Acute Decompensated HF Flashcards
1
Q
What is the definition of Acute Decompensated HF?
A
It’s an injury/insult to the body where not enough blood is being pumped into the heart, causing acute fluid overload
2
Q
Approx. how many pts will present to the ED with ADHF?
A
75% of pts
3
Q
What is the average age for ADHF?
A
72.4 yrs
4
Q
Why would a 40 yr old present to with ADHF?
A
Malignant/ untreated HTN, drug/ EtOH abuse, SLEEP APNEA
5
Q
What % of pts will be hospitalized d/t an insult in existing HF?
A
75%
6
Q
What % of pts will be hospitalized d/t de novo HF?
A
25%
7
Q
What % of pts will be hospitalized d/t disease progression?
A
5%
8
Q
Approx how many hospitalizations per year are d/t HF?
A
Over 1 mill.
9
Q
What is the avg length of hospital stay in ADHF?
A
4-5 days
10
Q
What % will re-hospitalization occur in ADHF pts?
What is the problem with this?
A
50%
Readmission for the same Dx w/in 30 days = no compensation from insurance companies
11
Q
What is the formula for Cardiac Index?
What is the normal range?
A
CI = CO m^2
Expressed in L/min/m^2
Nml range: 2.5 - 4 L/min/m^2
12
Q
What is the definition of Cardiac Output?
A
The volume of blood ejected from the LV during systole (expressed in L/ min)
13
Q
What is the utility of Cardiac Index?
A
To determine O2 delivery and perfusion: is there enough oxygenated blood being delivered to the periphery
14
Q
Would CI be high or low in a pt w/ ADHF?
A
LOW –> low-normal
15
Q
What is Pulmonary capillary wedge pressure (PCWP) aka pulmonary artery occlusion pressure (PAOP)? What is its utility?
A
It indirectly measures end diastolic volume to determine pt’s preload (EDV) / volume status; i.e. pulmonary edema, LV dysfunction
(Amount of blood @ end of diastole)
16
Q
How is PCWP measured? What are its limitations?
A
With a Swan-Ganz catheter: starting in the SVC, catheter is threaded thru RA –> RV –> PA –> lungs
Dangerous: risk vs. benefit analysis – should mostly be used if they’re refractory to all meds
Doesn’t change the outcome: finding the same signs on physical exam
17
Q
What is the normal range for PCWP?
A
8 - 12 mmHg
18
Q
Would PCWP be high or low in a pt w/ ADHF?
A
HIGH d/t fluid backup
19
Q
What is the most common type of ADHF?
A
Warm and wet
20
Q
How would you predict CI and PCWP for a pt in “warm and wet” AHF?
A
- CI: preserved, slightly depressed (CO is okay - dec.)
- PCWP: high
21
Q
What would a physical exam of a “warm and wet” AHF pt reveal?
A
Warm: stable BP, good perfusion, extremities are warm
Wet: pulm edema: auscultation, CXR, cough; peripheral edema: palpated in legs
22
Q
Give examples of how “warm and wet” HF occurs
A
- Valve dysfunction
- Post holiday/ weekend w/ high-Na+/ fat foods; tOH
- Drugs: B-Blocker (dec. CO); adding steroids for COPD exacerbation
23
Q
What are 3 compensatory mechanisms against ADHF?
A
- Endothelin-1 (ET-1)
- Arginine Vasopressin (AVP)
- B-type Natriuretic Peptide/ Atrial Natriuretic Peptide (BNP/ ANP)
24
Q
What are the 4 major actions of ET-1?
A
- Potent vasoconstriction (to inc BP, inc perfusion)
- Induces cardiac remodeling
- Dec renal blood flow (GFR)
- Acts to further stimulated RAAS and SNS systems (inc volume)
25
Will ET-1 levels be high or low in HF?
High
| ET-1 "hurts us"
26
What is AVP?
aka antidiuretic hormone
| A hormone secreted by the post. pituitary to maintain water homeostasis
27
What are 2 actions of AVP?
- Inhibits renal excretion of free water (inc. volume)
| - Potent vasoconstriction (inc. BP)
28
Will AVP levels be high or low in HF?
