AHF RW Exam 3

What is HFrEF?

EF ≤ 40%

Systolic HF

Squeezing problem

What is HFpEF?

EF ≥ 50%

Diastolic HF

Filling problem or relaxing problem

What factors are associated with causing decompensated HF?

Dietary and medication non-adherence

Medication induced

What are causes of medication-induced decompensated HF?

Sodium and water retention

Negative inotropic effects

Cardiotoxic drugs

What drugs cause Na and water retention?

NSAID,

TZD (-glitazone)

Salicylates

Glucocorticoids

Sex hormones

Na+ containing drugs (e.g. pip/tazo, amp/sulbac)

What drugs have nengative inotropic effects?

B-blockers

Calcium channel blockers

Antiarrhythmics (disopyramide, flecainide)

What drugs are cardiotoxic?

Doxorubicin

Daunomycin

Cyclophosphamide

What labs are used to assess HF?

BNP (low values can rule out HF)

SCr (to check for acute renal failure)

K (to check for hypo- or hyperkalemia)

Chest X-ray (to look for pulmonary edema)

CBC (to rule out anemia)

Echo (to assess heart function)

Troponin/CKMB (to check for heart damage)

What are the 4 categories included in the Forrester classification of AHF?

1: Normal (warm + dry)

2: Pulmonary congestion (warm + wet)

3: Hypoperfusion (cold + dry)

4: Pulmonary congestion and Hypoperfusion (cold + wet)

What does a normal PCWP (

Euvolemic (dry)

What does a high PCWP (>18) indicate?

Fluid overload/pulmonary congestion (wet)

What does a normal (>2.2) cardiac index (CI) indicate?

Adequately perfused (warm)

What does a low (

Hypoperfusion (cold)

What therapy is indicated for AHF category 1 - Normal (warm + dry)?

No specific intervention needed

What therapy is indicated for AHF category 2 - Pulmonary congestion (warm + wet)?

Diuretics

Vasodilators - Nitroprusside, Nitroglycerin

What therapy is indicated for AHF category 3 - hypoperfusion (cold + dry)?

Cautious IV fluid challenge

Inotropes - Dobutamine, Milrinone

What therapy is indicated for AHF category 4 - Pulmonary congestion and Hypoperfusion (cold + wet)?

Diuretics

Inotropes - Dobutamine, Milrinone

What are the diuretics of choice in management of AHF?

Furosemide, Bumetanide, and Torsemide

How should loop diuretics be used in AHF?

IV may work even when PO didn't

Give 2-2.5x the oral equivalent

What is the equivalent dose of Furosemide 40 mg PO if given IV?

Furosemide 20 mg IV (half oral dose)

What should be monitored while using loop diuretics?

SCr

K

Mg

Urine output

Weight

Edema

How should diuretic therapy non-response be managed?

Double the dose

Change to continuous infusion

Add a second diuretic with different mechanism - Metolazone, Hydrochlorothiazide

Fluid & sodium restriction

What vasodilators are used in AHF?

Nitroprusside

Nitroglycerin

When should vasodilator therapy be used in AHF?

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

For "wet" HF

Should be considered over inotropic drugs

IV therapy can only be used in the ICU setting

When should vasodilator therapy not be used?

In hypotensive patients

Avoid use if SBP < 90 mmHg

What are the clinical effects of Nitroprusside?

Balanced arterial and venous vasodilator

What are ADRs of Nitroprusside?

Hypotension

Cyanide toxicity, particularly in renal impairment or prolonged use

What are the clinical effects of Nitroglycerin?

Preferential venous vasodilator, arterial vasodilation at higher doses

What are ADRs of Nitroglycerin?

Hypotension,

Reflex tachycardia

Headache

Tachyphylaxis (>12 hours)

What are the effects of therapies for AHF?

No therapies proven to decrease mortality

Therapies only dec. symptoms, inc. perfusion, and minimize cardiac damage and adverse effects

Should optimize GDMT once stabilized, for mortality benefit

How should GDMT be addressed in pt.'s with AHF?

Continue

Unless hemodynamically unstable or contraindicated

What therapies are part of GDMT?

B-Blockers

ARNI (preferred), ACE, or ARB

Loop diuretic

If indicated: MRA, SGLT2

What is the effect of B-Blockers in HF?

Reduce mortality

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

How should B-blockers be used in AHF?

Continue unless it caused decompensation

D/C if cardiogenic shock, symptomatic hypotension or bradycardia

Initiate at low dose in stable, euvolemic patients

Which B-blockers are indicated for HF GDMT?

Carvedilol or metoprolol succinate (FDA-approved)

Or Bisoprolol (studied but not FDA-approved)

How should ACE/ARB be used in AHF?

Caution with aggressive diuresis

Consider D/C if worsening renal function, symptomatic hypotension, or K>5.5

What is the effect of loop diuretics in HF?

Symptom management

What inotropes are used in AHF?

Dobutamine

Milrinone

When are inotropes used in AHF?

Relieve symptoms and improve end-organ function in patients with reduced EF or decreased perfusion

For "cold" HF

What are indications for inotropic therapy in AHF?

SBP

What is the main difference between Dobutamine and Milrinone?

Milrinone can be used if the patient is on a B-blocker

When should Dobutamine be used for inotropic therapy?

Considered in severe hypotension

(no hypotension ADR - unlike milrinone)

What is the MOA of Dobutamine?

Beta1 Agonist,

Increases cAMP to increase CO

Slight peripheral vasodilation

What are the clinical effects of Dobutamine?

Positive inotropic, chronotropic, and lusitropic (relaxation) effects

What are the ADRs of Dobutamine?

Proarrythmia

Tachycardia

Myocardial ischemia

Tachyphylaxis (>72 hours)

Possible increased mortality with long-term use

When should Milrinone be used for inotropic therapy?

Consider if receiving Beta-blocker therapy

What is the MOA of Milrinone?

Phosphodiesterase inhibitor

Inhibits cAMP breakdown to increase CO and decrease SVR

What are the clinical effects of Milrinone?

Positive inotropic and lusitropic (relaxation) effects

What are the ADRs of Milrinone?

Proarrythmia

Tachycardia

Hypotension

Possible increased mortality with long-term use

What agents should be used for secondary prevention of HF?

GDMT:

- ACEI/ARB/ARNI

- B-blocker (metoprolol succinate, carvedilol, bisoprolol)

- Loop diuretic

Additional tx.:

-Aldosterone receptor antagonists

-Hydralazine/nitrates

-Ivabradine

-Digoxin

How is Digoxin used in HF?

May decrease hospitalizations - use after other GDMT

Preferred concentration 0.5-0.8

Monitor: SrCr, K, Mg, GI symptoms, drug interactions