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Therapeutics III > Sowinski Acute Heart Failure > Flashcards

Sowinski Acute Heart Failure Flashcards

1
Q

What is cardiogenic shock?

A

Hypotension (SBP <90mmHg or MAP <70mmHg) with low cardiac output

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2
Q

Non-invasive testing for acute HF

A

-Detailed physical exam
-Routine testing: Cr, K, Na
-BNP and NTproBNP: BNP >400 is closely associated with acute HF

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3
Q

Invasive hemodynamic monitoring for acute HF

A

-Routine use is discouraged
-Flow directed PA catheters (Swan-Ganz catheters)

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4
Q

Symptoms of heart congestion

A

-DOE
-Orthopnea
-PND
-PE
-Rales
-Ascites
-Hepatomegaly
-JVD
-HJR

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5
Q

Symptoms of inadequate perfusion

A

-Fatigue
-Altered mental status
-Cold extremities
-Worsening renal function
-Narrow pulse pressure
-Decreased blood pressure
-Decreased Na

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6
Q

What does warm or cold describe in acute HF?

A

Describes cardiac function or ability to perfuse tissues

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7
Q

What does wet or dry describe in acute HF?

A

Describes volume status

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8
Q

What would warm and dry indicate?

A

Normal

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9
Q

What would warm and wet indicate?

A

Pulmonary congestion

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10
Q

What would cool and dry indicate?

A

Hypoperfusion

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11
Q

What would cool and wet indicate?

A

Hypoperfusion and pulmonary congestion

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12
Q

What should happen with GDMT when a patient with chronic HF is admitted to the hospital?

A

GDMT should be continued in the absence of hemodynamic instability or contraindications . . . hypotension/cardiogenic shock

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13
Q

When should beta-blockers be held?

A

-Recent initiation or up-titration resulted in current decompensation
-Consider holding if dobutamine is needed or hemodynamically unstable

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14
Q

How to dose beta-blockers in patients with acute HF

A

-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

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15
Q

How to dose digoxin in patients with acute HF

A

-Continue at dose to achieve SDC 0.5-0.9 ng/mL
-Avoid DC unless compelling reason
-Caution with regard to renal function

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16
Q

What medications should be used to manage decompensation episodes?

A

-Diuretics
-Inotropes
-Vasodilators
-Vasopressors

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17
Q

What is the goal of therapy in patients with acute HF?

A

-No therapy shown to conclusively reduce mortality
-Treatments . . . reduce symptoms, restoring perfusion, and minimizing cardiac damage and adverse effects

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18
Q

What therapy is recommended in patients who are class I (warm and dry)?

A

Optimize chronic therapy

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19
Q

What therapy is recommended in patients who are class II (warm and wet)?

A

IV diuretics +/- IV venous vasodilator

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20
Q

What therapy is recommended in patients who are class III (cold and dry)?

A

-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

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21
Q

What therapy is recommended in patients who are class IV (cold and wet)?

A

-IV diuretics +
-If SBP is less than 90: IV inotrope
-If SBP is 90 or more: arterial vasodilator

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22
Q

When are diuretics used in hospitalized patients?

A

Used primarily to treat systemic/pulmonary congestion in subset II or IV, first line agents with fluid overload

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23
Q

Diuretic dosing in hospitalized patients

A

-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

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24
Q

What do you do if the patient is resistant to diuretics?

A

-Sodium and water restriction
-Increase dose, rather than frequency, to ceiling
-Combination therapy (thiazides + loops)
-Ultrafiltration

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25
Q

How to dose IV furosemide in hospitalized patients

A

-Increase dose patient was receiving at home
-If continuous infusion: 0.1 mg/kg/hr doubled q2-4h; max 0.4

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26
Q

Diuretic monitoring

A

-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

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27
Q

Initial bolus IV furosemide dose

A

40 mg

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28
Q

Infusion rate of IV furosemide

A

10 mg/hr

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29
Q

Initial bolus IV bumetanide dose

A

1 mg

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30
Q

Infusion rate of IV bumetanide

A

0.5 mg/hr

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31
Q

Initial bolus IV torsemide dose

A

20 mg

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32
Q

Infusion rate of IV torsemide

A

0.5 mg/hr

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33
Q

Maximum infusion of furosemide/24 hours

A

960 mg

34
Q

Maximum infusion of bumetanide/24 hours

A

48 mg

35
Q

Maximum infusion of torsemide/24 hours

A

480 mg

36
Q

When is vasodilator therapy used?

A

Used in combination with diuretics to reduce pulmonary congestion in wet, stage II and IV, acute HF

37
Q

Venodilator mechanism of action

A

-Increase venous capacitance and reduce preload and reduce myocardial stress
-Rapid symptomatic relief
-NTG is venodilator of choice

38
Q

When should patients not receive vasodilators?

A

Patients with symptomatic hypotension

39
Q

What should be considered first, vasodilators or inotropes?

