Exam 2 Acute Decompensated HF

Question 1

What is acute decompensated HF?

Answer 1

*Includes patients with both HFrEF and HFpEF

-New/acute onset HF

Question 2

What is cardiogenic shock?

Answer 2

Hypotension
SBP < 90 mmHg or MAP < 70 mmHG

and Low Cardiac output

(patients not moving blood or profusing their organs, in much worse state than normal Hf patients)

Question 3

What laboratory assessments are done on Acute HF patients?

Answer 3

Cr, K, Na
*important, tend to have low Na levels

BNP and NTproBNP
*BNP > 400 associated with acute HF

Question 4

What BNP is associated with acute HF?

Answer 4

> 400

Question 5

What does it mean if a patient is “warm”?

Answer 5

Adequate perfusion
(extremities not cold)

Question 6

What does it mean if a patient is “cold”?

Answer 6

Not perfusing correctly (hypoperfusion)
(extremities cold)

Question 7

What does it mean if a patient is “dry”?

Answer 7

No symptoms of volume overload
(no edema)

Question 8

What does it mean if a patient is “wet”?

Answer 8

Symptoms of pulmonary/systemic congestion

Question 9

What is the clinical presentation of a normal patient?

Answer 9

Warm + Dry

Question 10

What does it mean if a patient is warm + wet?

Answer 10

Perfusing fine but have pulmonary congestion
(level 2)

Question 11

What does it mean if a patient is cool+ dry?

Answer 11

Hypoperfusion but no pulmonary congestion
(level 3)

Question 12

What clinical presentation is associated with the highest mortality rate?

Answer 12

Cold + Wet
(hypoperfusion and pulmonary congestion)

Question 13

What clinical presentation is subset 1?

Answer 13

Warm + Dry

Question 14

What clinical presentation is subset 2?

Answer 14

Warm + Wet

Question 15

What clinical presentation is subset 3?

Answer 15

Cool + Dry

Question 16

What clinical presentation is subset 4?

Answer 16

Cool + Wet

Question 17

Can the typical HF guideline medications be continued with acute decompensated HF?

Answer 17

Yes, in the absence of hemodynamic instability or contraindications

(such as hypotension or cardiogenic shock)

*may need to decrease dosing if these develop, otherwise continue all chronic meds

Question 18

What medications should be used with caution in acute decompensated HF?

Answer 18

Aggressive diuresis
RAASi
SGLT2i

*because they lower BP and have diuretic effects

Question 19

How should we adjust beta blockers in ADHF?

Answer 19

DO NOT STOP unless recent initiation or titration is the cause of patient’s current decompensation

Consider withholding if dobutamine needed, or hemodynamically unstable

*do not add or titrate up until volume status is stabilized and IV diuretics, vasodilators, and inotropes are discontinued

Question 20

When should we consider holding Beta Blockers?

Answer 20

If dobutamine is needed or patient is hemodynamically unstable

Question 21

What should we do about Digoxin in patients with ADHF?

Answer 21

Continue dose to achieve desired concentration of 0.5-0.9 ng/mL

*avoid discontinuing unless compelling reason
*caution regarding renal function

Question 22

What 4 drug classes do we use in acute decompensated HF (besides standard Hf treatment)?

Answer 22

Diuretics (IV)
Inotropes
Vasodilators
Vasopressors

NOTE: none of these decrease mortality

Question 23

When a patient presents with fluid overload, what is the first-line agent to give them?

Answer 23

IV diuretic!

*loop preferred, thiazide can be used as an add-on

Question 24

What dose of IV diuretic should a patient with fluid overload be put on?

Answer 24

Initial Iv dose should equal or exceed the chronic daily po dose the patient is on

(can put patient on exact same IV dose as oral dose because the IV will be 2x more potent since po only has 50% bioavailability)

Question 25

If a patient is resistant to the diuretic, what can be done?

Answer 25

-Restrict sodium and water intake -Increase diuretic dose to ceiling (increasing frequency will have no effect) -Use combination of loop and thiazide -Ultrafiltration

Question 26

What is the highest single dose of furosemide that can be given to a patient IV?

Answer 26

160-200 mg IV furosemide *note: not the same as continuous infusion

Question 27

Is it better to give a continuous infusion or intermittent doses of IV diuretics?

Answer 27

Intermittent doses are better Note: efficacy of the drugs is very dose-dependent, want to stay at a high dose as long as possible

Question 28

What is the dosing of furosemide when given as a continuous infusion?

