Acute Heart Failure (AHF) Summary Slides HL

What is heart failure?

Inadequate ability of the heart to pump enough blood to meet the blood flow and metabolic demands of the body

Structural or functional cardiac disorder that impairs the ability of the ventricle to eject blood (systolic) and/or fill (diastolic)

What is HFrEF?

LVEF < 40%

Systolic dysfxn

Squeezing issue

What is HFpEF?

LVEF < 50%

Diastolic dysfxn

Filling/relaxing problem

What is NYHA Class I?

asymptomatic, no limitation in PA from HF

What is NYHA Class II?

mild symptoms, slight limitation during ordinary activity

What is NYHA Class III?

market limitation in activity due to symptoms (even during "less" than ordinary activity), comfort only at rest

What is NYHA Class IV?

severe limitations, symptoms even at rest

What is decompensation?

compensatory mechanisms fail

deterioration of previously stable chronic HF, S/S are worse than baseline, change in NYHA class status, and hospitalization typically is required

What causes decompensation?

nonadherence

What medication mechanisms cause HF?

Na/H2O retention,

Neg inotropic effect,

Cardiotoxicity

What meds lead to Na/H2O retetention?

NSAIDs

TZD

Salicylates

Glucocorticoids

Sex hormones

Na containing drugs: pip/tazo, amp/sulbac

What meds have negative inotropic effects?

BBs

CCBs

Anti-arrhythmics: Disopyramide, Flecainide

What meds are cardiotoxic?

Doxorubicin

Daunomycin

Cyclophosphamide

What are S/S of HF?

Dyspnea

Orthopnea

Paroxysmal nocturnal dyspnea

Exercise intolerance

Lethargy

Nausea

Ascites

Bloating

Pulmonary rales

Edema

S3 gallop

Tachycardia

Jugular venous distention (JVD)

+ others

What labs are measured in HF?

BNP, SCr, K, chest x-ray, CBC, Echo, Troponin/CKMB

What BNP level rules out HF?

< 100

Why do we check SCr?

check for acute renal failure

Why do we check K levels?

check for hypo/hyperkalemia

Why do we check chest x-rays?

check for pulmonary edema

Why do we check CBC?

rules out anemia

Why do we check an echo?

assess heart fxn

Why do we check troponin/CKMB?

check for heart damage

What is the forrester classification category I?

normal: warm + dry

NO TREATMENT

What is the forrester classification category II?

pulmonary congestion: warm + wet

How do we treat category II AHF?

diuretics and vasodilators (nitroprusside, NTG)

What is the forrester classification category III?

hypo-perfusion: cold + dry

How do we treat category III AHF?

cautious IV fluid challenge and inotropes (dobutamine, milrinone)

What is the forrester classification category IV?

pulmonargy congestion and hypo-perfusion (cold + wet)

How do we treat category IV AHF?

diuretics and inotropes (dobutamine, milrinone)

What are S/S of congestion?

Dyspnea (at exertion or rest)

Orthopnea

Paroxysmal nocturnal dyspnea

Peripheral edema

Rales

Early satiety, N/V

Ascites

JVD

Hepatojugular reflux

What are S/S of hypo-perfusion?

Fatigue

Mental status change

Sleepiness

Cold extremities

Worsening renal fxn

Hypotension

True or False: no therapy is proven to decrease mortality, just symptoms

True (i.e., improve perfusion, minimize cardiac damage, minimize ADRs)

Should we optimize guideline directed medical therapy (GDMT) for AHF?

Yes! continue unless hemodynamically unstable or C/I

When do we decide not to continue BB GDMT?

if causing decompensation, cardiogenic shock, hypotension (w S/S), or bradycardia

What dose should we start at for euvolemic patients?

low dose if stable

Which BB has more impact on BB?

carvedilol

Which BB has better use for reactive airway disease?

metoprolol

Which BB is not FDA approved?

bisoprolol

What is the purpose of BB?

Reverse cardiac remodeling, reduce all-cause and HF-related hospitalizations, and all cause mortality

What precautions are there for ACE/ARB GDMT?

aggressive diuresis

D/C if worsening renal fxn, hypotension (w S/S), or K > 5.5

What is in secondary ppx for AHF?

ACE/ARB/ARNI

BB

C (pee/loop diuretic)

MRA

Hydralazine/Nitrates

Ivabradine

Digoxin

True or False: IV diuretics will not work if PO didn't work

False (they might!)

What is the recommended IV dose for AHF?

2-2.5 x the PO equivalent

What is the IV dose of furosemide that's equivalent to 40mg PO furosemide?

20mg (50%)

What is the IV/PO dose of bumex that's equivalent to 40mg PO furosemide?

1mg

What is the PO dose of torsemide that's equivalent to 40mg PO furosemide?

20mg (50%)

What are monitoring parameters of loop diuretics?

SCr

K

Mg

Urine output

Weight

Edema

What to do if non-responsive to loop diuretics?

Double the dose

Change to continuous infusion

Add another diuretic (i.e., metalozone, HCTZ)

Na/fluid restriction

When are vasodilators used?

Can be used with diuretic therapy to quickly improve symptoms in patients with pulmonary edema or HTN

Consider over inotropic medications

When are vasodilators C/I?

hypotension (SBP < 90)

What dosage forms are available of vasodilators?

ICU: IV

Non-ICU: non-IV

What meds are vasodilators?

nitroprusside and NTG

What is the MOA of nitroprusside?

balanced arterial and venous vasodilation

When is nitroprusside or NTG used?

wet HF

What are ADRs of nitroprusside?

Hypotension

Cyanide toxicity (renal impairment or prolonged use)

What is the MOA of NTG?

venous vasodilation

high doses cause arterial vasodilation as well

What are ADRs of NTG?

Hypotension

Reflex tachycardia

HA

Tachyphylaxis (12+ hours)

What are inotropes used for?

Relieve S/S

Improve end-organ fxn in patients with rEF or decreased perfusion (i.e., worsening renal fxn)

SBP < 90 or hypotension with S/S

Unresponsive or intolerant to IV vasodilators

What meds are inotropes?

dobutamine and milrinone

What is the use of dobutamine?

severe hypotension

What is the MOA of dobutamine?

Beta 1 agonist

Increases cAMP → increases CO

Slight peripheral vasodilation

What are the clinical effects of dobutamine?

+ intropic

Chronotropic

Lusitropic

What are ADRs of dobutamine?

Pro-arrhythmia

Tachycardia

Myocardial ischemia

Tachyphylaxis (72+ hours)

Increased mortality with long-term use

When is milrinone used?

if on BB

What is the MOA of milrinone?

PDE inhibitor

Inhibits cAMP breakdown → increases CO and decreases SVR

What are the clinical effects of milrinone?

+ inotropic

Lusitropic

What are ADRs of milrinone?

Pro-arrhythmia

Tachycardia

Hypotension

Increase mortality with long-term use

True or False: digoxin may decrease hospitalizations and are preferred

False! Use after other GDMT

What is the goal serum concentration of digoxin for AHF?

0.5-0.8

How to draw trough levels of digoxin?

Draw 6-8 hours after last dose

Optimally 12-24 hours after last dose

Typically drawn prn once stable

Draw if any of the following are of concern: Compliance, Changing renal fxn, Suspected toxicity, Start or D/C any interaction medications

What are monitoring parameters of digoxin?

SCr

K

MG

GI S/S

Drug interactions

What is secondary ppx of AHF?

SAME AS ACS