13 Acute HF Flashcards
etiology/patho
- includes with both HF ___ and HF ___
- acute worsening of ___ HF accounts for 70% if cases (patients become refractory due to a realtively mild insult)
- new acute HF is ~25% of cases
- progressive worsening of ___ in chronic HF ~5% of cases
- cardiogenic shock: hypotension (SBP < ___ mmHg or MAP < ___ mmHg) with low ___
- HFrEF, HFpEF
- chronic
- CO
- 90, 70, CO
Diagnostic Tools
non-invasive
detailed physical exam
- congestion
- adequacy of perfusion
lab assessment
- Cr, K, Na
- BNP and NTproBNP > ___ is closely associated with acute HF
400
Diagnostic Tools
invasive hemodynamic monitoring
- routine use is discouraged
- flow directed PA catheters ( ___ catheters)
Swan-Ganz
Maintaining Chronic Therapy While Hospitalized
GDMT should be continued in the absence of hemodynamic instability or CI (hypotension/cardiogenic shock)
Caution with aggressive diuresis and ___ / ___
- caution with increases and titrating up
- increases in SCr (~ ___ %) do not worsen outcomes
RAASi/SGLT2i
20%
Maintaining Chronic Therapy While Hospitalized
Beta Blockers
- do not stop unless recent initiation or up-titiration resulted in current decompensation
- consider holding if ___ is needed or if hemodynamicaly ___
- do not add or up titrate until optimizational of volume status and successful D/C of IV diuretics, VDs and inotropes
dobutamine, unstable
Maintaining Chronic Therapy While Hospitalized
digoxin
- continue at a dose to achieve SDC ___ - ___ ng/mL
- avoid D/C unless compelling reason
- caution with regard to renal function
0.5-0.9
management of decompensated episodes
- diuretics, inotropes, vasodilators, vasopressors
- no therapy shown to reduce mortality
drug therapy by classification
warm and dry
optimize chronic therapy
drug therapy by classification
warm and wet
IV diuretics +/- venous vasodilator
drug therapy by classification
cold and dry
- if PCWP < 15: IV ___ until PCWP 15-18
- if PCWP > 15 and SBP < 90: IV ___
- if PCWP > 15 and SBP > 90: IV ___ or arterial ___
- fluids
- iontrope
- inotrope, arterial vasodilator
cold and wet
IV ___ and
if SBP < 90: IV ___
if SBP > 90: IV ___
diuretics
- inotrope
- arterial vasodilator
Diuretics in hospitalized patients
- used primarily to treat systemic/pulmonary ___ in subset ___ or ___
- first line agents with fluid overload
- initial IV dose should equal or ___ the chronic daily dose and be given as an intermittent bolus
- loops more widely used; THZ used as add-on if refractory
if resistance
- ___ and ___ restriction
- increase ___ rather than ___ to ceiling
- add THZ
- ultrafiltration
congestion, II, IV
exceed
Na, water
dose, frequency
diuretics in hospitalized patients
dosing
- increase dose patient was receiving at home
- if contiuous infusion: furosemide ___ mg/kg/hr doubled q2-4 hours; max ___
monitoring
- urine output and s/s of congestion
- ins/outs, body weight, vital signs, s/s perfusion and congestion
- desire ___ - ___ L/day above input ealy
0.1, 0.4
1-2
loop diuretics
furosemide ( ___ )
use
- fluid overload ( ___ )
PO/IV equivalent dose: ___ / ___
initial bolus and infusion rate
- ___ - ___ (10 mg/hr)
duration or response: ___ hours
AE
- Mg and K depletion
- hypotension
- worsened renal function
Lasix
- wet
- 80/40
- 40-120
- 2
loop diuetics
bumetanide ( ___ )
use
- fluid overload ( ___ )
PO/IV equivalent dose: ___ / ___
initial bolus and infusion rate
- ___ - ___ (0.5mg/hr)
duration or response: ___ hours
AE
- Mg and K depletion
- hypotension
- worsened renal function
Bumex
- wet
- 1/1
- 1-4
- 6
loop diuretics
torsemide ( ___ )
use
- fluid overload ( ___ )
PO/IV equivalent dose: ___ / ___
initial bolus and infusion rate
- ___ - ___ (0.5 mg/hr)
duration or response: ___ hours
AE
- Mg and K depletion
- hypotension
- worsened renal function
Demadex
- wet
- 20/20
- 10-40
- 6
Vasodilator therapy
used in combo with diuretics to reduce pulmonary congestion in wet HF, stage ___ and ___
- venodilators increase venous capacities and reduce___ and myocardial ___
- rapid symptomatic relief
- ___ is venodilator of choice
patients with symptomatic ___ should not receive vasodilators
- should be considerd over ___
- frequent BP monitoring is needed
II, IV
preload, stress
NTG
hypotension
inotropes
T or F: vasodilators have long t1/2
F; short
Vasodilators
nitroprusside ( ___ )
clinical effects:
- balanced ___
- decreases SVR
use:
- warm and wet
- cold and wet (alt to inotropes)
- HTN ____
dosing
- ___ mcg/kg/min, titrate to response (max 3)
