AVR RVR – MEDICATION – DOING
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– DILTIAZEM
– 1st bolus 0.25mg/kg IV (avg 20mg) over 2 min
– 2nd bolus 0.35mg/kg IV (avg 25mg) over 2 min if needed
– GTT IV start 5-10mg/hr post-bolus, max 15mg/hr
– PO dosing
– IR: 30mg QID, up to 120-480mg/day
– ER: 120mg QD or BID, up to 120-480mg/day
– ESMOLOL
– Rapid IV Titration
– 500 mcg/kg loading dose IV over 1 min, followed by 50 mcg/kg/min infusion
– Increase to 100 mcg/kg/min, 150 mcg/kg/min, up to 200 mcg/kg/min with
reassessment Q4min
– Slow IV Titration
– Start at 50 mcg/kg/min, incr. by 50 mcg/kg/min every 30 min
to max of 200 mcg/kg/min
– VERAPAMIL
– IV Bolus
– 5-10 mg IV over 2-3 min, repeat every 15-30 min as needed
– IV Infusion
– Start at 5 mg/hr, titrate to max of 20 mg/hr
– PO
– IR: 40mg TID-QID, up to 480mg/day
– ER: 120-180mg QD, up to 480mg/daY
– METOPROLOL
– IV Bolus
– 2.5-5 mg IV over 2 min, repeat up to total of 15 mg
– PO
– IR (tartrate): 25mg BID, up to 100mg BID
– ER (succinate): 50mg QD, up to 400mg QD
– PROPRANOLOL
– IV Bolus
– 1 mg IV over 1 min, repeat for up to 3 doses
– PO
– IR: 10mg TID-QID, up to 40mg TID-QID
– ER: 60mg QD, up to 160mg QD
– DIGOXIN
– IV/PO TDD
– 0.25-0.5mg over 3 min, followed by 0.25mg Q6hrs to total of 0.75-1.5mg
– Maintenance Dose
– 0.125-0.25mg QD post-TDD
– AMIODARONE
– IV Loading Dose
– 150mg IV over ≥10 min, followed by 1 mg/min for 6 hours, then 0.5 mg/min for 18 hours; repeat 150mg boluses as needed
– Post-Infusion/PO
– 400-1200mg/day divided, total ~10 grams; overlap IV and PO for 24-48 hours
– Maintenance: 100-200mg QD
# Acute-on-chronic CHF exacerbation
# HF w/ preserved EF (HFpEF) w/ LVEF >50%
– On presentation to ER ( #### ), patient endorsed worsening dyspnea on exertion, orthopnea, and PND
– Initial exam finding (1) B/L LE edmea, (2) crackles, (3) S3 sound on auscultation
– Initial CXR ( #### ) finding B/L pulmonary edmea
– BNP ( #### ):
– First diagnosed w/ CHF ####
– Last echo ( #### ): LVEF >50%
– NYHA Class I- no symptomatic limitation of physical activitiy
– NYHA Class II- slight limitation of physical activitiy (e.g. dyspnea w/ climbing stairs)
– NYHA Class III- marked limitation of physical activitiy (e.g. dypsnea w/ house chores)
PLAN
– (1) diuresis for volume overloaded patient w/ furosemide, fluid output goals 100-150 mL/hr (1-1.5 L/day), fluid restrict to 1.5L QD
1. – furosemide 20mg PO once and titrate to effective dose (if UOP <200mL in 2hrs)
1. – furosemide 40mg PO
1. – furosemide 20mg IV
1. – furosemide 40mg IV
1. – furosemide max effective single dose 80-200mg; MEDD 600mg/day
1. – furosemide IV GTT 5mg/hr titrate to effective dose (if UOP <200mL in 2hrs) –> 10mg/hr —> up to 40mg/hr
2. Hourly UOP goal ( ### mL/hr ) [100-150 mL/hr]
3. Daily UOP goal ( ### L/day) [1-1.5 L/day]
4. Fluid restriction to ### L QD [1.5 L QD]
5. Electrolyte monitoring/repletion in setting of diuresis (Mg to 2, K to 4, Phos to 3)
– (2) Initiate SGLT2 inhibitor (empagliflozin 10mg QD) w/ plan to initiate ACE in 2-weeks if well-tolerated
– (3) ACE lisinopril 2.5mg 5mg QD
# Acute-on-chronic CHF exacerbation
# HF w/ mildly reduced EF (HFmrEF)
– On presentation to ER ( #### ), patient endorsed worsening dyspnea on exertion, orthopnea, and PND
– Initial exam finding (1) B/L LE edmea, (2) crackles, (3) S3 sound on auscultation
– Initial CXR ( #### ) finding B/L pulmonary edmea
– BNP ( #### ):
