Lecture 2: Heart Failure Flashcards
Signs that pt HF getting worse (self-monitoring)
Changes in breathing
Changes in weight
New or worse swelling
Changes in ability to do everyday things
How much should you limit sodium intake to for hf?
max of 2000mg a day
How much fluid restriction for a stage D patient?
1.5-2L per day reasonable to reduce congestion
ADHF defintion
New or worsening signs or symptoms of HF that are usually caused by volume overload and/or hypo perfusion and leads to additional medical care
ADHF effect on curve…
inc afterload
Dec contractility and HR
What happens in ADHF
Most likely (excessive neurohormone release)
- AT2 = vasoconstriction on rigid vessels (inc after load)
- Aldosterone = Na/H20 retention (inc preload)
- NE = sympathetic stim (A+B), inc renin release, attempt to inc contractility (b), increase HR
- Vasopressin = inc H20 retention, inc preload
3 groups of ADHF
De novo disease = 25%
Exacerbated symptoms = 70% (stage c)
advanced or end-stage = 5% (stage d)
Main treatment goals
improve congestion and low output symptoms quickly
Wet =
excessive volume
congestion Distended internal JVD SOB Pulmonary Rales Peripheral Edema
Dry =
Not wet
Warm =
Warm extremities
Normal urine & renal function
confusion
Cold =
cold extremities
Hypotension
Bluish lips/nail beds
Mean arterial pressure calculation
((DBP X 2) + SBP ) / 3
What do you want to titrate MAP to when starting therapy?
> 65
How much volume do you typically remove from patient per day?
1-2
How to calculate volume
water weight in lbs /2.2
Drugs given in Warm & Wet stage
Diuretics
Vasodilators
NTG > Nitroprusside
Drugs given in Cold & Dry stage
Fluid Admin
Drugs given in Cold & Wet stage
Normal BP = Vasodilators
low BP = inotropic or vasopressors
General idea…if congested you use..
Diuretics Vasodilators Fluid Restrictions Sodium Restriction Compression devices to "move" fluid from tissues into vasculature
Need to reduce preload for heart to squeeze
General idea….if low perfusion you use….
Inotrope
Inodilator
Pressors
Mechanical Devices
Need to stimulate “squeeze” and maintain BP
Congestion Treatment w/ Diuretics dosing….
If pts already receiving loop diuretics, initial IV dose should be equal to or exceed the chronic oral daily dose and be given either Bolus or IV
Adverse effects to consider with diuretics
Hypokalemia Hypomagnesemia Uric Acid Resistance Reflex inc in neurohormones
Why might Diuretics be ineffective in ADHF?
Compensatory inc in RAAS leading to fluid retention
Diuretic resistance due to distal tubule hypertrophy
pts w/ renal insufficiency or low albumin req higher doses
If pt doesn’t respond to diuretics and congestion doesn’t improve, you can try to….
Restriction sodium to < 2g/d and fluids < 2l/day
inc dose of loop to max bolus dose
change to continuous IV
add second diuretic
ultrafiltration or Vasodilators
Role for Vasodilators
Can release symptoms of dyspnea
NTG > nitroprusside
Low perfusion treatments - inotropes….
Short term continuous IV inotrope support maybe reasonable in those hospitalized pts presenting w/ significant reduced cardiac output to maintain systemic perfusion and preserve end organ perfusion
when giving Dobutamine or Milrinone
need to discontinue Beta-blockers
Milrinone preferred when….
increased pulmonary artery pressure
Need for B-blockade
Dobutamine preferred when…
Hypotension
Renal insufficiency
Cardiogenic shock
persistant hypotension and tissue hypo perfusion due to cardiac dysfunction in presence of adequate vascular volume
goals for Cardiogenic Shock
Maintain arterial pressure ( > 65) adequate for tissue perfusion
1st line = pressers
Norepie tends to be more balanced, Dopamine good ton too
when is Norepi preferred over dopamine>
if high HR or arrhythmia concern
