The Curbsiders Internal Medicine Podcast

Episode #469: Inpatient Heart Failure

Release Date: February 3, 2025
Guest Expert: Dr. Gurushir Pundrath (Advanced Heart Failure and Transplant Cardiologist)

Overview

This episode provides a comprehensive, practical guide to the inpatient management of heart failure. Host Drs. Amonia "Moni" Amin and Meredith Trubitt interview Dr. Gurushir Pundrath, exploring clinical pearls on diagnosing acute decompensated heart failure, optimal use of diuretics and guideline-directed medical therapy (GDMT), strategies for patient monitoring, transitioning care, and the nuances of managing cardiogenic shock. The episode is full of actionable tips, real-world scenarios, and a healthy dose of Curbsiders-style camaraderie and humor.

Key Discussion Points & Clinical Pearls

1. Initial Approach to Inpatient Heart Failure

(10:44–16:53)

• Diagnosis: Start with fundamentals—confirm the diagnosis of heart failure versus mimickers (e.g., liver disease, nephrotic syndrome, venous stasis).
• Essential workup: Clinical history, risk factors, physical exam, natriuretic peptide levels (BNP/NT-proBNP), CXR, ECG, and early point-of-care ultrasound as an adjunct.
• Universal Definition: Use “signs and symptoms plus biomarkers” as per the latest universal definition.
• Quote:

  “Really, you have to go back to the basics—make sure, is this really heart failure?”
  — Dr. Pundrath (11:07)

Role of Point-of-Care Ultrasound (POCUS)

(13:35–16:22)

• Useful for confirming congestion, LVH, effusions, and distinguishing heart failure from other causes of dyspnea/edema.
• More additive/confirmatory than standalone diagnostic in clear-cut cases.

Echocardiogram Timing

(16:23–21:08)

• New diagnosis: Get an echo in all patients with suspected heart failure to guide further management.

• Known diagnosis: Only repeat if it will change management (e.g., unexpected clinical deterioration, new murmurs, reassessing volume-dependent valvular lesions after decongestion).

• Quote:

  “It’s recommended that you should get an echocardiogram of anybody with a suspicion for heart failure.”
  — Dr. Pundrath (16:53)

2. Diuretic Strategy for Decongestion

(25:34–37:55)

• Naïve patients: Start with IV furosemide 20–40mg. Dose according to symptom burden and kidney function; escalate based on response.

• Monitor response within 2 hours of administration; don’t wait to escalate therapy if inadequate.

• Bolus vs. Continuous Infusion:

  “If somebody is not responsive, if I’m giving them boluses one after another, I’ll move over to an infusion... continuous infusion gives us a better result.”
  — Dr. Pundrath (32:15)

• Dosing: Can go up to 3-4 times/day for boluses, but switch strategies if inadequate.

• Adjuncts: Switch loop diuretics (bumetanide, torsemide) or add thiazide diuretic targeting different nephron segments when necessary.

• Notable Pearl:

  “All these diuretics are working on some aspect of the nephron, so adding two loop diuretics is not going to give you the result. Add a thiazide on top.”
  — Dr. Pundrath (34:28)

Role of SGLT2 Inhibitors

(35:06–37:55)

• Early inpatient initiation now evidence-based; improves diuresis, cardiovascular and kidney outcomes; minimal effect on blood pressure.
• SGLT2i generally precede use of acetazolamide for refractory diuresis.

3. Afterload Reduction & Guideline-Directed Medical Therapy (GDMT)

(37:55–46:25, 51:39–57:07)

• Afterload reduction (ACEi, ARB, ARNI, hydralazine): Start alongside diuretic in hypertensive AHF; adjust timing based on BP and response.

• ARNI: Start when BP is stable. Watch for hypotension and allow appropriate ACE inhibitor washout.

• Aldosterone antagonists and SGLT2: Well-tolerated even with lower BP, can be started early.

• Beta-blockers: Start only after decongestion and clinical stability, not on day of discharge.

• Quote:

  “The first thing is still going to be diuretic... if you start off with a diuretic, you know what the blood pressure is; if it’s still high, that’s the time you kind of start focusing on afterload.”
  — Dr. Pundrath (38:22)

HFpEF Considerations

(57:07–59:06)

• SGLT2i: Only GDMT with evidence across all HF phenotypes.
• ARNI: Evidence supports use, especially in women with EF <60%.
• Beta-blockers: Only if separate indication (e.g., AFib, CAD).
• Sequence is similar unless limited by BP/kidney function.

