Acute Decompensated Heart Failure Flashcards
HF
What are the pharmacologic recommendations for patients at risk for HF?
- pt with HTN= control BP
- pt with T2DM and w/ CVD or at high risk for CVD= SGLT2i
- pt with CVD= optimal management of CVD
HF
What are the pharmacologic recommendations for patients with pre-HF (Stage B)?
pt with LVEF 40% or less= ACEi or ARB is ACEi intolerant and beta blocker
HF
What is initial pharmacologic treatment for HFrEF stage C/D?
- ARNi or ACEi/ARB
- beta blocker
- mineralcorticoid receptor antagonist (MRA)
- SGLT2i
- diuretics PRN
HF
Define: Acute Decompensated HF
worsening of heart failure requiring hospitalization
HF
What are the precipitating factors of HF?
- acute coronary syndrome (ACS)
- uncontrolled HTN
- atrial fibrillation (arrhythmias)
- dietary or medication non-adherence
- anemias
- acute infections
- hyper/hypo-thyroidism
- harmful medication use
HF
What medications contribute to fluid overload?
- NSAIDs
- COX-2 inhibitors
- glucocorticoids
- minoxidil
- TZDs
HF
What medications contribute to decreased perfusion?
- new or high doses of anti-hypertensives
- excessive diuretic use
HF
What medications can worsen HF due to negative inotrope properties?
- antiarrhythmics
- non-DHP calcium channel blockers (verapamil and diltiazem)
HF
How may a patient present with ADHF with congestion/fluid overload?
- edema
- dyspnea
- orthopnea
- elevated jugular venous pressure
- pulmonary rales/crackles
- S3 gallop
HF
How may a patient present with ADHF with low perfusion?
- narrow pulse pressure
- cool extremeties
- hypotension
- tachycardia
HF
What laboratory values/diagnostic test can assist in identifying ADHF?
- BNP or NT-proBNP!!!
- serum sodium
- LFT
- urine output
- BUN/serum creatinine
- chest xray
- TTE
HF
What device can allow for more objective fluid overload status?
flow-directed pulmonary artery catheter (Swan-Ganz catheter)
HF
What does a pulmonary capillary wedge pressure > 18 mmHg indicate?
congestion/fluid overload
HF
What does a reduced cardiac index of < 2.2 L/min/m2 indicate?
low cardiac output/low perfusion
HF
What does “warm” mean?
low perfusion NOT observed= cardiac index normal
HF
What does “cold” mean?
low perfusion= cardiac index <2.2 L/min/m2, signs/symptoms include narrow pulse pressure, cool extremeties, hypotension
HF
What does “dry” mean?
congestion at rest not present= capillary wedge pressure normal
HF
What does “wet” mean?
congestion at rest= capillary wedge pressure > 18 mmHg, signs/symptoms include orthopnea, elevated jugular venous, pulmonary rales, S3 gallop, edema, dyspnea
HF
What drugs may be used to treat fluid overload?
- loop diuretics
- thiazide diuretics
- venodilators (nitroglycerin/nitroprusside)
HF
What drugs may be used to treat low cardiac output?
- positive inotropes (dobutamine/milrinone)
- arterial vasodialators (nitroprusside)
HF
What is the initial pharmacologic management for congestion/fluid overload?
IV loop diuretics
HF
What are the preferred loop diuretics for decongestion?
furosemide, bumetanide, torsemide(not avaliable IV)
HF
What is the goal response with loop diuretics?
> 500 mL urine output within 2 hours
HF
What is the recommended dosing for loop diuretics for decongestion?
intermittent or continuous IV at equal or greater dose of the patients daily chronic dose
HF
What are the monitoring parameters while on loop diuretics?
- fluid intake and output
- vital signs
- body weight
- electrolytes, BUN, SCr
HF
How can “diuretic resistance” be overcome?
- higher doses of loops
- addition of second diuretic
- ultrafiltration
- low-does dobutamine
- vasopressin antagonist
- vasodilators
HF
What is the role of thiazide diuretics in ADHF?
may be used for congestion when loops are inadequate, adjunct therapy, close monitoring required
HF
What is the role of vasodilators for ADHF?
add on therapy for refractory congestion, hypotension must not be present
HF
What vasodilators may be used for congestion?
- nitroglycerin (venodilator)
- sodium nitropusside (venodialator + arterial vasodilator)
HF
What patients are ideal for nitroglycerin use in congestion?
pt with hypertension, coronary ischemia or significant mitral regurgitation
HF
What are the warnings/precautions associated with nitroglycerin?
- tachyphylaxis
- hypotension
- elevated intracranial pressure
HF
What patients are ideal for sodium nitroprusside use in congestion?
severe congestion with hypertension or severe mitral valve regurgitation
HF
What are the warnings/precautions associated with sodium nitroprusside?
- requires invasive BP monitoring!!!
- renal insufficiency
- rebound phenomenon
- elevated intracranial pressure
HF
What is the recommendation for using inotropes for low perfusion?
not to be used long-term, but can be used in patients with cardiogenic shock as a bridge therapy
HF
What drugs are inotropes that may potentially be used for low perfusion?
dobutamine and milirone
HF
What is the mechanism of dobutamine?
adrenergic agonist, primarly beta1and beta2, some alpha1
HF
What is the mechanism of milrinone?
vasodilator via PDE inhibition
HF
What are the adverse effects of dobutamine?
- tachyarrhythmias
- BP instability
- headache
- nausea
- fever
HF
What are the adverse effects of milrinone?
- arrhythmias
- hypotension
- thrombocytopenia
HF
What are the monitoring parameters for patients with ADHF?
- daily weights
- I/O
- electrolytes (Na+/K+/Ca2+/Mg2+)
- SCr/BUN
- vital signs
- physical exam
- BNP, NT-proBNP
