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Cardio > Advanced HF > Flashcards

Advanced HF Flashcards

1
Q

what are two options for palliative inotropes

A

dobutamine and milrinone

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2
Q

what drug class is dobutamine

A

beta adrenergic beta1 receptor agonist

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3
Q

what drug class is milrinone

A

phosphodiesterase inhibitor (PDE3)

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4
Q

what is the dosing for dobutamine

A

2.5-25 mcg/kg/min (usually 10)

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5
Q

what is the dosing for milrinone

A

0.125-0.5 mcg/kg/min

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6
Q

which has a longer half life, dobutamine or milrinone?

A

milrinone, and it is prolonged in renal dysfunction

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7
Q

which is a more potent vasodilator, dobutamine or milrinone?

A

milrinone is a more potent vasodilator, it can cause hypotension

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8
Q

how is milrinone beneficial in patients with RV dysfunction

A

decrease in pulmonary pressures

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9
Q

dobutamine on B1 receptors causes ____

A

increased contractility (CO)

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10
Q

dobutamine on B2 receptors causes ____

A

vasodilation (decreased MAP)

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11
Q

what is required for palliative inotropes?

A

go home with an implantable defibrillator because they can cause Vtach/VFib

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12
Q

palliative inotropes are associated with NO difference in ____

A

mortality

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13
Q

palliative inotropes are only to improve ____

A

functional status/quality of life

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14
Q

name 3 complications with palliative inotropes

A

central line infections, defibrillator shocks for VT/VF, cost

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15
Q

what are some considerations for dobutamine

A

use with beta blockers is controversial, may worsen tachycardia

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16
Q

what are some considerations for dobutamine

A

use with beta blockers is controversial; may worsen tachycardia

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17
Q

what are some considerations for milrinone

A

hypotension especially with renal dysfunction, may worsen ventricular dysrhythmias

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18
Q

name 3 risks for mechanical support

A

bleeding, thrombosis, infection

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19
Q

what is the intra aortic balloon pump (IABP)

A

inflatable balloon inserted into the descending aorta (femoral or axillary insertion) that is set to inflate in ratio to ventricular contractions

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20
Q

what are the pharmacological considerations for IABP

A

there is an anticoagulation debate but most centers use parenteral heparin or DTI

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21
Q

what are the settings for IABP

A

1:1 which is one inflation for every contraction, and 1:3 which is one inflation for every 3 contractions

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22
Q

what are the indications for IABP

A

temporary support during cardiogenic shock, PCI, acute ischemia (MI, unstable angina), bridge to transplant/device

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23
Q

what are 2 advantages for IABP

A

relatively quick insertion, hemodynamic improvements

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24
Q

what are the hemodynamic improvements from IABP

A

increased diastolic BP, decreased myocardial oxygen demand, improved coronary perfusion, afterload reduction, modest improvement in CO

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25
Q

what is a contraindication to IABP

A

aortic disease

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26
Q

what are some complications from IABP

A

infection, hematoma/bleeding (device requires heparin), thrombocytopenia, vascular complications, aortic dissection

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27
Q

what is the impella heart pump

A

a percutaneous LVAD with femoral or axial insertion

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28
Q

what are the four different impella device types

A

2.5, 5.5, CP, RP

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29
Q

what is the impella 2.5

A

delivers 2.5 L/min of CO`

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30
Q

what is the impella 5.5

A

delivers 5.5 L/min of CO

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31
Q

what is the impella CP

A

delivers 3.5 L/min of CO

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32
Q

what is the impella RP

A

delivers 4 L/min of flow for RV

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33
Q

indications for impella

A

6 hours or less for support during PCI, 6 days or less for support during cardiogenic shock, often used for much longer when patients are bridge to transplant

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34
Q

femoral insertion of impella

A

can be done in the cath lab by interventional cardiologist

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35
Q

axillary insertion of impella

A

must be done by cardiothoracic insertion

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36
Q

advantage to axillary insertion of impella

A

patients can mobilize

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37
Q

what is unique about impella pharmacotherapy

A

need a dextrose based purge solution (with either heparin or sodium bicarb) as well as parenteral anticoagulation with heparin or DTI

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38
Q

how should you titrate anticoagulation for impella

A

anti-Xa target range of 0.2-0.4 IU/mL or corresponding institutional aPTT range

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39
Q

improper anticoagulation or purge solution with impella can result in?

