Acute HF

Question 1

How to Treat Preload

Answer 1

Increase Contractility
-Inotropes

Lower Preload
-Diuretics
-Nitrates
-V2 antagonists

Question 2

How to Treat Afterload

Answer 2

Increase Contractility
-Inotropes

Lower Preload
-Nitrates
-Hydralazine
-ACEI/ARB/ARNI
-DHP CCB

Question 3

ADHF can be triggered by…

Answer 3

1. ACS
2. HTN (uncontrolled)
3. A fib
4. Dietary indiscretion
5. Acute infection
6. Thyroid issues
7. Med nonadh
8. Drug-induced

Question 4

Signs of ADHF

Answer 4

High Preload
-PCWP > 18
-JVP > 5

Low Output
-SBP < 90
-CI < 2.2
-Lactate > 2

Question 5

Warm/Wet/Cold/Dry

Answer 5

-Cold = poor perfusion, CI < 2.2, SBP < 90, lactate > 2 (low output)

-Wet = excess fluid, PCWP > 18, JVP > 5 (high preload)

-Dry and Warm = normal

Question 6

What to do with home guideline-directed medical therapy

Answer 6

Hold if high K, AKI
-MRA
-ACEI/ARB/ARNI
-Digoxin

Hold if hypotensive
-Vericiguat
-Ivabradine
-Hydra/Isos

Hold if shock, brady
-BB

Question 7

Warm and Wet Tx

Answer 7

1. IV loop
2. Thiazide
3. Acetazolamide
4. Tolvaptan

+/- Nitrates IF BP sufficient (SBP >90)

Question 8

Loop Diuretics: IV Bolus Dosing

Answer 8

Home oral dose x1-2.5

Give that as IV bolus BID
=
Double dose until goal is met
=
Then consider increase in frequency

UO goal of 2-3L per dose or 3-5L per day

Question 9

Loop: Max IV Bolus Doses

Answer 9

F 80 mg per dose

B 4 mg per dose

(EA and T not IVs)

Question 10

Loop: Continuous Infusion

Answer 10

Is total daily dose higher than these values?
-F > 161
-T > 81
-B > 9
-EA > 200

Then convert to CI
-F 80 then 10-20 mg/h
-B 2 then 0.5 mg/h

Question 11

Loop diuretics: making dose adjustments of continuous infusions

Answer 11

Not meeting UO goal

If on F CI
-Bolus F 80 mg IV once then increase rate by 5-10 mg/h

If on B CI
-Bolus B 2-4 mg IV once then increase rate by 0.5-1 mg/h

Question 12

Loops: Monitoring

Answer 12

AE:
-Low elecs
-Dehydration
-AKI
-Meta alkalosis
-Ototoxicity

CI:
-Sulfa allergy (not EA)

Question 13

Thiazides: When to give + Dosing

Answer 13

Consider giving if on
4 mg bumetanide IV BID, 80 mg furosemide IV BID, or
continuous infusion of diuretic

Meto 2.5-10 QD/div

Chloro 250-1000 QD/BID

Question 14

Thiazides: Monitoring

Answer 14

AE:
-Low elecs
-Dehydration
-AKI

Question 15

Acetazolamide

Answer 15

-Consider giving if on at least 2x home oral loop dose given as IV

-Additional consideration to use if bicarbonate is high (≥30 mEq/L)

-Dose is 500 mg IV QD to BID, given with loop

Question 16

Acetazolamide: Monitoring

Answer 16

AE:
-Low elecs
-Dehydration
-AKI
-Meta alkalosis

CI:
-Sulfa
-SJS hx

Question 17

Tolvaptan: When to give + Dosing

Answer 17

Hypervolemic or euvolemic hyponatremia (Na+ <125 mEq/L)

Dose: 15-60 QD (can double dose every 24 hr, allow pts to drink to thirst)

Question 18

Tolvaptan: Monitoring

Answer 18

BBW:
-Osmotic demyelination (caused by rapid sodium rise >12 mEq/L/24h)

AE:
-High K
-High glucose
-Dehydration
-Liver tox

GLOK

Question 19

Nitrates: Dosing

Answer 19

Nitroglycerin
-Start 10-20 mcg/min
-Max 200 mcg/min

Nitroprusside
-Start 0.25-0.5 mcg/kg/min
-Max 3 mcg/kg/min

Question 20

Nitrates: Monitoring

Answer 20

Nitroprusside
-Cyanide tox
-Thiocyanate tox
-CI: preg, hepatic/renal failure

Both
-Tachyphylaxis
-Hypotension
-HA
-Tachycardia rebound

Question 21

Cold and Dry Tx

Answer 21

1. Orthostasis, dry skin, mucous membranes, diarrhea, weight loss and PCWP < 15
   = GIVE 250-500 ml IV fluids
2. No dehydration and PCWP > 15
   -SBP < 90: Inotropes
   -SBP 90+: Vasodilators (then inotropes if refractory)

Question 22

Dopamine/Dobutamine Dosing

Answer 22

Start 3-5 mcg/kg/min

Max 20

Question 23

Milrinone Dosing

Answer 23

Start 0.125-0.25 mcg/kg/min

Max 0.75

Question 24

Inotropes: Monitoring

Answer 24

AE:

-Dopamine: after load increase

-Dobutamine/Milrinone: hypotension

-All: tachycardia, arrhythmia

CI: Renal dysfunction for Milrinone

Question 25

Cold and Wet Tx

Answer 25

SBP < 90
= do Inotropes + IV Diuretics

SBP 90+
= do IV Vasodilators + IV Diuretics