1. What is the relative risk reduction of ACEi’s/beta blockers for HFrEF?
CHF Exacerbations
C.L.I.P.S.
What is it?
Structural/functional impairment of ventricular filling or ejection of blood
HFrEF: EF ≤40%, HFpEF: EF ≥50%, HFpEF borderline: EF 41-49%
Exacerbation = New or worsening signs/symptoms of HF (ie acute dyspnea/volume overload)
What causes it?
New onset versus chronic CHF with acute decompensation
Med noncompliance, diet, acute infection, ACS, thyroid abnormalities, uncontrolled HTN, cardiomyopathies, valve disease, arrhythmias
What will it look like?
History: Progressive Dyspnea, abdominal/peripheral congestion
Exam: JVD, hepatojugular reflux, peripheral edema, pulmonary crackle, S3, hypertensive emergency, cardiogenic shock
Who makes these recommendation? ACCF/AHA/NYHA
How do we work up?
ABCs – stable?
Focused H&P
Labs: CBC, UA, electrolytes (Ca, Mg, PO4), BNP, BUN, Cr, glucose, TSH (Heart failure power plan) – case specific: screening for hemochromatosis, HIV, troponin, fasting lipids, LFTs, lactate
Studies: EKG, CXR, TTE, pulmonary POCUS? (pulm edema)
GDMT:
What is the relative risk reduction of ACEi’s/beta blockers for HFrEF?
ACEI 20%
Beta Blocker 31%
Carvedilol
Metoprolol XL
Bisoprolol
Updated 4/2/2018

2. In HFrEF, do we continue beta blocker during ADHF?
CHF Exacerbations
C.L.I.P.S.
In HFrEF, do we continue beta blocker during ADHF?
Mild– yes
Moderate – yes, can decrease 50%
Severe – decrease by 50% versus D/C if hypotension, bradycardia, need for inotropes
Abrupt discontinuation = increased mortality
What do we do?
HEART FAILURE POWER PLAN (HFPP)
DVT ppx
Cardiac monitoring, I/Os, daily weights, fluid restrict (2L) – on HFPP
Heart Failure Society of America recs: identify etiology, treat fluid overload, optimize volume status, optimize chronic meds, address precipitating factors, minimize med side effects
Which Diuretics do we use to optimize volume status?
Loop Diuretics: Lasix IV, Bumex IV, Ethacrynic Acid IV
Doses: Lasix naïve – start with 20mg IV and inc until adequate response, h/o Lasix use – ≥ PO dose, adjust PRN for response
Lasix 40mg = Bumex 1mg = Ethacrynic acid 50mg
Goal: >1L UOP in first 3-4 hrs
Hospital Discharge
Repeat H/H, BNP
“Guideline-Directed Medical Treatment” (GDMT) – ACEi and/or beta blocker
1 week follow-up, PHQ9, cardiac rehab referral, heart failure education, self care
Med Rec with Cards Pharmacist