Heart Failure Flashcards
What is heart failure
What is it ?
a decrease in cardiac output (amount of blood being ejected from the heart). Heart cant meet the demands of the body
1 cause of heart failure
MI
how is HF diagnosed
echo of heart
classification of HF based on EF
NORMAL ef 50-70%
HFrEF : ef< 40%
HFpEF: EF> 50% but less starting volume
HFmrEF: EF 40-50
clinical presentations of hypoperfuion
a. tachycardia
b.fatigue
c. cyanosis
d. cold extremities
e. organ dysfunction
I. increased SCr (AKI)
II. increased LFTs
III. Confusion/ AMS
clinical representations of congestion
a. Weight gain
b. SOB
c. Orthopnea
d. Paroxysmal nocturnal dyspnea
e. pleural effusion
f. Crackles/ rales
g. S3 and S4 heart sounds
h. pitting edema
I. increased B-type natriuretic Peptide (BNP)
J. Jugular venous distention
what is the first line treatments for HF
ARNI or ACE/ARB w. BB
what is the pharmacologic treatment approach to HF
initiate as many mortality benefiting drugs as the pt can tolerate and titrate up over time. start low and go slow
Sarcubatril/ Valsartan
what is the brand name
entresto
Sacubitril/Valsartan (Entresto)
Class:
Indication:
Mechanism of Action: Valsartan (ARB):
Effects of mechanism of Action:
Adverse Effects:
Absolute Contraindications:
Pregnancy:
Warning/ Precautions:
Drug-Drug Interactions (DDIs):
Monitoring Parameters:
Pearls:
Sacubitril/Valsartan (Entresto)
Class: ARNI-Neprilysin Inhibitor/ ARB
Indication: reduce risk of CV death and hospitalizations for HF in patients with chronic HF.
Mechanism of Action: Valsartan (ARB): blocks angiotensin II activity at the angiotensin receptor on vascular smooth muscle.
Sacubitril (Neprilysin Inhibitor): inhibits neprilysin (responsible for breakdown of BNP), blocks breakdown of BNP. ARB and sacubatril used together because Neprilysin inhibitor also prevents breakdown of angiotensin II, up regulating RAAS system effects. so valsartan is added to minimize those effects
Effects of mechanism of Action: causes natriuresis (excretion of sodium) and vasodilation.
Adverse Effects: HYPERkalemia, acute renal failure (in its with severe bilateral renal stenosis), , angioedma, hypotension.
Absolute Contraindications: pregnancy, 36 hours of an ACE inhibitor (b/c ACE and Neprolysin inhibitor both increase bradykinin, greatly increases the risk of angioedema) bilateral renal stenosis
Pregnancy: DO NOT USE
Warning/ Precautions: –Do not initiate if potassium > 5 mmol/L.Discontinue if potassium >5.6 mol/L
Drug-Drug Interactions (DDIs):ACE inhibitors : must have 36-hour wash out period). NSAIDS (can cause acute kidney injury), Potassium supplements (can cause hyperkalemia), other RAAS drugs (can cause AKI and Hyperkalemia), Lithium (increase lithium concentrations).
Monitoring Parameters: Assess electrolytes and renal function 2-4 weeks after initiating therapy or changing doses.
Pearls:
.1 do not use in combo with RAAS drugs
2. protect the myocardium from remodeling/ hypertrophy in patients with heart failure
Angiotensin converting enzyme inhibitors (ACEi)
examples:
Class: Ace inhibitors
Indication:
Mechanism of Action:
Effects of mechanism of Action:
Adverse Effects:
Absolute Contraindications:
Pregnancy:
Warning/ Precautions:
Drug-Drug Interactions (DDIs):
Monitoring Parameters:
Pearls: 1
Angiotensin converting enzyme inhibitors (ACEi)
examples: end in -PRIL. Lisinopril (Privinil/Zestril), Enalapril (Vasotec), Quinapril (Accupril)
Class: Ace inhibitors
Indication: Adjunctive therapy to reduce signs and symptoms of Heart Failure
Mechanism of Action:Prevents conversion of angiotensin 1 to angiotensin II by way of the angiotensin converting enzyme. this prevents actions such as vasoconstriction, sympathetic activation, and aldosterone release.
