Acute decompensated Heart Failure Flashcards
CI cardiac index =
CO/m2 Cardiac output (CO) is the volume of blood ejected from left ventricle during systole (L/min)
what is the normal range of CI
Normal range 2.5-4 L/min/m2
You would predict that CI is ___________ in patient with ADHF
Low
You would predict that PCWP is __________in patient with ADHF?
High
What is Endothelin-1 (ET-1)
Potent vasoconstriction
Induces cardiac remodeling
Decreases renal blood flow (GFR)
Also acts to further stimulate the RAAS and SNS systems
Elevated ET-1 levels in heart failure and other diseases
Pharmacologic actions of Arginine Vasopressin (AVP )
Hormone secreted by posterior pituitary to maintain water homeostasis Also known as antidiuretic hormore Actions Inhibits renal excretion of free water Potent vasoconstriction
Used as a diagnostic tool, very valuable from differentiating between ADHF and ?
pneumonia
Also, in a patient with a baseline of BNP, any sharp increase is an indicator of ?
worsening of their HF
BNP “helps us” do what with ET-1 and AVP
it balances ET-1 and AVP;
Science has even made synthetic BNP as a medication
what are the two main reason ADHF occur
Decreased CO/CI
Sodium/H2O retention
Drugs that cause water and Na retention
Corticosteroids
NSAIDs (ibuprofen, naproxen)
Thiazolidinediones (pioglitazone, rosiglitazone)
Some antibiotics
Drugs that decrease cardiac contractility
Alcohol Beta blockers Non-dihydropyridine CCB Some antiarrhythmics Some chemotherapy agents (doxorubicin)
Factors for in-hospital mortality include �BUN SBP SCr �
≥ 43 mg/dL
< 115 mmHg
≥ 2.75 mg/dL
Goals of therapy for all ADHF patients
Relieve congestion and optimize volume status
Treat symptoms of low CO
Minimize risks associated with drug therapy
Avoid future hospitalization by optimizing chronic therapies and providing patient education
Forrester Hemodynamic subset II?
Warm and wet
Forrester Hemodynamic subset III?
cold and dry
Forrester Hemodynamic subset IV?
cold and wet
“Warm & Wet”, subset II
Adequate perfusion
Volume overload
what are the Signs and symptoms of a person warm and wet
normal BP but increased weight
what would you use to treat a warm and wet Pt
furosemide and nitroglycerine
cold and dry subset III volume and perfusion status?
Hypoperfusion
Good volume status
what are the signs and symptoms of cold and dry?
lower BP systolic low 90’s, dehydrated
how do you treat cold and dry
gentle rehydration and intoptrope, dobutamine
cold and wet subset IV volume and perfusion status?
Hypoperfusion
Volume overload
cold and wet signs and symptoms
low SBP, increased volume i.e weight increase peripheral edema,
cold and wet Tx,
diuretics to lose water and dobutamine get CI up
possibly vasodilator depending on SBP
what is the Cornerstone of HF management
ACE-inhibitors
Most likely used in “warm and wet” while the other types of ADHF doesn’t have the BP tolerance
what drugs are part of the loop diuretic class
Furosemide (Lasix)
Bumetanide (Bumex)
Torsemide (Demadex)
loop diuretic MOA
Increases Na excretion at the loop of Henle
loop diuretic ADR
Electrolyte abnormalities Hyponatremia Hypokalemia Hypomagnesemia Renal dysfunction Hypotension
what is diuretic resistance
Failure to respond to several IV bolus doses of loop diuretics
Occurs in 1 of 3 pts taking diuretics at home
Methods for overcoming diuretic resistance?
Student responses? Increase loop diuretice Start loop diuretic infusion Add thiazide diuretic for synergy Ultrafiltration
what are 3 vasodilators
Nitroglycerin
Nitroprusside (Nipride™)
Nesiritide (Natrecor™)
Nitroprusside MOA
potent, balanced vasodilator
acts directly on vascular smooth muscle (nitric oxide donor)
also used for hypertensive crisis
CAN NOT BE USED IN RENAL DYSFUNCTION because it will cause cyanide poisioning
Nitroprusside adverse drug effects
Hypotension
Coronary steal syndrome
worse outcomes in s/p MI patients who are NOT in heart failure
Metabolized to cyanide and thiocyanate, increased risk of toxicity in patients with renal dysfunction or if high dose for prolonged period
antidote (sodium thiosulfate)
Nitroglycerin MOA
primarily a venous vasodilator
Acts as a nitric oxide donor
Nitroglycerin side notes
IV infusion, short-term
useful in heart failure with myocardial ischemia
Risk of tachyphylaxis
Other side effects: HA, hypotension
Nesiritide MOA
Recombinant B-type Natriuretic Peptide
reduces sympathetic stimulation
inhibits renin-angiotension-aldosterone system
Results in vascular smooth muscle relaxation, balanced vasodilator AND diuresis
Nesiritide adverse effects
hypotension, especially if on ACE-I
worsens renal function
Increased mortality?
Dopamine MOA
Has inotropic and vasopressor activities, converted in norepinephrine
dobutamine MOA
– β-agonist:
Binds to beta 1 receptor and increases calcium influx during systole
dobutamine pharmacologic effects and place in therapy
Increase contractility increase CO/CI
dobutamine adverse effects
Adverse effects:
Tachycardia
Arrythymogenic
Increase in mortality in long term use
Milrinone MOA
Phosphodiesterase inhibitor (PDE3) Increases intracellular cAMP which increases intracellular calcium
Milrinone Pharmacologic effect:
increased contractility
Vasodilatory effects
milrinone adverse effects
Arrythymogenic May decrease BP and result in reflex tachycardia Hypotension Thrombocytopenia Increase in mortality
Diagnostic value of BNP�
less than 100 pg/ml no HF
inconclusive 100-500pg/ml
greater than 500 pg/ml high sensitivity to cardiac issues
