Acute Decomp HF Flashcards
Definitions
- Cardiac output
- Afterload
- Preload
- Contractility
What can contribute to a higher preload?
- amount of blood pumped by the heart per minute
- resistance that the heart ejects blood against
- pressure exerted by the blood in the left ventricle when the heart is fully relaxed (end diastole)
- Ability of the heart to contract/flex
higher volume of blood –> higher pressure
What can cause cardiac output to incr?
In heart failure, more blood in LV can lead to more CO, but why does the curve flatten out ?
- Too much preload means?
More preload
Loss of contractility.
Too much preload = backward failure sx’s (weight gain, edema, dyspnea,) –> Congestive sx’s
What meds will you use to treat high preload?
(Meds for contractility 1 and meds to lower preload itself 3 )
Incr contractility : Inotropes
Lower Preload : Diuretics, nitrates, V2 antags
Afterload depends largely on ?
In Heart failure, what happens with MORE AFTERLOAD?
- arterial pressure
- Way less Cardiac output
How to treat HIGH AFTERLOAD :
1) Meds to incr contractility and push blood forward
2) Meds to LOWER afterload (4)
- Inotropes
- Nitrates (nitroprusside, high dose nitroglycerin)
-Hydralazine
-DHP CCB’s
-ACEI/ARB/ARNI
Acute Decomp HF is :
-An acute ____ that is secondary to ___ and or ___
What can cause low cardiac output ? (3)
What can cause volume overload?
worsening of sx’s
- low CO, volume overload
-Too much afterload, too little preload, too little contractility (one, or a combo of all 3)
- Too much preload
Signs and Sx’s of HIGH PRELOAD (Backward Failure) = Back-up of blood from heart
- Pulm
- heart
- hepatic
- abdomen
- feet
- Back up of blood to pulm vasculature
- incr volume of blood in ventricles (incr preload)
- Back up of fluid to hepatic vein
- Build up of fluid in abdomen
- Back up of fluid in the feet
Signs and Sx’s of LOW CARDIAC OUTPUT (Forward failure)
- Brain
- Heart
- Liver
- Kidney
- Skin
- decr perfusion to brain
- decr coronary blood flow
- decr perfusion to the liver
- decr perfusion to the kidney
- decr perfusion to the skin
Sx’s of High Preload :
1. Lungs
2. Abdomen
3. Ankles
Sx’s of Low Cardiac Output
1. Brain
2. Heart
3. Kidney
4. Skin
- Dyspnea, cough, orthopnea, paroxysmal nocturnal dyspnea
- Abdominal swelling, cramps, weight gain
- swelling in feet and ankles
- Fatigue/confusion
- irreg heart beats, exercise intolerance
- Decr urine output
- cold skin
Signs of HIGH PRELOAD :
1. Lungs
2. Heart
3. Liver
4. Feet
5. PCWP value? (Pulm capillary wedge pressure)
-Normal value? what does this approximately equal to?
6. Jugular Venous pressure?
SIGNS of LOW CARDIAC OUTPUT
1. Heart
2. SBP
3. CI?
4. Liver
5. Lactate value?
6. Kidney
- Rales, crackles, pleural effusion on xray
- elevated BNP, NTproBNP, S3 heart sound
- Elevated INR, Hepatojugular reflex
- Pitting edema
- PCWP > 18 mmhg
-Normal = 4-12 mmHg
-LVEDP - > = 5 cm H2O
- TACHYCARDIA, arrhythmia
- SBP < 90 mmhg for > 30 mins
- CI < 2.2 L/min/M^2
- ELEVATED AST/ALT
- Elevated Lactate > 2 mmol/L
- Elevated creatinine (also elevated in high preload)
Whats a direct measure of AFTERLOAD?
-Whats the normal value for this?
SVR (Systemic Vasc Resistance)
- 800-1400 dyne/s/Cm^-5
Classifying ADHF based on signs/sx’s
- Warm and Dry
- Cold and Dry
- Warm and Wet
- Cold and Wet
- No issues with high preload or low output (Not actually in ADHF)
- Low output, Normal or LOW preload
- Normal output, HIGH preload
- LOW output, HIGH preload
What to do with home guideline directed medical therapies :
- Digoxin
- Vericiguat
- Ivabradine
- Hydral/ISDN
- ACE/ARNI/ARB
- BB
- MRA
- SGLT2
- Diuretics
- hold if AKI, bradycardia
- hold if hypotensive
- hold if bradycardiac or in AF
- Hold if hypotensive
- Hold if hypotensive, high K, AKI
- hold if in shock (cold status! ), bradycardic
- hold if high K, AKI
- hold if planned NPO > 12h
- admin IV
Goal of Therapy for : Warm and Wet
1. Treat the ?
2. Whats the agents u can use? (5)
- High preload
- IV loop diuretic + thiazide diuretic + Acetazolamide + tolvaptan +/- IV nitrates if sufficienct BP (SBP>=90)
Loop Diuretics : IV BOLUS DOSING
- Starting with the home oral dose, how do u get the IV bolus dose and whats the frequency of its dosing?
