The Curbsiders podcast

#292 Acute Heart Failure, CHF Triple Distilled

September 1, 2021 | By

Enjoy this rapid clinical overview of heart failure based on Episode #230 Kittleson Rules Acute Heart Failure Featuring Dr. Michelle Kittleson @MKittlesonMD (Cedars Sinai)

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  • Written, Produced, and Hosted by: Matthew Watto MD, FACP; Paul Williams MD, FACP; Beth Garbitelli

Editor: Matthew Watto MD (written materials); Clair Morgan of

Sponsor: Locumstory

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Show Segments

  • Intro, disclaimer, guest bio
  • The History, Failure mnemonic
  • CHF exam
  • CHF Labs, Swan (RHC)
  • Management of ADHF
  • Outro

Episode #230 Kittleson Rules Acute Heart Failure

Featuring Dr. Michelle Kittleson, production by Deb Gorth and Graphics by Edison “Young Eddie” Jyang

Heart Failure History

  • Dr. Kittleson asks about PND, and orthopnea. Abdominal bloating and LE edema are also useful symptoms/signs.
  • Don’t blame the patient! But, consider the FAILURE mnemonic: 
    • Forgetting medication (or taking beta blockers, NSAIDs, methamphetamine, or cocaine)
    • Arrhythmia or Anemia
    • Ischemia or Infarction
    • Lifestyle choices including dietary indiscretions.
    • Upregulation of cardiac demand from either pregnancy or hyperthyroidism.
    • Renal failure from progression of kidney disease or insufficient dialysis.
    • Embolus (pulmonary embolism) 
    • Stenosis from worsening renal artery stenosis, aortic stenosis, or other valvular disease.

The CHF Exam

  • Are they warm and wet? Or cold and wet? The latter is worse!
  • Elevated JVP, S3 gallop (“Ken-tu-CKY”), displaced PMI are most useful to suggest heart failure (check out #236 Approach to SOB episode)
  • Dr. Kittleson gets zen with the JVP (turn head gently, use normal lighting, check hepatojugular reflux, and palpate to determine carotid vs jugular). Track the JVP over time!
  • Be scared when you see sinus tachycardia (or tachyarrhythmias)!
  • Watto points out that bedside ultrasound is an emerging way to augment physical exam (Marini et al 2020; Qaseem, 2021)

CHF Labs & Swans (RHC)

  • Dr. Kittleson regards both elevated Cr and low serum Na+ as markers of more advanced illness.
  • Check the Cr, Na+, and K+ every day. Do NOT trend BNP!
  • Higher BNPs correlate with an increased risk of mortality and recurrent heart failure hospitalization (Januzzi, 2013).
  • List the patient’s admission weight and discharge weight on DC summary (expert opinion).
  • Right heart cath (Swan Ganz) can be useful when patients do not respond to high doses of diuretics (expert opinion). For example, a patient with rising Cr, volume overload and/or hypotension despite diuretics.

Management of ADHF

  • Put the patient on 2L fluid and 2gm sodium (expert opinion). Stricter rules (800 mL fluid, 800 mg Na+) make unhappy patients and lack evidence of benefit (Badin Aliti, 2013; Machado d’Almeida, 2018).
  • There’s no gentle diuresis! Loop diuretics have a threshold and are On or Off. (Anisman, 2019)
  • Start with 2.5x outpatient diuretic dose IV twice a day (DOSE-Trial), but let the patient sleep!
  • Dr. Kittleson has a low threshold to start a furosemide drip. Start 10 mg/h and titrate up (expert opinion). Turn it off at night unless the patient has a foley!
  • Metolazone can be added if not responding to high doses IV furosemide (at least 80 mg IV twice daily, or drip at high rate) —expert opinion
  • Elevated Cr should pique your interest if above 2x patient’s baseline (expert opinion). Mild elevations may improve with diuretics via relief of venous congestion. 
  • Inotropes (milrinone, dobutamine) can be used to augment diuresis for select patients. 
  • Low potassium can be mitigated by spironolactone (expert opinion)
  • Switch to an oral diuretic when patient achieves a resolution of symptoms, normalization of JVP, and improved edema (expert opinion). 
  • Dr. Kittleson starts oral diuretics for 24 hours prior to discharge (expert opinion)
  • Follow up with exam and metabolic panel should be within 7 days of discharge (based on ACC’s H2H program).


Listeners will review tops pearls from Curbsiders episode on acute heart failure

Learning objectives

After listening to this episode listeners will…

  1. Diagnose and treat acute decompensated heart failure (ADHF)
  2. Provide effective diuretic therapy to patients with ADHF
  3. Recognize sicker patients with heart failure who may need more advanced diagnostics and therapeutics


The Curbsiders report no relevant financial disclosures. 


Watto MF, Williams PN, Garbitelli B. “#292 CHF Triple Distilled”. The Curbsiders Internal Medicine Podcast. Final publishing date September 1, 2021.

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