Acute Decompensated HF Drugs 2

Question 1

Medical Factors Contributing to Decompensation

Answer 1

Noncompliance with meds or dietary restrictions MI, Arrhythmia (afib), uncontrolled HTN, or valvular diseases

Question 2

Pharmacological Factors Contributing to Decompensation

Answer 2

Over-diuresis with diuretics Negative inotrope of beta blockers, Non-DHP CCB, itraconazole or Class 1 anti-arrhythmic Certain chemotherapies NSAIDs (Na/H20 retention) Glitazones and steroids bc of fluid retention

Question 3

B-type naturetic peptide (BNP)

Answer 3

Increases with fluid overload bc of distention of heart chambers Less than 50 = fluid overload unlikely 100-500: fluid overload possible >500 Fluid overload very likely

Question 4

BNP things to keep in mind

Answer 4

Can be elevated in age, myocardial hypertrophy, myocardial stress, and renal dysfunction

Question 5

Invasive hemodynamic monitoring

Answer 5

Swan-Ganz catheter or pulmonary artery catheter

Question 6

PAOP

Answer 6

without HF 6-10 >18 = fluid overload/congestion (need for diuresis)

Question 7

CI

Answer 7

without HF 3-4 Less than 2.2 with cold signs and symptoms (may need vasodilators or inotropes)

Question 8

Swan-Ganz Catheters can cause

Answer 8

Arrhythmias, thrombosis, infection, bleeding, pneumothorax or rupture of pulmonary artery

Question 9

CHF meds might be

Answer 9

Reduced or temporarily discontinued if entering the hospital bc of HF but they need to be re-initiated after especially ACEi, BB, Aldosterone antagonists

Question 10

ACEi/Aldosterone antagonists reduce the dose or d/c if…

Answer 10

Hypotension Hyperkalemia > 5.5 Worsening renal function (increasing SCr or decreased urine output)

Question 11

Beta-blockers reduce the dose or d/c if:

Answer 11

Hypotension Requiring inotropes - Stopping increases likelihood of arrhythmias and mortality (start low and go slow when re-starting)

Question 12

Define Warm and Dry

Answer 12

Volume status is normal and cardiac output is adequate Maintain or optimize chronic oral meds and fluid status

Question 13

Warm and Dry Patients should be counseled on:

Answer 13

Don’t take NSAIDs if your weight is increasing BB may make you feel works before you get better and have some long-term benefits

Question 14

Define Warm and Wet

Answer 14

Volume status is increased but cardiac output is adequate Symptoms of congestion (edema, orthopnea) No symptomsof low cardiac output PAOP > 15-18; Cardiac Index > 2.2

Question 15

Warm and Wet patients need

Answer 15

to be diuresised

Question 16

Warm and Wet General management strategy

Answer 16

Decrease weight by 1-1.5 kg/d (avoid decrease in renal function) Start IV loop diuretic Double dose Coninuous infusion Add thiazide Add vasodilator Consider Swan-Ganz or possible inotrope Last line: hypofiltration

Question 17

Define Cold and Dry

Answer 17

Volume status is normal or low Cardiac ouput is decreased No symptoms of congestion Symptoms of decreased cardiac output (decreased renal function, altered mental status, cold/cyanotic extremities) PAOP 15-18 or less Cardiac Index less than 2.2

Question 18

Cold and Dry Management Strategy

Answer 18

Ensure volume status is adequate then add inotrope to main CI > 2.2 Give NS 250-500 mL IV x2 (if improve, pt is dehydrated) Insert Swan-Ganz to determine fluid status and CI Give IV fluids to increase PAOP to ~15 Then start inotrope if CI still less than 2.2

Question 19

Dobutamine/Milirone can be used in Cold and Dry if

Answer 19

BP > 90/60

Question 20

Noreepinephrine if

Answer 20

BP is less than 90/60 (titrate to BP of 90/60 - Add dobutamine if CI is still less than 2.2

Question 21

Define Cold and Wet

Answer 21

Volume status is increase Cardiac output is decreased Symptoms of congestion Symptoms of decreased cardiac output PAOP >18 CI less than 2.2

Question 22

Cold and Wet Management strategy:

Answer 22

Fix underlying cause Maintain BP over 90/60 Slowly remove excess volume with diuretics

Question 23

Cold and Wet SBP >110

Answer 23

Diuretic + Vasodilator - If BP drops below 110 stop the vasodilator and add inotrope - If CI is less than 2.2 or no improvement with vasodilator, add or switch to inotrope - Nitropresside or nitroglycerin and then start diuretics

Question 24

Cold and Wet SBP 90-110

Answer 24

Diuretic + Inotrope - Dobutamine (less than 90) or milrinone if >90 (acts like a vasodilator in HF)

Question 25

Cold and Wet SBP Less than 90

Answer 25

NE to maintain BP > 90/60 - If cardiac index is less than 2.2 add dobutamine and slowly diurese (avoid hypotension) - Cardiogenic shock - Get of NE ASAP

Question 26

Goals of Therapy

Answer 26

Identify and correct precipitating factors ID and improve hemodynamic status Optimize CHF therapy to reduce mortality