Answer 28

0.1 mg/kg/hr doubled every 2-4 hours *max: 0.4 mg/kg/hr

Question 29

What is the target water excretion when on IV diuretics?

Answer 29

1-2 L/day above input

Question 30

When should we consider vasodilator therapy?

Answer 30

In combination with diuretics to reduce pulmonary congestion in wet (Stage II or IV) HF

Question 31

How do venodilators work?

Answer 31

Increase venous capacitance to reduce preload and myocardial stress

Question 32

What is the venodilator of choice to use in ADHF?

Answer 32

Nitroglycerin

Question 33

What patients should NOT receive vasodilator therapy?

Answer 33

Patients with symptomatic hypotension

Question 34

True or False: vasodilator therapy should be considered over inotropes

Answer 34

TRUE

Question 35

What are the 3 commonly used vasodilators?

Answer 35

Nitroprusside (Nitropress) Nitroglycerin Nesiritide (Natrecor)

Question 36

What are the 2 balanced vasodilators?

Answer 36

Nitroprusside and Nesiritide *reduce systemic vascular resistance

Question 37

Does nitroglycerin dilate veins or arteries more?

Answer 37

Veins *venodilator

Question 38

What indication is nitroprusside often used for besides pulmonary congestion?

Answer 38

HTN crisis

Question 39

What 2 indications is nitroglycerin used for besides pulmonary congestion?

Answer 39

HTN crisis Acute Coronary Syndrome

Question 40

Which vasodilator has toxicities associated with it and what are they?

Answer 40

Nitroprusside -Cyanide and Thiocyanate toxicity

Question 41

When do we use a positive inotrope?

Answer 41

To manage hypoperfusion or cold HF patients -Symptom relief in hypotension -End organ dysfunction (altered mental status, etc) *consider vasodilators before inotropes when adequate BP

Question 42

What 2 positive inotropes are beta-agonists?

Answer 42

Dobutamine Dopamine

Question 43

What 2 positive inotropes are PDE 3 Inhibitors?

Answer 43

Milrinone Amrinone (no longer used)

Question 44

When a beta-agonist binds to the beta receptor on a G protein, what happens?

Answer 44

cAMP is enhanced *ultimately causes more Ca to enter the cell which causes an increase in contraction

Question 45

How do PDE 3 inhibitors increase intracellular Ca levels?

Answer 45

Reduce the degradation of cAMP by inhibiting PDE3 (leads to increased force in contraction)

Question 46

How long should a patient be on a positive inotrope?

Answer 46

NOT LONG-TERM 72 hours, 96 hours or less!!! *otherwise will cause desensitization

Question 47

What are the important differences between Dobutamine and Milrinone?

Answer 47

Dobutamine: --Requires the beta receptor to increase cAMP -Reduces K Milrinone: --Does not require beta receptor --Inodilator (both inotrope and vasodilator, decreases systemic vascular resistant through same mechanism) *both cause arrythmias, tachycardia

Question 48

Why may it be challenging to use dobutamine in HF patients?

Answer 48

Because it requires the beta receptors to function and many HF patients will be on a beta blocker! *have to put patient on higher dose which is associated with more toxicities

Question 49

What is the other name for Dopamine?

Answer 49

Opressor (vasopressor---increases blood pressure as well as inotropy!!)

Question 50

What is the preferred inotrope therapy (milrinone or dobutamine)?

Answer 50

Milrinone *because it is both an inotrope and a vasodilator *especially when patient has high systemic vascular resistance or uses a beta blocker

Question 51

What are the overarching effects of diuretics, vasodilators, and inotropes?

Answer 51

Diuretics: reduce fluid Vasodilators: reduce preload and afterload Inotropes: increase CO

Question 52

What treatment should a Subset I patient receive (warm and dry)?

Answer 52

Optimize chronic therapy

Question 53

What treatment should a Subset II patient receive (warm and wet)?

Answer 53

IV diuretic IV venous vasodilator

Question 54

What treatment should a Subset III patient receive (cold and dry)?

Answer 54

PCWP <15: IV fluids until 15-18 PCWP >= 15 and SBP <90: IV inotrope PCWP >= 15 and SBP >=90: Iv inotrope or arterial vasodilator *PCWP= pulmonary wedge pressure

Question 55

What treatment should a subset IV patient receive (cold and wet)?

Answer 55

IV diuretic SBP<90: IV inotrope SBP>90: IV arterial vasodilator