E.4 ADHF Treatment

Question 1

In ADHF should we discontinue any medications?

Answer 1

We try not to due to rebound adrenergic output or vasoconstriction which could actually worsen the patients condition.

Question 2

What is our goal for treatment of ADHF?

Answer 2

To maintain or achieve Class I. This means the patient is warm and dry. In other words they are perfusing well and are not congested.

Question 3

What is the primary problem in a patient with class II ADHF?

Answer 3

Congestion (they are fluid overloaded but perfusing well.)

Question 4

How do we treat Class II ADHF?

Answer 4

We need to dry them out using diuretics to reverse the fluid overload.

Question 5

Patients with class ______ should receive diuresis that is _______ the home dose as IV.

If they are loop diuretic naive, they should be initiated on _____.

Answer 5

1) Class II ADHF
2) 1.5-2.5 X the home dose.
3) Furosemide 40 mg or equivalent IV.

Question 6

After initiating a patient with congestion on a loop diurectic, what is our goal respnse?

What should we do if they do not achieve the goal?

Answer 6

1) At least 500 mL of urine per hour over the first 6 hours.

2) Double the dose.

Question 7

In ADHF with congestion, what is our goal urine output?

Answer 7

1-2 liters negative/day. (losing 2 liters essentially)

Question 8

In class III ADHF, what is the primary physiological problem?

Answer 8

Hypoperfusion.

Question 9

What is the goal of treatment in class III ADHF?

Answer 9

Increase perfusion.

Question 10

In class III ADHF, what methods can be used to increase perfusion?

Answer 10

1) Vasodilators
2) Positive Inotropic Agents

Question 11

How does vasodilation increase perufsion?

Answer 11

Arterial vasodilation makes it easier to move blood from the LV to the aorta due to decrease afterload.

Question 12

In Class III ADHF, _____ is best for patients who are hemodynamically stable.

Answer 12

Vasodilators.

Question 13

What vasodilators are used in Class III ADHF?

Answer 13

1) ARNI/ACEi/ARB
2) Hydralazine
3) IV vasodilators

Question 14

What do positive inotropic agents do?

Answer 14

They increase the squeeze of the LV to move blood forward.

Question 15

Positive inotropic agents are best for what patients?

Answer 15

Class III ADHF with low BP that are not in shock.

Question 16

What positive inotropic agents are used in Class III ADHF?

Answer 16

1) Dobutamine
2) Milrinone

Question 17

The mechanism of action of this vasodilator is to form nitric oxide. this leads to the activation of cGMP in smooth muscle leading to dephophorylation of myosin light chains —> leads to smooth muscle relaxation.

This smooth muscle relaxation leads to a vasodilator effect on the peripheral veins and arteries. It should be noted that there is a more prominent effect on the veins.

Answer 17

Nitroglycerin

Question 18

Nitroglycerin has more impact on _____ at low doses and _____ at high doses.

Answer 18

1) Venous Circulation
2) Arterial Circulation

Question 19

Nitroglycerin is contraindicated with the concurrent use of _____ and ____.

Answer 19

1) PDE-5 Inhibitors (Sildenafil, Avanafil, Tadalafil, Vardenafil)

2) Soluble guanylate cyclase stimulators (Vericguat, Riociguat)

Question 20

For ADHF III patients who are hemodynamically stable, nitroglycerin should be administered as _____

Answer 20

A continous IV infusion.

Question 21

The mechanism of action of this vasodilator is to cause peripheral vasodilation by direct action on venous and arteriolar smooth muscle and release of nitric oxide.
This leads to a reduction in peripheral resistance, leading to an increase in cardiac output due to a reduction of afterload.

Answer 21

Nitroprusside.

Question 22

This vasodilator carries a risk for cyanide and thiocyanate toxicity.

Answer 22

Nitroprusside

Question 23

Patients on nitroprusside are at increased risk for cyanide toxicity if they are on it for ______ at ____ dose.

Answer 23

Greater than 3 days at greater than 3 mcg/kg/min.

RULE OF 3s.

Question 24

For ADHF III in hemodynamic stability, nitroprusside should be administered ____.

Answer 24

As a continuous infusion.

Question 25

Dobutamine Drug Class

Answer 25

Inotrope

Question 26

The mechanism of action of this drug includes:

1) Stimulate Myocardial Beta-1 Receptors. This results in increased contractility and HR.
2) Alpha-1 and Beta-2 stimulation in the vasculature. The effects of beta activation may equally offset or be slightly greater than alpha. This results in some vasodilation in addition to the inotropic and chronotropic action produced above.

Answer 26

Dobutamine.

Question 27

Dobutamine MAJOR DDI

Answer 27

Increases arrhythmogenic potential in combination with other pro-arrhythmic agents.

Question 28

Dobutamine carries a high risk for _____, and a moderate-low risk for ___.

Answer 28

1) Arrythmia
2) Hypotension

Question 29

Dobutamine must be administered ___

Answer 29

As a continuous infusion.

Question 30

This vasodilator is a phosphodiesterase-3 inhibitor in cardiac and vascular tissue. This results in vasodilation and inotropic effects.

Answer 30

Milrinone.

Question 31

Milrinone drug class.

Answer 31

Inotropic Agent

Question 32

This drug has a category X drug interaction with Anagrelide.

Answer 32

Milrinone

Question 33

All inotropic agents increase _____ in combination with other pro-arrythmic agents.

Answer 33

Arrhythmogenic potential. (probability o arrythmia.

Question 34

Milrinone carries a moderate risk for _____, but a high risk for ____.

Answer 34

1) Arrythmia
2) Hypotension

Question 35

This inotropic agent is renally eliminated, and should not be used in kidney failure.

Answer 35

Milrinone.

Question 36

Milrinone should be administered ____.

Answer 36

As a continous infusion.

Question 37

How do we treat ADHF IV patients.

Answer 37

Fix the perfusion first to prevent further organ damage.

Question 38

In ADHF IV, if the patient is hemodynamically unstable we would consider using ____.

Answer 38

Vasopressors.

Question 39

These are used in hemodynamic instability to increase the squeeze of the LV and cause vasoconstriction to keep BP high.

Answer 39

Vasopressors

Question 40

Vasopressor mechanism of action.

Answer 40

Alpha/Beta agonist to increase inotropy/chronotropy and vasoconstriction.

Question 41

Vasopressors increase ___ in combination with other pro-arrhythmic agents.

Answer 41

Arrhythmogenic potential

Question 42

____ is the first line agent for cardiogenic shock. (hint: vasopressor)

Answer 42

Norepinephrine

Question 43

____ increases fatal arrythmia and mortality in cardiogenic shock and should be avoided. (hint: vasopressor)

Answer 43

Dopamine.

Question 44

Vasopressors should be administered ____

Answer 44

As a continuous infusion.