PK: t1/2 < ___ min
AEs:
- ___ and thiocyanate toxicity
- hypotension
Nitropress
- vasodilator
- cirsis
- 0.25
- 10
- cyanide
vasodilators
NTG
clinical effects:
- ___ > arterial VD
- decreased PCWP
use:
- warm and wet
- ___ , HTN ___
dosing: ___ mcg/min initially, inc by 5 mcg/min every 5-10 min (max 200)
PK: t1/2 ~1-4 min
AE:
- hypotension
- HA
- reflex ___
- nitrate ____
- venous
- ACS, crisis
- 5
- tachycardia
- tolerance
vasodilators
nesiritide ( ___ )
clinical effects:
- balanced ___
- increase ____ output and ___ excretion
use:
- warm and wet
- cold and wet (alt to inotropes)
dosing:
- bolus ___ mcg/kg
- infusion: ___ mcg/kg/min, increase by ___ mcg/kg/min (max 0.03)
PK: t1/2 ~ 20 min
AE
- hypotension
- tachycardia
- renal dysfunction
Natrecor
- vasodilation
- urine, Na
- 2
- 0.01
- 0.005
other vasodilators (3)
morphine, enalaprilat, hydralazine
positive inotropes
beta-agonists (2)
PDE 3 inh (2)
- dobutamine
- dopamine
- milrinone
- amrinone
amrinone isnt used
positive inotropes
dobutamine ( ___ )
MOA:
- B1 and B2 receptor ___ and weak a1 agonist
- stimulates AC to increase ___
clinical effects
- positive inotrope
- chronotrope
- lusitrope
- conside if low ___
use:
- cold and wet
- cold and dry (if PCWP > 15)
dosing
- ___ to ___ mcg/kg/min titrate
PK : t1/2 = 2 min
AE:
- arrhythmogenic
- tachycardia
- ischemia
- reduced K
- tolerance after 48-72 h
Dobutrex
- agonist
- cAMP
- BP
- 2.5, 5
positive inotropes
milrinone ( ___ )
MOA:
- ___ inhibitor
- increase ___ in myocardium (increased ___ ) and vasculature (decreased ___ )
- “inodilator”
clinical effects:
- positive inotrope
- ___ > arterial VD
- consider if on ___
use
- cold and wet
- cold and dry (if PCWP > 15)
dosing:
- ___ - ___ mcg/kg/mi infusion titrate
PK: t1/2 ~ 1 hr (2-3 hrs in HF and CrCl < 50 )
AE
- arrhythmogenic
- tachycardia
- ischemia
- hypotension
- thrombocytpenia
Primacor
- PDE
- cAMP, CO, SVR
- venous
- BB
- 0.1-0.375
positive inotropes
dopamine
MOA
- dose dependent ___ on D1R, B1, B2, and a1
- cause release of ___ from adrenergic nerve terminals
effects
- positive inotrope
- chronotrope
- lusitrope
use
- typically plays secondary role to ___ / ___
- sometimes referred to as a ___
dosing
- 0-3 mcg/kg/min - D1R, ___ vasculature VD, increased urine output
- 3-10 mcg/kg/min - B1, B2, increase myocardial ___ , SV, CO, and BP
- > 10 mcg/kg/min - a1, arterial ___ , increase SVR and BP,
- causes venous VC, increased PCWP, increases O2 demand (may worsen ___ )
PK: t1/2 = 2 min
AE
- arrhythmogenic
- tachycardia
- ischemia
- decreased ___
- tolerance after 48-72 hrs
- skin necrosis upon infiltration
- agonist
- NE
- dobutamine/milrinone
- vasopressor
- renal
- contractility
- vasoconstriction
- ischemia
- K
positive inotropes ___ curve
raise
ADHR: positive inotrope therapy
- primarily to manage ___ or cold HF patients
- reasonable to consider ___ before inotropes when adequate BP
- useful for symptom relief in hypotension (SBP < ___ )
- useful in patients with end ___ dysfunction (AKI, altered mental status, systemic hypoperfusioin, hypotension, CV collapse)
- useful when disease is ___ to other HF therapies (need for mechanical circulatory support/transplant/palliative care)
- choice of dobutamine vs milrinone is individualized (low ___ vs ___ use)
- hypoperfusion
- vasodilators
- 90
- organ
- refractory
- BP, BB
management of decompensation episodes overview
Diuretic therapy
- IV ___ diuretics for patients with fluid overload
- change to PO route on day before discharge if possible
- when response to duretics is minimal, consider other options
loop
management of decompensation episodes overview
inotropic therapy
relieve symptoms and improve end-organ function in patients with reduced LVEF and diminished perfusion or end-organ dusfunction, esp if:
- SBP < ___
- symptomatic ___ despite adequate filling pressure
- no response to/intolerance of IV ___
patients with evidence of fluid overload and ___ to IV diuretics or they are associated with worsening ___ functions
- 90
- hypotension
- vasodilators
- unresponsive, renal
management of decompensation episodes overview
vasodilator therapy
- may be considered in addition to IV ___ to rapidly improve symptoms in patients with acute PE or severe HTN
- may be considered in patients with persistent symptoms despite aggressive diuretics and PO drug therapy
- when adjunctive therapy is necessary in addition to loop diuretics, IV vasodilators should be considered over ___ drugs
- loop diuretics
- inotropic