High
| AVP "hurts us"
29
What triggers the release of ANP?
In response to atrial dilation and stretch, ANP is released from atrial myocardium
30
What triggers the release of BNP?
In response to elevated end diastolic volume (preload), BNP is released from ventricular myocardium
31
Will ANP/BNP levels be high or low in HF?
High
| BNP "helps us" as it balances ET-1 and AVP
32
What are the 3 major actions of ANP/BNP?
- Vasodilation: peripheral & coronary
- Natriuresis
- Diureses
33
Used as a diagnostic tool, ANP/BNP levels are useful in differentiating between which conditions?
ADHF (cardiac origin) and pneumonia/ COPD (pulmonary congestion/ edema)
-Suggestive of CHF; compare with baseline
34
If someone with CHF with an elevated baseline BNP comes in with an increased BNP, what would that suggest?
- Renal insufficiency: the kidneys can't clear the BNP
| - Worsening HF
35
What values would be indicative of NO HF vs. inconclusive vs. Cardiac issues?
No HF: < 100 pg/mL
Inconclusive: >100 - < 500 pg/mL
Cardiac issues (highly sensitive): > 500 pg/mL
36
What are the 3 neurohormonal actions of ANP & BNP?
- Antagonist to RAAS
- Inhibits SNS
- Antagonist to ET-1
37
What are 3 renal effects of ANP & BNP?
- Increases GFR
- Inc diuresis
- Inc natriuresis
38
What are the 2 main causes of ADHF?
1. Decreased CO/ CI
| 2. Sodium / H2O retention
39
What are 3 prognostic factors for in-hospital mortality according to the ADHERE registry?
1. BUN >/= 43 mg/dL
2. SBP < 115 mmHg (< 90 = cardiogenic shock)
3. SCr >/= 2.75 mg/dL
40
What is the mortality correlated with the number of prognostic factors according to the ADHERE registry?
```
0 = low risk, 2% mortality
1 = mod risk, 6% mortality
2 = high risk, 13% mortality
3 = very high risk, 20% mortality
```
41
What are the 4 goals of therapy for all ADHF pts?
1. Relieve congestion and optimized volume status
2. Treat symptoms of low CO
3. Minimize risks associated with drug therapy
4. Avoid future hospitalization by optimizing chronic therapies & providing pt education --> B-Blockers, ACEis; counseling
42
What is the diagnosis of ADHF based on?
Primarily based on pt's signs & symptoms
43
What are some signs of congestion?
- + CXR
- Auscultation
- Observe breathing
- Cough
44
What are some signs of hypoperfusion?
- Looking hemodynamically unstable
- Gasping
- Cyanosis
- Asking family members if they look normal
- Borderline hypotension: NOT in shock SBP > 90 mmHg, compare it to baseline
45
Which 3 drugs increase Cardiac Index?
- Dobutamine (IV, pure B1 agonist)
- Dopamine (watch out for inc. BP)
- Milrinone/ Amrinone (inc CO)
46
Which 2 factors encompass the "warm and wet" subset of AHF?
- Adequate perfusion
| - Volume overload: systemic or pulmonary
47
Visually how would a "warm and wet" pt present?
- Non-cyanotic, stable, nml BP
| - Sxs of pulmonary congestion, systemic congestion e.g. if 200 lbs on Sat, 215 lbs on Tues --> need diuretic
48
What are some precipitating events for a "warm and wet" pt?
- A pt with chronic HF who has a part w/ high Na+/ EtOh
| - Too high of a B-Blocker dose (dec. CO) i.e. Atenolol
49
How would you treat a "warm and wet" pt?
- Diuretics: Lasix
- Vasodilators: Nitroglycerine
- MC drug combination
50
Is C.I. high or low in a "warm and wet" pt?
| PCWP high or low?
- C.I. is high
| - PCWP is high
51
Which 2 factors encompass the "cold and dry" subset of AHF?
- Hypoperfusion
| - Good volume status
52
Visually how would a "cold and dry" pt present
-Cyanotic, dec. BP (not hypotensive)
53
What are some precipitating events for a "cold and dry" pt?
