Congestive Heart Failure
Congestive Heart Failure
CHF is a complex disease. MOST CHF exacerbations warrant admission. Occasionally, mild CHF can be cared for in the CDU.
Known prior history of CHF
Patients with systolic failure must already be established on GDMT:
Long acting Beta Blocker (E.g. Metoprolol Succinate)
Mineralocorticoid Receptor Antagonist (E.g. Spironolactone)
Angiotensin Receptor Neprilysin Inhibitor (E.g. Sacubitril/Valsartan)
SGLT-2 Inhibitor (e.g. Empagliflozin)
Normal EKG or unchanged from baseline
Initial cardiac enzymes non-critical or unchanged from baseline.
No more than 10 lbs / 5 kg above "dry weight".
O2 Sat > 90% on Room Air or baseline O2 requirement
Creatinine < 2 or at baseline
Normal CXR or mild to moderate vascular congestion or small pleural effusions
Ensure adequate home support to be discharged within 24 hours
NYHA classification of I to II
Systolic blood pressure > 100mm Hg
New onset heart failure
Clear evidence of severe volume overload that requires more than 24hr of diuresis
Patient with systolic failure who is not yet on GDMT
Requirements for continuous vasoactive medication to stabilize hemodynamics (nitroglycerine, nitroprusside, dobutamine, milrinone).
Acute ischemia (Concern for ACS )
New arrhythmias
Unstable vital signs after initial treatment in ED
Patients requiring Positive Pressure ventilation (CPAP or BiPAP)
Abnormal labs- severe anemia with HGB < 8, new renal insufficiency/AKI/CKD (creatinine > 2 mg/dL), hyponatremia (Na<130)
Evidence of poor perfusion (AMS, cool extremities, weakness, nausea and vomiting)
Unsafe home environment for discharge after observation
Comorbidities: ESLD, hx of transplant, EF< 30%, ESRD
Severe Aortic stenosis with valve area < 1.0 cm
Cardiac monitoring
Fluid restriction
Low sodium diet
Medications
If Furosemide naïve: Furosemide IV (40 mg Q6 hours x 2 doses or Bumetenide 2 mg IV Q12 hours.
If taking furosemide as outpatient: order same dose as outpatient but as IV. As an example if a patient is taking a home dose of 80 mg Furosemide PO BID, then order Furosemide 80 mg IV BID
Consider one time dose of Acetazolamide 500 mg IV with first dose of Furosemide.
Continue home dose of beta blocker
Continue home ACE/ARB or ARB/Neprilysin inhibitor unless SBP < 100
Continue home SGLT-2 Inhibitor, if not already taking, could consider starting in CDU after discussion with cardiology
Continue home Mineralocorticoid Receptor Antagonist unless hyperkalemia > 5.0
SL Nitroglycerine prn
Labs
Serial hsTroponin x 2
Digoxin level if patient on medication
BMP Q12 hours x 2 after initial dose of Lasix/IV diuretic
Other Studies
Obtain echocardiogram if not completed in previous 1 year or if none on record
Nursing Tasks
Strict I/Os
Daily weight
Consults
Cardiology consult as needed
Disposition
Subjective improvements – no chest pain, no DOE above baseline, no orthopnea
Acceptable vital signs (oxygen saturation at baseline or > 90% on RA or if on chronic oxygen)
Negative cardiac markers or changes in EKG from baseline
Evidence of adequate diuresis > 1 liter of urine, decrease in weight, decrease in jugular venous distention (JVD)
New Ischemic EKG changes, arrhythmia, abnormal cardiac markers or evidence of ischemia
Persistent hypoxia (Sats < 90%), rales or dyspnea
Failure to improve subjectively and not at baseline
Failure to adequately diurese and/or worsening renal function
New systolic dysfunction or severe valvular disease on echo (if repeated)
Cardiology requesting further evaluation and treatment