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What are the factors that can cause acute decompensated HF?
- Cardiac events
- Pulmonary events
- Diabetes & obesity
- Worsening renal function
- Thyroid dysfunction
- Alcohol and drug abuse
- Non-adherence to medications & diet
- Concomitant medications
What are the indicators for Low CO in an acute decompensated HF patient?
- Skin pale, gray/cyanotic
- Decreased BP
- Decreased urine output
- Weak pulse
- Cool moist skin
S/S of congestions/fluid overload =
Increased JVD, + HJR, Peripheral edema, Orthopenea, Rales, Weight gain
S/S of low perfusion/low CO =
Cool extremities, low urine output, Altered mental state, inadequate response to Diuretic, prerenal axotemia
Overdiuresing could cause what effects in ADHF?
- Deplete electrolytes = arrhythmias
Overuse of vasodilators like NG, can cause what in ADHF?
Agents used for low CO in ADHF, carry what risk?
Arrhythmias and Myocardial ischemia
What treatments should be at the forefront when treating ADHF?
- Arrhythmia management
For an ADHF patient, you would continue home treatment with ACEI, ARB or AAs unless what situation arises?
- Cardiogenic shock
- Renal dysfunction
For an ADHF patient, you would continue home treatment with BBssunless what situation arises?
- Volume overload
- Marginal/ low CO
If you are starting to max out on the doses of diuretics and ADHF patient continues to be short of breath what drugs can you use?
- IV vasodilators:
What are the additional diuretic options for people that are fluid overloaded and did not respond to a single initial Loop diuretic treatment?
- IV chlorothiazide
- PO metolazone 2.5-10 mg QD
- PO HCTZ* 25-50 mg BID
- PO spironolactone
What is the Furosemide initial bolus dose for a patient who is Diuretic Naïve and presents with ADHF?
40 mg IV
What group of patients should receive diuretic treatment with ADHF?
Wet = volume overloaded
What are the CIs to diuretic use in ADHF?
- Severe hypotension
- Cardiogenic shock
What is the PO: IV ratio for Furosemide?
What is the PO: IV ratio for Torsemide?
What is the PO: IV ratio for Butenemide?
What is the Butenemide initial bolus dose for a patient who is Diuretic Naïve and presents with ADHF?
1 mg IV
What is the Torsemide initial bolus dose for a patient who is Diuretic Naïve and presents with ADHF?
10-20 mg IV
What drugs can be given for ADHF patients that are diuretic naïve?
- Furosemide 40 mg IV
- Bumetanide 1 mg IV
- Torsemide 10-20 mg IV
How should you monitor an ADHF patient on Diuretics?
- Volume status
- Daily ins and outs
- Side effects
- Symptomatic hypotension
What is the fluid reduction goal at 2 hours of therapy?
What are the vasodilators used in ADHF?
What Do you need to watch for when giving Vasodilators for ADHF?
BP and Tolerance
What group of ADHF patients are Vasodilators useful in?
- No hypotension (>90/60)
- Maxed Diuretics
- Still fluid overloaded w/ symptoms (SOB)
What is the preferred vasodilator for ADHF?
What are the adverse effects of NG in ADHF?
Tachyphylaxis, HA, reflex tachycardia
What are the hemodynamic effects of NG?
- Decrease venous LV filling pressure = Decrease Preload
- Increase arterial stroke volume and CO = Decrease Afterload
If an ADHF patient w/ low CO has SBP > or = 90, what inotropic agent would you use?
- On BB chronically: Milrinone
- Not on BB chronically: Dobutamine
If an ADHF patient w/ low CO has SBP <90, what inotropic agent would you use?
If an initial Dobutamine or Milrinone treatment for an ADHF patient with Low CO is not sufficient, what other options could you add on?
PAC, Vasodilators, Dopamine or mechanical assistance
What are the inotropic agents available for ADHF?
Dobutamine, Milrinone and Dopamine
What type of patients should receive Inotropes?
- SHF Cold patients (Low CO):
- Severe LV systolic dysfunction
- Low output syndrome
- Low BP and/or inadequate response to other txt’s
- Palliative measure for end stage HF
Inotropes are CI in what group of ADHF patients?
DHF: Preserved or Normal EF
What are the adverse effects of Dobutamine?
Proarrhythmic, hypokalemia, myocardial ischemia, tachyphylaxis
What is the main MOA for Dobutamine?
- B1 agonism (som slight B2 and a1 agonsim too)
- Increases contractility, HR and CO
What other drug with contradict Dobutamine?
When should you use Milrinone for INotropic effects in ADHF?
On a BB and not hypotensive
Can you use Milrinone when a patient is Hypotensive?
Can you use Dobutamine when a patient is Hypotensive?
What is the MOA of milrinone?
- PDE-3 inhibitor
- Increase Contractility
- Decreases afterload via vasodilation
What are the adverse effects of Milrinone?
What are the first line agents for Inotropic effects in ADHF?
Dobutamine and Milrinone
What is the Third line agents for Inotropic effects in ADHF?
Low doses of Dopamine have what main effect?
Increases renal perfusion
Middle/Moderate doses of Dopamine have what main effect?
Positive inotropic and chronotropic effect
What group is Dopamine mainly used in?
Severely hypotensive or in cardiogenic shock
What are the adverse effects of Dopamine in ADHF?
MI and Proarrhythmia