Cardiology - Heart Failure: Acute Management

Question 1

Indicators of WORSE OUTCOMES in decompensated HF

Answer 1

BUN >15.3mmol/L
SBP <115mmHg
Cr >243microg/L

Question 2

Which is the superior form of diuresis in acute decompensated HF?

Answer 2

NO superiority between:

• high dose vs low dose
• continuous vs bolus

But give Intravenous as oral absorption can be limited in GIT oedema

Question 3

Cardiorenal syndrome

• what does it mean
• acute management

Answer 3

= impaired renal function associated with increased mortality and longer hospitalisation

Short term: inotropes or mechanical support if PROFOUND low cardiac output state whilst awaiting assisted circulation or transplant

Question 4

Role of ultrafiltration in acute decompensated HF?

Answer 4

UF vs conventional:
- UF had reduced hospitalisations
BUT no change to renal function / dyspnoea or adverse events

UF vs pharma
- UF worsened Creatinine and had more adverse events
BUT no change to mortality or hospitalisations

Question 5

What is NESIRITIDE? Does it have a role in acute decompensated heart failure?

Answer 5

Nesiritide = recombinant BNP with vasodilatory properties
–> binds to guanylyl cyclase-A receptors on vascular + SM + endotheium

nesiritide+standard care vs standard care

• -> NO CHANGE to renal function
• -> INCREASED hypotension with nesiritide
• -> NO CHANGE to mortality / hospitalsation / dyspnoea scores

Question 6

What is SERELAXIN? Does it have a role in acute decompensated heart failure?

Answer 6

Serelaxin = human recombinant relaxin 2 (a naturally occurring vasodilatory peptide)

In patients with EF<40%, evidence of congestion, SBP >125mmHg and decompensated HF:

• IMPROVED dyspnoea and symptoms of congestion
• REDUCED MORTALITY at 180 days

Question 7

INOTROPES: which positive inotropes are used in acute decompensated heart failure?

Answer 7

** used to increased intracellular cAMP **
Dobutamine (sympathomimetic amine)
Milrinone (phosphodiesterase-3 inhibitor)

In low output states inotropes can:

• augment cardiac output
• improve perfusion
• relieve congestion

Question 8

INOTROPES: which inotrope is best used in acute decompensated heart failure patients on beta blockade?

Answer 8

Milrinone
- slower acting and RENALLY excreted
BUT
- acts downstream to Beta1 adrenergic receptor (so useful if pt is on beta blocker)

Question 9

INOTROPE effect on mortality in patients with heart failure?

Answer 9

LONGTERM: increase mortality

SHORT TERM: no impact on mortality (but increase arrythmias and hypotension)

Question 10

Levosimendan: what is it? Does it have a role in Acute Decompensated HF?

Answer 10

Novel inotrope
= calcium sensitiser with inotropic activity
PLUS phosphodiesterase-3 inhibition properties with VASODILATION action

In acute decompensated HF with EF<35%
- improved symptoms
- shorter LOS
- reduced BNP at 24 hours
BUT: increased hypotension, AF and VT
TREND TOWARDS INCREASED MORTALITY (but not significant)

In comparison to dobutamine in acute decompensated HF and EF <30%
- decreased BNP
NO OTHER BENEFIT
NO MORTALITY CHANGE
INCREASED CARDIAC FAILURE AND AF
(no change to VT or hypotension)

Question 11

What is Omecamtiv Mecarbil and does it have a role in acute decompensated HF?

Answer 11

= selective cardiac myosin activator
- prolongs ejection period
DOES NOT increase contractility

Some benefit to DYSPNOEA scores in continuous 48 infusion at high doses if EF <40% and acute decompensated