Acute HF Flashcards
MOA of Loop Diuretics
Increase Na excretion at the loop of henle
ADEs of loop diuretics
Electrolyte abnormalities- hyponatremia, hypokalemia, hypomagnesemia
Renal dysfunction
Hypotension
Name loops
Furosemide
Butemanide
Torsemide
What is the Function and indication of ultrafiltration aka aquaphoresis
Removes a predictable amount of H2O
Diuretic resistance
Severe renal impairment
Only a minimal drop in BP
What are the vasodilators?
Nitroprusside
Nitroglycerin
What is the cornerstone drug in acute heart failure?
ACE-I
Potent, balanced vasodilator, act on vascular smooth muscleMOA of?
Nitroprusside
Indication of Nitroprusside
vasodilator of the vascular (NO donor)
also for hypertensive crisis
protection from light
ADE nitroprusside
hypotension
coronary
renal syndrome (worse in s/p MI pt with heart failure)
consideration of nitroprusside
breaks down to thiocyanate/cyanide (orange-brown-blue)
so increase risk of toxicity for renal dysfxn pts or if HIGH dose is prolonged
antidote=sodium thiosulfate
What is the MOA and Indications of Nitroglycerin?
acts as a primary venous vasodilator
acts as a NO donor
used in HF with myocardial ischemia
What are the ADEs of Nitro? Can it be used IV?
H/A
hypotension
tachyphylaxsis
YES IV
What are the drugs for Inotropic therapy?
Dobutamine
Dopamine
Milrione
What is the MOA of dobutamine?
B agonist: binds to B1 receptor and increase calcium influx during systole
Indications of Dobutamine?
typical used in “cold” HF, almost cardiogenic shock
increase in contractility causes increase CO/CI
place in therapy: acute CHF “cold” pts
Tachycardiaarrththymogenicincrease mortality with long term useADE’s of?
Dobutamine
MOA dopamine?Indications of dopamine?
converts to NE, activates alpha, beta and dopaminergic receptor
also for “cold” patients
D+D for cold
Inotropic + vasopressor activity
MOA Milrione?
Phosphodiesterase inhibitor (PDE3) increase intracellular cAMP which increases intracellular calcium in the heart
Indications of Milrione
increase contractility because increase cAMP vasodilatory effects
“inodilator”
Arrhthmogenicmay decrease BP and result in reflex tachycardiathrobocytopeniaincrease in mortality
ADE of Milrione
What percent of patients present with heart failure to the ED?What is their average length of stay?
75%
3-4days
What is the Cardiac index?What is it’s utility?
CI= CO/ m^2 determines the O2 delivery and perfusion
What is the normal range of the CI?In pts with acute CHF, is CI high or low?
2.5-4
Low
What determines the pts preload/ volume status?
pulmonary capillary wedge pressure/pulmonary artery occlusion pressure (PAOP)
What is the normal PAOP/PCWP range?Is it high or low in patients with acute heart failure?
8-12 mmHg
High
What is the most common warm/cold dry/wet type?
Warm and wet!
What is the action of Endothelin-1
potent vasoconstriction, induce cardiac remodeling, decrease renal blood flow (GSR), stimulate RAAS+SNS elevated levels in heart failure + other diseases
ET-1 hurts us
Where does ET-1 monitor for its effects?
at the carotids and kidneys
What is the Action of Arginine Vasopressin (antiduretic hormone)
hormone secreted by the posterior pituitary to maintain water homeostasis inhibits renal excretion of free water potent vasoconstriction elevated AVP levels in heart failure AVP- hurts us
Atrial Naturetic Peptide function
released from atrial myocardium in response to atrial dilation and stretch
B- Type naturetic Peptide
released from ventricular myocardium in response to elevated end diastolic volume (preload)
What is the action of BNP?
vasodilation natriuresis diuresis antagonize RAAS inhibit SNS antagonize ET-1
What are the important values of BNP? No HFinconclusive”cardiac issue”
No HF is less than 100
inconclusive is 100-500
“cardiac issue” greater than 500
Does BNP help or hurt us
HELPS us!!!
What are the two main reasons ADHF occurs
Decrease CO/CI
Sodium/H2O restriction
What are the non drug related precipitating factors
ischemia diet indiscretion PE valvular dysfunction anemia worse renal fxn arrhythmias disease progression thyroid disorders electrolyte abnormalities infection non compliance
Drugs that cause water and sodium retention
corticosteroids
thiazolindediones
NSAIDS
some abx
Drugs that decrease cardiac contractility
alcohol
beta blockers
some antiarrhythmics
some chemo agents
Adequate perfusionvolume overloadPCWP greater than 18CI greater than 2.2 characteristics of:
Warm and Wet
subset II
(this pt gets a holiday heart)
hypoperfusiongood volume statusPCWP less than 18CI less than 2.2
“cold and dry”
this is the pt who has chronic HF, and super vigilant about Na and H2O who gets dehydrated, arrhthymias and low BP
Ssx: pulm congetsion, and/or system congestion, the congestion is visible on CXR or legs Tx?
Wet and Warm
ACE I plus diuretic
Ssx: hypoperfusion, see cyanosis, cold extremities and low BPTx?
Cold and Dry
NO diuretics, Inotropic meds but NOT digoxin
YES dobutamine
Hypoperfusionvolume overloadPCWP greater than 18CI less than 2.2
Cold and Wet
Ssx: pulm or systemic congestion and hypoperfustionTx?
Cold and Wet
low dose diuretic, inotropic- dobutamine
cold and wet pt appearance
almost in cardiogenic shock?
MI?
to high dose of BB diuretic/inotropes/vasodilators