- A pt with chronic HF and is really vigilant with Na+/ H2O restriction (slightly dehydrated); compliant w/ Lasix
- Cardiac arrhythmias
- Lower BP (systolic low 90s)
54
How would you treat a "cold and dry" pt?
- GENTLE rehydration
| - Inotropes (e.g. dobutamine)
55
Why wouldn't you use a vasodilator for a "cold and dry" pt?
Don't need to lower their blood pressure, borderline hypotensive
56
Is C.I. high or low in a "cold and dry" pt?
| PCWP high or low?
C.I is low
| PCWP is low
57
Which 2 factors encompass the "cold and wet" subset of AHF?
- Hypoperfusion
| - Volume overload
58
Visually how would a "cold and wet" pt present?
- Almost in cardiogenic shock; cyanosis
| - Wet lungs on auscultation; cough w/ sputum; peripheral edema
59
What are some precipitating events for a "cold and wet" pt?
- S/p M.I.: acute insult to heart, dec. CO, borderline shock d/t BP
- Possible too high dose of B-B i.e. Labetolol, Carvedilol (a & B blocker)
60
How would you treat a "cold and wet" pt?
- Diuretics
- Inotropes (Dobutamine)
- Occasional vasodilators unless BP is too low
61
Is C.I. high or low in a "cold and wet" pt?
| PCWP high or low?
C.I is low
| PCWP is high
62
For ADHF, how would you manage a pt's ACEi dose?
Maintain home dose if possible (5-10 mg Lisinopril), consider INCREASE dose to goal if BP allows
63
What is the most likely subset of HF that would require an ACEi?
"Warm and wet" (other subsets usually won't have the BP tolerance)
64
What are the 2 most common Loop Diuretics used in "wet" HF pts?
Furosemide (Lasix) -- IV
| Bumetanide (Bumex)
65
What is the MOA of Loop diuretics?
Increases Na+ excretion at the loop of Henle
66
What is the onset & duration of action for both PO and IV Loop Diuretics?
PO: onset 30 min, duration 6 hrs
IV: onset 5 min, duration 2 hrs
67
If a patient is already taking 20mg PO Lasix and they are fluid overloaded by 5kg, how would you proceed?
Give more Loop! Not getting enough response
68
What is the dose conversion of Loops from PO to IV?
40 mg PO QD --> 20 mg IV infusion
69
What are the two possible options w/in the IV route for Loops? Which is better?
IV Bolus
| Continuous IV infusion: less stress on kidneys
70
What are the 3 main ADRs with Loop Diuretics?
- Electrolyte abnormalities: dec. Na+, K+, and Mg++
- Renal dysfunction: strains kidney; want to see diuresis w/ stable SCr
- Hypotension
71
What is diuretic resistance? How often does it occur?
- Failure to respond to several IV bolus doses of Loops
| - Occurs in 1 in 3 pts taking diuretics at home
72
What are the 5 possible methods for overcoming diuretic resistance?
- Give an increased dose
- Add a thiazide for synergistic action (except in renal dysfunction)
- Start a Lasix infusion at 10mg/hr
- Ultrafiltration
- Add a vasodilator if tolerated (more volume to excrete)
73
What is the purpose of ultrafiltration? What are the indications?
- Modality for fluid removal, removes a predictable amt of Na+/ H2O; rate is slow --> minimal drop in BP
- For diuretic resistance, severe renal impairment
74
What are 3 potent vasodilators used in ADHF?
Nitroglycerine (MC)
Nitroprusside (pts w/ NTG intolerance)
Nesiritide (restricted use)
75
What is the MOA of Nitroprusside?
- Potent, balanced vasodilator (dec. BP)
| - Acts directly on vascular smooth muscle --> NO donor
76
What is another use for Nitroprusside besides HF?
-Also used in HYPERTENSIVE CRISIS
77
What are some main take away points for Nitroprusside?
- Ordered as mcg/kg/min infusion
- Protected from light
- Byproduct is cyanide so it CANNOT be used in RENAL DYSFUNCTION/ prolonged high dose --> inc risk for toxicity
78
What are 2 other adverse effects associated with Nitroprusside?
