Acute decompensated Heart Failure

Question 1

CI cardiac index =

Answer 1

CO/m2
Cardiac output (CO) is the volume of blood ejected from left ventricle during systole (L/min)

Question 2

what is the normal range of CI

Answer 2

Normal range 2.5-4 L/min/m2

Question 3

You would predict that CI is ___________ in patient with ADHF

Answer 3

Low

Question 4

You would predict that PCWP is __________in patient with ADHF?

Answer 4

High

Question 5

What is Endothelin-1 (ET-1)

Answer 5

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

Question 6

Pharmacologic actions of Arginine Vasopressin (AVP )

Answer 6

Hormone secreted by posterior pituitary to maintain water homeostasis
Also known as antidiuretic hormore
Actions
Inhibits renal excretion of free water
Potent vasoconstriction

Question 7

Used as a diagnostic tool, very valuable from differentiating between ADHF and ?

Answer 7

pneumonia

Question 8

Also, in a patient with a baseline of BNP, any sharp increase is an indicator of ?

Answer 8

worsening of their HF

Question 9

BNP “helps us” do what with ET-1 and AVP

Answer 9

it balances ET-1 and AVP;

Science has even made synthetic BNP as a medication

Question 10

what are the two main reason ADHF occur

Answer 10

Decreased CO/CI

Sodium/H2O retention

Question 11

Drugs that cause water and Na retention

Answer 11

Corticosteroids
NSAIDs (ibuprofen, naproxen)
Thiazolidinediones (pioglitazone, rosiglitazone)
Some antibiotics

Question 12

Drugs that decrease cardiac contractility

Answer 12

Alcohol
 Beta blockers
 Non-dihydropyridine CCB
 Some antiarrhythmics
 Some chemotherapy agents (doxorubicin)

Question 13

Factors for in-hospital mortality include
�BUN
SBP 
SCr 
�

Answer 13

≥ 43 mg/dL
< 115 mmHg
≥ 2.75 mg/dL

Question 14

Goals of therapy for all ADHF patients

Answer 14

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

Question 15

Forrester Hemodynamic subset II?

Answer 15

Warm and wet

Question 16

Forrester Hemodynamic subset III?

Answer 16

cold and dry

Question 17

Forrester Hemodynamic subset IV?

Answer 17

cold and wet

Question 18

“Warm & Wet”, subset II

Answer 18

Adequate perfusion

Volume overload

Question 19

what are the Signs and symptoms of a person warm and wet

Answer 19

normal BP but increased weight

Question 20

what would you use to treat a warm and wet Pt

Answer 20

furosemide and nitroglycerine

Question 21

cold and dry subset III volume and perfusion status?

Answer 21

Hypoperfusion

Good volume status

Question 22

what are the signs and symptoms of cold and dry?

Answer 22

lower BP systolic low 90’s, dehydrated

Question 23

how do you treat cold and dry

Answer 23

gentle rehydration and intoptrope, dobutamine

Question 24

cold and wet subset IV volume and perfusion status?

Answer 24

Hypoperfusion

Volume overload

Question 25

cold and wet signs and symptoms

Answer 25

low SBP, increased volume i.e weight increase peripheral edema,

Question 26

cold and wet Tx,

Answer 26

diuretics to lose water and dobutamine get CI up | possibly vasodilator depending on SBP

Question 27

what is the Cornerstone of HF management

Answer 27

ACE-inhibitors | Most likely used in “warm and wet” while the other types of ADHF doesn’t have the BP tolerance

Question 28

what drugs are part of the loop diuretic class

Answer 28

Furosemide (Lasix) Bumetanide (Bumex) Torsemide (Demadex)

Question 29

loop diuretic MOA

Answer 29

Increases Na excretion at the loop of Henle

Question 30

loop diuretic ADR

Answer 30

``` Electrolyte abnormalities Hyponatremia Hypokalemia Hypomagnesemia Renal dysfunction Hypotension ```

Question 31

what is diuretic resistance

Answer 31

Failure to respond to several IV bolus doses of loop diuretics Occurs in 1 of 3 pts taking diuretics at home

Question 32

Methods for overcoming diuretic resistance?

Answer 32

``` Student responses? Increase loop diuretice Start loop diuretic infusion Add thiazide diuretic for synergy Ultrafiltration ```

Question 33

what are 3 vasodilators

Answer 33

Nitroglycerin Nitroprusside (Nipride™) Nesiritide (Natrecor™)

Question 34

Nitroprusside MOA

Answer 34

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

Question 35

Nitroprusside adverse drug effects

Answer 35

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)

Question 36

Nitroglycerin MOA

Answer 36

primarily a venous vasodilator | Acts as a nitric oxide donor

Question 37

Nitroglycerin side notes

Answer 37

IV infusion, short-term useful in heart failure with myocardial ischemia Risk of tachyphylaxis Other side effects: HA, hypotension

Question 38

Nesiritide MOA

Answer 38

Recombinant B-type Natriuretic Peptide reduces sympathetic stimulation inhibits renin-angiotension-aldosterone system Results in vascular smooth muscle relaxation, balanced vasodilator AND diuresis

Question 39

Nesiritide adverse effects

Answer 39

hypotension, especially if on ACE-I worsens renal function Increased mortality?

Question 40

Dopamine MOA

Answer 40

Has inotropic and vasopressor activities, converted in norepinephrine

Question 41

dobutamine MOA

Answer 41

– β-agonist: | Binds to beta 1 receptor and increases calcium influx during systole

Question 42

dobutamine pharmacologic effects and place in therapy

Answer 42

Increase contractility  increase CO/CI | acute CHF: “cold” patients

Question 43

dobutamine adverse effects

Answer 43

Adverse effects: Tachycardia Arrythymogenic Increase in mortality in long term use

Question 44

Milrinone MOA

Answer 44

``` Phosphodiesterase inhibitor (PDE3) Increases intracellular cAMP which increases intracellular calcium ```

Question 45

Milrinone Pharmacologic effect:

Answer 45

increased contractility | Vasodilatory effects

Question 46

milrinone adverse effects

Answer 46

``` Arrythymogenic May decrease BP and result in reflex tachycardia Hypotension Thrombocytopenia Increase in mortality ```

Question 47

Diagnostic value of BNP�

Answer 47

less than 100 pg/ml no HF inconclusive 100-500pg/ml greater than 500 pg/ml high sensitivity to cardiac issues