Effects of mechanism of Action: decreased vasoconstriction and decreased aldosterone( corticosteroid that stimulates absorption of sodium by the kidneys) release.
Adverse Effects: HYPERkalemia, acute renal failure (in its with severe bilateral renal stenosis), dry cough( because of bradykinin), angioedma, orthostatic hypotension.
Absolute Contraindications:pregnancy, history of angioedema, 36 hours of an angiotensin receptor/ neprilysin inhibitor[ARNI-sacubritil/valsartan], bilateral renal stenosis
Pregnancy: DO NOT USE
Warning/ Precautions: –Do not initiate if potassium > 5 mmol/L.Discontinue if potassium >5.6 mol/L
Drug-Drug Interactions (DDIs): NSAIDS (can cause acute kidney injury), Potassium supplements (can cause hyperkalemia), other RAAS drugs (can cause AKI and Hyperkalemia, Lithium (increase lithium concentrations). Quinalipril contains magnesium: avoid with fluoroquinones and tetracyclines.
Monitoring Parameters: Assess electrolytes and renal function 2-4 weeks after initiating therapy or changing doses.
Pearls: 1.drug of choice in its with diabetes, heart failure, post MI, stroke, and/ or CKD due to target organ protection
- do not use in combo with RAAS drugs
- protect the myocardium from remodeling/ hypertrophy in patients with heart failure
Angiotensin Receptor blockers (ARBs)
examples:
Class:
Indication:
Mechanism of Action:
Effects of mechanism of Action:
Adverse Effects:
Absolute Contraindications:
Pregnancy:
Warning/ Precautions:
Drug-Drug Interactions (DDIs):
Monitoring Parameters:
Pearls:
Angiotensin Receptor blockers (ARBs)
examples: end in -SARTAN. i.e Irbesartan (Avapro), Losartan (Cozaar), Valsartan (Diovan)
Class: ARBS
Indication: Adunctive therapy to reduce signs and symptoms of heart failure
Mechanism of Action: blocks angiotensin II activity at the angiotensin receptor on vascular smooth muscle
Effects of mechanism of Action: decreased vasoconstriction and decreased aldosterone( mineralocorticoid that stimulates sodium reabsorption by way of the kidneys) release.
Adverse Effects: HYPERkalemia, acute renal failure (in its with severe bilateral renal stenosis), orthostatic hypotension, hypotension. Olmesartan: can cause spur-like enteropathy (severe diarrhea with profound weightloss)
Absolute Contraindications:pregnancy, bilateral renal stenosis
Pregnancy: DO NOT USE
Warning/ Precautions: –Do not initiate if potassium > 5 mmol/L.Discontinue if potassium >5.6 mol/L
history of angioedema (angioedema may be less likely to occur in ARBS over ACEI, but risk cannot be ruled out)
Drug-Drug Interactions (DDIs):
Monitoring Parameters: Assess electrolytes and renal function 2-4 weeks after initiating therapy or changing doses.
Pearls: 1.drug of choice in its with diabetes, heart failure, post MI, stroke, and/ or CKD due to target organ protection
- do not use in combo with RAAS drugs
- protect the myocardium from remodeling/ hypertrophy in patients with heart failure
- no washout period required when transitioning to a neprilysin inhibitor
- Less dry cough/ angioedema due to lack of peripheral effects of angioedema
- Olmesartan can cause spur-like enteropathy (severe diarrhea with profound weight loss.
