CME

Acute HF Management: Early

Hospital Treatment to
Optimal Discharge
Authors:Alexandre Mebazaa, MD, PhD;Faculty and Disclosures

CME Released: 12/12/2016

Valid for credit through: 12/12/2017

Introduction
Voiceover: Sofia Simon is a 75-year-old woman
with a longstanding history of hypertension and
type 2 diabetes mellitus. She was diagnosed
with heart failure (HF) 18 months ago, and she
has been followed by a cardiologist. Her current
medications include metoprolol 100 mg daily,
enalapril 10 mg daily, and metformin 1,000 mg
daily. She is a nonsmoker, and she has no
history of coronary disease or peripheral arterial
disease. Her baseline left ventricular ejection
fraction (LVEF) is 35%. She just presented to the
emergency room (ER) a few minutes ago
complaining of shortness of breath.
Scene 1A:
ER Doctor: Hello, Mrs Simon. I am Dr Phillips. I
see you're having quite a bit of trouble with
your breathing. How long has this been going
on?
Patient [working hard to breathe; speaks
haltingly] Past couple of days.
Doctor Did it come on suddenly, or has it been
gradually getting worse?
Patient Getting worse.
ER Doctor: Yes, I see. I understand you have a
history of heart failure. [presses his fingers
against patient's ankles and looks to check for
swelling] Have you noticed any swelling of your
legs?
Patient Yes. Trying putting them up. Doesn't
work.
ER Doctor: Yes, I can see. When was the last
time you saw your cardiologist?
Patient Made appointment. Things got worse.
Couldn't wait.
ER Doctor: I'm glad you didn't try to wait until
your appointment. [looks at monitor and speaks
to nurse] What was her oxygen level when she
came in?
Nurse: It was 86% on room air. Respiratory rate
was 30. Initial BP was 160/100 and pulse was
irregularly irregular at a rate of 127. Temp was
37.2.
ER Doctor: I see. Your nurse and I will be
keeping a close eye on you. I need to step out
just briefly to arrange for a chest x-ray and lab
tests, but I'll be back after that to talk to you a
bit more about everything. Let me take a listen
to your lungs and heart first, please.
What should be done first for a patient with
shortness of breath and lung congestion,
suspicious for acute heart failure (AHF), upon
initial presentation to the ER?

Establish the severity of the condition; assess

oxygenation and vital signs
Perform a chest x-ray to confirm HF diagnosis
Assess for the source of congestion
Obtain lab tests including B-type natriuretic
peptide (BNP) for definitive diagnosis
Start an IV and give diuretics

What should be done first for a patient with

shortness of breath and lung congestion,
suspicious for acute heart failure (AHF), upon
initial presentation to the ER?
Your Peers Chose:
Establish the severity of the condition; assess
oxygenation and vital signs
82%
Perform a chest x-ray to confirm HF diagnosis
2%

