The Curbsiders Internal Medicine Podcast

REBOOT #230 Kittleson Rules Heart Failure

15 snips

Aug 30, 2021

Dr. Michelle Kittleson shares insights on managing acute decompensated heart failure, discussing jugular venous pressure exams, diuresis, and hospital discharge. Other topics include book recommendations, evaluation and diagnosis of heart failure, diuretic dosing, and interventions in heart failure prevention.

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ADVICE

Tachycardia Signals Severity

Treat tachycardia as a concerning sign in heart failure.
Recognize atrial fibrillation with rapid ventricular response as an indicator of underlying problems.

ADVICE

Limited Role of BNP

Check BNP cautiously; do not rely on it alone to diagnose heart failure.
Avoid serial BNP testing to guide inpatient therapy.

ADVICE

Essential Labs to Monitor

Prioritize daily labs of sodium, potassium, and creatinine for heart failure admissions.
Use these labs to monitor risk and adjust therapy.

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Does the thought of managing acute decompensated heart failure (ADHF) give you paroxysmal nocturnal dyspnea? Recline for a bit while Dr. Michelle Kittleson MD, PhD @MKittlesonMD (Cedars Sinai) takes us through the Zen of jugular venous pressure (JVP) exams, how to approach diuresis, and the fine points of hospital discharge. This knowledge food is easier to swallow than an oral potassium replacement. Enjoy this Curbsiders classic and stay tuned this Wednesday, September 1, 2021 for a brand new CHF Triple Distilled episode.

Credits

Written and Produced by: Deborah Gorth ScM
Cover Art and Infographic by: Edison Jyang
Hosts: Matthew Watto MD, FACP and Paul Williams MD, FACP
Editor: Cyrus Askin MD (written materials); Clair Morgan of nodderly.com
Guest: Michelle Kittleson MD, PhD

Sponsor: Ten Thousand tenthousand.cc

Head to tenthousand.cc and enter our code CURB at checkout to save 15%.

Sponsor: BetterHelp betterhelp.com/curb

Special offer for Curbsiders listeners: get 10% off your first month at betterhelp.com/curb

Time Stamps*

Time Stamps refer to ad-free version

00:00 Intro, disclaimer, guest bio
02:40 Guest one-liner; Picks of the Week
08:33 Case from Kashlak part 1, Definition of acute decompensated heart failure (ADHF), Factors that lead to ADHF (FAILURE mnemonic)
13:39 Historical clues for ADHF; Is salt restriction needed? Fluid restriction?
20:42 More on History and Physical exam for ADHF; JVP exam in detail; Crackles are worthless?!
28:36 Labs to trend during an ADHF admission
33:15 Recap of history, physical exam, and initial approach; Initiating diuresis; Goal urine output; Diuresis in HFrEF vs HFpEF phenotypes
45:32 Diuretic resistance and when to use a drip, metolazone; Do K and Mg need to be 4 and 2?
49:05 When to hold guideline directed medical therapy (Beta blockers, ARNI, ACEI/ARB)
56:05 Who needs a right heart cath?
59:30 Endpoints for discharge; Switch to PO diuretics; Approach to discharge and transitions of care
64:04 SGLT2i in heart failure 
68:15 Take home points and outro