Sowinski Acute Heart Failure Flashcards
What is cardiogenic shock?
Hypotension (SBP <90mmHg or MAP <70mmHg) with low cardiac output
Non-invasive testing for acute HF
-Detailed physical exam
-Routine testing: Cr, K, Na
-BNP and NTproBNP: BNP >400 is closely associated with acute HF
Invasive hemodynamic monitoring for acute HF
-Routine use is discouraged
-Flow directed PA catheters (Swan-Ganz catheters)
Symptoms of heart congestion
-DOE
-Orthopnea
-PND
-PE
-Rales
-Ascites
-Hepatomegaly
-JVD
-HJR
Symptoms of inadequate perfusion
-Fatigue
-Altered mental status
-Cold extremities
-Worsening renal function
-Narrow pulse pressure
-Decreased blood pressure
-Decreased Na
What does warm or cold describe in acute HF?
Describes cardiac function or ability to perfuse tissues
What does wet or dry describe in acute HF?
Describes volume status
What would warm and dry indicate?
Normal
What would warm and wet indicate?
Pulmonary congestion
What would cool and dry indicate?
Hypoperfusion
What would cool and wet indicate?
Hypoperfusion and pulmonary congestion
What should happen with GDMT when a patient with chronic HF is admitted to the hospital?
GDMT should be continued in the absence of hemodynamic instability or contraindications . . . hypotension/cardiogenic shock
When should beta-blockers be held?
-Recent initiation or up-titration resulted in current decompensation
-Consider holding if dobutamine is needed or hemodynamically unstable
How to dose beta-blockers in patients with acute HF
-Do not add or up titrate until optimization of volume status and successful DC of IV diuretics, VDs and inotropes
-Start at low doses and use special caution if inotropes used in hospital
How to dose digoxin in patients with acute HF
-Continue at dose to achieve SDC 0.5-0.9 ng/mL
-Avoid DC unless compelling reason
-Caution with regard to renal function
What medications should be used to manage decompensation episodes?
-Diuretics
-Inotropes
-Vasodilators
-Vasopressors
What is the goal of therapy in patients with acute HF?
-No therapy shown to conclusively reduce mortality
-Treatments . . . reduce symptoms, restoring perfusion, and minimizing cardiac damage and adverse effects
What therapy is recommended in patients who are class I (warm and dry)?
Optimize chronic therapy
What therapy is recommended in patients who are class II (warm and wet)?
IV diuretics +/- IV venous vasodilator
What therapy is recommended in patients who are class III (cold and dry)?
-If PCWP less than 15: IV fluids until PCWP is 15-18
-If PCWP is 15 or more and SBP is less than 90: IV inotrope
-If PCWP is 15 or more and SBP is 90 or more: IV inotrope or arterial vasodilator
What therapy is recommended in patients who are class IV (cold and wet)?
-IV diuretics +
-If SBP is less than 90: IV inotrope
-If SBP is 90 or more: arterial vasodilator
When are diuretics used in hospitalized patients?
Used primarily to treat systemic/pulmonary congestion in subset II or IV, first line agents with fluid overload
Diuretic dosing in hospitalized patients
-No difference in efficacy between intermittent dosing and continuous infusion
-Initial IV dose should equal or exceed chronic daily dose and given as intermittent bolus
What do you do if the patient is resistant to diuretics?
-Sodium and water restriction
-Increase dose, rather than frequency, to ceiling
-Combination therapy (thiazides + loops)
-Ultrafiltration
How to dose IV furosemide in hospitalized patients
-Increase dose patient was receiving at home
-If continuous infusion: 0.1 mg/kg/hr doubled q2-4h; max 0.4
Diuretic monitoring
-Urine output and signs/symptoms of congestion
-Ins/outs, body weight, vital signs, signs/symptoms of perfusion and congestion, serum electrolytes, BUN, and creatinine daily
-Desire 1-2 L/day above input early
Initial bolus IV furosemide dose
40 mg
Infusion rate of IV furosemide
10 mg/hr
Initial bolus IV bumetanide dose
1 mg
Infusion rate of IV bumetanide
0.5 mg/hr
Initial bolus IV torsemide dose
20 mg
Infusion rate of IV torsemide
0.5 mg/hr
Maximum infusion of furosemide/24 hours
960 mg
Maximum infusion of bumetanide/24 hours
48 mg
Maximum infusion of torsemide/24 hours
480 mg
When is vasodilator therapy used?
Used in combination with diuretics to reduce pulmonary congestion in wet, stage II and IV, acute HF
Venodilator mechanism of action
-Increase venous capacitance and reduce preload and reduce myocardial stress
-Rapid symptomatic relief
-NTG is venodilator of choice
When should patients not receive vasodilators?