- comes available (with HCTZ, CCBs)
Beta Blockers
examples:
Class: Beta blockers
Indication:
Mechanism of Action:
Effects of mechanism of Action:
Adverse Effects:
Absolute Contraindications:
Pregnancy: —
Warning/ Precautions:
Drug-Drug Interactions (DDIs):
Monitoring Parameters:–
Pearls:
Beta Blockers
examples: in general, end in -OLOL. * have mortality benefit in HF (Metoprolol Succinate (Toprol xl) Carvedilol(Coreg), Bisoprolol (Zebeta)
Class: Beta blockers
Indication: treatment of stable, symptomatic HF to reduce the mortality plus hospitalization
Mechanism of Action: inhibiting Beta 1 +/- Beta 2 receptors.
contains subclasses:
Cardio-selective Beta blockers:More selective for beta 1 receptors then beta 2 (metoprolol, Bisoprolol)
Cardio-selective and vasodilatory: block beta 1 only
intrinsic sympathomimetic activity (ISA): exhibit low level agonist activity at the beta adrenergic receptor site while simultaneously acting as a receptor antagonist.
Combined alpha and beta blockade: Carvedilol
Effects of mechanism of Action: decreased heart rate and myocardial contractility. (variable based on beta blocker subclass
Adverse Effects: Bradycardia, heart block, worsening heart failure, bronchospasm fatigue, depression, reduced exercise tolerance, decreased libido, insomnia, impotence.
Absolute Contraindications: severe bradycardia
Pregnancy: —
Warning/ Precautions: Use with cautioning patients with bronchospastic diseases (COPD, asthma). use with caution in patients with diabetes
Drug-Drug Interactions (DDIs): Use with caution with other drugs that cause bradycardia
Monitoring Parameters:–
Pearls:
- Beta blockers with mortality benefit in HF. Metoprolol succinate, Carvedilol, Bisoprolol
- do not initiate in heart failure exacerbation
- lower dose if patient experiencing exacerbation (try not to D/C due to rebound hypertension)
- MUST BE TAPERED upon D/C. can cause rebound hypertension
- can mask symptoms of hypoglycemia in patients with diabetes.( i.e palpitations, shakiness, anxiety)
- enhance hypoglycemic effects of insulin and sulfonylureas
which beta blockers have mortality benefit in patient with HF
metoprolol succinate, carvedilol, bisiprolol
entrsto
starting dose
target dose
SD: 24/26 mg-49/51 mg twice daily
97/103 twice daily
LISINOPRIL
brand name
SD:
TD:
ZeSTRIL/PRIVINIL
sd: 2.5-5 mg daily
TD: 20-40 mg daily
enalopril
BRAND NAME
SD:
TD:
vasotec
sd: 2.5-5 mg twice daily
TD:10-20 mg twice daily
Losartan
brand name:
SD:
td:
cozaar
sd: 25-50 mg dally
td: 150 mg daily
Valsartan
brand name
sd
td
diovan
sd: 40 mg twice daily
td: 160 mg twice daily
metoprolol succinate
brand name
sd
td
toprol XL
sd: 12.5-25 mg daily
td: 200 mg daily
bisoprolol
brand name
sd
td
zebeta
sd: 2.5 mg daily
td: 10 mg daily
carvedilol
brand name
sd
td
coreg
sd: 3.125 mg -6.25 mg twice daily
td: 25 mg twice daily
>85 kg: 50 mg BID
Mineralcorticoid receptor antagonists
examples:
Class: Mineralcorticoid receptor antagonists
Indication:
Mechanism of Action:
Effects of mechanism of Action:
Adverse Effects:
Absolute Contraindications:
Pregnancy: –
Warning/ Precautions:—-
Monitoring Parameters:
Pearls:
Mineralcorticoid receptor antagonists
examples:Sprinolactone (non selective) , Eplerenone (selective)
Class: Mineralcorticoid receptor antagonists
Indication: To increase survival, manage edema, and reduce need for hospitalization in patients with heart failure with reduced ejection fraction and NYHA class II-IV, normally in conjunction with other heart failure therapies
Mechanism of Action: competitive antagonists of the mineralocorticoid receptor
Effects of mechanism of Action: decreased sodium reabsorption and increasing potassium reabsorption
Adverse Effects: hyperkalemia, dehydration, hyponatremia.
