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PHRM 845 > Acute HF > Flashcards

Acute HF Flashcards

1
Q

What is the pathophysiology of acute HF?

A

Cardiogenic shock: hypotension (SBP <90 or MAP <70) w low CO

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2
Q

What are the diagnostic tools?

A

Non invasive testing:
- Detailed physical examination
- Laboratory assessment (Cr, K, Na, BNP, NTproNBP)
Invasive hemodynamic monitoring:
- Flow directed PA cath (Swan-Ganz cath)

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3
Q

What BNP level is closely associated w acute HF?

A

BNP >400

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4
Q

What sx is associated w warm and dry?

A

Normal

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5
Q

What sx is associated w warm and wet?

A

Pulmonary congestion

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6
Q

What sx is cool and dry?

A

Hypoperfusion

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7
Q

What sxs are associated w cool and wet?

A

Hypoperfusion and pulmonary congestion

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8
Q

What does warm or cold describe?

A

Cardiac function or ability to perfuse tissues

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9
Q

What does wet or dry describe?

A

Describes volume status

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10
Q

How to maintain chronic diuresis and RAAsi/SGLT2i?

A
  • Caution w increases and up-titration
  • Increases in SCr (about 20%) do not worsen outcomes
  • Significant worsening may warrant reduction or temporary d/c
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11
Q

How to maintain chronic BBs?

A
  • Do not stop unless recent initiation or up-titration resulted in current decompensation
  • Consider holding if dobutamine needed or hemodynamically unstable
  • Do not add or up titrate until optimization of volume status and successful d/c of IV diuretics, VDs, inotropes
  • Start at low doses and use special caution if inotropes used in hospital
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12
Q

How to maintain chronic digoxin?

A
  • Continue at dose to achieve SDC 0.5-0.9 ng/ml
  • Avoid d/c unless compelling reason
  • Caution w regard to renal function
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13
Q

What do diuretics, inotropes, vasodilators, vasopressors do?

A
  • None of these therapies shown conclusively to reduce mortality
  • Tx reduce sxs, restores perfusion, and minimizes cardiac damage and AEs
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14
Q

What tx is used for subset 1 warm and dry?

A

Optimizes chronic therapy

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15
Q

What tx is used for subset 2 warm and wet?

A

IV diuretics +/- IV venous vasodilator

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16
Q

What tx is used for subset 3 cold and dry?

A
  • If PCWP <15: IV fluids until PCWP 15-18
  • If PCWP >= 15 and SBP <90: IV inotrope
  • If PCWP >= 15 and SBP >= 90: IV inotrope or arterial vasodilator
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17
Q

What tx is used for subset 4 cold and wet?

A

IV diuretics +
- If SBP <90: IV inotrope
- If SBP >= 90: IV arterial vasodilator

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18
Q

When are diuretics mainly used?

A

To tx systemic/pulmonary congestion in subset 2 or 4, first line agents w fluid overload in hospitalized pts

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19
Q

Is there a difference between intermittent dosing and continuous infusion?

A

No

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20
Q

What dose of diuretics is administered?

A

Initial IV dose should equal or exceed the chronic daily dose and given as intermittent bolus

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21
Q

Which diuretic is mainly used?

A

Loops are most widely used, THZ used as add on if refractory

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22
Q

What should be done if there is diuretic resistance?

A
  • Sodium and water restriction
  • Increase dose, rather than frequency, to ceiling
  • Combo therapy (THZ + loops): PO MTZ 2.5-5 mg/day, HCTZ 12.25-25 mg/day; IV CTZ 250-500 mg/day
  • Ultrafiltration
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23
Q

How to dose diuretics in hospitalized pts?

A
  • Increase dose pt was receiving at home
  • If ceiling effect: 160-200 mg IV furosemide (depends on renal fx)
  • If continuous infusion: F 0.1 mg/kg/hr doubled q2-4h; max 0.4 mg
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24
Q

What are monitoring parameters of diuretics in hospitalized pts?

A
  • Urine output and s/sxs of congestion, should be serially assessed
  • Ins/outs, body weight, vital signs, s/sxs of perfusion and congestion
  • Serum electrolytes, BUN, creatinine daily
  • Desire 1-2 L/day above input early
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25
Q

What is the use of loops in ADHF?

A

Fluid overload (wet)

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26
Q

What drug can be used if pt cannot take loops for ADHF?

A

Ethacrynic acid

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27
Q

What is the approximate PO/IV equivalent dose of furosemide?

A

80/40 mg

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28
Q

What is the approximate PO/IV equivalent dose of bumetanide?

A

1/1 mg

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29
Q

What is the approximate PO/IV equivalent dose of torsemide?

A

20/20 mg

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30
Q

What is the initial IV bolus dose of furosemide?

A

40-120 mg

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31
Q

What is the initial IV bolus dose of bumetanide?

A

1-4 mg

32
Q

What is the initial IV bolus dose of torsemide?

A

10-40 mg

33
Q

What is the initial IV bolus dose of ethacrynic acid?

A

0.5-1 mg/kg

34
Q

What is the max bolus dose of furosemide?

A

160-200 mg

35
Q

What is the max bolus dose of bumetanide?