- What should you monitor? (4)
- Multiple home dose by 1-2.5x
-Give that value as an IV bolus BID - Weight loss
-Resolution of congestive sx’s
-Goal urine output of 2-3 L per dose
-3-5 L per day
Loop diuretics : Max IV Bolus Doses
- Lasix
- torsemide (Demadex)
- Bumetanide (Bumex)
- Ethacrynic acid (Edecrin)
What if you’re taking Torsemide and there’s no IV option? What do u do to get it to an IV form?
- 80 mg per dose
- not avail in IV
- 4 mg per dose
- No iv form
Convert oral dose to furosemide or bumetanide po –> (40 lasix = 20 tors = 1 bumex = 50 mg ethacryn)
Multiply dose by 1-2.5x and give that value as IV bolus BID
Loop Diuretics : CONTINUOUS IV infusion if HIGH total daily dose
For each, state what would be a HIGHER total daily dose that warrants switching to continuous IV infusion
- Furosemide
- Torsemide
- Bumetanide
- Ethacrynic ACid
Whats the Continous IV infusion dose for each?
For example, if your pt is on Bumex 4mg IV bolus BID, and you’re considering incr their dose, what should u do?
- > =161 mg
- > =81 mg
- > = 9 mg
- > = 201 mg
- 80 mg bolus, then 10-20mg/h
- not avail in IV
- 2 mg bolus then 0.5 mg/h
- no iv avail
Doubling their bumex dose puts them >9mg, so u have to switch to continuous IV infusion of bumex!
Loops : Dose adj for continous infusions
If your pt is not meeting urine output of 3-5 L per day, what should u do in the following to incr their continuous infusion dose
- Currently on lasix infusion
- currently on bumex infusion
- Bolus lasix 80 mg IV once, then incr rate by 5-10 mg/h
- bolus bumex 2-4 mg IV once, then incr rate by 0.5-1 mg/h
Ae’s of Loop diuretics?
1. HYPO ___ (4)
2. D
3.A
4.M
5. O
CI?
- Hypo kalemia, natremia, chloremia, magnesemia
- dehyration
- AKI
- Metab alkalosis
- Ototoxicty especially at high bolus doses
SULFA ALLERGY
Thiazide Diuretics :
1. When should u consider giving these ? (3)
- Metolazone initial dose
- Chlorthiazide initial dose
- if pt on 4 mg bumex IV BID, 80 mg lasix IV BID, or continuous infusion of diuretic
- 2.5-10 mg PO daily or in divided doses admin 30 min before loop diuretic
- 250-1000 mg IV daily or BID administered 30 mins before loop diuretics
Thiazides : Ae’s?
1. HYPO ___ (4)
2. D
3. A
ACETAZOLAMIDE
1. When should u consider giving this? (2)
2. Dose?
- Hypo kalemia, natremia, magnesemia, chloremia
- dehyration
- AKI
- If pt on at least 2x home oral loop dose given as IV
-additional consideration to use if bicarb is high (>= 30 mEq/L ) - 500 mg IV daily to twice daily given with IV loop diuretic
ACetazolamide : AE’s and CI’s
1. Ae’s (5)
2. CI”s ? (2)
- Hypokalemia
hyponatremia
dehydration
AKI
metab ACIDOSIS !***** - Sulfa allergy, HX of Stevens JOhnsons syndrome
Tolvaptan :
1. Which pt’s should u use it in ?
2. Initial Dose ?
3. Incr as needed by doubling dose how often?
4. Max dose?
5. Monitor __ and __ at least q6hrs
6. Allow pt’s to ?
- HYPERvolemic or EUVOLEMIC HYPOnatremia (Na + < 125 mEq/L)
- 15 mg PO ONCE
- at intervals >=24h
- 60 mg daily
- sodium , potassium
- drink to thirst (DONOT restrict fluids)
Tolvaptan : AE’s and CI’s
1. AE’s
-BBW for ?
-Hyper __ and ___
-D
-L
- CI
-strong__ and moderate ___
- Osmotic demyelination (Rapid sodium rise > 12 mEq/L/24 h)
-Hyperkalemia, Hyperglycemia
-Dehydration
-liver toxicity - Strong CYP 3A4 Inducers
-Mod CYP 3A4 Inhibs