A

Vasodilators

40
Q

Vasodilator monitoring

A

Frequent BP monitoring is needed

41
Q

Examples of vasodilators

A

-Nitroprusside
-Nitroglycerin
-Nesiritide
-Morphine
-Enalaprilat
-Hydralazine

42
Q

Clinical effects of nitroprusside

A

-Balanced vasodilator
-Decreases SVR

43
Q

Clinical effects of nitroglycerin

A

-Venous > arterial VD
-Decreased PCWP

44
Q

Clinical effects of nesiritide

A

-Balanced vasodilation
-Increased urine output and Na secretion
-Expensive

45
Q

When to use nitroprusside in ADHF

A

-Warm and wet
-Cold and wet (alt to inotropes)
-HTN crisis

46
Q

When to use nitroglycerin in ADHF

A

-Warm and wet
-ACS, HTN crisis

47
Q

When to use nesiritide in ADHF

A

-Warm and wet
-Cold and wet (alt to inotropes)

48
Q

Nitroprusside dosing

A

0.25 mcg/kg/min, titrate to response (max 3 mcg)

49
Q

Nitroglycerin dosing

A

5 mcg/min initially, increase by 5 mcg/min every 5 to 10 min (max 200 mcg)

50
Q

Nesiritide dosing

A

-Bolus: 2 mcg/kg
-Infusion: 0.01 mcg/kg/min, increase by 0.005 mcg/kg/min (max 0.03 mcg)

51
Q

Nitroprusside adverse effects

A

-Cyanide and thiocyanate toxicity (usually after 3 days of use)
-Hypotension

52
Q

Nitroglycerin adverse effects

A

-Hypotension
-Headache
-Reflex tachycardia
-Nitrate tolerance

53
Q

Nesiritide adverse effects

A

-Hypotension
-Tachycardia
-Renal dysfunction

54
Q

What are the beta-agonist positive inotropes?

A

-Dobutamine
-Dopamine

55
Q

What are the PDE 3 inhibitor positive inotropes?

A

-Milrinone
-Amrinone (Not used anymore)

56
Q

Dobutamine mechanism of action

A

-Beta1- and beta2-receptor agonist and weak alpha1-receptor agonist
-Stimulates AC to increase cAMP

57
Q

Clinical effects of dobutamine

A

Positive inotrope, chronotrope, lusitrope

58
Q

When to use dobutamine in patients with ADHF

A

-Cold and wet
-Cold and dry (if PCWP is greater than 15)

59
Q

Dobutamine dosing

A

2.5 to 5 mcg/kg/min titrate

60
Q

When to consider dobutamine

A

If low BP

61
Q

Dobutamine adverse effects

A

-Arrhythmogenic
-Tachycardia
-Ischemia
-Reduced K
-Tolerance after 48-72 hours

62
Q

Milrinone mechanism of action

A

-PDE inhibition
-Increased cAMP in myocardium (increased cardiac output) and vasculature (decreased SVR) “inodilator”

63
Q

Clinical effects of milrinone

A

Positive inotrope, venous > arterial VD

64
Q

When to use milrinone in patients with ADHF

A

-Cold and wet
-Cold and dry (if PCWP is greater than 15)

65
Q

Milrinone dosing

A

0.1-0.375 mcg/kg/min infusion titrate

66
Q

When to consider milrinone

A

If on beta-blocker

67
Q

Milrinone adverse effects

A

-Arrhythmogenic
-Tachycardia
-Ischemia
-Hypotension
-Thrombocytopenia

68
Q

Dopamine mechanism of action

A

-Dose dependant agonist on dopamine1, beta1, beta2 and alpha1 receptors
-Causes release of NE from adrenergic nerve terminals

69
Q

Clinical effects of dopamine

A

Positive inotrope, chronotrope, lusitrope

70
Q

When to use dopamine in patients with ADHF

A

-Typically plays secondary role to dobutamine/milrinone
-Sometimes referred to as a vasopressor

71
Q

Dopamine adverse effects

A

-Arrhythmogenic
-Tachycardia
-Ischemia
-Decreased potassium
-Tolerance after 48-72 hours
-Skin necrosis upon infiltration

72
Q

When is it useful to use positive inotrope therapy?

A

-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)

73
Q

Should dobutamine or milrinone be used?

A

-Choice of dobutamine vs. milrinone is individualized
-High SVR
-Beta-blocker use
-Milrinone is the better choice

74
Q

PCWP of class I ADHF

A

15-18

75
Q

CI of class I ADHF

A

2.2 or more

76
Q

PCWP of class II ADHF

A

18 or more

77
Q

CI of class II ADHF

A

2.2 or more

78
Q

PCWP of class III ADHF

A

15-18

79
Q

CI of class III ADHF

A

less than 2.2

80
Q

PCWP of class IV ADHF

A

18 or more

81
Q

CI of class IV ADHF

A

less than 2.2

Therapeutics III (42 decks)

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