A

device failure and hemolysis

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40
Q

what is the ECMO

A

extracorporeal membrane oxygenation: percutaneous support by where blood is pumped through an extracorporeal oxygenator (supplies blood with oxygen, removes carbon dioxide)

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41
Q

2 major types of ECMOs

A

vevovenous (v-v) and venoarterial (v-a)

42
Q

v-v ECMO

A

provides only PULMONARY support

43
Q

with the v-v ECMO, deoxygenated venous blood is pumped through the oxygenator and returned oxygenated to ______

A

venous circulation

44
Q

the v-v ECMO is used in _______

A

respiratory distress syndrome (ARDS)- lung failure

45
Q

the v-a ECMO provides ______

A

cardiopulmonary support

46
Q

with the v-a ECMO, deoxygenated venous blood is pumped through the oxygenator and returned oxygenated to ____

A

arterial circulation

47
Q

the v-a ECMO is used in ______

A

cardiogenic shock

48
Q

what pharmacotherapy is required with ECMO

A

anticoagulation with heparin or DTI

49
Q

it is imperative to monitor for _______ with the ECMO

A

peripheral limb ischemia

50
Q

what else should you treat with the v-a ECMO

A

it provides retrograde blood flow into the aorta resulting in increased afterload so you should treat with an afterload decreasing agent such as vasodilators

51
Q

what are two types of total artificial hearts

A

syncardia, carmat

52
Q

what is syncardia

A

pneumatic (air-driven) implantable device that provides biventricular support)

53
Q

total artificial hearts are _____ ONLY

A

bridge to transplant

54
Q

you can have a stroke volume of ___ or ___ with syncardia

A

50cc or 70cc

55
Q

the contraction frequency with syncardia is adjusted to provide _____

A

appropriate cardiac output

56
Q

what thrombotic prophylaxis does syncardia require

A

multi-modal: aspirin, heparin transitioned to warfarin, dipyramidole, pentoxifylline

57
Q

what does the carmat provide

A

hydroelectric ventricular contraction

58
Q

why does carmat have less intense anticoagulation needs than syncardia

A

it has 4 biological valves (bovine), biocompatible ventricular lining

59
Q

what pharmacotherapy is used for carmat

A

treatment dose LMWH until hospital d/c then prophylactic dose LMWH

60
Q

types of LVAD flow

A

continuous flow, pulsatile

61
Q

types of LVAD continuous flow

A

axial flow, centrifugal flow

62
Q

what is the name of the pulsatile LVAD

A

heartmate XVE, it’s off the market

63
Q

what is the name of the axial flow LVAD

A

heartmate II, it’s off the market

64
Q

what is the name of the centrifugal flow LVAD

A

heartmate III (only one on the market)

65
Q

definition of left ventricular assist device (LVAD)

A

serves as a permanent prosthetic left ventricle to deliver oxygenated blood to peripheral circulation

66
Q

components of LVAD

A

pump, driveline (delivers power and settings to pump), external battery

67
Q

pharmacologic considerations for LVAD

A

prosthetic device (infection, thrombosis), requires anticoagulation/antiplatelet therapy (bleeding, thrombosis), blood pressure management (don’t have a pulse)

68
Q

blood from the _____ enters the LVAD. the LVAD then pumps blood into ____

A

left ventricle. aorta (to the body).