– First diagnosed w/ CHF ####
– LVEF 41-49%
– Last echo ( #### ):
– NYHA Class I- no symptomatic limitation of physical activitiy
– NYHA Class II- slight limitation of physical activitiy (e.g. dyspnea w/ climbing stairs)
– NYHA Class III- marked limitation of physical activitiy (e.g. dypsnea w/ house chores)
PLAN
GDMT Initial optimized therapy (diuresis, ARNI, beta-blocker)
– (1) diuresis for volume overloaded patient w/ furosemide, fluid output goals 100-150 mL/hr (1-1.5 L/day), fluid restrict to 1.5L QD
1. – furosemide 20mg PO once and titrate to effective dose (if UOP <200mL in 2hrs)
1. – furosemide 40mg PO
1. – furosemide 20mg IV
1. – furosemide 40mg IV
1. – furosemide max effective single dose 80-200mg; MEDD 600mg/day
1. – furosemide IV GTT 5mg/hr titrate to effective dose (if UOP <200mL in 2hrs) –> 10mg/hr —> up to 40mg/hr
2. Hourly UOP goal ( ### mL/hr ) [100-150 mL/hr]
3. Daily UOP goal ( ### L/day) [1-1.5 L/day]
4. Fluid restriction to ### L QD [1.5 L QD]
5. Electrolyte monitoring/repletion in setting of diuresis (Mg to 2, K to 4, Phos to 3)
– (2) Initiate ACE/ARB/ARNI on day 2-3 of diuresis
– (3) Beta-blocker (carvedilol CR 10-80mg QD) (metoprolol succinate ER 12.5mg25mg-200mg QD), with outpatient titration 2-4 weeks
– GDMT Step 2 NYHA II-IV w/ LVEF <35% : aldosterone antagonist (spironolactone)
– GDMT Step 3 NYHA III-IV: SGLT2 inhibitor (empagliflozin 10mg QD)
– CHF supplementary agents for refractory symptoms:
– isosorbide dinitrate + hydralazine
– digoxin
# Acute-on-chronic CHF exacerbation
# HF w/ reduced EF (HFrEF) w/ LVEF <40%
– On presentation to ER ( #### ), patient endorsed worsening dyspnea on exertion, orthopnea, and PND
– Initial exam finding (1) B/L LE edmea, (2) crackles, (3) S3 sound on auscultation
– Initial CXR ( #### ) finding B/L pulmonary edmea
– BNP ( #### ):
– First diagnosed w/ CHF ####
– Last echo ( #### ): LVEF <40%
– NYHA Class I- no symptomatic limitation of physical activitiy
– NYHA Class II- slight limitation of physical activitiy (e.g. dyspnea w/ climbing stairs)
– NYHA Class III- marked limitation of physical activitiy (e.g. dypsnea w/ house chores)
– NYHA CLass IV- inability to perform any physical activitiy w/o significant discomfort
– Last BNP ( #### ):
PLAN
GDMT Initial optimized therapy (diuresis, ARNI, beta-blocker)
– (1) diuresis for volume overloaded patient w/ furosemide, fluid output goals 100-150 mL/hr (1-1.5 L/day), fluid restrict to 1.5L QD
1. – furosemide 20mg PO once and titrate to effective dose (if UOP <200mL in 2hrs)
1. – furosemide 40mg PO
1. – furosemide 20mg IV
1. – furosemide 40mg IV
1. – furosemide max effective single dose 80-200mg; MEDD 600mg/day
1. – furosemide IV GTT 5mg/hr titrate to effective dose (if UOP <200mL in 2hrs) –> 10mg/hr —> up to 40mg/hr
2. Hourly UOP goal ( ### mL/hr ) [100-150 mL/hr]
3. Daily UOP goal ( ### L/day) [1-1.5 L/day]
4. Fluid restriction to ### L QD [1.5 L QD]
5. Electrolyte monitoring/repletion in setting of diuresis (Mg to 2, K to 4, Phos to 3)
– (2) Initiate ACE/ARB/ARNI on day 2-3 of diuresis
– (3) Beta-blocker (carvedilol CR 10-80mg QD) (metoprolol succinate ER 12.5mg25mg-200mg QD), with outpatient titration 2-4 weeks
– GDMT Step 2 NYHA II-IV w/ LVEF <35% : aldosterone antagonist (spironolactone)
– GDMT Step 3 NYHA III-IV: SGLT2 inhibitor (empagliflozin 10mg QD)
– CHF supplementary agents for refractory symptoms:
– isosorbide dinitrate + hydralazine
– digoxin