- Hypotension
- Coronary steal syndrome (diverting blood away from coronary arteries) --> worse outcome s/p M.I. in pts who are NOT in heart failure
79
What is the MOA of Nitroglycerine?
- Venous vasodilator
| - Acts as a NO donor
80
What is another use for Nitroglycerine besides HF?
Useful in HF with myocardial ischemia
81
What are some take away points for NTG?
- Given as IV infusion, short-term
| - Risk for tachyphylaxis (dec. response)
82
What are 2 main side effects of NTG?
H.A
| Hypotension
83
What is the MOA of Nesiritide?
- Reduces SNS stimulation
| - Inhibits RAAS
84
What effects are seen with Nesiritide?
- Vascular smooth muscle relaxation
- Balanced vasodilator
- Diuresis
85
Which subset of HF would Nesiritide be useful for? Limitation?
"Warm and wet" pts, esp those who have failed Nitro/Lasix combo: USED AS A LAST RESORT
- Expensive
- May increase mortality for some pts; no more effective than traditional standard of care
86
What are 3 major ADRs for Nesiritide?
- Hypotension, esp. with ACEi
- Worsens renal function (inc. SCr)
- Possible increased mortality
87
What are some advantages of using Nesiritide?
-Increases Na+ excretion & urine output WITHOUT excessive hypokalemia
88
What are 3 inotropic agents used in ADHF?
- Dopamine
- Dobutamine
- Milrinone
89
Which subsets of pts would inotropic agents be best for?
Cold & wet
| Cold & dry
90
What is the MOA behind Dopamine?
- Has inotropic & vasopressor activities
| - Converted into NE and activates alpha, Beta & dopaminergic receptors --> vasoconstriction
91
What is the general MOA behind dobutamine & milrinone?
Inotropic activities
| NO vasopressor properties (unlike Dopamine)
92
In what setting would Dopamine be used? Not used?
- Typically for COLD patients, almost cardiogenic shock
| - A pt w/ preserved SBP, shouldn't get dopamine d/t peripheral vasoconstriction --> dec. capillary perfusion
93
What is the specific MOA of Dobutamine?
-B - agonist, binds to receptor & inc. Ca++ influx during systole
94
What is the pharmacologic effect of dobutamine?
- Increases contractility (CO/ CI)
| - Blood pressure neutral
95
What is the place in therapy for dobutamine?
-Acute CHF --> "cold" pts (w/ dec. CO)
96
What are adverse effects of dobutamine?
- Tachycardia (B1 receptor)
- Arrhythmogenic
- Increase in mortality w/ long term use: typical 4-5 day stay for "cold" inpts; stage D: w/ pump @ home
97
What is the specific MOA of Milrinone?
- Phosphodiesterase inhibitor (PDE3) -- inodilator
| - Increases intracellular cAMP --> inc. intracellular Ca++
98
What is the pharmacologic effect of milrinone?
- Increased contractility
| - Vasodilatory effects -- inodilator
99
What are some adverse effects of milrinone?
- Arrhythmogenic
- May DEC. BP and result in reflex tachycardia
- Hypotension
- Thrombocytopenia
- Inc in mortality
100
What are 3 main drug classes to consider when discharging an inpatient and initiating/ maximizing a chronic HF regimen?
ACEi
B-Blocker (Toprol 200 mg QD)
For systolic HF; inc. 1 drug dose Q 2-4 wks
-Low dose diuretic
101
What are 3 other important aspects to consider when discharging an inpatient and initiating/ maximizing a chronic HF regimen?
- Ejection fraction documentation
- Smoking cessation counseling
- HF clinic esp if they don't have a cardiologist
102
For a pt with chronic heart failure (diagnosed 1 yr ago) and this is their 2nd admission, they are already on ACEi/ B-B, what is the next best step?
- Spironolactone (K+ sparing)
- SHORT COURSE digoxin to inc CO
- Hydralazine/ nitrates for an African Am or C/I to ACEi) req. inc frequency, dec. BP
