Exam 2 Acute Decompensated HF Flashcards
What is acute decompensated HF?
*Includes patients with both HFrEF and HFpEF
-New/acute onset HF
What is cardiogenic shock?
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)
What laboratory assessments are done on Acute HF patients?
Cr, K, Na
*important, tend to have low Na levels
BNP and NTproBNP
*BNP > 400 associated with acute HF
What BNP is associated with acute HF?
> 400
What does it mean if a patient is “warm”?
Adequate perfusion
(extremities not cold)
What does it mean if a patient is “cold”?
Not perfusing correctly (hypoperfusion)
(extremities cold)
What does it mean if a patient is “dry”?
No symptoms of volume overload
(no edema)
What does it mean if a patient is “wet”?
Symptoms of pulmonary/systemic congestion
What is the clinical presentation of a normal patient?
Warm + Dry
What does it mean if a patient is warm + wet?
Perfusing fine but have pulmonary congestion
(level 2)
What does it mean if a patient is cool+ dry?
Hypoperfusion but no pulmonary congestion
(level 3)
What clinical presentation is associated with the highest mortality rate?
Cold + Wet
(hypoperfusion and pulmonary congestion)
What clinical presentation is subset 1?
Warm + Dry
What clinical presentation is subset 2?
Warm + Wet
What clinical presentation is subset 3?
Cool + Dry
What clinical presentation is subset 4?
Cool + Wet
Can the typical HF guideline medications be continued with acute decompensated HF?
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
What medications should be used with caution in acute decompensated HF?
Aggressive diuresis
RAASi
SGLT2i
*because they lower BP and have diuretic effects
How should we adjust beta blockers in ADHF?
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
When should we consider holding Beta Blockers?
If dobutamine is needed or patient is hemodynamically unstable
What should we do about Digoxin in patients with ADHF?
Continue dose to achieve desired concentration of 0.5-0.9 ng/mL
*avoid discontinuing unless compelling reason
*caution regarding renal function
What 4 drug classes do we use in acute decompensated HF (besides standard Hf treatment)?
Diuretics (IV)
Inotropes
Vasodilators
Vasopressors
NOTE: none of these decrease mortality
When a patient presents with fluid overload, what is the first-line agent to give them?
IV diuretic!
*loop preferred, thiazide can be used as an add-on
What dose of IV diuretic should a patient with fluid overload be put on?
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)
If a patient is resistant to the diuretic, what can be done?
-Restrict sodium and water intake
-Increase diuretic dose to ceiling (increasing frequency will have no effect)
-Use combination of loop and thiazide
-Ultrafiltration
What is the highest single dose of furosemide that can be given to a patient IV?
160-200 mg IV furosemide
*note: not the same as continuous infusion
Is it better to give a continuous infusion or intermittent doses of IV diuretics?
Intermittent doses are better
Note: efficacy of the drugs is very dose-dependent, want to stay at a high dose as long as possible
What is the dosing of furosemide when given as a continuous infusion?
0.1 mg/kg/hr doubled every 2-4 hours
*max: 0.4 mg/kg/hr
What is the target water excretion when on IV diuretics?
1-2 L/day above input
When should we consider vasodilator therapy?
In combination with diuretics to reduce pulmonary congestion in wet (Stage II or IV) HF
How do venodilators work?
Increase venous capacitance to reduce preload and myocardial stress
What is the venodilator of choice to use in ADHF?
Nitroglycerin
What patients should NOT receive vasodilator therapy?
Patients with symptomatic hypotension
True or False: vasodilator therapy should be considered over inotropes
TRUE
What are the 3 commonly used vasodilators?
Nitroprusside (Nitropress)
Nitroglycerin
Nesiritide (Natrecor)
What are the 2 balanced vasodilators?
Nitroprusside and Nesiritide
*reduce systemic vascular resistance
Does nitroglycerin dilate veins or arteries more?
Veins
*venodilator
What indication is nitroprusside often used for besides pulmonary congestion?
HTN crisis
What 2 indications is nitroglycerin used for besides pulmonary congestion?
HTN crisis
Acute Coronary Syndrome
Which vasodilator has toxicities associated with it and what are they?
Nitroprusside
-Cyanide and Thiocyanate toxicity
When do we use a positive inotrope?
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
What 2 positive inotropes are beta-agonists?
Dobutamine
Dopamine
What 2 positive inotropes are PDE 3 Inhibitors?
Milrinone
Amrinone (no longer used)
When a beta-agonist binds to the beta receptor on a G protein, what happens?
cAMP is enhanced
*ultimately causes more Ca to enter the cell which causes an increase in contraction
How do PDE 3 inhibitors increase intracellular Ca levels?
Reduce the degradation of cAMP by inhibiting PDE3
(leads to increased force in contraction)
How long should a patient be on a positive inotrope?
NOT LONG-TERM
72 hours, 96 hours or less!!!
*otherwise will cause desensitization
What are the important differences between Dobutamine and Milrinone?
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
Why may it be challenging to use dobutamine in HF patients?
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
What is the other name for Dopamine?
Opressor
(vasopressor—increases blood pressure as well as inotropy!!)
What is the preferred inotrope therapy (milrinone or dobutamine)?
Milrinone
*because it is both an inotrope and a vasodilator
*especially when patient has high systemic vascular resistance or uses a beta blocker
What are the overarching effects of diuretics, vasodilators, and inotropes?
Diuretics: reduce fluid
Vasodilators: reduce preload and afterload
Inotropes: increase CO
What treatment should a Subset I patient receive (warm and dry)?
Optimize chronic therapy
What treatment should a Subset II patient receive (warm and wet)?
IV diuretic
IV venous vasodilator
What treatment should a Subset III patient receive (cold and dry)?
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
What treatment should a subset IV patient receive (cold and wet)?
IV diuretic
SBP<90: IV inotrope
SBP>90: IV arterial vasodilator