spironolactone: gynecomastia, breast tenderness, impotence (inability of a man to get an erection and/or orgasm)
eplerenone: increased triglycerides
Absolute Contraindications: hyperkalemia, anuria, CrCl < 30 mL/min (different than <50mL/min in HTN)
Pregnancy: –
Warning/ Precautions:—-
Monitoring Parameters: HF: monitor electrolytes (especially K+) and renal function at 2-3 days following initiation, and then 7 days after initiation/ titration. Then check monthly for 3 months and then every 3 months afterwards (this is different than monitoring 2-6 weeks after initiation or titration of therapy.
Pearls:
- preferred in primary aldosteronism and resistant hypertension
- minimally efficacious BP control when used as mono therapy.
- used in combo with loops and thiazides to combat potassium loss
sprinolactone
sd
td
sd: 25 mg daily
td: 50 mg daily
eplerenone sd:
td:
sd: 12.5-25 mg daily
td: 25-50 mg daily
SGLT-2 Inhibitors
examples:
Class:
Indication:
Mechanism of Action:
Effects of mechanism of Action:
Adverse Effects:
Absolute Contraindications:
Pregnancy: –
Warning/ Precautions:—-
Monitoring Parameters:
Pearls:
SGLT-2 Inhibitors
examples: Dapagliflozin, Empagliflozin
Class: SGLT-2 inhibitors
Indication: to reduce the risk of CV death and hospitalization for heart failure, with or without diabetes
Mechanism of Action: inhibiting sodium glucose co transporter 2 (SGLT-2) in the proximal renal tubules, SGLT-2 inhibitors reduce reabsorption of filtered glucose and sodium from the tubular lumen and lowers the renal threshold for glucose
Effects of mechanism of Action: decreased sodium and glucose reabsorption, and increases sodium delivery to proximal tubule, which decreased cardiac preload/ afterload, down regulate sympathetic activity, and decrease intraglomerular pressure
Adverse Effects:Dehydration, genetic mycotic infections/ UTI, hypoglycemia, euglycemic ketoacidosis
Absolute Contraindications: Dapagliflozin: eGFR <30 mL/min
Epagliflozin: eGFR <20 mL/ min
Pregnancy: –
Warning/ Precautions:—-
Monitoring Parameters: Volume status, in patients with diabetes: blood glucose and ketones
Pearls:
may require adjustment to loop diuretic doses
1. no titration needed if no diagnosis of diabetes
dapagliflozin
sd
td:
sd: 10 mg daily
td: 10 mg daily
empagliflozin
sd:
td:
sd: 10 mg daily
td: 10 mg daily
Loop Diuretics
examples:
Class: Loop diuretic
Indication:
Mechanism of Action:
Effects of mechanism of Action:
Adverse Effects:
Absolute Contraindications:
Pregnancy:–
Warning/ Precautions:
Drug-Drug Interactions (DDIs):
Monitoring Parameters:
Pearls:
1.
Loop Diuretics
examples:Furosemide (Lasix), Butanemide (Bumex), Torsemide (Demadex)
Class: Loop diuretic
Indication: management of edema associated with Heart Failure, reduces morbidity of heart failure
Mechanism of Action:inhibits sodium, chloride, and potassium reabsorption in the thick ascending limb of the nephron
Effects of mechanism of Action: decreased blood volume, cardiac output, and peripheral vascular resistance.