Assess for the source of congestion

0%

Obtain lab tests including B-type natriuretic

peptide (BNP) for definitive diagnosis
2%

Start an IV and give diuretics

14%
Scene 1B: 2 Hours Later
ER Doctor: Hello, Mrs Simon, Dr Carr. I'm at the
end of my shift, and I wanted to check in on you
before I leave. It's been about 2 hours since we
gave you the IV medicine in the ER. I see that
your oxygen saturation is now 92%. It looks like
the CPAP mask was very helpful. How are you
feeling now?
Patient: [appears slightly more comfortable
than in previous scene and is able to speak
without having to catch her breath] A bit better.
It's getting a bit easier to breathe, and my heart
isn't beating quite as fast. I feel like I can
actually talk now.
ER Doctor: Good. It sounds like the furosemide
and the vasodilator we gave you in the ER
helped you get rid of quite a bit of fluid. Your
heart is also now in a regular rhythm. I was
quite concerned about you when Dr Carr and I
discussed your situation. We determined that it
would be best to transfer you to the cardiac
unit.
Cardiologist: Yes, we want to watch you
closely. It is important to treat this acute heart
failure without delay. When did you realize that
you needed to go to the ER rather than come to
my office?
Patient: Well,I usually go to my daughter's
house after supper, but when I couldn't walk the
2 blocks to her house, I got concerned. I thought
I could make it until morning, but then when I
tried to lie down to go to sleep, I couldn't
breathe. I got worried.
Cardiologist: We need to figure out why this
happened so that we can adjust your
medications and your treatments to help keep
you out of the hospital. You'll probably be here
just a day or two until we have completed our
testing. Then we'll send you home.
Patient: Okay.
ER Doctor: I'm glad to see things are improving
already. Hopefully you won't have to see me in
the ER again after you are discharged. Madam,
take care.
Patient: Thank you.
ER Doctor: You're welcome.
 Thought Leader Discussion 1
Dr Mebazaa: Acute heart failure is a serious
condition, and it should be treated aggressively,
in a time-sensitive manner. Patients with AHF
may present with peripheral edema, fatigue,
decreased exercise tolerance, shortness of
breath, orthopnea, and paroxysmal nocturnal
dyspnea. Symptoms can develop rather rapidly,
and the patient's condition can deteriorate
quickly.
The treatment algorithm for AHF involves
immediate assessment of the patient upon
presentation and requires frequent
reassessment over the course of 2 hours.[1]
The first step is to determine the severity of
the episode. If the patient is at high risk for
acute coronary syndrome, they should be sent
to the catheterization lab immediately. The
patient's respiratory rate, lung sounds, oxygen
saturation levels, and blood pressure should all
be monitored. If the patient has an oxygen
saturation less than 90% and exhibits signs of
hypoperfusion with a systolic blood pressure
less than 90 mm Hg or other hemodynamic
instability, they may need to be transferred to
an intensive care unit or cardiac care unit.
Additional intensive care unit (ICU) admission
criteria include heart rate below 40 or above
130, or presence of a severe arrhythmia.
 Diagnostic tests should be performed to help
guide further treatment, but treatment with IV
diuretics or vasodilators should be initiated
immediately, while diagnostic testing is in
progress.[1]

Do not wait for test results to come back

before starting therapy. An electrocardiogram
(ECG) can help rule out myocardial infarction,
and a chest x-ray (CXR) will help rule out other
potential causes of shortness of breath. An
echocardiogram should be done at some point
but does not have to be done immediately. If
available, bedside ultrasonography may help
determine the severity of pulmonary edema.
Initial laboratory tests should include a plasma
natriuretic peptide level, troponin, electrolytes,
serum glucose, blood urea nitrogen (BUN)
creatinine, a complete blood count, and if you
suspect a pulmonary embolism, a D-dimer level
should also be done. Arterial blood gas (ABG)
levels are not routinely drawn, but they can be
helpful.
 Oxygen should be administered if the patient's
saturation level is below 90%.[1]

If the patient is in respiratory distress, start

non-invasive ventilation, such as pressure
support-positive end expiratory pressure (PS-
PEEP) or continuous positive airway pressure
(CPAP), to reduce the potential need for
intubation.
All patients should be reassessed after 2 hours.
If they have adequate urine output, oxygen
saturation greater than 95%, a resting heart
rate less than 100, and no postural hypotension
and report improvement of their symptoms,
they may be able to be discharged home from
the ER as long as there is close outpatient
follow-up and the cause of the acute episode
can be determined. By contrast, if the patient
remains unstable based on previously discussed
criteria, they should be admitted to an intensive
or cardiac care unit for close monitoring.
Otherwise, patients can be admitted to a
regular hospital ward and monitored there for
24 to 48 hours before discharge.[1]

