Exam 2 lecture 4 Flashcards
acute worsening of chronic HF accounts for what percent of cases
25%
CI (cardiac index) is a measure of what
stroke volume
PCWP (pulmonary capillary wedge pressure) is a measure of
preload
What are the 4 hemodynamic subsets when pt presents with ADHF
I- warm and dry
II-Warm and wet
III- cool and dry
IV- cool and wet
what do wet or dry describe
volume status
dry- euvolemic
wet- fluid overloaded
what do cool and warm describe
ability to perfuse tissue
warm- adequate cardiac output
cool- hypoperfusion
what do we do if pt presents with ADHF and is on SGLT2, ARNI, BB and MRA
we continue those meds unless they are in cardiogenic shock (low BP)
What to do with BB in patient that presents with ADHF
do not stop BB unless it is a recent initiation
consider holding BB if dobutamine needed or hemodynamically unstable
What are the drugs used in ADHF
Diuretics, Inotropes, Vasodilators, Vasopressors
ADHF classifications and hemodynamics
I- Warm and dry- PCWP 15-18, CI> or =2.2
II=- Warm and wet- PCWP> or = 18, CI> or =2.2
III- Cold and dry- PCWP 15-18, CI<2.2
IV- Cold and wet- PCWP > or = 18, CI<2.2
Treatment of different classes of ADHF
I (warm and dry)- optimize current therapy
II - IV diuretics (+/- venous vasodilator)
III- If PCWP <15, IV until 15-18
If PCWP is 15 or greater and SBP<90, IV inotrope
If PCWP is 15 or greater, SBP> or = 90, IV inotrope or arterial vasodilator
IV- Cold and wet- IV diuretics+ (if SBP<90, IV inotrope,
if SBP>90, IV arterial vasodilation)
what is DOE? orthopnea?
DOE- dyspnea on exertion
Orthopnea- discomfort when breathing while lying down
In a patient admitted for ADHF Subset II what to do? What not to do?
Do not increase BB, you should increase IV diuretic
What is usually used to treat Classes II and IV
diuretics
What to do if pt is ADHF II or IV and is resistent to diuretics
Na and H20 restriction
increase dose rather than frequency
Combo therapy
ultrafiltration
How to dose diuretics during Stage II and IV for ADHF
Increase dose pt was on at home.
Furosemide bioavailability Po and IV equivalence
160-200 mg IV furosemide is equivalent to 320-400 PO furosemide
is giving intermittent doses of diuretics better or continous diuretics doses for ADHF
Intermittent
Monitoring while on diuretics for stage II and IV ADHF
urine output
ins and outs, body weights, vitals
serum electrolytes, BUN creatinine daily
when a pt gets started on IV furosemide and Secr and K go up drastically, what does that mean
his kidneys are shutting down
What is used in combination with diuretics to reduce pulmonary congestion in stage II and IV ADHF
Vasodilators
what is the vasodilator of choice
NTG
how do vasodilators affect preload
reduce it
who should not receive vasodilators
pts with hypotension
Name the 3 vasodilators. Are they balanced, venous or arterial
Nitroprusside (nitropress)
Nesiritide (Natrecor)
NTG
NTG is venous and the others are balanced
Use of nitroprusside and NTG
Nitroprusside - HTN crisis
NTG- ACS, HTN crisis
adverse effects of nitropress
Cyanide and theocyanate toxicity if > 3 days use
What drugs are positive inotropes
B agonists and PDE3 inibitors
What are B agonist drugs
Dobutamine and dopamine
What are PDE3 inhibitors
Milrinone
Amrinone
dobutamine brand
Dobutrex
Milrinone brand
Primacor
Difference between Dobutamine and milrinone? what should we be cautious of?
dobutamine stimulates increase in CAMP that requires B receptor
Milrinone does not
That is why we should be cautious of dobutamine use if pt is on BB
When are positive inotropes used?
Primarily used in pts who are hypoperfused or cold HF pts
When would we use dobutamine over milrinone
high systemic vascular resistance (SVR) or if BB is being used
monitoring of ADHF pts
weight (in AM)
Fluid intake/output
Vital signs BID
S/S (BID)
electrolytes QD
renal functions (QD)
If pt is not experiencing any sx what stage of HF is he in?
Stage B
Stage B HF tx
ACE and BB
when do we reduce dose of ACE in relation to SeCr/eGFR
30 percent reduction
why should we change from furosemide to torsemide
bioavailability is low for furosemide, better for torsemide
metorpolol succinate target dosing
200 mg daily
SGLT2 inhibitor CI
Crcl<30
when not to use MRA
Crcl<30
Sacubitril/valsartan dose if CRCL<30
24/26
Know brand names of drugs
