Heart failure pt 2 Flashcards
(29 cards)
Generalities:
1) Although increasing the dose of oral diuretic therapy may be effective in some cases, the use of ____________ is recommended
2) β-Blocker therapy may be temporarily_________ or ___________if recent initiation or up-titration is responsible for acute decompensation
1) IV diuretics
2) held or dose-reduced
Select _________ may also need to be temporarily held in the setting of renal dysfunction, especially if oliguria or hyperkalemia is present (e.g., ACE inhibitors, angiotensin receptor blockers, angiotensin receptor-neprilysin inhibitors, aldosterone antagonists)
GDMT
Discontinuation of digoxin is generally ___________ as an association between ____________ of therapy and worsening HF has been well-documented
discouraged; withdrawal
1) Subset I (warm & dry): What is the goal of Tx?
2) Subset II (warm & wet): What characterizes this subset?
1) Optimization of GDMT
2) Adequate CO but a PCWP greater than 18 mm Hg
Subset II (warm & wet):
1) IV agents that reduce preload via ________ and/or _________________ are the most appropriate initial therapy.
2) Failure to respond to the above therapies may indicate the presence of impaired CO, and _______________________________ should be considered
1) diuresis and/or direct venodilation
2) IV inotropic therapy (with or without PA catheter insertion)
Subset II (warm & wet):
What may also be considered for severe euvolemic or hypervolemic hyponatremia, particularly if neurologic symptoms emerge?
Arginine vasopressin (AVP) antagonists
Subset III (cold & dry):
1) If evidence of hypovolemia exists (e.g., orthostatic hypotension) or PCWP is below ____ mm Hg, IV fluids should be cautiously administered.
2) What should be withheld?
3) In patients whose CI remains low despite restoration of optimal left ventricular filling pressures, what may be necessary to achieve adequate CI?
1) 15
2) Diuretic therapy
3) IV positive inotropic agents (e.g., dobutamine and milrinone) and/or IV arterial vasodilators (e.g., nitroprusside)
Subset IV (cold & wet):
1) In the presence of significant hypotension and low MAP (and SVR is low to normal or unknown), ___________ should be avoided
2) Sometimes, what may be required?
1) vasodilators
2) Combined inotrope and vasopressor therapy (e.g., dobutamine plus norepinephrine) or an inotrope with vasopressor activity (e.g., dopamine) be used to achieve adequate end-organ perfusion
True or false: None of the therapies used in the treatment of ADHF confer long-term improvements in morbidity and mortality
True
Loops
1) IV loop diuretics furosemide and bumetanide are the mainstay of therapy for relieving ___________ in the setting of ADHF.
2) For patients taking loop diuretics prior to admission, a total daily dose of _____ to ______-times their home dose is recommended.
3) Doses may be administered as either an IV bolus (i.e., divided every _____ hours) or continuous IV infusion
1) congestion
2) 1- to 2.5
3) 12
1) Resistance leads to what?
2) What are the 2 options to compensate resistance?
1) Reduced renal perfusion
2) ↑ loop dose > may worsen renal function
Add thiazide
Give examples of other diuretics you can combine with loops
Distal tubule blockers such as oral metolazone, oral hydrochlorothiazide, or IV chlorothiazide
True or false: Loop diuretics and adj. diuretics have synergistic effects
True
Define (numerically):
1) Hyponatremia
2) Hypovolemic
3) Hypervolemic
1) Serum sodium < 125 mmol/L
2) Urine sodium < 30 mmol /L
3) Urine sodium > 30 mmol /L
Vasopressin receptor antagonists: List 2 and their MOAs
1) Tolvaptan (Samsca or Jynarque)
-MOA: selectively binds to and inhibits the V2 receptor
2) Conivaptan (Vaprisol)
-MOA: nonselectively inhibits both V1A and V2 receptors
Vasopressin receptor antagonists:
Stimulation of V1A receptors of smooth muscle and myocardium results in vasoconstriction as well as what 3 other effects?
Myocyte hypertrophy, coronary vasoconstriction, and positive inotropic effects
Vasopressin receptor antagonists:
V2 receptors are located in the ______________ where they regulate water reabsorption
renal tubules
List the routes of administration for the 2 Vasopressin receptor antagonists. Which of these has a BBW for hepatotoxicity?
1) Tolvaptan: PO; BBW
2) Conivaptan: IV
Intravenous vasodilators should be considered _______ to positive inotropic therapy in patients with low CO and elevated SVR (or elevated blood pressure in those without a PA catheter)
prior
True or false: Hypotension may preclude the use of IV vasodilators
True
Tolerance may develop after 12 – 72 hours of use of what?
Nitroglycerin
Nitroprusside may cause _______ and ___________ toxicity
Cyanide; thiocyanate
Cyanide & thiocyanate are unlikely with what doses of nitroprusside?
Unlikely when doses less than 3 mcg/kg/min are administered for less than 3 days unless patient has significant renal impairment
Initial doses of 2.5 to 5 mcg/kg/min may be increased progressively to 20 mcg/kg/min based on clinical and hemodynamic responses.
This describes what med?
Dobutamine
