Acute Decompensated Heart Failure

True

(True/False) Treatment for acute Decompensated HF is extremely expensive in the hospital setting

Verapamil, Diltiazem, Nifedipine

Name the 3 Negative Inotropic medications that may lead to Acute Decompensated HF

True

(True/False) NSAIDs are responsible for many HF admissions

TZDs, Steroids, DPP4i

What are 3 other classes of medications that can lead to Acute Decompensated HF

Acute Decompensated HF

The signs and symptoms for this disease state include:

- Acute pulmonary congestion

- SOB

- Severe respiratory distress, tachyons, orthopnea

- O2 stats <90%

90

O2 stats <_____% are indicative of Acute Decompensated HF

Pulmonary Capillary Wedge Pressure

What is the hemodynamic monitoring parameter used in Acute Decompensated HF

volume overload

Elevated PCWP in Acute Decompensated HF Indicates...

Dehydration or Inadequate filling pressures

Decreased PCWP in Acute Decompensated HF Indicates...

Preload

PCWP reflects _____________

Contractility

Cardiac output in Acute Decompensated HF (volume pumped out by left ventricle) reflects ____________

Contractility

Cardiac Index (CI) (CO/Body Surface Area) in Acute Decompensated HF reflects _____________

Afterload

Systemic Vascular Resistance (SVR) (inversely related to CO) in Acute Decompensated HF reflects _____________

Cardiogenic Shock

This occurs by tissue hypoperfusion induced by HF after attempt to correct preload and arrhythmias (organ hypoperfusion and pulmonary congestion develop rapidly)

90, 30, 0.5

The following are indicative of Cardiogenic Shock:

SBP <_____ or drop in MAP of >_____

Urine Output < _____ mL/kg/hour

Aggressive diuretic therapy (may require dialysis)

What is first step in treating Acute Decompensated HF

Oxygen Saturation

In Acute Decompensated HF, it is important to maintain ____________ ______________

Vasoactive agents and IV positive inotropic agents

These two agents can be used as needed in Acute Decompensated HF

oxygen and morphine

If patient is experiencing pain and dyspnea, they can find relief with ____________ and _____________

vasodilator, preload

Oxygen and Morphine, used in Acute Decompensated HF, have _______________ properties which can help reduce __________

Morphine

Which pain/dyspnea relief medication must be used with caution in those with hypotension, bradycardia, advanced AV block and CO2 retention

True (as long as not contraindicated and patient is hemodynamically stable)

(True/False) In the treatment of Acute Decompensated HF, GDMT should be continued

Beta blocker

GDMT in the treatment of Acute Decompensated HF recommends the initiation of a ______________ only in stable patients, and after optimization of volume status, and successful discontinuation of IV diuretics, vasodilators, inotropic agents

IV Loop Diuretics

Significant fluid overload in Acute Decompensated HF can be treated with what?

Preload

IV loop diuretics help reduce ____________ by venous vasodilation (onset: 20-30 minutes)

2.5 times higher than pre-admission dose (IV)

If patient is already on a loop diuretic and is presenting with Acute Decompensated HF, initial Loop diuretic dose should be....

Higher dose IV loop diuretics or add a second diuretic

If diuresis in the treatment of Acute Decompensated HF is inadequate to relief symptoms what two things that you do...

dopamine

If there is still significant fluid overload with loop diuretics one may consider low dose ____________ IV infusion to loop diuretic in order to improve diuresis while preserving renal function and renal blood flow

IV nitroglycerin

If symptomatic hypotension absent in Acute Decompensated HF, and patient is seeking relief to dyspnea in addition to diuretics, use...

True

(True/False) Vasoactive agents relieve both preload and afterload in Acute Decompensated HF

PCWP

Decreased preload, and the effects of vasoactive agents, can be seen through the decrease in _________

Congestion

No benefits in routine treatment with Inotropic agents in acute HR due to ______________ only... may increase adverse outcomes

Low BP and CO

Inotropic agents in the treatment of Acute Decompensated HF Should be used with caution in patients with ___________ and ___________ with careful monitoring of BP and rhythm

Inotropic Agents

In the treatment of Acute Decompensated HF, _______________ may relieve symptoms due to poor perfusion and preserve end-organ function in patients with severe systolic dysfunction and dilated cardiomyopathy

Relative hypotension

Intolerance

No response to vasodilators and diuretics

In what three instances do we find the most value in using Inotropic agents

1-3 mcg/kg/min

This dose of Dopamine only effects DA receptors

Dilates renal and mesenteric arteries

3-10 mcg/kg/min

this dose of dopamine has affinity for beta-1, beta-2 and DA leading to more inotropic effects

Increased CO (by increasing SV)

10-20 mcg/kg/min

This dose of dopamine has an affinity to alpha-1, beta-1, beta-2 and DA and has the strongest inotropic effects

Milrinone

This inotropic agent, used in the treatment of Acute Decompensated HF, Increases myocardial inotropy, reduces systemic and pulmonary vascular resistance, improves LV diastolic compliance

Dobutamine

This inotropic agent, Acute Decompensated HF, Increase in stroke volume and CO, decrease SVR and PCWP

Vasopressors

These drugs may be needed to increase SVR... (norepinephrine, phenylephrine, high dose dopamine, vasopressin)

Cardiogenic shock

Occurs when an inotropic and fluid challenge fails to maintain SBP >90 with inadequate organ perfusion

vasopressors

Cardiogenic shock usually has increased SVR, so use _____________ with caution

Vasopressin receptor antagonists

These can be used as adjunct to diuretics for short term in patients with fluid overload and persistent severe hyponatremia at risk of cognitive symptoms despite fluid restriction

Tolvaptan

This Vasopressin receptor antagonist is contraindicated in hypovolemic hyponatremia, concurrent strong CYP3A4 inhibitors (cost $550 dollars per tablet)

sodium

While on Tolvaptan, monitor __________ levels very closely.