•Urine output < 2L/ 24 hours•Weight loss <0.5 kg/24 hours•New or worsening hyponatremia or K+ > 5.5 mmol/L•ANY significant new illness GUIDELINE TERRITORY Five considerations:•Know what a ‘good’ trajectory looks like•Know how to use diuretic strategies•Know the volume status, measure I/O•Know why patients ‘stall’•Know a few tricks 11 Can check viaU/O > 150/hrUrine Na> 70For same day decisions Also acceptable strategies:Change to infusion, MRA, Acetazolamide, Tolvaptan Five considerations:•Know what a ‘good’ trajectory looks like•Know how to use diuretic strategies•Know the volume status, measure I/O•Know why patients ‘stall’•Know a few tricks Hollenberget al: JACC 20 19, 74(15):1966-20 11 Overlap: misclassified ~40%Large errors:10-20% The Chest X Ray is your friend! Discordance Between Clinical Assessment and Invasive Hemodynamics in Patients With Advanced Heart Failure Narang et al, Journal of Cardiac Failure2020;26(2) DOI: 10.1016/j.cardfail.2019.08.004 •218 cases, clinical assessment, then RHC within 6-12 hours•Compared to RHC results by categoryRight atrial pressure (mmHg)Pulmonary wedge pressure (mmHg)Cardiac index (CI)< 67-12< 1.56-1213-181.5-2.212-1819-24> 202>18>24 Fig. 3 Journal of Cardiac Failure2020 26128-135DOI: (10.1016/j.cardfail.2019.08.004) Narang et al, Journal of Cardiac Failure2020;26(2) DOI: 10.1016/j.cardfail.2019.08.004 Although experience matters Especially for PWP Over 70% led to change in treatment strategy:PVR/SVR LOWER than thoughtCardiac output LOWER than thoughtPVR/ SVR HIGHER than thought with normal CO POCUS for assessment of fluid status Five considerations:•Know what a ‘good’ trajectory looks like•Know how to use diuretic strategies•Know the volume status, measure I/O•Know why patients ‘stall’•Know a few tricks Failure to Diurese: Common ‘Cardiorenal’ Reasons•Inadequate diuresis is COMMON•Low Cardiac output state•With or without volume depletion•Advanced renal disease•Symptomatic Hypotension•Atypical/ Right Sided Heart Failure•Unrecognized Non Adherence SpecificHemodynamic Considerations(not including inadequate diuresis)•Rhythm:•Control HR if too high•Reduce BB if rate low, especially if pacing•Consider DCCV for AF associated WHF•Consider CRT if wide complex QRS•Consider PVC suppression if frequent PVCs•You May need to reduce GDMT drugs, espRAASiand BB medications•Perfusion pressure is necessary for diuresis•Rarely•Pericardial constriction Five considerations:•Know what a ‘good’ trajectory looks like•Know how to use diuretic strategies•Know the volume status, measure I/O•Know why patients ‘stall’•Know a few tricks GALACTIC –AHF: Within 180 Days Among Patients Treated With Early Intensive and Sustained Vasodilation vs Usual Care Kozhuharovet al. JAMA. 2019;322(23):2292-2302. doi:10.1001/jama.2019.18598, Packer N EnglJ Med. 2017;376(20):1956-1964. Metra N EnglJ Med. 2019;381(8):716-726., O’Connor, N EnglJ Med. 2011;365(1):32-43. Randomized trials of intravenous vasodilator therapy for NON-hypertensive AHFStudyVasodilatorSample sizeShort term benefit?Longer term benefit?ASCEND HFnesiritide7141NoNoTRUE-AHFularitide2157NoNoRELAX-AHFrelaxin6545NoNo Positive inotropic agents ‘-’cold and wet ’ patients 24 Use of hypertonic saline facilitated diuresis Alternative diuretic aids: Not for routine use JACC Heart Fail.2016 Feb;4(2):95-105. doi: 10.1016/j.jchf.2015.08.005. Epub2015 Oct 2 SGLTi-promising therapy for AHF The Stalled HF Patient: Final thoughts at 30 years•Know what a ‘good’ trajectory looks like•Simple clinical response•Know how to use diuretic strategies•Especially important is early, adequate trial, combination Rx•Know the volume status•Often trickiest part, provides clues to other issues. May need aids•Know why patients ‘stall’•Systematic approach is helpful, be ready to revisit earlier decisions•Know a few tricks•There are many, even if not rigorously studied….