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
IV Nitrates : Dosing
1. Nitroglycerin
a. starting dose?
b. Increase by ?
c. Max dose?
d. afterload reduction starts at doses ? Preload reduction at ?
- Nitroprusside
a. starting dose
b. incr by ?
c. Max Dose?
d. Afterload and preload reduction at ?
1a. 10-20 mcg/min
b. 5-10 mcg/min q5mins until desired response
c. 200 mcg/min
d. >= 50 mcg/min, preload reduction at ALL doses
2a. 0.25-0.5 mcg/kg/min
b. 0.25 mcg/kg/min every 2 mins
c. 3 mcg/kg/min
d. at all doses
IV NITRATES: AE’s and CI ‘s
- AE’s for Nitropruss (2)
- AE’s for Both (4)
- CI for Nitropruss (3)
- Cyanide toxicity (acidosis, bradycardia, confusion, convulsions)
-Thiocyanate toxicity (tinnitus, abd pain, weakness, confusion, seizures) - Tachyphylaxis (stops after 24-48 hrs)
-Sx’s of hypotension
-HA
-Rebound tachycardia - Caution in hepatic failure AND renal failure
-avoid in preg !
Markers of Efficacy when Tx WARM AND WET ****
1. improvement in (lungs)
2. Improvement in o___
3. Improvement in P__
4. Increased___
5. Improve ___
6. Decr ___
7. Lower ___
8. Resolution of labs such as ? (4)
- SOB
- Orthopnea
- paroxysmal nocturnal dyspnea
- urine output
- edema
- body weight
- JVP
- NTproBNP, INR, PCWP, Scr
What could be the cause of LOW OUTPUT in someone who is dry? (2)
Goals of therapy for pt’s who are COLD AND DRY?
- Low preload
- High Afterload
Treat low preload and/or high afterload and/or LOW contractility
Cold and Dry :
- What are some sx’s and signs that can suggest low preload ?
- In this case, what do you do?
- What if they have NORMAL preload? (No signs and sx’s of dehyration and/or PCWP > 15)
a. SBP < 90 (Low contractility)
b. SBP >= 90 (high afterload) - What if ur pt has HIGH afterload AND low preload, what do u treat first?
- Orthostasis, dry skin, mucuous membranes, recent emesis, diarrhea, poor oral intake, weight Loss, PCWP < 15 mmHg
- Give 250-500 mL IV fluids
3a. Inotropes (to incr contractility)
3b. IV vasodilators (afterload reduction)
- treat afterload first , THEN give fluids for preload (Giving fluids prior to tx of BP –> pulm edema)
Inotropes : Dopamine
1. SVR?
2. HR?
3. CO?
Dobutamine :
At doses less than or equal to 5 mcg/kg/min (Beta 1 and Beta 2)
1. SVR
2. HR
3. CO
At doses 5-20 (Alpha 1 + B1 and B2)
1. SVR
2. HR
3. CO
- incr
- incr
- incr
- Decr
- INCR
- INCR
- no change
- Incr
- Incr
Inotropes : Milrinone
1. SVR
2. HR
3. CO
- Decr
- nothing changes rlly it may go up
- incr
Dopamine
1. Start dose
2. Incr by
3. Max dose
Dobutamine
1. Start dose
2. Increase by
3. Max dose
Milrinone
1. Start dose
2. incr by
3. Max dose
- 3-5 mcg/kg/min
- 2-5 mcg/kg/min if still showing low output (wait at least 5-10 min before incr)
- 20 mcg/kg/min
- 3-5 mcg/kg/min
- Incr by 2.5 mcg/kg/min incr if low output still, wait at least 5-10 mins before incr
- 20 mcg/kg/min
- 0.125-0.25 mcg/kg/min
- Incr by 0.125-0.25 mcg/kg/min incr (WAIT AT LEAST 2-4hrs before incr)
- 0.75 mcg/kg/min
Inotropes ae’s
- Dopamine specific
- Dobutamine/Milrinone
- All of them (2)
- CI’s for milrinone?
IV NITRATES IN COLD AND DRY
-Same as Warm and wet
- Afterload INCR
- Hypotension
- tachycardia, arrhythmia (AFIB)
- Caution in renal dysfunction
Markers of efficacy for tx of Cold and Dry
1. Improved ___
2. Incr ___
3. Warmer ___
4. improved F
5. Improvement in __
6. Resolution of labs such as
- mentation
- urine output
- skin
- functional capacity
- vitals (BP and HR)
- CI, Scr, LFTs, lactate
What could be the cause of low output in COLD AND WET?
Goals of therapy : Treat the ___ and or ____ and or ___
Low contractility or high afterload
High preload, high afterload, low contractility
Assessment : COLd and WET
Assess SBP
1. If SBP < 90 (low contractility) , What do u do?
2. If SBP >= 90 (high afterload) , what do u do?
- markers of efficacy = markers of warm and wet + markers of cold and dry
- Inotropes + IV diuretics
- IV vasodilators + IV diuretics
