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Use of diuretics and other decongestion modalities in patients presenting with acutely decompensated heart failure and volume overload

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Clinical scenario

Patient
64 year-old male

Presentation
- Over the last month gradually deteriorating exertional dyspnoea, now at minimal exertion, paroxysmal nocturnal dyspnoea, orthopnoea, lower limb oedema up to upper thighs, reported body weight gain of 11 kgs over the last month.
- The patient increased his oral furosemide to 80 mg BD two weeks ago (from 40 mg BD) after telephone contact with his GP but with no clinical improvement.
- He does not report having palpitations, chest pain, fever, poor blood pressure control or poor compliance.

Medical History
- HFrEF (last known EF 30%)
- Ischaemic cardiomyopathy
- Chronic kidney disease (last known Creatinine 140 μmol/L-1.58mg/dl)
- Hypertension
- Dyslipidaemia
- Gout
- Ex-smoker

Previous medication
Carvedilol 25 mg BD
Sacubitril/valsartan 97/103 mg BD
Spironolactone 25 mg OD
Furosemide 80 mg BD
Αtorvastatin 40 mg ON
Αllopurinol 100 mg OD
Aspirin 75 mg OD
Omeprazole 20 mg OD

Clinical examination at presentation
BP:100/70 mmHg, HR: regular, 115 bpm, sPO2: 95% on room air, Respiratory rate: 28/min
Lungs: bilateral crackles basal and mid zones
HS 1+2
JVP: elevated
Periphery: lower extremity pitting oedema up to the upper thighs
Weight: 102 kgs (baseline 91 kgs)
ECG: sinus tachycardia, QS I, aVL, V2-V6, QRS=80msec, no signs of ischaemia
CXR: increased cardiothoracic ratio, bilateral pleural effusions, perihilar congestion
Bloods: Cr 186 μmol/l (2.1mg/dl), Na 139 mmol/l, K 4.7 mmol/l, Hs-troponin T 133 pg/ml (ULN 14 pg/ml), NT-pro-BNP: 15,038 pg/ml

2.Are you aware of different phenotypes of acute heart failure?
Check only one
3.What phenotype of acute heart failure would this patient fall into?
4.How many patients with this similar presentation have you treated in the last month?
5.When would you first be involved in this patient’s care after the initial presentation to ED?
6.Which diagnostic modalities are you using in your clinical practice to diagnose congestion?
7.On which diuretic regime would you start this patient?
8.What non-pharmacological management options would you consider (select all that apply)?
9.At this point, what changes to his regular medications would you make?
No change
Decrease
Increase
Discontinue
Carvedilol 25 mg BD
Sacubitril/valsartan 97/103 mg BD
Spironolactone 25 mg OD
Αtorvastatin 40 mg ON
Αllopurinol 100 mg OD
Aspirin 75 mg OD
Omeprazole 20 mg OD
10.The patient has lost 0.5kg weight over the last 24 hours, creatinine 186 μmol/l (2.1mg/dl), BP remains unchanged and patient is well perfused. What would you do next?
11.Based on previous question, what weight loss would you target over a 24 hour period?
12.The next day the patient achievs the desired weight loss, but remains clinically congested with an increase in creatinine to 210 μmol/L (2.4mg/dl) from 186 μmol/L. BP remains stable. What would you do?
13.The following day (day 3), the patient remains clinically overloaded and the weight has not dropped. What would you do? (select all that apply)
14.How do you assess diuretic response in a patient with decompensated heart failure?
15.How common is it in your practice to measure urinary spot sodium?
16.Which strategy for decongestion are you using in clinical practice to safely discharge a HF patient?
17.When do you consider your patient “stabilised”?
18.When would you refer this patient to HF service?
19.Do you feel confident in managing patients with acute decompensated heart failure?
20.Does your hospital have a protocol for managing patients hospitalised with heart failure?
21.Are you aware of any international guidelines on managing patients with HF and congestion?
22.Are you aware of any national guidelines on managing patients with HF and congestion?
23.What is your specialty?
24.Grade / Years of internal medicine experience
Less than 1 year
1-3 years
4-5 years
More than 5 years
Practicing physician
Trainee/Resident
25.Grade / Years of cardiology experience
Less than 1 year
1-3 years
4-5 years
More than 5 years
Practicing physician
Trainee/Resident
26.Country of practice
27.City of practice
28.Type of hospital
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