69
Q

what pharmacotherapy did heartmate XVE require when it was on the market

A

only aspirin 325 mg daily

70
Q

what were some complications with heartmate XVE

A

infection, bleed, thrombosis (pump, stroke), pump failure

71
Q

what pharmacotherapy did heartmate II require when it was on the market

A

aspirin 325 mg daily and warfarin titrated to goal INR 2-3, antibiotics around the time of implant

72
Q

what advantage did heartmate II carry over heartmate XVE

A

it was a smaller pump, simpler surgical procedure, improved device durability

73
Q

what are the three components of virchow’s triad

A

hypercoagulable state, circulatory stasis, vascular wall injury

74
Q

how do LVADs cause a hypercoagulable state

A

increased thrombin production by interaction between blood and device components (blood touches metal, wants to clot)

75
Q

how do LVADs cause circulatory stasis

A

LVAD recipients may have stasis due to lack of LV function

76
Q

how do LVADs cause vascular wall injury

A

the implantation requires major surgery

77
Q

how do LVAD recipients have circulatory stasis

A

due to lack of LV function

78
Q

how can LVADs lead to clot

A

platelet activation through tissue injury, clotting cascade activation

79
Q

what drugs are needed to prevent clots for LVAD

A

antiplatelet (aspirin, p2y12, dipyramidole) to prevent platelet thrombus, anticoagulant (heparin, LMWH, warfarin, DOACs?) to prevent platelet thrombus

80
Q

aspirin mechanism

A

inhibits COX-1 resulting in lack of thromboxane A2 production

81
Q

P2Y12i mechanism

A

prevent platelet activation downstream of aspirin; inhibit ADP production resulting in reduction of platelet-based thrombin

82
Q

dipyramidole mechanism

A

inhibits breakdown of cAMP resulting in reduced activation and aggregation

83
Q

what is the primary antiplatelet choice in LVAD

A

aspirin (given the increased risk of bleeding with P2Y12i)

84
Q

when is DAPT reserved for with LVAD

A

patients with history of pump thrombosis

85
Q

anticoagulation for LVAD

A

heparin infusion w/ low aPTT goal (50-80s) for bridging to therapeutic warfarin (goal INR=2-3 regardless of device)

86
Q

when is INR goal for LVAD different?

A

patients with GI bleeding, patients with history of pump thrombosis

87
Q

what is INR goal for LVAD patients with GI bleeding

A

1.8-2.5

88
Q

what is INR goal for LVAD patients with history of pump thrombosis

A

2.5-3.5

89
Q

how do you monitor for hypertension with continuous flow devices??

A

the patients do not have a pulse so you monitor by MAP

90
Q

MAP=

A

1/3(SBP) + 2/3(DBP)

91
Q

what is considered HTN based on MAP?

A

anything above 85/90? is considered hypertension with a VAD and may increase stroke risk

92
Q

how do axial flow pumps work

A

they have an impeller (similar to a boat propeller) that helps draw blood from LV through a cannula into the aorta)

93
Q

how do centrifugal flow pumps work

A

they use magnetic levitation (mag-lev) with a bladed disk in the pump cavity to deliver blood from LV to aorta)

94
Q

stroke risk factors with LVAD

A

MAP > 85 mmHg, INR<2, aspirin dose <81 mg daily

95
Q

how was HVAD better than heartmate II

A

pump size was smaller, further simplification of the surgical procedure, less pump thrombosis risk, but similar to increased stroke risk

96
Q

heartmate III advantages

A

fully magnetized levitation technology, results in improved hemo-compatibility with patients (reduced pump thrombosis)

97
Q

LVAD complications

A

hemocompatibility (bleeding, thrombosis), infectious, right ventricular failure, pump malfunctions

98
Q

bleeding complications with LVAD

A

hemorrhagic stroke, GI bleeding, epistaxis

99
Q

thrombosis complications with LVAD

A

ischemic stroke, pump thrombosis

100
Q

infectious complications with LVAD

A

driveline infection, infected device

Cardio (26 decks)

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