Adverse Effects:hypokalemia,hyponatremia, HYPOcalcemia, hyperuricemia, hypochloremia, metabolic acidosis, ototoxicity, hyperglycemia, hypertryglyceridemia, orthostatic hypotension
Absolute Contraindications:Severe kidney dysfunction (anuria)
Pregnancy:
Warning/ Precautions: use precaution in patients with gout
Drug-Drug Interactions (DDIs): Aminoglycosides, ACEi/ ARBS (hypotension)’ Lithium toxicity
Monitoring Parameters: Blood Pressure, BUN SCr, Serum electrolytes; Fluid status
Pearls:
1. all loops (excepts Ethacrynic acid) have sulfa moieties:
able to still be used in sulfa allergies, unless allergic to loop specifically
loop diuretic dosing
iv po
Furosemide 20 40
butanemide 1 1
torsemide 20 20
how to go about loop dosing in hf
double home dose and give as iv,
goal urine output is 100 m/L for 6/hours
overall goal output is 1-2 L negative
HYDRALAZINE
Class: direct vasodilators
Indication:
Mechanism of Action:
Effects of mechanism of Action:
Adverse Effects:
Absolute Contraindications:–
Pregnancy: –
Warning/ Precautions:—-
Monitoring Parameters: –
Pearls:–
HYDRALAZINE
Class: direct vasodilators
Indication: additional therapy to optimal guideline directed medical therapy for self identified african american patients with persistent NYHA class III-IV HFrEF who are also on ARNI/BB/MRA/SGLT-2 inhibitor
Mechanism of Action:direct vasodilation
Effects of mechanism of Action: decreased systemic vascular resistance
Adverse Effects: Hydralazine: reflex tachycardia, peripheral edema, palpitations, DILE
Absolute Contraindications:–
Pregnancy: –
Warning/ Precautions:—-
Monitoring Parameters: –
Pearls:–
hydralazine
sd
td
sd: 25 mg TID
td: 75 mg TID
Long acting nitrates
examples:
Indication:
Mechanism of Action:
Effects of mechanism of Action:
Adverse Effects:
Pregnancy: —
Warning/ Precautions: –
Drug-Drug Interactions (DDIs): –
Monitoring Parameters:
Pearls:
1
Long acting nitrates
examples: PO isosorbide dinitrate, isosorbide mononitrate (Transdermal patch)
Class: Beta blockers
Indication: As additional therapy for persistent NYHA class III-IV HF with reduced ejection fraction despite optimal guideline.
Mechanism of Action:form free radical nitric oxide. this activates cyclic GMP
(cGMP) leading to smooth muscle relaxation.
Effects of mechanism of Action:peripheral dilation of veins and arteries, more so veins.overall decreases O2 demand.
Adverse Effects: headache, hypotension,
Absolute Contraindications:
Pregnancy: —
Warning/ Precautions: –
Drug-Drug Interactions (DDIs): –
Monitoring Parameters:BP, HR
Pearls:
- isosorbide dinitrate is approved for HFrEF in combination with hydralazine. Combo product BiDil (20 mg isosorbide dinitrate/37.5 mg hydralazine) TID.
- can have lack of efficacy after consistent exposure (tachyphylaxis) (tolerance)
- provide 10-14 your nitrate free period
isosorbide dinitrate
sd:
td:
sd: 25 mg TID
td: 40 mg TID
when do you initiate vaso/venodilators such as hydralazine/nitrates?
to persistently symptomatic black patients on ARNI/BB/MRA/SGLT2 inhibitors, bp must be high enough to tolerate additional lowering
Ivabridine (Corlanor)
Class: Cardiovascular agent
Indication:
Mechanism of Action:
Effects of mechanism of Action:
Adverse Effects:
Absolute Contraindications:
Pregnancy: –
Warning/ Precautions:—-
Interactions:
Monitoring Parameters:
Pearls:
Ivabridine (Corlanor)
Class: Cardiovascular agent
Indication: to reduce risk of hospitalization in adult with stable, symptomatic HF with left ventricular ejection fraction = 35% who are in sinus rhythm with resting heart rate of >70 bpm despite being on a maximally tolerated beta blocker.
