Links To And Excerpts From “5 Pearls On Inpatient Heart Failure” From CoreIM

This post is in progress. As I reviewed this outstanding  podcast and show notes, a number of additional topics came up for me to review (which I will be doing soon):

In this post I link to and excerpt from 5 Pearls On Inpatient Heart Failure From CoreIM Posted: June 24, 2020
By: Dr. Michael Dunleavy, Dr. Shreya P. Trivedi, Dr. Greg Katz, Dr. Swapnil Heremeth, Dr. Ayesha Hasan, Dr. Zaven Sargsyan, Dr. Michelle Kittleson and Dr. Martin Fried
Graphic: Dr. Cathy Cichon
Audio: Solon Kellaher
Peer Review: Dr. Eugene Yurditsky, Dr. Stephan Pan

Here are direct links to different parts of the show notes:

Here are excerpts:

Time Stamps

  • 03:17 Clinical Assessment of HF exacerbation
  • 10:09 Labs in HF
  • 17:14 Home medications
  • 22:12 Adjusting diuretics
  • 28:43 Additional Volume Removal
  • 38:09 Expert Recap

See Cardiorenal Syndrome: Classification, Pathophysiology, Diagnosis, and Treatment Strategies: A Scientific Statement From the American Heart Association. Originally published 11 Mar 2019 Circulation. 2019;139:e840–e878

More excerpts from show notes:

Show Notes

Heart Failure (HF) exacerbation is a clinical syndrome (collection of signs and symptoms) due to elevated intracardiac filling pressures leading to vasoconstriction and/or volume retention.

Pearl 1: Initial clinical assessment 

  • Blood pressure:
  • Heart Rate:
    • Tachycardia could be a sign of shock, but if beta-blockers are on board, they can prevent this physiologic response. A normal heart rate does not rule out shock in a heart failure patient.
  • Jugular venous distention/pulsation*
    • *I have great difficulty using the physical exam methods detailed in the articles on determining JVD by physical exam. I will be investigating the use of POCUS as this method seems like it might be better than physical exam.
    • Used to determine the intracardiac filling pressure, which is a marker for LV preload
    • 2 ways to check:
    • Tricuspid regurgitation can cause JVD elevation in the absence of elevated cardiac filling pressures
    • Need to differentiate between atrial and venous when assessing JVD
      • Check the radial pulse. Venous pulsation should result in two upstrokes for every pulsation in the wrist. If it correlates 1:1, it may be arterial.
      • JVP should have increased fullness of the pulsation when applying abdominal pressure

Pearl 2: Initial lab workup 

  • BNP
    • Elevated BNP (>1000) supports HF diagnosis, and <100 makes CHF less likely
    • BNP of 350 has a likelihood ratio of 1 in one study
    • Assess the trend. Some factors increase or decrease the BNP
  •  Troponins
    • Particularly for patients with impending shock or shock or if any clinical symptoms concerning of acute coronary syndrome as a culprit of decompensated heart failure
    • In patients with an acute MI who developed cardiogenic shock, early revascularization lowers 6 month mortality 
  • Sodium
    • Low Na on admission is a predictor of both all-cause mortality and cardiovascular mortality for patients admitted with a heart failure exacerbation
    • A drop in sodium levels of >3 mEq/L was associated with increased mortality
    • Risk of death was particularly  worse for Na <125 in heart failure exacerbations
  • Creatinine



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