31 - Acute Heart Failure Flashcards

1
Q

ADHF
Acute Decompensated Heart Failure

2 Characterizations

A

Rapidly developing symptoms of:
NEW ONSET HF
or
more commonly:
Gradually…
WORSENING of CHRONIC HF

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2
Q

S/Sx of ADHF:

WET
Class 2 or Class 4

A

VOLUME OVERLOAD = CONGESTION

Weight Gain
EDEMA - Peripheral & Pulmonary
Bilateral Apical RALES RRR
BNP
JVD + HJR

BUN/SCR - for BOTH

Cough / Dyspnea@rest / PND
Anorexia-Nausea-Early Satiety

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3
Q

S/Sx of ADHF:

COLD
Class 3 or CLASS 4

A

Low CO = POOR PERFUSION

Urine Output + ↑BUN/Scr

  • *Cold + Clammy** extremeties
  • *Narrow Pulse** Pressure
  • *HypoTension_ / _Tachycardia**

Exercise Tolerance / Fatigue
Obtunded / AMS

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4
Q

Role of BNP in ADHF

A

BNP in “WET” = Volume Overload
associated with WORSE outcomes

Causes ↑BNP than Expected:

  • *Age / ACS / AFib**
  • *SACUBITRIL/VALSARTAN Use**
  • *Sepsis / Renal insufficiency**

Causes ↓BNP than Expected:
OBESITY / EDEMA

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5
Q

What Hemodynamic Subset of ADHF?

WARM** + **WET
Adequate Perfusion + Volume Overloaded
Normal CO + Congested

A

CLASS 2
Warm + Wet

Diuretics** +/- **VASODILATORS
nitroglycerin or nitroprusside

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6
Q

What Hemodynamic Subset of ADHF?

  • *COLD_ + _WET**
  • POOR* Perfusion + Volume Overloaded
  • LOW* CO + Congested
A

CLASS 4
COLD + Wet

Diuretics + INOTROPES
Dobutamine or Milrinone

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7
Q
  • *ADHF**
  • *IV LOOP DIURETICS**

Furosemide Dose for NAIVE PATIENTS

A

Initiate EARLY

Furosemide:

  • *20-80mg IV**
  • *q8-12h**
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8
Q
  • *ADHF**
  • *IV LOOP DIURETICS**

Furosemide Dose for CHRONIC PATIENTS

A

Initiate EARLY

TOTAL DAILY DOSE
is the
Initial IV dose

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9
Q

ADHF
IV Loop Diuretics

GOAL URINE OUTPUT

A

Each DOSE:
> 250-500mL within 2hrs of dose

Each DAY:
1.5 - 2 L NET diuresis
(output - input)

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10
Q

Intensification of IV Diuresis:

1st Step
if
inadequate response to INITIAL diuretic regimen

A

DOUBLE DIURETIC DOSE

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11
Q

Intensification of IV Diuresis:

2nd Step
if
inadequate response to INCREASED/DOUBLED diuretic dose

A

Administer as:
CONTINUOUS INFUSION
OR
Add a SECOND Diuretic
PO metolazone / PO spironolactone
IV chlorothiazide

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12
Q

Intensification of IV Diuresis:

3rd & Final Step
if
ALL STRATEGIES are UNSUCCESSFUL

A

Consider:
ULTRAFILTRATION

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13
Q

Hemodynamic Effects of
VASODILATORS

NitroGlycerin / NitroPrusside

A

Venous Dilation
↓ preload↓ PCWP, ↓ MAP ↓ LV workload
+
Arterial Dilation
↓afterload ↓MAP ↓force LV must pump agaisnt

====
↑CARDIAC OUTPUT

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14
Q

ADHF

IV VASODILATORS
NitroGlycerin / NitroPrusside

INDICATIONS

A
  • *Class 2** = Warm + WET
  • generally reserved for patients with* HF-rEF, preserved is more preload sensisitive

Pulmonary EDEMA** +/- **severe HTN

Need for:
Rapid improvement of Symptoms

refractory to IV diuresis:
Pulmonary Congestion

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15
Q

IV VASODILATORS

When/why would we use
NITROPRUSSIDE > Nitroglycerin

A
  • *More severe ↑BP / ↑HTN**
  • *Nitroprusside has more POTENT BP lowering effects**
  • but is RENALLY cleared –> Cyanide/Thiocyanate Toxicity*
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16
Q