Mechanism of Action:selective and specific inhibition of the hyperpolarization-activated cyclic nucleotide - gated HCN channels (f-channels) within the sinoatrial node (SA node) of cardiac tissue resulting in disruption of the If ion current flow prolonging diastolic depolarization, slowing muring in the SA node, and ultimately reducing heart rate
Effects of mechanism of Action: reduce heart rate
Adverse Effects: bradycardia, atrial fibrillation
Absolute Contraindications:Severe hepatic impairment, acute decompensated heart failure, clinically significant hypotension, sick sinus syndrome, sinoatrial block, or third degree AV block
Pregnancy: –
Warning/ Precautions:—-
Interactions: major CYP3A4 substrate
Monitoring Parameters: monitor heart rate and rhythm
Pearls: complicated dosing algorithm in the guidelines
Vericiguat (Verquvo)
Class:
Indication:
Mechanism of Action:
Effects of mechanism of Action: i
Adverse Effects:hypotension
Absolute Contraindications:
Pregnancy:
Warning/ Precautions:–
Drug-Drug Interactions (DDIs):
Monitoring Parameters:
Pearls:
1.
Vericiguat (Verquvo)
Class: Soluble Guanylate Cyclase (sGC) stimulator
Indication:
Mechanism of Action:enhances production of cyclic GMP (cGMP) by directly stimulating soluble guanylate cyclase independent of nitric oxide (NO) and enhances sGC sensitivity to endogenous NO, thereby increasing cGMP production
Effects of mechanism of Action: increased levels of cGMP lead to smooth muscle relaxation and vasodilation
Adverse Effects:hypotension
Absolute Contraindications: PREGNANCY, use with PDE5 inhibitors
Pregnancy: DO NOT USE
Warning/ Precautions:–
Drug-Drug Interactions (DDIs): use with pde5 inhibitors
Monitoring Parameters: Blood Pressure, negative pregnancy test prior to initiation
Pearls:
1.complicated dosing algorithm based on BP in VICTORIA trial
Digoxin
Class:
Indication:
Mechanism of Action:
Effects of mechanism of Action:
Adverse Effects:
Absolute Contraindications:–
Pregnancy: -
Warning/ Precautions:
Drug-Drug Interactions (DDIs):
Monitoring Parameters:
Pearls:
Digoxin
Class: cardiac glycoside
Indication: treatment of mild to moderate heart failure in adults
Mechanism of Action:inhibition of sodium potassium ATPase pump in the myocardial cells results in a transient increase of intracellular sodium, which in turn promotes calcium influx via the socdium-calcium exchange pump leading to increased contractility
Effects of mechanism of Action: increased contractility of the heart
Adverse Effects: arhythmia, heart block, GI side effects (anorexia, , nausea and vomiting), neurologic side effects: visual disturbances, disorientation, confusion)
Absolute Contraindications:–
Pregnancy: -
Warning/ Precautions:
Drug-Drug Interactions (DDIs): Major substrate of P-glycoprotein, minor substrate of CYP3A4.
Monitoring Parameters: Heart rate and rhythm,
Serum concentrations: ideally a trough, goal 0.5-0.9 ng/mL
Pearls:
- on the Beers Criteria list (not safe for people over the age of 65)
- while target concentration is 0.5-0.9 ng/mL, patients can still develop toxicity in this range
which HF treatment drugs are mortality and morbidity decreasing agents
ARNI ACE/ARBS beta blockers MRA's SGLT-2 inhibitors vaso/veno dilators
which HF drugs re morbidity decreasing agents
loop diuretics
ivabridine
digoxin
soluble guanylate cyclase inhibitor (vericiguat)
What is acute decompensated HF
What is it?
clinical syndrome of new or worsening signs and symptoms of heart failure, often leading to hospitalization or a visit to the emergency department
classifications of acute decompensated heart failure
Classifications of Acute Decompensated Heart Failure
Class I. Warm and Dry
Class II. Warm and Wet
Class III. Cold and dry
Class IV. Cold and Wet
Class I.Warm and dry
what do you do
warm and dry is the goal. no treatment for those needed
class II. Warm and wet
what do u do?
what can you use?
what is the goal?
warm: goal. do nothing about that
wet: congested: DRY THEM OUT.
use loop diuretics. 1.5-2.5x home dose as iv.
if no home dose loop, start with 40 IV or equivalent
GOAL: 1-2 L negativ a day.
dose is working if there is at least 100 mL urine output in 6 hours
class III. Cold and dry
what do you do?
what can you use?
what is the goal?
cold. want to perfuse them
IF HEMODYNAMICALLY STABLE, use..