Scene 2: Next Day
Cardiologist: How are you feeling today, Mrs
Simon? Are you continuing to improve?
Patient Yes, I'm definitely feeling better than I
did yesterday.
Cardiologist: Good. When someone comes in
with an episode of worsening heart failure like
you did, we want to figure out why it happened
so that we can adjust your medicines and
treatment appropriately. I was reviewing your
chart and the results of your tests. It looks like
when you came in to the ER, you were in an
abnormal heart rhythm called atrial fibrillation.
Patient: Oh. I know my heart was beating
terribly fast. I just thought it was just because I
was anxious.
Cardiologist: Certainly anxiety can sometimes
make your heart beat fast, but in this case, the
abnormal heart rhythm was the cause of it
when you came in to the ER last night. Did you
ever notice your heart beating fast before this?
Patient: No. I don't recall it ever beat fast like
this.
Cardiologist: Okay. So, as far as we know, this
is the first time you have ever been in atrial
fibrillation. Let me explain. When your heart
goes into an abnormal rhythm like that, it
doesn't pump your blood efficiently, and that is
the likely reason why you noticed more
problems breathing and the swelling in your
ankles.
Patient Yes, the swelling seems to be down a
bit today. Will my heart stay in that rhythm
now?
Cardiologist: Your heart is now back in a
normal rhythm, but there is a possibility that it
may go into that abnormal rhythm in the future.
I think we can control your heart rate with your
metoprolol. Though, I'm going to increase the
dose a bit. My goal is to keep your heart rate
between 60 and 100.
Patient Is the heart rate the only reason why I
had problems breathing?
Cardiologist: This episode is likely due to that,
yes. We do want to do another echo to look at
your heart, and we'll be monitoring your weight
and your lab tests to make sure we get your
symptoms under control before we send you
home. I think it may be a day or two before you
go home, but I anticipate we will transfer you
out of this unit and into a regular hospital room
within the next 24 hours, as long as things
remain stable.
Patient: Okay. Good.
This patient has atrial fibrillation (AF) and AHF. A
multidisciplinary team is employed to stabilize
and manage her care while she is in the
hospital. What are the primary tasks to consider
to improve her outcomes and minimize frequent
rehospitalizations?
Discontinue metoprolol and start amiodarone
to better control rate and rhythm
Uptitrate metoprolol and enalapril; daily
weights; obtain pre-discharge BNP
Discontinue enalapril and metoprolol; order
digoxin and cardiac rehab
Discharge only when her renal function, BNP,
and CXR are normal
SAVE AND PROCEED

This patient has atrial fibrillation (AF) and AHF. A

multidisciplinary team is employed to stabilize
and manage her care while she is in the
hospital. What are the primary tasks to consider
to improve her outcomes and minimize frequent
rehospitalizations?
Your Peers Chose:
 Discontinue metoprolol and start amiodarone
to better control rate and rhythm
10%
Uptitrate metoprolol and enalapril; daily
weights; obtain pre-discharge BNP
82%
Discontinue enalapril and metoprolol; order
digoxin and cardiac rehab
3%
Discharge only when her renal function, BNP,
and CXR are normal
5%
Thought Leader Discussion 2
Dr Mebazaa: The most common causes of AHF
are hypertension, acute coronary syndrome,
arrhythmias, and infection. Non-compliance with
treatment regimen should also be considered,
and it is important to review whether the
patient has been taking their medication
regularly.
In this case, the patient presented with AF, and
a thoracic ultrasound needs to be done to rule
out thrombus. This patient converted to regular
rhythm without any specific intervention. For
some patients, cardioversion is necessary.
Amiodarone can be used short term in patients
who need cardioversion to reduce the likelihood
of recurrent AF. The goal is to maintain the
 patient's resting ventricular rate between 60
and 100 beats per minute. If a beta blocker (BB)
alone is not effective at controlling the patient's
rate, digoxin may be added.[2] Patients with AF
should be put on an anticoagulant, preferably a
non-vitamin K antagonist anticoagulant, based
on stroke risk assessment. Despite the fact she
is now in a sinus rhythm, her CHA2DS2VASc
score is 5.[3]
She receives 1 point for congestive heart
failure, 1 point for hypertension, 2 points for
age 75 or greater, and 1 point for being female.
Therefore, an anticoagulant is recommended.
While the patient is in the hospital, her weight
should be checked daily and her fluid input and
output monitored. Electrolytes and renal
function testing should be measured daily, and
the patient should be euvolemic with stable
renal function for 24 hours prior to discharge. It
is helpful to also check the level of natriuretic
peptides prior to discharge.[1]
The patient's current medications should be
uptitrated to optimal doses while they are in the
hospital, and the patient should receive
instructions about how to manage their HF
before they go home.

