Matthew F. Watto, MD: Welcome back to The Curbsiders. I'm Matthew Watto, here with my greatest friend, Dr Paul Williams. Paul, tell us what we are going to do on this short video.
Paul N. Williams, MD: We're going to highlight some of our favorite clinical pearls and practice-changing knowledge that we gleaned from a recent interview with the amazing Dr Michelle Kittleson, a renowned cardiologist, heart failure expert, and Twitter phenom. We had a long conversation about the inpatient management of acute decompensated heart failure, and we thought we'd spend a little time in this video talking about the things that we liked best from that discussion.
Watto: Pearl number one. She made it pretty easy on the physical exam. What she cares about is elevated jugular venous pressure or pulsations, and she looks for lower-extremity edema. She gave us permission not to listen to the lungs. She doesn't really care about crackles because they are very nonspecific.
When it comes to the labs, you can check the B-type natriuretic peptide (BNP) once if you are making the diagnosis of heart failure, but it shouldn't be trended. The things you should trend are sodium, potassium, and creatinine levels. Those are the important labs that have some prognostic value. With potassium you just have to make sure it's high enough so that the patient doesn't code on you.
Williams: Tremendous advice. I made a half-hearted defense of the lung examination, but I was scared of her so I didn't really lean too hard into it. Another point that came from a nice conversation the two of you had was about precipitants of heart failure exacerbation and whether we should be blaming the patient for the exacerbation, in terms of things like medication or diet nonadherence. I liked her take on this, which was, you really aren't duty-bound to look for precipitants, whether that's an acute ischemic event or medication nonadherence, either because they couldn't afford the medication or any of the other reasons patients might not have access to them.
You need to look and examine for those problems because they are reversible. But she also made the point that if patients are doing everything right and they still have acute decompensated heart failure, that's a pretty bad prognostic indicator.
Watto: I loved that point. It can't be said enough that when you read notes, people are clearly blaming the patient for their exacerbation. Sometimes the patient might have been able to avoid it, but a lot of times, it's just progression of disease. And I really liked what she said about fluid and salt restriction.
Williams: Her point was that there is no point to mercilessly restricting fluid and salt in the inpatient setting. If you can't control someone's volume status when they are on 2 g of sodium and 2 L of fluid daily, it doesn't matter how much more you restrict them at that point. You need to adjust their diuretic to optimize them. There's no point in relentlessly controlling fluid and sodium intake because you aren't going to significantly impact the volume status that way. It has to be done with medications at that point.
Watto: She even implied that the physician ordering the very restrictive diet should be put on the same diet. I like that point.
Williams: She didn't imply it; she outright said it.
Watto: That's right. She was not mincing words.
Finally, there was one other pearl that I thought was really great and very important, because I see this all the time. When a patient comes into the hospital, we should not just automatically pull off the ACE inhibitor or the beta-blocker. The guideline-directed medical therapy should be continued if you can do it — if there's room in the blood pressure.
She talked about spending the blood pressure. In her practice (and we're talking about systolic heart failure here), she prioritizes the ACE inhibitor, the ARB, or these new angiotensin receptor–neprilysin inhibitor (ARNi) compounds. Those would be her first agents that she would keep the patient on if she could. The next agent she would try to prioritize is the beta-blocker. You really should have a higher threshold to stop those agents because patients will do better, and we speculate that they might not get restarted when the patient is discharged from the hospital. It's really best to leave them on if you can safely do so.
Williams: That's exactly right. Prioritizing the ARNi over the beta-blocker feels like such a paradigm shift in recent years. It was fascinating to have that discussion.
Those are just a few nuggets of goodness from a wide-ranging conversation. If you want to hear the whole podcast (and you should), just click on the link below. You can also subscribe to our show to get our weekly episodes, and you can get a free PDF copy of our show notes and infographics at thecurbsiders.com.
The Curbsiders is a national network of students, residents, and clinician educators from across the country, representing 15 different institutions. They "curbside" experts to deconstruct various topics in the world of medicine to provide listeners with clinical pearls, practice-changing knowledge, and bad puns. Learn more about their contributors and follow them on Twitter.
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Cite this: Heart Failure in Primary Care: Do's and Don't's - Medscape - Sep 21, 2020.