ACE/ARBS/ARNI, hydralazine, IV vasodilators like…
IV nitroglycerin, IV nitroprusside,
if low bp, can use milrinone or dobutamine
in acute decompensated HF
NTG
Nitroglycerin
Class:
Indication: .
Mechanism of Action:
Effects of mechanism of Action:
Adverse Effects:
Absolute Contraindications:
Pregnancy: –
Warning/ Precautions: –
Drug-Drug Interactions (DDIs):
Monitoring Parameters: –
Pearls:
NTG
Nitroglycerin
Class: nitrates
Indication: . IV: vasodilator in acute decompensated heart failure
Mechanism of Action: forms free radical nitric oxide, which activates cyclic GMP (cGMP), which causes smooth muscle relaxation. .
Effects of mechanism of Action: produces vasodilator effect on peripheral arteries and veins but more so on veins. overall reduces demand of oxygen to relieve angina.
Adverse Effects: Headache
Absolute Contraindications:recent use with phosphodiesterase inhibitor . Sildenafil/ Avanafil: 24 hr, Tadalafil: 48 hr, concurrent use with soluble guanylate cyclase stimulators (veriguat, riociguat)
Pregnancy: –
Warning/ Precautions: –
Drug-Drug Interactions (DDIs): can cause profound hypotension with recent use of PDE inhibitors like sildenafil, Avanafil, and Tadalafil
Monitoring Parameters: –
Pearls:
give as continuous IV infusion
Nitroprusside
Class:
Indication: .
Mechanism of Action:
Effects of mechanism of Action:
Adverse Effects:
Absolute Contraindications:–
Pregnancy: –
Warning/ Precautions: –
Drug-Drug Interactions (DDIs): –
Monitoring Parameters:
Pearls:
Nitroprusside
Class: vasodilator
Indication: . IV: vasodilator in acute decompensated heart failure
Mechanism of Action: causes peripheral vasodilation by direct action on venous and arterial smooth muscle and release of nitric oxide, this reducing peripheral resistance; with increased cardiac output and after load.
Effects of mechanism of Action: produces vasodilator effect on peripheral arteries
Adverse Effects: Hypotension, cyanide and thiocyanate toxicity (by arterial blood gas or levels)
Absolute Contraindications:–
Pregnancy: –
Warning/ Precautions: –
Drug-Drug Interactions (DDIs): –
Monitoring Parameters: blood pressure, cyanide and thiocyanate toxicity (particularly if on for >3 days at > 3mcg/kg/min)
Pearls:
give as continuous IV infusion
Milrinone
Class:
Indication: .