Arrangements for follow-up with a disease
management team should be made prior to
discharge. The multidisciplinary team should
include the patient's cardiologist and primary
care physician, as well as other staff who may
be involved in the patient's care, such as
physiotherapists, dieticians, pharmacists, and
social workers.[1,2]

Scene 3A: 2 Days Later

Cardiologist: So, Mrs Simon, how are you
feeling today? Has your breathing worsened, or
have you noticed any increased swelling of your
ankles?
Patient: No. I feel okay. But I'm not back to
where I was. My breathing is certainly better
than when I came in. I'm able to walk around
without feeling short of breath. I noticed this
today that when I took a shower, I did not feel
quite as tired.
Cardiologist: I think you can be discharged
today. I want to follow up with you closely,
though. We have to keep a close eye on you
over the next month or 2 so that we can adjust
your medications promptly if you don't improve.
I want you to be able to stay out of the hospital.
Patient I certainly want that too.
Cardiologist: You should continue taking the
medicines you were taking prior to being
admitted, but at the dose we had you on here in
the hospital. You will also be on a couple of new
medications that we added since you were
admitted. One is the blood thinner that we
started due to the abnormal heart rhythm. The
other is spironolactone, a kind of water pill that
helps get rid of excess fluid. In addition, the
nurse and discharge planner have enrolled you
in a cardiac rehab program.
Patient When do I need to follow up with you?
Cardiologist: I'd like you to follow up with your
primary care provider next week and then come
and see me again the week after that. We'll see
how you are doing then.
Patient Okay. Thank you.
Scene 3B: 2 Weeks Later
Cardiologist: So, Mrs Simon, how have you
been doing over the past couple of weeks? Does
it feel like your breathing has continued to
improve?
Patient: I'm certainly better than I was when I
went to the hospital. Though, I still don't feel
quite back to my normal self. I am able to do
more around the house, though. I don't get tired
as quickly.
Cardiologist: Have you had any more swelling,
or does that seem to be resolving?
Patient: Oh, that's much better. I have some
swelling of my ankles by the end of the day, but
it is gone when I get up in the morning.
Cardiologist: Good. I want you to keep an eye
on that. If you start noticing more swelling, or if
you have swelling when you first get up in the
morning, you should call your nurse. I think you
have instructions, too, on when you should take
an extra water pill.
Patient: Yes, the nurse did give me some
instructions when I left the hospital. My primary
care doctor also reviewed that with me last
week.
Cardiologist: Great. Have you started the
cardiac rehab program yet?
Patient: Yes. I had my first visit last week, and I
go again tomorrow.
Cardiologist: Good. I anticipate that you will
continue to improve over the course of the next
few weeks, but I want to see you again in two
weeks. We may need to bump up the dose of
your spironolactone, depending on how you
feel. If we fear we can't get things under control
that way, then we may need to consider adding
another medication -- actually, a combination of
two medicines, sacubitril and valsartan -- that
would take the place of your enalapril. I will
order another echo to be done before I see you
again, since that will help us determine whether
we need to adjust your medications.
Patient: Okay. I'm glad there are some other
options. Thank you.
Which of the statements most accurately
reflects the risk of rehospitalization after AHF?
Less than 10% are admitted within 10 days
10% of patients are readmitted within 30 days
30% of patients are readmitted within 60 days
20% of patients are readmitted within 6
months
SAVE AND PROCEED
 Which of the statements most accurately
reflects the risk of rehospitalization after AHF?
Your Peers Chose:
Less than 10% are admitted within 10 days
7%

