Heart Failure Management with Dr. Brandon Varr

Dr. Brandon Varr, an advanced heart failure and transplant cardiologist, provides insight into how heart failure is managed by diuretics and whether or not fluid restriction is important. 

Heart Failure (HF) Refresher

Heart Failure (HF) simple means that the heart is not pumping enough blood to adequately supply organs.

• Body’s “Short Term Fix”: Kidneys sense that there is not enough blood → salt retention to expand fluid volume in body
• Long Term effect of above “Short Term Fix”: Fluid retention → congestion, breathing discomfort, edema 

TYPES OF DIURETICS (MAIN 4):

1. Loop 
   • “Workhorse” or most commonly known diuretic known time and time again for their effectiveness and safety
   • Furosemide (Lasix) is the most commonly used loop diuretic in the hospital. Bumetanide (Bumex) is also used.
2. Thiazide 
   • Adjunct (aka booster) therapy to loop diuretics in HF (ie augments the effects of loop diuretics when a loop diuretic is not producing the desired effects)
3. Potassium Sparing (Aldosterone Antagonists)
   • Another adjunct diuretic. Notably, as its name implies, does not lower serum potassium levels
   • Per Dr. Varr, this class of medication is often under-dosed or not given when could be beneficial to stabilize serum potassium levels
   • Most common: Spironolactone (Aldactone)
4. Other
   1. Vasopressin inhibitors
      • Reserved for patients who are experiencing significant hyponatremia
   2. SGLT2 Inhibitors 
      • (-FLOZIN) Ex: Empagliflozin 
      • Per Dr. Varr: Upcoming blockbuster agent because it not only provides diuresis but also increases cardiac efficiency
   3. Angiotensin Receptor Neprilysin Inhibitor (ARNI) 
      • Ex: Entresto

Holding Parameters

How much do diuretics influence BP?

• Concerned more with combo diuretic therapy with thiazide
• Loop and aldosterone antagonists with modest effects

When are we justified in holding on diuretics?

• Hypotension due to hypovolemia
• Hypotension with symptoms
• Severe electrolyte derangements

Important Take-Aways

Think critically as to WHY your patient is here in the hospital. For example, a decompensated HF patient is in the hospital to lose weight, salt, and take aggressive diuretics to help them feel better. 

If a patient is hypotensive, look at their meds and think about which medication to hold (usually NOT the diuretic). Consider adjusting BP meds before holding a diuretic.

Nurses should hold other BP meds before holding diuretics if patient is hospitalized for fluid overload

Fluid Restrictions

• Think about patient’s quality of life and patient happiness when it comes to fluid restriction. 
• Drinking tap water (1800 – 2200 ccs) will not be hugely impactful on HF management, but can be for their quality of life.
• Keeping people on fluid restrictions as they are nearing their dry weight can lead to adverse effects → low BP, dehydration, worsening kidney function 

I&Os v. Os & Weight

I think that strict intakes are just complete waste of time, from a general telemetry floor level patient who’s getting Lasix BID and responding. What I’m more concerned with is how much urine came out that day, what was their weight yesterday and what was their weight today on the same scale standing up in the morning? Those are the most useful things to me is their overall urine output for the day and how much weight they’ve gained or lost.
Dr. Brandon Varr

• More useful: Overall output for day and daily weights