IV VASODILATORS

When/why would we use
NITROGLYCERIN > Nitroprusside

A

Nitroglycerin is preffered in patients with:
CORONARY ISCHEMIA

  • *NOT RENALLY CLEARED**
  • *Nitroglycerin is only liver elimination**, preferred for Renal Patients

ADRs:

  • *Tachyphylaxis - 20% resistance**
  • *Reflex Tachycardia + Headache**
17
Q

ADHF:
HEMODYNAMIC EFFECTS
Of
IV INOTROPES
Dobutamine + Milrinone

A

Contractility + ↓Afterload

↑STROKE VOLUME
+
HEART RATE

=====
↑CARDIAC OUTPUT

18
Q

ADHF:
IV INOTROPES
Dobutamine + Milrinone

INDICATIONS

A

CLASS 4 = WET + COLD

Severe HF-rEF who present with:
LOW Blood Pressure** + **significantly DEPRESSED Cardiac Output
↓BP + ↓CO

Indication:
IMPROVE FORWARD FLOW for:
Diminished peripheral perfusion or end-organ dysfunction
Marginal Systolic BP < 90mmhg
Symptomatic HYPOtension

pallitive therapy for STAGE D patients

19
Q

IV INOTROPES

  • *When/why would we use**
  • *DOBUTAMINE > Milrinone?**
A

concerned about:

  • *RENAL CLEARANCE**
  • *Dobutamine is HEPATIC, Milrinone is 90% renal cleared**
  • *HYPOTENSION CONCERN**
  • *Dobutamine is LESS hypotensive than Milrinone**

ADR:
Proarrhythmia / Tachycardia / Tachyphalaxis
Hypotension @ HIGH doses

20
Q

IV INOTROPES

  • *When/why would we use**
  • *MILRINONE > Dobutamine**
A

Need for:
MORE VASODILATION = HYPOTENSION
Milrinone has MORE vasodilation and is RENALLY cleared

ADR:
Proarrhythmia / Tachycardia
HYPOTENSION

21
Q

ADHF:
IV INOTROPES
Dobutamine + Milrinone

PROS + CONS

A

PROS
↑ contractility + ↓afterload = ↑CO
Improved End-organ Persion + Diuresis

CONS
Tachycardia / Tachyarrhythmias
Myocardial O2 Demand
HYPOTENSION

22
Q

ADHF

When would we add:
IV INOTROPES
on top of
Diuretic + Vasodilator Therapy

A

even when NOT in SHOCK:
Add IV Inotropes = Dobutamine / Milrinone
if
Need for MORE DIURESIS

23
Q

ADHF

When would we add:
IV VASODILATORS
on top of:
Diuretic + Inotrope Therapy

AKA:
IV VASOACTIVE THERAPY
Inotrope + Vasodilator + DIuretic

A

Low Cardiac Output
+ SHOCK
+
hypotensive state SBP <90 + altered mental status

Would have:
Hemodynamic Monitoring As Well

24
Q

Special Monitoring Parameters:

When would you want
CONTINUOUS TELEMETRY?

on top of normal DAILY monitoring:
Weight / Fluids / Vitals
ADHF SSx / Electrolytes / Renal Fxn

A

ARRHYTHMIAS

or

IV VASOACTIVE THERAPY
Cardiac SHOCK –>ALL 3: Inotrope + Diuretic + Vasodilator

25
Q

Special Monitoring Parameters:

When would you want
INVASIVE HEMODYNAMIC MONITORING

Pulmonary Artery Catheter
on top of normal DAILY monitoring:
Weight / Fluids / Vitals
ADHF SSx / Electrolytes / Renal Fxn

A

SHOCK

or

HYPOTENSION

or

  • *CLASS 4**
  • *COLD + WET**
26
Q

ADHF Discharge Criteria:
TRANSITIONS OF CARE for ALL PATIENTS

A

OPTIMIZE GDMT
maximize drug therapy, IV –> PO diuretic

F/U Clinic 7-10 days

Address Exacerbating Factor + Near OPTIMAL Volume

LV-EF documented

Smoking cessation

27
Q

ADHF TOC:
Optimization of GDMT
guideline directed medication therapy

A

Initiation / Continuation / Titration
ACE/ARB + BB

PO Diuretic Adjustment
↑Dose or change to more BV agent (Furosemide -> Dobutamide)
+ADD+ THIAZIDE

  • *Addition of other GDMT**
  • *MRA / Hydralazine-nitrate / ARNI / Ivabridine / digoxin**