10% of patients are readmitted within 30 days

30%

30% of patients are readmitted within 60 days

32%

20% of patients are readmitted within 6 months

31%
None
Espaol
Thought Leader Summary Discussion
Dr Mebazaa: It is very important to keep close
follow-up on patients once they are discharged
from the hospital. Thirty percent of patients
admitted to the hospital for AHF end up being
readmitted within the next 60 days. We need to
make sure that their therapy is optimized before
they leave the hospital and then closely follow
them as an outpatient. Some patients will still
end up being readmitted despite optimization of
therapy. It is important to emphasize to the
patient the importance of regular follow-up to
reduce their likelihood of being readmitted. [1,2]
 If in 2 to 4 weeks, the patient's dyspnea has not
improved, you may need to consider adding a
new class of medication, which combines a
neprilysin inhibitor with an angiotensin receptor
blocker (ARB). It is called sacubitril/valsartan.
The patient's angiotensin converting
enzyme (ACE) inhibitor must be discontinued
prior to the initiation of that new medication.
[4]
With the recent 2016 update of the European
Society of Cardiology (ECS) guidelines for
management of heart failure,
sacubitril/valsartan has a Class 1B indication in
symptomatic New York Heart Association
(NYHA) Class II-IV heart failure with reduced
ejection fraction, as a replacement for an ACE
inhibitor to further reduce the risk for HF
hospitalization and death in ambulatory
patients who remain symptomatic, despite
optimal treatment with an ACE inhibitor, a BB,
and an mineralocorticoid receptor antagonist
(MRA).[2] This recommendation was based on
results of the PARADIGM-HF trial.[5]
In summary, it is critical to treat AHF
immediately and aggressively. There should be
no delay due to diagnostic testing. The patients
should be routinely reassessed for
hemodynamic stability and triaged according to
the severity of their symptoms. They should be
admitted to determine the cause of their acute
episode and to optimize their medication
regimen. Prior to discharge, they should be
 hemodynamically stable and given appropriate
education in how to manage their disease. They
should follow up with their primary care
physician within 1 week of discharge and see
their cardiologist within 2 weeks of discharge.
Close follow-up is critical to reduce the
likelihood of readmission. A multidisciplinary
team approach is best in order to coordinate
care with psychosocial support and ongoing
patient education.[1,2]

This transcript has been edited for style and

clarity.
BACK
The questions you answered incorrectly are highlighted below.

1. When patients present in the emergency department with acute

heart failure (AHF), which of the following is most appropriate for early
intervention?

Answer: Admission to intensive care unit (ICU) for hemodynamic

instability
It is important to proceed with IV diuretics and vasodilators as needed
while the diagnostic testing is in progress. Use of CPAP is recommended
in initial respiratory distress as defined by oxygen saturation less than
90%; respiratory rate greater than 25/minute; and increased work of
breathing or orthopnea. It can even be started in the pre-hospital setting
 if proper training has taken place. If respiratory distress persists, CPAP
should be used in the presence of a normal pH and normal pCO 2.
Criteria for admission to ICU includes oxygen saturation less than 90%,
hemodynamic instability, heart rate below 40 or above 130, or presence
of a severe arrhythmia. ABGs may be helpful in some cases but are not
routinely drawn.

2. If sacubitril/valsartan is considered in the outpatient setting for

treatment of HF after optimal treatment with an angiotensin converting
enzyme (ACE) inhibitor, beta blocker (BB), and mineralocorticoid
receptor antagonist (MRA), all of the following factors are important to
consider except:

Answer: The patient should have a preserved ejection fraction

With the recent 2016 update of the European Society of Cardiology
(ESC) guidelines for management of HF, sacubitril/valsartan has a Class
1B indication in symptomatic New York Heart Association (NYHA) Class
II-IV heart failure with reduced ejection fraction, as a replacement for an
ACE inhibitor to further reduce the risk for HF hospitalization and death
in ambulatory patients who remain symptomatic, despite optimal
treatment with an ACE inhibitor, a BB, and an MRA. According to
prescribing information, the ACE inhibitor or angiotensin receptor blocker
(ARB) should be stopped 36 hours prior to starting sacubitril/valsartan
and the patient's systolic blood pressure should be 100 mmHg.

Proceed to Evaluation