A

10 mg

36
Q

What is the max bolus dose of torsemide?

A

100 mg

37
Q

What is the infusion rate of furosemide?

A

10 mg/hr

38
Q

What is the infusion rate of bumetanide?

A

0.5 mg/hr

39
Q

What is the infusion rate of torsemide?

A

0.5 mg/hr

40
Q

What is the purpose of vasodilator therapy in ADHF?

A

Use in combo w diuretics to reduce pulmonary congestion in wet, stage 2 and 4, HF

41
Q

Why do vasodilators work?

A

Venodilators increase venous capacitance and reduce preload and reduce myocardial stress:
- Rapid sx relief

42
Q

Which vasodilator is the most preferred drug of choice?

A

NTG

43
Q

When are arterial vasodilators particularly useful?

A

In pts w elevated SVR

44
Q

When should a pt not receive vasodilators?

A

Symptomatic hypotension

45
Q

Vasodilators are considered over:

A

Inotropes

46
Q

What is a required monitoring parameter w the use of vasodilators?

A

Frequent BP

47
Q

What are the clinical effects of nitroprusside (Nitropress)?

A
  • Balanced vasodilator
  • Decreases SVR
48
Q

What is the use of nitroprusside in ADHF?

A
  • Warm and wet
  • Cold and wet (alt to inotropes)
  • HTN crisis
49
Q

What are the AEs of nitroprusside?

A
  • Cyanide and thiocyanate toxicity (usually w >3 days use)
  • Hypotension
50
Q

What are the clinical effects of NTG?

A
  • Venous > arterial VD
  • Decreased PCWP
51
Q

What is use of NTG in ADHF?

A
  • Warm and wet
  • ACS, HTN crisis
52
Q

What are the AEs of NTG?

A

Hypotension, HA, reflex tachycardia, and nitrate tolerance

53
Q

What are the clinical effects of nesiritide (natrecor)?

A
  • Balanced vasodilation
  • Increased urine output and Na excretion
54
Q

What is the use of nesiritide in ADHF?

A
  • Warm and wet
  • Cold and wet (alt to inotropes)
55
Q

What are the AEs of nesiritide?

A

Hypotension, tachycardia, renal dysfunction

56
Q

What drugs are positive inotropes?

A

Dobutamine (Dobutrex), Milrinone (Primacor), Dopamine

57
Q

What is the MOA of dobutamine (Dubotrex)?

A
  • B1 and B2 receptor agonist and weak A1 receptor agonist
  • Simulates AC to increase cAMP
58
Q

What are the clinical effects of dobutamine?

A

Positive inotrope, chronotrope, lusitrope

59
Q

What is the use dobutamine in ADHF?

A
  • Cold and wet
  • Cold and dry (if PCWP >15)
60
Q

When is dobutamine considered?

A

Consider if low BP

61
Q

What are the AEs of dobutamine?

A

Arrhthmogenic, tachycardia, ischemia, reduced K, tolerance after 48-72hr

62
Q

What is the MOA of milrinone?

A
  • PDE inhib, inc cAMP in myocardium (increased CO), and vasculature (decreased SVR)
  • “Inodilator”
63
Q

What are the clinical effects of milrinone?

A

Positive inotrope, venous > arterial VD

64
Q

What is the use of milrinone in ADHF?

A
  • Cold and wet
  • Cold and dry (if PCWP >15)
65
Q

What is the half life of milrinone?

A

1 hr in healthy, 2-3 hr in HF and CrCl <50

66
Q

When is milrinone considered?

A

Consider if on BB

67
Q

What are the AEs of milrinone?

A

Arrhythmogenic, tachycardia, ischemia, hypotension, thrombocytopenia (<0.5%)

68
Q

What is the MOA of dopamine?

A
  • Dose dependent agonist on dopamine, B1, B2, and A1 receptors
  • Causes release of NE from adrenergic nerve terminals
69
Q

What are the clinical effects of dopamine?

A

Positive inotrope, chronotrope, lusitrope

70
Q

What is the use of dopamine in ADHF?

A
  • Typically plays secondary role to dobutamine/milrinone
  • Sometimes referred to as a vasopressor
71
Q

What are the AEs of dopamine?

A

Arrhythmogenic, tachycardia, ischemia, decreased K, tolerance after 48-72h, skin necrosis upon infiltration

72
Q

What is the use of positive inotrope therapy?

A
  • Primarily to manage hypoperfusion or cold HF pts
  • Reasonable to consider vasodilators before inotropes when adequate BP
  • Useful for sx relief in hypotension (SBP <90)
  • Useful in pts w end organ dysfunction
  • Useful when disease is refractory to other HF therapies
73
Q

What sxs would cool and dry (subset 3) pts have?

A
  • Sxs of low output (cool) but not congestion (dry)
  • i.e. inadequate perfusion w no congestion
74
Q

What is the primary goal of therapy in subset 3 pts?

A

Increase output and perfusion w positive inotropes +/- IV fluids

75
Q

What is the therapy for subset 3 pts?

A
  • Initial therapy: fluids until BP maximized
  • Therapy following fluids: if pts still remains “cool,” inotropic or arterial vasodilator therapy maybe required

PHRM 845 (48 decks)

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