4. Monitoring Response and Troubleshooting

(39:49–44:08)

• Ins & Outs/Weight: Use both, but remember weight can be confounded by nutritional status. Engaged, reliable patients sometimes best to track their own I/Os.
• Pulmonary artery pressure monitors: Niche role in high-risk or recurrently admitted patients.

Sodium and Fluid Restriction

(44:26–46:25)

• Data mixed; modest sodium restriction reasonable, focus on practical patient-specific advice (e.g., avoid highly salty food rather than rigid restriction).

5. Advanced Cases: Cardiogenic Shock & Escalation

(64:00–71:47)

• Signs: Hypotension, cold/clammy extremities, reduced UOP, elevated lactate.

• Do not delay inotrope/vasopressor support in true shock; escalate quickly.

• Inotropes: Dobutamine or milrinone preferred over dopamine in tachycardic patients.

• Avoid starting/continuing neurohormonal blockers in acutely unstable patients.

• Right heart catheterization: Indicated for diagnostic uncertainty, low output state, non-response to therapy, worsening kidney function.

• Quote:

  “In this particular patient... she's already declared herself. Right? So you really need to know, and this is a patient you're upgrading to the CCU... now that's a patient who needs a Swan right there."
  — Dr. Pundrath (70:27)

6. Discharge, Titration, and Transitions of Care

(71:47–84:08)

• Medication strategy:

  “Low dose of all [four pillars] is superior to high dose of a few. You’re addressing different pathways, so you’re getting incremental benefit.”
  — Dr. Pundrath (73:57)

• Ensure patient is on all tolerated GDMT classes at low dose before discharge; titrate up as outpatient.
• Beta blockers: Start prior to discharge—never on the day of discharge; observe at least 24 hours.
• Oral diuretic: See response for 24h prior to discharge; adjust carefully, especially if adding SGLT2i/MRA (additional diuresis).
• Use orthostatic vital signs and risk stratify elderly/frail patients before discharge.

Follow-up & Outpatient Transitions

• Arrange prompt follow-up (<7 days ideal).
• Coordinate with care managers/social workers for access to medications (esp. ARNI), prior auth, patient assistance.
• Patient education is ongoing, not one-time—engage multidisciplinary team (physicians, nurses, pharmacists, social workers).

Notable Quotes & Memorable Moments

• On SGLT2 inhibitors:

  “SGLT2 is the statin for heart failure.” (63:53)
  — Dr. Pundrath

• On education:

  “Education is key and making sure that transition of care is important—because that's the key focus in overall outcome.”
  — Dr. Pundrath (88:22)

• Practical encouragement:

  “Yes, there’s a rare chance of somebody coming back with presyncope, it's usually because we didn't adjust the diuretic dose before they went out.”
  — Dr. Pundrath (75:27)

Timestamps for Important Segments

• [10:44] Typical inpatient HF presentations & differential
• [13:35] Role of point-of-care ultrasound
• [16:23] When to get (and not get) an echocardiogram
• [25:54] Initiating and escalating IV diuretics
• [35:06] Role & sequence of SGLT2 inhibitors and adjunct diuretics
• [37:55] Afterload reduction strategies
• [47:44] Interpreting echo findings and classifying HF
• [51:39] GDMT sequencing for HFrEF
• [57:07] How acute HFpEF management differs
• [64:00] Recognizing and responding to cardiogenic shock
• [71:47] Post-shock stabilization, restarting/titrating GDMT
• [73:57] Titration strategy: low dose all vs. high dose some
• [79:29] Monitoring orthostasis; considerations for elderly
• [83:45] Multidisciplinary discharge planning, cost navigation
• [84:08] Patient education best practices & continuity

Take-Home Points – Dr. Pundrath’s Top Three

(87:29)

1. Escalate decongestion therapy aggressively.
   Don’t hesitate to change strategies quickly if initial diuresis is inadequate.
2. Start guideline-directed therapies early.
   SGLT2i is “for everyone,” even when others limited by hypotension or kidney function.
3. Education and transitions of care are essential.
   Thorough education, follow-up, and strong care transitions dramatically impact outcomes.

Summary

This episode distills complex guidelines into bedside-ready advice for any physician managing inpatient heart failure. The Curbsiders, with Dr. Pundrath’s expert insights, guide listeners step-by-step through clinical decision points—from diagnosis to GDMT optimization, from challenging cases of shock to transitions home—with humor and humility. Whether you’re a hospitalist, resident, or advanced provider, this episode is packed with practical pearls you can act on immediately.

Curbsiders Catchphrase:

“Bringing you a little knowledge food for your brain hole.” (89:11)

For even more detailed notes, CME credit, and links to guidelines discussed, visit thecurbsiders.com.