Patients with symptomatic hypotension
What should be considered first, vasodilators or inotropes?
Vasodilators
Vasodilator monitoring
Frequent BP monitoring is needed
Examples of vasodilators
-Nitroprusside
-Nitroglycerin
-Nesiritide
-Morphine
-Enalaprilat
-Hydralazine
Clinical effects of nitroprusside
-Balanced vasodilator
-Decreases SVR
Clinical effects of nitroglycerin
-Venous > arterial VD
-Decreased PCWP
Clinical effects of nesiritide
-Balanced vasodilation
-Increased urine output and Na secretion
-Expensive
When to use nitroprusside in ADHF
-Warm and wet
-Cold and wet (alt to inotropes)
-HTN crisis
When to use nitroglycerin in ADHF
-Warm and wet
-ACS, HTN crisis
When to use nesiritide in ADHF
-Warm and wet
-Cold and wet (alt to inotropes)
Nitroprusside dosing
0.25 mcg/kg/min, titrate to response (max 3 mcg)
Nitroglycerin dosing
5 mcg/min initially, increase by 5 mcg/min every 5 to 10 min (max 200 mcg)
Nesiritide dosing
-Bolus: 2 mcg/kg
-Infusion: 0.01 mcg/kg/min, increase by 0.005 mcg/kg/min (max 0.03 mcg)
Nitroprusside adverse effects
-Cyanide and thiocyanate toxicity (usually after 3 days of use)
-Hypotension
Nitroglycerin adverse effects
-Hypotension
-Headache
-Reflex tachycardia
-Nitrate tolerance
Nesiritide adverse effects
-Hypotension
-Tachycardia
-Renal dysfunction
What are the beta-agonist positive inotropes?
-Dobutamine
-Dopamine
What are the PDE 3 inhibitor positive inotropes?
-Milrinone
-Amrinone (Not used anymore)
Dobutamine mechanism of action
-Beta1- and beta2-receptor agonist and weak alpha1-receptor agonist
-Stimulates AC to increase cAMP
Clinical effects of dobutamine
Positive inotrope, chronotrope, lusitrope
When to use dobutamine in patients with ADHF
-Cold and wet
-Cold and dry (if PCWP is greater than 15)
Dobutamine dosing
2.5 to 5 mcg/kg/min titrate
When to consider dobutamine
If low BP
Dobutamine adverse effects
-Arrhythmogenic
-Tachycardia
-Ischemia
-Reduced K
-Tolerance after 48-72 hours
Milrinone mechanism of action
-PDE inhibition
-Increased cAMP in myocardium (increased cardiac output) and vasculature (decreased SVR) “inodilator”
Clinical effects of milrinone
Positive inotrope, venous > arterial VD
When to use milrinone in patients with ADHF
-Cold and wet
-Cold and dry (if PCWP is greater than 15)
Milrinone dosing
0.1-0.375 mcg/kg/min infusion titrate
When to consider milrinone
If on beta-blocker
Milrinone adverse effects
-Arrhythmogenic
-Tachycardia
-Ischemia
-Hypotension
-Thrombocytopenia
Dopamine mechanism of action
-Dose dependant agonist on dopamine1, beta1, beta2 and alpha1 receptors
-Causes release of NE from adrenergic nerve terminals
Clinical effects of dopamine
Positive inotrope, chronotrope, lusitrope
When to use dopamine in patients with ADHF
-Typically plays secondary role to dobutamine/milrinone
-Sometimes referred to as a vasopressor
Dopamine adverse effects
-Arrhythmogenic
-Tachycardia
-Ischemia
-Decreased potassium
-Tolerance after 48-72 hours
-Skin necrosis upon infiltration
When is it useful to use positive inotrope therapy?
-Useful for symptom relief in hypotension (SBP <90 mmHg)
-Useful in patients with end organ dysfunction (AKI, altered mental status, systemic hypoperfusion, hypotension, CV collapse)
-Useful when disease is refractory to other HF therapies (need for mechanical circulatory support, transplant, palliative care)
Should dobutamine or milrinone be used?
-Choice of dobutamine vs. milrinone is individualized
-High SVR
-Beta-blocker use
-Milrinone is the better choice
PCWP of class I ADHF
15-18
CI of class I ADHF
2.2 or more
PCWP of class II ADHF
18 or more
CI of class II ADHF
2.2 or more
PCWP of class III ADHF
15-18
CI of class III ADHF
less than 2.2
PCWP of class IV ADHF
18 or more
CI of class IV ADHF
less than 2.2