Mechanism of Action:
Effects of mechanism of Action:
Adverse Effects:
Absolute Contraindications:–
Pregnancy: –
Warning/ Precautions: –
Drug-Drug Interactions (DDIs):
Monitoring Parameters:
Pearls:
Milrinone
Class: inotrope, phosphodiesterase 3 inhibitor
Indication: . use for patient in acute decompensated heart failure with reduced cardiac output. (when patient is cold (hypo perfused) and no hemodynamically stable. need to raise bp)
Mechanism of Action: selective PDE3 inhibitor in cardiac and vascular tissue
Effects of mechanism of Action: results in vasodilation and inotropic effects
Adverse Effects: increased or decreased BP, increased HR, arryhthmias
Absolute Contraindications:–
Pregnancy: –
Warning/ Precautions: –
Drug-Drug Interactions (DDIs): Anagrelide: category X. increases aryhtmia potential in combo with other anti arrhythmic agents
Monitoring Parameters: BP, HR, ECG, for arrhythmia
Pearls:
- moderate risk of arryhthmia, high risk of hypotension
- give as continuous IV infusion
- renal eliminated (more renal dysfunction-> more drug exposure and hypotension)
Dobutamine
Class:
Indication:
Mechanism of Action:
Effects of mechanism of Action:
Adverse Effects:
Absolute Contraindications:–
Pregnancy: –
Warning/ Precautions: –
Drug-Drug Interactions (DDIs):
Monitoring Parameters:
Pearls:
1
Dobutamine
Class: Adrenergic agonist agent, inotrope
Indication: . short term management of patients with cardiac decompensation to reperfuse. (when patient is cold (hypo perfused) and Low BP. need to raise bp)
Mechanism of Action: stimulate myocardial beta 1 adrenergic receptors resulting in increased contractility of the heart
stimulate beta 2 and alpha 1 in vasculature, resulting in vasodilation
Effects of mechanism of Action: increases ionotropic properties (increased contractility) produces vasodilator effect on peripheral arteries
Adverse Effects: increased or decreased BP, increased HR, arryhthmias
Absolute Contraindications:–
Pregnancy: –
Warning/ Precautions: –
Drug-Drug Interactions (DDIs): increased arrythmogenic potential in combo with other anti arrhythmic agents
Monitoring Parameters: BP, HR, ECG, for arrhythmia
Pearls:
- high risk o arryhthmia, moderate-low risk of hypotension
- give as continuous IV infusion
cold and wet
what to do?
what to use?
warm them up, and then dry them out.
warm. if hemodynamically stable, can use ace/arb/arni/ hydralazine, IV nitroglycerin, iv nitroprusside
if low bp. use inotropes like milrinone or dobutamine.
if hemodynamically unstable, can use vasopressors like norepinephrine, epinephrine, dobutamine
wet. MUST warm them up before drying them out. need to make sure kidneys ar perfused properly before giving loops.
then give loops as directed with wet. 1.5-2.5 x home dose or start with furosemide 40 IV if no home dose. goal is to be 1-2 L negative
Vasopressors
Class: Vasopressors
Examples:
Indication: .
Mechanism of Action:
Effects of mechanism of Action:
Adverse Effects:
Absolute Contraindications:r–
Pregnancy: –
Warning/ Precautions: –
Drug-Drug Interactions (DDIs):
Monitoring Parameters:
Pearls:
Vasopressors
Class: Vasopressors
Examples: Norepinephrine, epinephrine, Dopamine
Indication: . IV: vasodilator in acute decompensated heart failure. (used when pt is cold and wet. in cold when the patient is hemodynamically unstable)
Mechanism of Action: generally alpha/beta agonists to increase iontropy and chronotropy and vasoconstriction
Effects of mechanism of Action: increase ionotropy/chronotropy and cause vasoconstriction
Adverse Effects: increased BP, increased HR, arrhythmia, extravasation (leakage of injected drugs from blood vessels causing damage to the surrounding tissues
Absolute Contraindications:r–
Pregnancy: –
Warning/ Precautions: –
Drug-Drug Interactions (DDIs): increases arrythmogenic potential in combo with other pro-arrhythmic agents
Monitoring Parameters: BP, HR, ECG for arrythmias
Pearls:
norepinephrine is given as the first line agent for cariogenic shock
dopamine increases fatal arrhythmia and mortality in cardigenic shock (AVOID)
give as continuous IV infusion
What is HFpEF
What is it?
the left ventricule doesn’t fill properly, but does contract, so the same percentage of blood leaves the ventricle, but from a smaller starting volume
approved meds for HFpEF
- sacubatril/ valsartan (entresto)
2. SGLT-2 inhibitors only empagliflozin right now
