Acute Decompensated Heart Failure Hospitalization

In this segment, Sheryl Chow, PharmD, BCPS; Akshay Desai, MD; Peter L. Salgo, MD; and Scott Solomon, MD, review the typical workup for patients who are admitted to the hospital with acute decompensated heart failure.

Peter L. Salgo, MD: This is a very large waterfront that we’re attempting to cover. There are interesting new drugs, impressive research, and recommendations that we change therapy for people that are on previous therapy. We can do better for them. Now, we find a patient with acute heart failure, and I guess this would be reduced-ejection fraction heart failure. What is a typical workup by a primary care physician, or you guys, for somebody with acute heart failure? Where do we start?

Akshay Desai, MD: I think the first question is, where are you? Many of the circumstances were either in, or out, of the hospital, and I think there’s a slightly different pathway for patients who present sick, acutely, in the hospital. But for the most part, what we’re trying to do is figure out, why now? What precipitated the heart failure? If it’s low-ejection fraction heart failure, one question is, “How did you get there?” And we walk through the differential diagnosis that Scott gave us, which is, is there coronary artery disease since that is a critical cause? Is there uncontrolled hypertension? Does the patient have other risk factors? Is there a family history? Once we walk through the etiologies, then we can decide what’s likely in this patient. And then we can begin the diagnostic workup. I think once you’ve made the diagnosis, then we need to think through the therapy.

Peter L. Salgo, MD: If you’ve established the diagnosis of acute heart failure, does it matter how you got there? Do the drugs that you prescribe, the therapy you’re going to initiate, does that really depend upon the etiology of the heart failure once the heart failure is established?

Scott Solomon, MD: Well, yes and no. As we’ve alluded to, if you find out that a patient has heart failure because of coronary disease, then the first thing you want to do is treat the coronary disease. You want to make sure that the patient is properly revascularized. You don’t want active ischemia in a patient with heart failure. If it’s valvular disease, for example, you want to address those issues, potentially. But one of the things about heart failure with reduced ejection fraction (HFrEF) is there is a final common pathway that tends to respond (no matter what the etiology is) to pretty much the same therapies with, maybe, the exception of CRT which is useful particularly in patients with left bundle branch block, wide QRS, electrical disease.

Peter L. Salgo, MD: CRT is?

Scott Solomon, MD: Cardiac resynchronization therapy.

Akshay Desai, MD: Biventricular pacing.

Peter L. Salgo, MD: But again, that’s almost a mechanical answer, with electrodes and pacing. In terms of pharmacology, with the exception of resynchronizing patients, once you’ve gotten at the etiology, in the sense that you’d rather not have wide open MRA (mineralocorticoid receptor antagonist) or really tight AS and you’d rather not have a 90% occlusion of the LAD (left anterior descending) artery, because these are bad things and you want to fix them, you’re still left with a patient with heart failure. At that point, are all-comers the same?

Sheryl Chow, PharmD, BCPS: Well, initially when you’re acutely presenting, you’re going to present the same way whether you have HFpEF (heart failure with preserved ejection fraction) or HFrEF, and you want to treat according to the acute presentation. But once the patient stabilizes, that’s when things really change, dramatically. The HFrEF strategy completely changes. You put them on all those chronic heart failure medications that we talked about earlier.

Peter L. Salgo, MD: Again, HFpEF, for the non—heart failure expert doctors out there who all have to treat heart failure, is preserved ejection fraction and rEF is reduced ejection fraction.

Scott Solomon, MD: It’s really important to make this distinction because, as Sheryl mentioned, when patients present with acute decompensated heart failure, we treat them, in many ways, the same. We essentially use diuretics acutely. We don’t have very good therapies, unfortunately, for acute decompensated heart failure. There is no magic bullet, yet, that we have for this disorder. But once you do stabilize a patient and you figure out if they’re in this “under 40” or “over 40” ejection fraction category, we do have a lot of options for the “under 40” patients. For “over 40,” we’re unfortunately in a much tighter place because there is no evidence-based therapy, as of yet.

Akshay Desai, MD: But essentially, the workup for almost all patients (because of these issues) has to begin with a clinical exam, a history, an echocardiogram, and, in most cases, some assessment for coronary disease in patients at risk.

Peter L. Salgo, MD: Would there be any time you wouldn’t look for coronary disease? Why wouldn’t you?

Akshay Desai, MD: In a 20-year-old or in a young patient who doesn’t really have risk factors for coronary artery disease, then the differential is weighted toward familial causes or congenital causes or valvular causes. And in those populations, we don’t necessarily suspect coronary disease quite as much.

Peter L. Salgo, MD: Again, these are inpatients. These are folks who, if you will, caught heart failure and they got sick and they’re in the hospital and you’re working them up. You’re going to go through the etiology and then you’re going to go through, if I hear you correctly, the physiology that presents to you, whether its heart failure or reduced ejection fraction, and whether it’s above or below 40% (40% being kind of a magic number). And then you’re going to have to decide what to do about it.